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Eating disorders are one of the “great masqueraders” of the twenty-first century. Seemingly healthy young men and women with underlying eating disorders present to emergency departments with a myriad of complaints that are not unique to patients with eating disorders. The challenge for the Emergency Medicine physician is in recognizing that these complaints result from an eating disorder and then understanding the unique pathophysiologic changes inherent to these disorders that should shape management in the emergency department. In this article, we will review, from the perspective of the Emergency Medicine physician, how to recognize patients with anorexia and bulimia nervosa, the medical complications and psychiatric comorbidities, and their appropriate management. Anorexia and bulimia nervosa are complex psychiatric disorders with significant medical complications. Recognizing patients with eating disorders in the ED is difficult, but failure to recognize these disorders, or failure to manage their symptoms with an understanding of their unique underlying pathophysiology and psychopathology, can be detrimental to the patient. Screening tools, such as the SCOFF questionnaire, are available for use by the EM physician. Once identified, the medical complications described in this article can help the EM physician tailor management of the patient to their underlying pathophysiology and effectuate a successful therapeutic intervention.

Early identification of trauma patients at risk for inhospital mortality may facilitate goal-directed resuscitation and secondary triage to improve outcomes. The objective of this study was to compare prognostic accuracies of the Denver Emergency Department (ED) Trauma Organ Failure (TOF) Score, ED Sequential Organ Failure Assessment (SOFA) score, and ED base deficit and ED lactate for inhospital mortality in adult trauma patients. Consecutive adult trauma patients from 2005 to 2008 from the Denver Health Trauma Registry were included. Prognostic accuracies of the Denver ED TOF Score, ED SOFA score, ED base deficit, and ED lactate for inhospital mortality were evaluated with receiver operating characteristic curves. Of the 4355 patients, the median age was 37 years (interquartile range [IQR], 26-51 years), median Injury Severity Score was 9 (IQR, 4-16), and 81% had blunt mechanisms. In addition, 38% (1670 patients) were admitted to the intensive care unit with a median intensive care unit length of stay of 2.5 days (IQR, 1-8 days), and 3% (138 patients) died. The areas under the receiver operating characteristic curves for the Denver ED TOF, ED lactate, ED base deficit, and ED SOFA were 0.94 (95% confidence interval [CI], 0.94-0.96), 0.88 (95% CI, 0.85-0.91), 0.82 (95% CI, 0.78-0.86), and 0.78 (95% CI, 0.73-0.82), respectively. The Denver ED TOF Score more accurately predicts inhospital mortality in adult trauma patients compared to the ED SOFA score, ED base deficit, or ED lactate. The Denver ED TOF Score may help identify patients early who are at risk for mortality, allowing for targeted resuscitation and secondary triage to improve outcomes

There is a need for emergency planners to accurately plan for and accommodate a potentially significant increase in patient volume in response to a disaster. In addition, an equally large political demand exists for leaders in government and the healthcare sector to develop these capabilities in a financially feasible and evidence-based manner. However, it is important to begin with a clear understanding of this concept on a theoretical level to create this capacity. Intuitively, it is easy to understand that surge capacity describes the ability of a healthcare facility or system to expand beyond its regular operations and accommodate a greater number of patients in response to a multiple casualty-producing event. The way a response to this need is implemented will, of course, vary dramatically depending on numerous issues, including the type of event that has transpired, the planning that has occurred before its occurrence, and the resources that are available. Much has been written on strategies for developing and implementing surge capacity. However, despite the frequency with which the term is used in the medical literature and by the lay press, a clear description of surge capacity as a concept is lacking. The following article will provide this foundation. A conceptual framework of surge capacity will be described, and some new nomenclature will be proposed. This is done to provide the reader with a comprehensive yet simplified view of the various elements that make up the concept of surge capacity. This framework will cover the types of events that can cause a surge of patients, the general ways in which healthcare facilities respond to these events, and the categories of people who would make up the population of affected victims.

