Edward Castillo - Academia.edu (original) (raw)

Papers by Edward Castillo

Research paper thumbnail of Missed and missing cases of abusive injuries: The magnitude and the measurement of the problem

Child Abuse & Neglect, 2010

ObjectiveThe authors’ objective is to describe the disparity between the case-fatality rates for ... more ObjectiveThe authors’ objective is to describe the disparity between the case-fatality rates for inflicted versus unintentional injuries of children, and to emphasize its utility as a way of estimating the effectiveness of the ascertainment of inflicted injuries of children.

Research paper thumbnail of Clinical outcomes of ED patients with bandemia

The American journal of emergency medicine, 2015

Although an elevated white blood cell count is a widely utilized measure for evidence of infectio... more Although an elevated white blood cell count is a widely utilized measure for evidence of infection and an important criterion for evaluation of systemic inflammatory response syndrome, its component band count occupies a more contested position within clinical emergency medicine. Recent studies indicate that bandemia is highly predictive of a serious infection, suggesting that clinicians who do not appreciate the value of band counts may delay diagnosis or overlook severe infections. Whereas previous studies focused on determining the quantitative value of the band count (ie, determining sensitivity, threshold for bandemia, etc.), this study directs attention to patient-centered outcomes, hypothesizing that the degree of bandemia predisposes patients to subsequent negative clinical outcomes associated with underappreciated severe infections. This retrospective study of electronic medical records includes patients who initially presented to the emergency department (ED) with bandemia...

Research paper thumbnail of Safety and Efficacy of Milk and Molasses Enemas in the Emergency Department

The Journal of emergency medicine, Jan 4, 2015

Increased scrutiny is occurring from regulatory agencies about the use of nonsterile enema prepar... more Increased scrutiny is occurring from regulatory agencies about the use of nonsterile enema preparations in the emergency department (ED) for constipation. This includes the "off-label" use of milk and molasses (M&M) enemas, as there are no reported data in the medical literature to determine safety and efficacy. To evaluate the success and complication rates of administering M&M enemas in the ED. This was a structured retrospective study at two EDs over 8 years. Primary success was defined as the patient having a bowel movement. Secondary measures of success included improved pain score by 2 or more points or lowering of a heart rate initially over 100 beats/min by 20 or more beats/min. Complications included: hemodynamic compromise, increased pain, electrolyte disturbances, bacteremia, bowel perforation, rectal pain or bleeding, cardiac dysrhythmias, anaphylaxis, electrolyte disturbances, dizziness or syncope, or hospital admission for issues surrounding enema. There were...

Research paper thumbnail of Ketamine Use for Acute Agitation in the Emergency Department

The Journal of emergency medicine, Jan 2, 2015

Emergency physicians regularly encounter agitated patients. In extremely agitated and violent pat... more Emergency physicians regularly encounter agitated patients. In extremely agitated and violent patients, the onset of many traditional medications is relatively slow and often requires additional medication. Ketamine is frequently used in emergency departments (EDs) for procedural sedation and intubation, but has recently been suggested as a treatment for acute agitation. We sought to examine the use of ketamine in the treatment of acute agitation in an ED setting, including vital sign changes as a result of this medication. This is a structured review of an historical cohort of patients over 7 years at two university EDs. Patients were included if they received ketamine as treatment for acute agitation. Abstracted data included age, vital signs including hypoxia, any additional medications for agitation, and alcohol/drug intoxication. Ketamine was administered for agitation on 32 visits involving 27 patients. Preadministration systolic blood pressure was 131 ± 20 mm Hg, with an aver...

Research paper thumbnail of Twelve-lead electrocardiogram monitoring of subjects before and after voluntary exposure to the Taser X26

Objectives: The Taser (Taser International, Scottsdale, Ariz) uses high-voltage electricity to in... more Objectives: The Taser (Taser International, Scottsdale, Ariz) uses high-voltage electricity to incapacitate subjects. We sought to evaluate cardiac rhythm changes during deployment of the Taser on healthy volunteers. Methods: This prospective study was performed on 32 healthy volunteer subjects receiving a Taser X26 discharge. The subjects had baseline 12-lead electrocardiogram (ECG) monitoring performed immediately before and within 1 minute after the Taser discharge. Changes in cardiac rhythm, morphology, and interval duration were evaluated. Descriptive statistics and paired-sample t test comparisons are reported. Results: All 32 subjects had an interpretable 12-lead ECG obtained before and after the Taser activation, although 1 subject's post-PR interval could not be determined. The mean age and body mass index were 33 years and 26.5 kg/m 2 , respectively. Overall, there was a significant increase in heart rate (2.4; 95% confidence interval [CI], 0.0-4.9) and a decrease in PR interval (À6.5; 95% CI, À9.7 to À3.3). When stratified by sex, only the PR interval in men significantly decreased (À5.9; 95% CI, À9.2 to À2.5). There were significant changes in heart rate (4.0; 95% CI, 1.3-6.7), PR interval (À6.0; 95% CI, À11.3 to À0.7), and QT interval (À18.8; 95% CI, À33.2 to À4.3) among those with a normal body mass index, and in PR interval among those who were overweight/obese (À6.7; 95% CI, À10.8 to À2.5). None of the statistically significant differences between ECG measures were clinically relevant. Conclusions: There were no cardiac dysrhythmia and interval or morphology changes in subjects who received a Taser discharge based on a 12-lead ECG performed immediately before and within 1 minute after a Taser activation. D

Research paper thumbnail of Sarcopenia in elderly men and women: the Rancho Bernardo study

American journal of preventive medicine, 2003

Sarcopenia risk factors are poorly understood. This study examines sarcopenia prevalence and risk... more Sarcopenia risk factors are poorly understood. This study examines sarcopenia prevalence and risk factors in community-dwelling men (694) and women (1006) aged 55-98 years (mean=73) who attended a 1988-1992 Rancho Bernardo Study clinic visit. Height, weight, muscle strength, fat-free mass (FFM), fat mass by bioelectric impedance analysis, and grip strength were measured; alcohol and medication use, smoking, and physical activity were ascertained. Mean FFM was 43.5 kg for women and 61.7 kg for men. Sarcopenia, defined as FFM of > or =2.0 standard deviations below the gender-specific mean of a young reference population, was present in 6.0% overall. Prevalence increased dramatically from 4% of men and 3% of women aged 70-75 to 16% of men and 13% of women aged 85 and older. Both men and women with sarcopenia had a significantly lower fat mass and body mass index than those without sarcopenia. Men with sarcopenia were twice as likely to have fallen in the past year compared with thos...