Denver Health is a public, academic health system, a model integrated system of care, and Colorado's principal safety-net institution. It serves a third of Denver's citizens including the most vulnerable, with 75% of its patients having incomes below 185 percent of the federal poverty level, two-thirds being ethnic minorities and almost one-half are uninsured. These patient characteristics embody health care disparities which typically impede the intended outcomes of a system's quality and safety interventions [1]. In reality, however, it was precisely these challenges which inspired Denver Health's leadership to embark upon a relentless journey towards quality improvement seven years ago [2]. Specifically, in consideration of a safety-nets limited resources in the setting of a population of socially disadvantaged and clinically complex patients, Denver Health's quality program was impelled to focus on creating programs to manage high-risk and high-opportunity clinical situations. Although Denver Health's renewed structured approach to quality and safety began seven years ago, a number of foundational elements were already in place including most importantly an integrated health care system which provides seamless continuity of care in the setting of a system of care which is staffed by an employed physician medical staff. This employed-physician model promotes alignment of goals across the enterprise and helps implement new quality and safety interventions [2]. Quality and safety interventions Some of Denver Health's recent programs to manage high-risk/high-opportunity areas include our unique rapid response system to prevent \"failure to rescue\" [3, 4]. Indeed, a recent study of postoperative mortality stressed \"failure to rescue,\" rather than the number of complications, as the key variable in explaining differences in mortality rates cross hospitals [5]. Using our \"clinical triggers\" to identify clinical deterioration, we were able to reduce our cardiopulmonary arrest rate and the number of patients requiring transfer back to an intensive care unit within 48 hours after having been previously transferred to a hospital ward [3]. In addition, we instituted hospitalist co-management for all patients on the orthopedic service, patients on low-volume inpatient surgical subspecialty services and patients on the psychiatry service with significant medical comorbidities. Moreover, a formal and robust antibiotic stewardship program was established. This approach spawned new programs including mandatory infectious disease consultation for certain serious infections, concurrent feedback to a prescribing team when multiple antibiotics were used for the same patient and formal infectious disease consultant rounds with intensive care unit teams. As a result Denver Health's antibacterial drug use was the lowest of thirty-five U.S. academic health centers reporting through the University Health System Consortium (UHC) [6]. Moreover, proper treatment of infections has increased - and adverse consequences from illness have decreased - for the highly virulent and prevalent staphylococcus aureus bacteremia [7]. Another high-risk condition in hospitalized patients, and the leading cause of potentially preventable death, is represented by venous thromboembolism (VTE). By designing and implementing an evidence-based risk-assessment tool and clinical practice guideline, embedded into admission order sets in the computerized physician order system (CPOE), the compliance with the VTE prophylaxis guideline was drastically increased [8]. Denver Health's performance in preventing venous thromboembolism climbed to the top 10 percent nationwide [8]. Quality Assurance (QA) process in Orthopaedics Surgical patients remain highly susceptible to preventable perioperative complications, despite the nationwide implementation of standardized patient safety protocols in recent years. Preventable adverse occurrences include so-called \"never events\", such as wrong-patient and wrong-site surgery [9, 10]. Recent publications emphasize the fact that our current patient safety protocols are indeed not safe in protecting our patients from suffering unintended and preventable harm [11-13]. New strategies to improve patient safety in surgery include the implementation of defined surgical safety checklists, standardized \"readbacks\" to improve communication in perioperative services, and medical team training programs [14-18]. Disclosing and reporting of medical errors is compelling beyond a doubt from a moral, ethical, and scientific perspective, and therefore represents a basic tenet for improving patient safety. Underreporting of surgical complications creates a gap of information which may otherwise help prevent the recurrence of a similar adverse event. The Department of Orthopaedics at Denver Health implemented a new Quality Assurance (QA) process in 2007 [19]. This new QA protocol was designed to lower the threshold of reporting all perceived complications, \"near-misses\", and \"no-harm events\", mandating a standardized peer-review of all reported occurrences in a \"real-time\" fashion, and relies on the following three cornerstones: 1. 