Research paper thumbnail of The tooth, the whole tooth, and nothing but the tooth: can dental pain ever be the sole presenting symptom of a myocardial infarction? A systematic review

The Journal of emergency medicine, 2014

Pain symptoms related to cardiac ischemia can vary greatly from patient to patient. However, shou... more Pain symptoms related to cardiac ischemia can vary greatly from patient to patient. However, should emergency physicians consider the possibility of myocardial infarction in patients who present solely with dental pain? This is a systematic review of the literature investigating the incidence of jaw, tooth, or facial pain as the sole symptom of cardiac ischemia. Studies investigating jaw, tooth, or facial pain of cardiac origin were identified using the PubMed database. All English studies in which cardiac pain originated in the face, teeth, or jaw were screened for inclusion. Data were abstracted from each study utilizing a structured review process, and rated for methodological quality. Eighteen studies met study criteria: 16 were case reports, and the remaining 2 were prospective cohort studies. After quality assessment and categorization, nine reports were categorized as weak, eight moderate, and one strong methodological quality. Cardiac ischemia may present in no anatomic loca...

Research paper thumbnail of Lengths of stay for involuntarily-held psychiatric patients in the emergency department are affected both by patient characteristics and medication use

The American Journal of Emergency Medicine, 2015

Background: Psychiatric patients experience longer treatment times (length of stay [LOS]) in the ... more Background: Psychiatric patients experience longer treatment times (length of stay [LOS]) in the emergency department (ED) compared to nonpsychiatric patients. Although patients on involuntary mental health holds are relatively understudied, common wisdom would hold that times for these patients can only be affected by addressing systems issues because they are not free to leave. The objective of this study was to determine whether both selected ED and patient-specific factors were associated with longer LOS. We hypothesized that nonmodifiable factors (age, sex, agitation, presentation during evenings/nights, presentation during weekends, suicidal ideation) would prolong LOS but that potentially modifiable factors (such as use of medication) would reduce LOS. Methods: A historical cohort of patients (placed on involuntary mental health holds was studied in 2 general EDs. A regression model was used to calculate the effects of modifiable and nonmodifiable factors on LOS. Results: Six hundred forty patient visits met all inclusion/exclusion criteria. Longer LOSs were significantly associated with suicidal ideation, use of antipsychotics, and use of benzodiazepines, although agitation did not predict longer LOSs. Longer LOSs were also longer with presentation on the weekends. Conclusions: Lengths of stay for patients on involuntary mental health holds are associated with several factors outside the control of the typical ED clinician such as the ability to clear holds quickly due to day of week or placement of the hold for suicidal ideation. Lengths of stay are also increased by factors within the control of the typical ED clinician, such as administration of calming medication.

Research paper thumbnail of Corpus callosotomy: A palliative therapeutic technique may help identify resectable epileptogenic foci

Seizure, 2007

Corpus callosotomy has a long history as a palliative treatment for intractable epilepsy. Identif... more Corpus callosotomy has a long history as a palliative treatment for intractable epilepsy. Identification of a single epileptogenic zone is critical to performing successful resective surgery. We describe three patients in which corpus callosotomy allowed recognition of unapparent seizure foci, leading to subsequent successful resection. We retrospectively reviewed our epilepsy surgery database from 2003 to 2005 for children who had a prior callosotomy and were candidates for focal resection. All underwent magnetic resonance imaging and scalp video electroencephalograph monitoring, and two had magnetoencephalography, electrocorticography and/or intracranial video electroencephalograph monitoring. The children were 8 and 9 years old, and seizure onset varied from early infancy to early childhood. One child had a history of head trauma preceding seizure onset, one had a large intracerebral infarct and dysplastic cortex in the contralateral frontal lobe, and the other had an anterior temporal lobe resection without improvement in seizure frequency. After medical management failed, callosotomy was performed with the expectation of decreasing the seizure types affecting both hemispheres. Following transection of the callosal fibers, a single focus was recognized and resected, with resultant dramatic improvement in seizure control. In medically refractory epilepsy, where rapid secondary bisynchrony is suspected but the electroencephalograph is non-localizing, callosotomy should be considered as a means of treating generalized seizure types, but may also assist in identifying potentially operable seizure foci. Study limitations include its retrospective nature and cohort size. The findings, however, suggest the need for prospective, systematic, well-controlled studies of the use of corpus callostomy in this intractable patient population.

Research paper thumbnail of Minimizing pre- and post-defibrillation pauses increases the likelihood of return of spontaneous circulation (ROSC)

Resuscitation, 2010

Background: The three-phase model of ventricular fibrillation (VF) arrest suggests a period of co... more Background: The three-phase model of ventricular fibrillation (VF) arrest suggests a period of compressions to "prime" the heart prior to defibrillation attempts. In addition, post-shock compressions may increase the likelihood of return of spontaneous circulation (ROSC). The optimal intervals for shock delivery following cessation of compressions (pre-shock interval) and resumption of compressions following a shock (post-shock interval) remain unclear. Objective: To define optimal pre-and post-defibrillation compression pauses for out-of-hospital cardiac arrest (OOHCA). Methods: All patients suffering OOHCA from VF were identified over a 1-month period. Defibrillator data were abstracted and analyzed using the combination of ECG, impedance, and audio recording. Receiver-operator curve (ROC) analysis was used to define the optimal pre-and post-shock compression intervals. Multiple logistic regression analysis was used to quantify the relationship between these intervals and ROSC. Covariates included cumulative number of defibrillation attempts, intubation status, and administration of epinephrine in the immediate pre-shock compression cycle. Cluster adjustment was performed due to the possibility of multiple defibrillation attempts for each patient. Results: A total of 36 patients with 96 defibrillation attempts were included. The ROC analysis identified an optimal pre-shock interval of <3 s and an optimal post-shock interval of <6 s. Increased likelihood of ROSC was observed with a pre-shock interval <3 s (adjusted OR 6.7, 95% CI 2.0-22.3, p = 0.002) and a postshock interval of <6 s (adjusted OR 10.7, 95% CI 2.8-41.4, p = 0.001). Likelihood of ROSC was substantially increased with the optimization of both pre-and post-shock intervals (adjusted OR 13.1, 95% CI 3.4-49.9, p < 0.001). Conclusions: Decreasing pre-and post-shock compression intervals increases the likelihood of ROSC in OOHCA from VF.

Research paper thumbnail of Evaluation of Pediatric Glucose Monitoring and Hypoglycemic Therapy in the Field

Pediatric Emergency Care, 2005

As specific indications for glucose monitoring in pediatric patients are not standardized, we sou... more As specific indications for glucose monitoring in pediatric patients are not standardized, we sought to evaluate our EMS system regarding the use of this test, so that objective data can be used for prehospital provider education. We performed a 5-year electronic search of prehospital records to assess pediatric patients who had glucose monitoring performed, with subgroup analysis on those requiring therapy. We found that 6018 pediatric patients received glucose monitoring with the most common chief complaints for testing including: seizure, &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;other medical,&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; trauma head/neck, and OD/poisoning. Of these, 270 (4.5%) required therapy for hypoglycemia with an additional 100 (1.7%) patients receiving treatment without use of the paramedic&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s monitor. Age breakdowns for therapy were as follows: 0-4 years, 44 (11.9%); 5-9, 36 (9.7%); 10-14, 58 (15.7%); 15-19, 232 (62.7%). In the prehospital setting, the need to treat hypoglycemia in pediatric patients is infrequent. The chief complaints associated with the highest frequencies of hypoglycemia are seizures and altered neurologic status.

Research paper thumbnail of Prevalence of Use of Performance-Enhancing Substances Among United States Adolescents

Pediatric Clinics of North America, 2007

Adolescents may regard the use of performance-enhancing substances as an easy means to gain self-... more Adolescents may regard the use of performance-enhancing substances as an easy means to gain self-esteem through improved body appearance and athletic performance. The use of performance-enhancing substances by adolescents is particularly troubling because safety data are largely lacking. This poses a dilemma for the pediatrician who needs correct information, including the potential efficacy and negative health effects of such substances, to identify the patients in need of counseling and to find the best way to help adolescent patients make informed decisions to promote healthy behaviors. This article is intended to assist pediatricians by providing a summary of the current state of knowledge regarding the prevalence of use of performance-enhancing substances by United States adolescents.

Research paper thumbnail of Identifying Frequent Users of Emergency Department Resources

The Journal of Emergency Medicine, 2014

There is growing focus on frequent users of acute care resources. If these patients can be identi... more There is growing focus on frequent users of acute care resources. If these patients can be identified, interventions can be established to offer more consistent management plans to decrease inappropriate utilization. To compare a hospital-specific approach with a region-wide approach to identify frequent Emergency Department (ED) users. A retrospective multi-center cohort study of hospital ED visits from all 18 nonmilitary, acute care hospitals serving the San Diego region (population 3.2 million) between 2008 and 2010 using data submitted to the California Office of Statewide Health Planning and Development. Frequent users and super users were defined as having 6 to 20 and 21 or more visits, respectively, during any consecutive 12 months in the study period. Comparisons between community-wide and hospital-specific methods were made. There were 925,719 individual patients seen in an ED, resulting in 2,016,537 total visits. There were 28,569 patients identified as frequent users and 1661 identified as super users, using a community-wide approach. Individual hospitals could identify 15.6% to 62.4% of all frequent users, and from 0.3% to 15.2% of all the super users who visited their facility. Overall, the hospital-specific approach identified 20,314 frequent users and 571 super users, failing to identify 28.9% of frequent users and 65.6% of super users visiting San Diego County EDs that would otherwise have been identified using a community-wide approach. A community-wide identification method resulted in greater numbers of individuals being identified as frequent and super ED users than when utilizing individual hospital data.

Research paper thumbnail of Collaborative to Decrease Ambulance Diversion: The California Emergency Department Diversion Project

The Journal of Emergency Medicine, 2011

e Abstract-Background: Ambulance diversion is a national problem that affects more than half of a... more e Abstract-Background: Ambulance diversion is a national problem that affects more than half of all emergency departments (EDs). Although diversion was meant to be used for short periods of time to offer temporary relief to EDs, it has evolved into a normal routine in many communities to manage the growing problem of ED and hospital crowding. Study Objectives: To assess the impact of a collaborative effort to decrease ambulance diversion. Methods: This is a pre/post study investigating ED diversion in four emergency medical services agency regions in California from September 2006 through August 2008. Hospitals developed and implemented a number of best practices revolved around patient flow initiatives, specifically looking to improve input, throughput, and output. Monthly ED diversion data are compared and reported as means and standard deviations (SD). Results: During the study period, there were a total of 31,735 diversion hours in the collaborative regions, with 17,618 during the pre-consortium period and 14,117 in the post-consortium period (19.9% decrease). The monthly average hours of diversion before the consortium was 1468 (SD ‫؍‬ 390.6). This decreased to 1176 (SD ‫؍‬ 605.8) after the initiation of the consortium (difference of 292 h; 95% confidence interval 99 -484; p ‫؍‬ 0.007). There was a decrease in diversion hours for every month-to-month comparison except January and February (increases of 1% and 14.6%, respectively). Conclusion: This study suggests that a decrease in ambulance diversion can be achieved through ongoing collaboration and the implementation of best practices. Continued communication and emphasis on diversion are likely needed to sustain these decreases.