1. Anonymous \"real-time\" reporting of any suspected adverse occurrence, including \"near miss\" and \"no harm\" events, by any member of the surgical team. Occurrences are reported to an independent nurse provider in charge of managing the adverse event database. A \"no fault\" policy for reporting occurrences is encouraged with strong support from the department leadership. 2. 2. Peer-review of each reported event at a weekly QA conference, using a standardized case review form, in the presence of the responsible attending surgeon and at least two additional faculty staff members who were not involved in the occurrence. 3. 3. Corrective action is defined for each reviewed case, if deemed necessary during the peer-review process. Each closed case is prospectively entered into a departmental QA database. All team members involved in the adverse occurrence are notified about the final assessment of the peer-review process. Within two years of implementation of this new QA process, the median rate of reported occurrences increased more than 6-fold from 1.7 to 11.1 per 100 surgical procedures [19]. Similarly, the overall complication rate for the entire Department of Orthopaedics at Denver Health increased almost 5-fold, from 1.4% to 6.7%. These data emphasize the \"double-edged sword\" aspect of reporting adverse events: The reported 5-fold increase in complications within the department likely reflects the improved open and more honest reporting format and critical peer-review of each reported occurrence, rather than a decreased quality of care. And herein lies the paradox: If the parameters of \"reported adverse events\" and \"incidence of complications\" were used as a measure of institutional quality, the facility would be penalized for its improved surveillance and educational process. The thorough reporting and peer-review of surgical errors creates a new dilemma for the practicing surgeon: an increased quality of reporting leads to an increased complication rate, thus affecting the individual surgeon's professional track record and the respective institution's ranking among peers. Until legislation provides legal protection for medical error disclosure and analysis, we continue to rely on the limited and anecdotal reporting of medical errors and surgical complications in the peer-reviewed biomedical literature [20, 21]. Coordinated management of high risk patients As a part of Denver Health's integrated system, the Emergency Department (ED) has identified a number of areas where coordination of care may benefit quality of care and outcomes measures. There was recognition that variance in approaches to care for several common diagnoses may adversely impact quality in terms of percentage of Intensive Care Unit (ICU) admissions, length of stays, and outcomes. In particular, acute alcohol withdrawal, sepsis, and diabetic ketoacidosis were identified as having variable ICU admission rates as well as a high rate of change in management after the patient had transitioned from the Emergency Department to the ICU. In particular, management was changed after transition to the ICU in more than 33% of patients with these admitting diagnoses. In response, a group consisting of emergency physicians, intensive care specialists, infectious disease specialist, and endocrinologists convened to create guidelines for the management of these specific entities to ensure a coordinated and standardized approach across the institution for the initial management of these patients. Outcomes measures will include ICU admission rates, intubation rates, length of stay in the ICU and hospital, as well as return visits to the Emergency Department for all three identified entities to determine the true impact of this coordination. The goal will be to improve institutional consistency in the management of disease processes in order to reduce waste and redundancy. Moving forward, the identification of evidenced based quality measures that reach across specialties and encouraging a multispecialty approach to the management of these entities from the initial point of care should enhance quality as well as the patient experience. The evaluation of ED quality of care has been hampered by the absence of consensus on appropriate measures [22]. Some investigators have used a Modified-Delphi process to identify specific condition-outcome pairs linking quality of care to specific outcomes [23]. They identified asthma, pneumonia, acute myocardial infarction, deep vein thrombosis/pulmonary embolism, chest pain, minor head trauma, and ankle/foot trauma as clinical conditions for which indicators could be identified and measured to assess quality of care within the ED. Another group looking specifically at pediatric emergency care found 405 performance measures that could po