Research paper thumbnail of Assessment of the Addition of Prehospital Continuous Positive Airway Pressure (CPAP) to an Urban Emergency Medical Services (EMS) System in Persons with Severe Respiratory Distress

The Journal of Emergency Medicine, 2013

The use of continuous positive airway pressure (CPAP) assisted ventilation in the emergency depar... more The use of continuous positive airway pressure (CPAP) assisted ventilation in the emergency department(ED) has been well described. The purpose of this study was to measure the efficacy of adding pre-hospital CPAP to an urban emergency medical service (EMS) respiratory distress protocol on persons with respiratory distress. A historical cohort analysis of consecutive patients between 2005 and 2010. Groups were matched for severity of respiratory distress. Physiologic variables were the primary outcome obtained from first responders and upon triage in the ED. Additional outcomes included endotracheal intubation rate, hospital mortality, overall hospital length of stay(LOS), intensive care unit (ICU) admission, and ICU length of stay (ICU LOS). There were 410 consecutive patients with predetermined criteria for severe respiratory distress, 235 historical controls matched with 175 post-implementation patients. Average age was 67 years, 54% being male. There were significant median differences in heart and respiratory rates favoring the historical cohort (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.05). There were no significant differences in intubation rate, overall hospital LOS, ICU admission rate, ICU LOS, and hospital mortality (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt; 0.05).Patients that were continued on noninvasive ventilatory assistance had a significantly improved rate of intubation and ICU LOS (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.05). The addition of CPAP to our pre-hospital respiratory distress protocol did not improve physiologic variables.There were no differences in overall and ICU LOS between groups. Persons with apparent continued ventilatory assistance appeared to have improved rates of intubation and ICU LOS [corrected].

Research paper thumbnail of The Impact of Patient Telephone Call after Discharge on Likelihood to Recommend in an Academic Emergency Department

The Journal of Emergency Medicine, 2014

Research paper thumbnail of Pediatric Poisonings in Children Younger than Five Years Responded to by Paramedics

The Journal of Emergency Medicine, 2011

Background: Treatment of poisonings in children has been well studied, but few data are available... more Background: Treatment of poisonings in children has been well studied, but few data are available on the various causes of the poisoning episodes in the pediatric population. Objectives: To describe the incidence and demographics of accidental poisonings incurred by children < 5 years old in the County of San Diego, California who accessed paramedics through the 9-1-1 system. Methods: Eight years of prehospital records for children < 5 years of age were searched for poisoning cases. Detailed narrative information was abstracted to determine the circumstances surrounding the incident. Results: There were more than 40,000 paramedic transport calls for patients 5 years and younger over the study period; 996 (2.5%) of these calls had the chief complaint of poisoning. Of the calls classified as poisonings, 38% involved a 1-year-old and 35% involved a 2-year-old. Fifty-six percent of these poisonings involved either prescription or over-the-counter medications. An additional 16% were due to household cleaners. Eighty-eight percent of all calls were classified as mild in acuity, with 13% of poisoning calls for children under a year of age classified as moderate or acute; 50% of moderate or acute poisoning calls were to children 2 years of age. July and March were the months with the highest incidence of poisoning calls. The fewest calls were received on Saturdays and Sundays. Conclusions: Children 1 year of age had the highest incidence of unintentional poisonings. Among all age groups, medications were the number one cause of unintentional poisonings. Other unintentional poisonings could be prevented if hazardous materials were out of reach of chil-dren; many of the cases in this study happened in front of the parent with the parent watching. Ó 2011 Elsevier Inc.

Research paper thumbnail of Impact of the San Diego Serial Inebriate Program on Use of Emergency Medical Resources

Annals of Emergency Medicine, 2006

sentences (Ͻ0.001). Treatment acceptance was 20% among those with sentences of 0 to 30 days and r... more sentences (Ͻ0.001). Treatment acceptance was 20% among those with sentences of 0 to 30 days and reached 63% for those with sentences longer than 150 days. Operational costs and alternate care at clinics and nonparticipating hospitals were not analyzed.

Research paper thumbnail of Community trial to decrease ambulance diversion hours: The San Diego county patient destination trial

Annals of Emergency Medicine, 2004

Emergency department (ED) ambulance diversion is a major issue in many communities. When patients... more Emergency department (ED) ambulance diversion is a major issue in many communities. When patients do not reach requested facilities, challenges in care are compounded by lack of available medical records and delays in transferring admitted patients back to the originally requested facility. We seek to evaluate a community intervention to reduce ambulance diversion. This was a community intervention in a county of 2.8 million individuals. Ambulance diversion guidelines were revised for all ambulance agencies and EDs. Participation by EDs was voluntary, and main outcome measures, which included ambulance transports, ambulance diversions, and bypass hours, were compared for the pretrial, trial, and posttrial periods. A total of 235,766 patients were transported to an ED by advanced life support ambulance during the 2-year study period. There was a significant decrease in the number of patients who did not reach the requested facility because of ambulance diversion for the trial period (n=322) and posttrial period (n=449) compared with the pretrial period (n=1,320; -998 diverted patients per month [95% confidence interval (CI) -1,162 to -833 patients] and -871 diverted patients per month [95% CI -963 to -780 patients], respectively). There was also a significant decrease in average monthly hours on diversion for the trial period (n=1,079) and posttrial period (n=1,774) compared with the pretrial period (n=4,007; -2,928 hours on bypass [95% CI -3,936 to -1,919 hours on bypass] and -2,232 hours on bypass [95% CI -3,620 to -2,235 hours on bypass], respectively). A voluntary community-wide approach to reducing hospital ED diversion and getting more ambulance patients to requested facilities was effective.

Research paper thumbnail of Use of a Urine Dipstick and Brief Clinical Questionnaire to Predict an Abnormal Serum Creatinine in the Emergency Department

Academic Emergency Medicine, 2009

Objectives: Prior data demonstrated that a urine dipstick used alone was a sensitive predictor of... more Objectives: Prior data demonstrated that a urine dipstick used alone was a sensitive predictor of abnormal creatinine, but not sufficiently enough to forego screening of serum creatinine prior to administration of contrast for diagnostic studies. The authors hypothesized that a brief historical questionnaire coupled with a urine dipstick would have high sensitivity for renal dysfunction, potentially eliminating the need for a serum creatinine prior to contrast administration.

Research paper thumbnail of Missed and missing cases of abusive injuries: The magnitude and the measurement of the problem

Child Abuse & Neglect, 2010

ObjectiveThe authors’ objective is to describe the disparity between the case-fatality rates for ... more ObjectiveThe authors’ objective is to describe the disparity between the case-fatality rates for inflicted versus unintentional injuries of children, and to emphasize its utility as a way of estimating the effectiveness of the ascertainment of inflicted injuries of children.

Research paper thumbnail of Clinical outcomes of ED patients with bandemia

The American journal of emergency medicine, 2015

Although an elevated white blood cell count is a widely utilized measure for evidence of infectio... more Although an elevated white blood cell count is a widely utilized measure for evidence of infection and an important criterion for evaluation of systemic inflammatory response syndrome, its component band count occupies a more contested position within clinical emergency medicine. Recent studies indicate that bandemia is highly predictive of a serious infection, suggesting that clinicians who do not appreciate the value of band counts may delay diagnosis or overlook severe infections. Whereas previous studies focused on determining the quantitative value of the band count (ie, determining sensitivity, threshold for bandemia, etc.), this study directs attention to patient-centered outcomes, hypothesizing that the degree of bandemia predisposes patients to subsequent negative clinical outcomes associated with underappreciated severe infections. This retrospective study of electronic medical records includes patients who initially presented to the emergency department (ED) with bandemia...

Research paper thumbnail of Safety and Efficacy of Milk and Molasses Enemas in the Emergency Department

The Journal of emergency medicine, Jan 4, 2015

Increased scrutiny is occurring from regulatory agencies about the use of nonsterile enema prepar... more Increased scrutiny is occurring from regulatory agencies about the use of nonsterile enema preparations in the emergency department (ED) for constipation. This includes the "off-label" use of milk and molasses (M&M) enemas, as there are no reported data in the medical literature to determine safety and efficacy. To evaluate the success and complication rates of administering M&M enemas in the ED. This was a structured retrospective study at two EDs over 8 years. Primary success was defined as the patient having a bowel movement. Secondary measures of success included improved pain score by 2 or more points or lowering of a heart rate initially over 100 beats/min by 20 or more beats/min. Complications included: hemodynamic compromise, increased pain, electrolyte disturbances, bacteremia, bowel perforation, rectal pain or bleeding, cardiac dysrhythmias, anaphylaxis, electrolyte disturbances, dizziness or syncope, or hospital admission for issues surrounding enema. There were...

Research paper thumbnail of Ketamine Use for Acute Agitation in the Emergency Department

The Journal of emergency medicine, Jan 2, 2015

Emergency physicians regularly encounter agitated patients. In extremely agitated and violent pat... more Emergency physicians regularly encounter agitated patients. In extremely agitated and violent patients, the onset of many traditional medications is relatively slow and often requires additional medication. Ketamine is frequently used in emergency departments (EDs) for procedural sedation and intubation, but has recently been suggested as a treatment for acute agitation. We sought to examine the use of ketamine in the treatment of acute agitation in an ED setting, including vital sign changes as a result of this medication. This is a structured review of an historical cohort of patients over 7 years at two university EDs. Patients were included if they received ketamine as treatment for acute agitation. Abstracted data included age, vital signs including hypoxia, any additional medications for agitation, and alcohol/drug intoxication. Ketamine was administered for agitation on 32 visits involving 27 patients. Preadministration systolic blood pressure was 131 ± 20 mm Hg, with an aver...

Research paper thumbnail of Twelve-lead electrocardiogram monitoring of subjects before and after voluntary exposure to the Taser X26

Objectives: The Taser (Taser International, Scottsdale, Ariz) uses high-voltage electricity to in... more Objectives: The Taser (Taser International, Scottsdale, Ariz) uses high-voltage electricity to incapacitate subjects. We sought to evaluate cardiac rhythm changes during deployment of the Taser on healthy volunteers. Methods: This prospective study was performed on 32 healthy volunteer subjects receiving a Taser X26 discharge. The subjects had baseline 12-lead electrocardiogram (ECG) monitoring performed immediately before and within 1 minute after the Taser discharge. Changes in cardiac rhythm, morphology, and interval duration were evaluated. Descriptive statistics and paired-sample t test comparisons are reported. Results: All 32 subjects had an interpretable 12-lead ECG obtained before and after the Taser activation, although 1 subject's post-PR interval could not be determined. The mean age and body mass index were 33 years and 26.5 kg/m 2 , respectively. Overall, there was a significant increase in heart rate (2.4; 95% confidence interval [CI], 0.0-4.9) and a decrease in PR interval (À6.5; 95% CI, À9.7 to À3.3). When stratified by sex, only the PR interval in men significantly decreased (À5.9; 95% CI, À9.2 to À2.5). There were significant changes in heart rate (4.0; 95% CI, 1.3-6.7), PR interval (À6.0; 95% CI, À11.3 to À0.7), and QT interval (À18.8; 95% CI, À33.2 to À4.3) among those with a normal body mass index, and in PR interval among those who were overweight/obese (À6.7; 95% CI, À10.8 to À2.5). None of the statistically significant differences between ECG measures were clinically relevant. Conclusions: There were no cardiac dysrhythmia and interval or morphology changes in subjects who received a Taser discharge based on a 12-lead ECG performed immediately before and within 1 minute after a Taser activation. D

Research paper thumbnail of Sarcopenia in elderly men and women: the Rancho Bernardo study

American journal of preventive medicine, 2003

Sarcopenia risk factors are poorly understood. This study examines sarcopenia prevalence and risk... more Sarcopenia risk factors are poorly understood. This study examines sarcopenia prevalence and risk factors in community-dwelling men (694) and women (1006) aged 55-98 years (mean=73) who attended a 1988-1992 Rancho Bernardo Study clinic visit. Height, weight, muscle strength, fat-free mass (FFM), fat mass by bioelectric impedance analysis, and grip strength were measured; alcohol and medication use, smoking, and physical activity were ascertained. Mean FFM was 43.5 kg for women and 61.7 kg for men. Sarcopenia, defined as FFM of > or =2.0 standard deviations below the gender-specific mean of a young reference population, was present in 6.0% overall. Prevalence increased dramatically from 4% of men and 3% of women aged 70-75 to 16% of men and 13% of women aged 85 and older. Both men and women with sarcopenia had a significantly lower fat mass and body mass index than those without sarcopenia. Men with sarcopenia were twice as likely to have fallen in the past year compared with thos...