During a Medline search from 1999 to April 2003, using the strategy \"abdominal pain\" in the MESH Major Topic field and subsequent reference review of retrieved articles, we found 4 prospective trials [4-7] and 2 reviews [8,9] that investigated the use of analgesia for acute abdominal pain. The consensus of these prospective studies and review articles is best summarized by Thomas and Silen [8], who state that, \"pending further research, which should address some of the shortcomings of extant studies, (many of which are very well documented by Nissman et al) judicious provision of analgesia appears safe, reasonable, and in the best interests of patients in pain.\"

Background. Aspirin (ASA) has unquestioned benefit to patients with cardiac ischemia. Previous studies indicate health care providers may not adequately treat patients experiencing cardiac ischemia with ASA. Objective. To determine the rate of ASA use for patients being treated for chest pain suggestive of cardiac ischemia in the prehospital setting. Methods. This was a retrospective study of paramedic encounters identified through billing records for all patients receiving the combination of an intravenous catheter, supplemental oxygen, andcardiac monitoring from November 2001 to January 2002. Prehospital medical records were reviewed in order to determine the proportion of patients with suspected cardiac ischemia who received ASA. The setting was a single prehospital emergency medical services system serving an urban population. Results. A total of 2,457 paramedic encounters were reviewed over a three-month period. Two hundred thirty-two patients were assessed as having cardiac ischemia, of whom 169 (73%) had no absolute or relative contraindication to ASA. Of the 169 patients, only 92 (54%) received ASA. Of the 99 patients, who received nitroglycerin for presumed cardiac ischemia andhad no contraindication to receiving ASA, only 78 (79%) received ASA. Of the 453 patients complaining of nontraumatic chest pain andwithout a contraindication, 157 (35%) received ASA. Conclusions. Paramedics do not use ASA optimally andmay choose therapies with less proven benefit.

Abstrast Objectives. To determine 1) the success rate of prehospital endotracheal intubation; 2) the unrecognized tube malposition rate; and 3) predictors of tube malposition upon arrival to the emergency department (ED) in the setting of a large metropolitan area that includes 18 hospitals and 34 transporting emergency medical services (EMS) agencies. Methods. Prospective data were collected on patients for whom prehospital intubation was attempted between September 1, 2004, and January 31, 2005. Endotracheal tube (ETT) position upon arrival to the ED was verified by emergency medicine attending physicians. Missing cases were identified by matching prospective data with lists of attempted intubations submitted by EMS agencies, and data were obtained for these cases by retrospective chart review. Successful intubation was defined as an \"endotracheal tube balloon below the cords\" on arrival to the ED. Patients were the unit of analysis; proportions with 95% confidence intervals were calculated. Results. Nine hundred twenty-six patients had an attempted intubation. Methods of airway management were determined for 97.5% (825/846) of those transported to a hospital and 33.8% (27/80) of those who died in the field. For transported patients, 74.8% were successfully intubated, 20% had a failed intubation, 5.2% had a malpositioned tube on arrival to the ED, and 0.6% had another method of airway management used. Malpositioned tubes were significantly more common in pediatric patients (13.0%, compared with 4.0% for nonpediatric patients). Conclusions. Overall intubation success was low, and consistent with previously published series. The frequency of malpositioned ETT was unacceptably high, and also consistent with prior studies. Our data support the need for ongoing monitoring of EMS providers' practices of endotracheal intubation.

[...]the study findings exceeded expectations. [...]the lone exception, a chronically-unresponsive, 64-year-old (with in-dwelling tracheostomy and new-onset sepsis) did not re-seize until after hospital arrival. [...]convulsions were consistently controlled during the entire prehospital phase of care for 100% of on-protocol adults (n=57), but also, among the eight \"off-protocol\" adult cases (100% rapid, sustained termination) including one adult experiencing recurrent seizures about 1.5 hours before EMS arrival. [...]ketamine provided a consistent multi-faceted protective effect for EMS, both physically and physiologically.

* Agitation seen in the emergency department has many causes. * The first step in assessing an agitated patient is to initiate measures to prevent physical harm to the staff and patient. * The next step is to verbally engage the patient and establish a collaborative relationship, if possible. * Early assessment of vital signs and point-of-care glucose is important. * Physical restraints may be necessary, but they should be applied thoughtfully in escalating fashion as needed, and according to hospital protocol. * Continuous monitoring of respiration is required when pharmacological sedation is used. * Evaluate the decision-making capacity of agitated patients prior to disposition.