Research paper thumbnail of The tooth, the whole tooth, and nothing but the tooth: can dental pain ever be the sole presenting symptom of a myocardial infarction? A systematic review

The Journal of emergency medicine, 2014

Pain symptoms related to cardiac ischemia can vary greatly from patient to patient. However, shou... more Pain symptoms related to cardiac ischemia can vary greatly from patient to patient. However, should emergency physicians consider the possibility of myocardial infarction in patients who present solely with dental pain? This is a systematic review of the literature investigating the incidence of jaw, tooth, or facial pain as the sole symptom of cardiac ischemia. Studies investigating jaw, tooth, or facial pain of cardiac origin were identified using the PubMed database. All English studies in which cardiac pain originated in the face, teeth, or jaw were screened for inclusion. Data were abstracted from each study utilizing a structured review process, and rated for methodological quality. Eighteen studies met study criteria: 16 were case reports, and the remaining 2 were prospective cohort studies. After quality assessment and categorization, nine reports were categorized as weak, eight moderate, and one strong methodological quality. Cardiac ischemia may present in no anatomic loca...

Research paper thumbnail of Lengths of stay for involuntarily-held psychiatric patients in the emergency department are affected both by patient characteristics and medication use

The American Journal of Emergency Medicine, 2015

Background: Psychiatric patients experience longer treatment times (length of stay [LOS]) in the ... more Background: Psychiatric patients experience longer treatment times (length of stay [LOS]) in the emergency department (ED) compared to nonpsychiatric patients. Although patients on involuntary mental health holds are relatively understudied, common wisdom would hold that times for these patients can only be affected by addressing systems issues because they are not free to leave. The objective of this study was to determine whether both selected ED and patient-specific factors were associated with longer LOS. We hypothesized that nonmodifiable factors (age, sex, agitation, presentation during evenings/nights, presentation during weekends, suicidal ideation) would prolong LOS but that potentially modifiable factors (such as use of medication) would reduce LOS. Methods: A historical cohort of patients (placed on involuntary mental health holds was studied in 2 general EDs. A regression model was used to calculate the effects of modifiable and nonmodifiable factors on LOS. Results: Six hundred forty patient visits met all inclusion/exclusion criteria. Longer LOSs were significantly associated with suicidal ideation, use of antipsychotics, and use of benzodiazepines, although agitation did not predict longer LOSs. Longer LOSs were also longer with presentation on the weekends. Conclusions: Lengths of stay for patients on involuntary mental health holds are associated with several factors outside the control of the typical ED clinician such as the ability to clear holds quickly due to day of week or placement of the hold for suicidal ideation. Lengths of stay are also increased by factors within the control of the typical ED clinician, such as administration of calming medication.

Research paper thumbnail of Corpus callosotomy: A palliative therapeutic technique may help identify resectable epileptogenic foci

Seizure, 2007

Corpus callosotomy has a long history as a palliative treatment for intractable epilepsy. Identif... more Corpus callosotomy has a long history as a palliative treatment for intractable epilepsy. Identification of a single epileptogenic zone is critical to performing successful resective surgery. We describe three patients in which corpus callosotomy allowed recognition of unapparent seizure foci, leading to subsequent successful resection. We retrospectively reviewed our epilepsy surgery database from 2003 to 2005 for children who had a prior callosotomy and were candidates for focal resection. All underwent magnetic resonance imaging and scalp video electroencephalograph monitoring, and two had magnetoencephalography, electrocorticography and/or intracranial video electroencephalograph monitoring. The children were 8 and 9 years old, and seizure onset varied from early infancy to early childhood. One child had a history of head trauma preceding seizure onset, one had a large intracerebral infarct and dysplastic cortex in the contralateral frontal lobe, and the other had an anterior temporal lobe resection without improvement in seizure frequency. After medical management failed, callosotomy was performed with the expectation of decreasing the seizure types affecting both hemispheres. Following transection of the callosal fibers, a single focus was recognized and resected, with resultant dramatic improvement in seizure control. In medically refractory epilepsy, where rapid secondary bisynchrony is suspected but the electroencephalograph is non-localizing, callosotomy should be considered as a means of treating generalized seizure types, but may also assist in identifying potentially operable seizure foci. Study limitations include its retrospective nature and cohort size. The findings, however, suggest the need for prospective, systematic, well-controlled studies of the use of corpus callostomy in this intractable patient population.

Research paper thumbnail of Minimizing pre- and post-defibrillation pauses increases the likelihood of return of spontaneous circulation (ROSC)

Resuscitation, 2010

Background: The three-phase model of ventricular fibrillation (VF) arrest suggests a period of co... more Background: The three-phase model of ventricular fibrillation (VF) arrest suggests a period of compressions to "prime" the heart prior to defibrillation attempts. In addition, post-shock compressions may increase the likelihood of return of spontaneous circulation (ROSC). The optimal intervals for shock delivery following cessation of compressions (pre-shock interval) and resumption of compressions following a shock (post-shock interval) remain unclear. Objective: To define optimal pre-and post-defibrillation compression pauses for out-of-hospital cardiac arrest (OOHCA). Methods: All patients suffering OOHCA from VF were identified over a 1-month period. Defibrillator data were abstracted and analyzed using the combination of ECG, impedance, and audio recording. Receiver-operator curve (ROC) analysis was used to define the optimal pre-and post-shock compression intervals. Multiple logistic regression analysis was used to quantify the relationship between these intervals and ROSC. Covariates included cumulative number of defibrillation attempts, intubation status, and administration of epinephrine in the immediate pre-shock compression cycle. Cluster adjustment was performed due to the possibility of multiple defibrillation attempts for each patient. Results: A total of 36 patients with 96 defibrillation attempts were included. The ROC analysis identified an optimal pre-shock interval of <3 s and an optimal post-shock interval of <6 s. Increased likelihood of ROSC was observed with a pre-shock interval <3 s (adjusted OR 6.7, 95% CI 2.0-22.3, p = 0.002) and a postshock interval of <6 s (adjusted OR 10.7, 95% CI 2.8-41.4, p = 0.001). Likelihood of ROSC was substantially increased with the optimization of both pre-and post-shock intervals (adjusted OR 13.1, 95% CI 3.4-49.9, p < 0.001). Conclusions: Decreasing pre-and post-shock compression intervals increases the likelihood of ROSC in OOHCA from VF.

Research paper thumbnail of Evaluation of Pediatric Glucose Monitoring and Hypoglycemic Therapy in the Field

Pediatric Emergency Care, 2005

As specific indications for glucose monitoring in pediatric patients are not standardized, we sou... more As specific indications for glucose monitoring in pediatric patients are not standardized, we sought to evaluate our EMS system regarding the use of this test, so that objective data can be used for prehospital provider education. We performed a 5-year electronic search of prehospital records to assess pediatric patients who had glucose monitoring performed, with subgroup analysis on those requiring therapy. We found that 6018 pediatric patients received glucose monitoring with the most common chief complaints for testing including: seizure, &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;other medical,&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; trauma head/neck, and OD/poisoning. Of these, 270 (4.5%) required therapy for hypoglycemia with an additional 100 (1.7%) patients receiving treatment without use of the paramedic&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s monitor. Age breakdowns for therapy were as follows: 0-4 years, 44 (11.9%); 5-9, 36 (9.7%); 10-14, 58 (15.7%); 15-19, 232 (62.7%). In the prehospital setting, the need to treat hypoglycemia in pediatric patients is infrequent. The chief complaints associated with the highest frequencies of hypoglycemia are seizures and altered neurologic status.

Research paper thumbnail of Prevalence of Use of Performance-Enhancing Substances Among United States Adolescents

Pediatric Clinics of North America, 2007

Adolescents may regard the use of performance-enhancing substances as an easy means to gain self-... more Adolescents may regard the use of performance-enhancing substances as an easy means to gain self-esteem through improved body appearance and athletic performance. The use of performance-enhancing substances by adolescents is particularly troubling because safety data are largely lacking. This poses a dilemma for the pediatrician who needs correct information, including the potential efficacy and negative health effects of such substances, to identify the patients in need of counseling and to find the best way to help adolescent patients make informed decisions to promote healthy behaviors. This article is intended to assist pediatricians by providing a summary of the current state of knowledge regarding the prevalence of use of performance-enhancing substances by United States adolescents.

Research paper thumbnail of Identifying Frequent Users of Emergency Department Resources

The Journal of Emergency Medicine, 2014

There is growing focus on frequent users of acute care resources. If these patients can be identi... more There is growing focus on frequent users of acute care resources. If these patients can be identified, interventions can be established to offer more consistent management plans to decrease inappropriate utilization. To compare a hospital-specific approach with a region-wide approach to identify frequent Emergency Department (ED) users. A retrospective multi-center cohort study of hospital ED visits from all 18 nonmilitary, acute care hospitals serving the San Diego region (population 3.2 million) between 2008 and 2010 using data submitted to the California Office of Statewide Health Planning and Development. Frequent users and super users were defined as having 6 to 20 and 21 or more visits, respectively, during any consecutive 12 months in the study period. Comparisons between community-wide and hospital-specific methods were made. There were 925,719 individual patients seen in an ED, resulting in 2,016,537 total visits. There were 28,569 patients identified as frequent users and 1661 identified as super users, using a community-wide approach. Individual hospitals could identify 15.6% to 62.4% of all frequent users, and from 0.3% to 15.2% of all the super users who visited their facility. Overall, the hospital-specific approach identified 20,314 frequent users and 571 super users, failing to identify 28.9% of frequent users and 65.6% of super users visiting San Diego County EDs that would otherwise have been identified using a community-wide approach. A community-wide identification method resulted in greater numbers of individuals being identified as frequent and super ED users than when utilizing individual hospital data.

Research paper thumbnail of Collaborative to Decrease Ambulance Diversion: The California Emergency Department Diversion Project

The Journal of Emergency Medicine, 2011

e Abstract-Background: Ambulance diversion is a national problem that affects more than half of a... more e Abstract-Background: Ambulance diversion is a national problem that affects more than half of all emergency departments (EDs). Although diversion was meant to be used for short periods of time to offer temporary relief to EDs, it has evolved into a normal routine in many communities to manage the growing problem of ED and hospital crowding. Study Objectives: To assess the impact of a collaborative effort to decrease ambulance diversion. Methods: This is a pre/post study investigating ED diversion in four emergency medical services agency regions in California from September 2006 through August 2008. Hospitals developed and implemented a number of best practices revolved around patient flow initiatives, specifically looking to improve input, throughput, and output. Monthly ED diversion data are compared and reported as means and standard deviations (SD). Results: During the study period, there were a total of 31,735 diversion hours in the collaborative regions, with 17,618 during the pre-consortium period and 14,117 in the post-consortium period (19.9% decrease). The monthly average hours of diversion before the consortium was 1468 (SD ‫؍‬ 390.6). This decreased to 1176 (SD ‫؍‬ 605.8) after the initiation of the consortium (difference of 292 h; 95% confidence interval 99 -484; p ‫؍‬ 0.007). There was a decrease in diversion hours for every month-to-month comparison except January and February (increases of 1% and 14.6%, respectively). Conclusion: This study suggests that a decrease in ambulance diversion can be achieved through ongoing collaboration and the implementation of best practices. Continued communication and emphasis on diversion are likely needed to sustain these decreases.

Research paper thumbnail of Assessment of the Addition of Prehospital Continuous Positive Airway Pressure (CPAP) to an Urban Emergency Medical Services (EMS) System in Persons with Severe Respiratory Distress

The Journal of Emergency Medicine, 2013

The use of continuous positive airway pressure (CPAP) assisted ventilation in the emergency depar... more The use of continuous positive airway pressure (CPAP) assisted ventilation in the emergency department(ED) has been well described. The purpose of this study was to measure the efficacy of adding pre-hospital CPAP to an urban emergency medical service (EMS) respiratory distress protocol on persons with respiratory distress. A historical cohort analysis of consecutive patients between 2005 and 2010. Groups were matched for severity of respiratory distress. Physiologic variables were the primary outcome obtained from first responders and upon triage in the ED. Additional outcomes included endotracheal intubation rate, hospital mortality, overall hospital length of stay(LOS), intensive care unit (ICU) admission, and ICU length of stay (ICU LOS). There were 410 consecutive patients with predetermined criteria for severe respiratory distress, 235 historical controls matched with 175 post-implementation patients. Average age was 67 years, 54% being male. There were significant median differences in heart and respiratory rates favoring the historical cohort (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.05). There were no significant differences in intubation rate, overall hospital LOS, ICU admission rate, ICU LOS, and hospital mortality (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt; 0.05).Patients that were continued on noninvasive ventilatory assistance had a significantly improved rate of intubation and ICU LOS (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.05). The addition of CPAP to our pre-hospital respiratory distress protocol did not improve physiologic variables.There were no differences in overall and ICU LOS between groups. Persons with apparent continued ventilatory assistance appeared to have improved rates of intubation and ICU LOS [corrected].

Research paper thumbnail of The Impact of Patient Telephone Call after Discharge on Likelihood to Recommend in an Academic Emergency Department

The Journal of Emergency Medicine, 2014

Research paper thumbnail of Pediatric Poisonings in Children Younger than Five Years Responded to by Paramedics

The Journal of Emergency Medicine, 2011

Background: Treatment of poisonings in children has been well studied, but few data are available... more Background: Treatment of poisonings in children has been well studied, but few data are available on the various causes of the poisoning episodes in the pediatric population. Objectives: To describe the incidence and demographics of accidental poisonings incurred by children < 5 years old in the County of San Diego, California who accessed paramedics through the 9-1-1 system. Methods: Eight years of prehospital records for children < 5 years of age were searched for poisoning cases. Detailed narrative information was abstracted to determine the circumstances surrounding the incident. Results: There were more than 40,000 paramedic transport calls for patients 5 years and younger over the study period; 996 (2.5%) of these calls had the chief complaint of poisoning. Of the calls classified as poisonings, 38% involved a 1-year-old and 35% involved a 2-year-old. Fifty-six percent of these poisonings involved either prescription or over-the-counter medications. An additional 16% were due to household cleaners. Eighty-eight percent of all calls were classified as mild in acuity, with 13% of poisoning calls for children under a year of age classified as moderate or acute; 50% of moderate or acute poisoning calls were to children 2 years of age. July and March were the months with the highest incidence of poisoning calls. The fewest calls were received on Saturdays and Sundays. Conclusions: Children 1 year of age had the highest incidence of unintentional poisonings. Among all age groups, medications were the number one cause of unintentional poisonings. Other unintentional poisonings could be prevented if hazardous materials were out of reach of chil-dren; many of the cases in this study happened in front of the parent with the parent watching. Ó 2011 Elsevier Inc.

Research paper thumbnail of Impact of the San Diego Serial Inebriate Program on Use of Emergency Medical Resources

Annals of Emergency Medicine, 2006

sentences (Ͻ0.001). Treatment acceptance was 20% among those with sentences of 0 to 30 days and r... more sentences (Ͻ0.001). Treatment acceptance was 20% among those with sentences of 0 to 30 days and reached 63% for those with sentences longer than 150 days. Operational costs and alternate care at clinics and nonparticipating hospitals were not analyzed.

Research paper thumbnail of Community trial to decrease ambulance diversion hours: The San Diego county patient destination trial

Annals of Emergency Medicine, 2004

Emergency department (ED) ambulance diversion is a major issue in many communities. When patients... more Emergency department (ED) ambulance diversion is a major issue in many communities. When patients do not reach requested facilities, challenges in care are compounded by lack of available medical records and delays in transferring admitted patients back to the originally requested facility. We seek to evaluate a community intervention to reduce ambulance diversion. This was a community intervention in a county of 2.8 million individuals. Ambulance diversion guidelines were revised for all ambulance agencies and EDs. Participation by EDs was voluntary, and main outcome measures, which included ambulance transports, ambulance diversions, and bypass hours, were compared for the pretrial, trial, and posttrial periods. A total of 235,766 patients were transported to an ED by advanced life support ambulance during the 2-year study period. There was a significant decrease in the number of patients who did not reach the requested facility because of ambulance diversion for the trial period (n=322) and posttrial period (n=449) compared with the pretrial period (n=1,320; -998 diverted patients per month [95% confidence interval (CI) -1,162 to -833 patients] and -871 diverted patients per month [95% CI -963 to -780 patients], respectively). There was also a significant decrease in average monthly hours on diversion for the trial period (n=1,079) and posttrial period (n=1,774) compared with the pretrial period (n=4,007; -2,928 hours on bypass [95% CI -3,936 to -1,919 hours on bypass] and -2,232 hours on bypass [95% CI -3,620 to -2,235 hours on bypass], respectively). A voluntary community-wide approach to reducing hospital ED diversion and getting more ambulance patients to requested facilities was effective.

Research paper thumbnail of Use of a Urine Dipstick and Brief Clinical Questionnaire to Predict an Abnormal Serum Creatinine in the Emergency Department

Academic Emergency Medicine, 2009

Objectives: Prior data demonstrated that a urine dipstick used alone was a sensitive predictor of... more Objectives: Prior data demonstrated that a urine dipstick used alone was a sensitive predictor of abnormal creatinine, but not sufficiently enough to forego screening of serum creatinine prior to administration of contrast for diagnostic studies. The authors hypothesized that a brief historical questionnaire coupled with a urine dipstick would have high sensitivity for renal dysfunction, potentially eliminating the need for a serum creatinine prior to contrast administration.