Time-Driven Activity-Based Costing in Emergency Medicine.

Value in emergency medicine is determined by both patient-important outcomes and the costs associated with achieving them. However, measuring true costs is challenging. Without an understanding of costs, emergency department (ED) leaders will be unable to determine which interventions might improve value for their patients.

Incidental findings and recommendations are common on ED CT angiography to evaluate for aortic dissection.

Purpose: The aim of this study was to assess the outcomes, incidental findings, recommendations, and adherence to recommendations on computed tomography angiography (CTA) studies obtained in the emergency department (ED) to evaluate for aortic dissection.

Methods: The institutional database of ED patients was retrospectively reviewed to identify CTA examinations for dissection during 2014. The radiology report and electronic medical records were reviewed to assess outcomes, radiology report incidental findings, and recommendations, as well as adherence to these recommendations.

How do Medical Societies Select Science for Conference Presentation? How Should They?

Introduction: Nothing has been published to describe the practices of medical societies in choosing abstracts for presentations at their annual meetings. We surveyed medical societies to determine their practices, and also present a theoretical analysis of the topic.

Methods: We contacted a convenience sample of large U.

Safety incident reporting in emergency radiology: analysis of 1717 safety incident reports.

The aim of this article is to describe the incidence and types of safety reports logged in the radiology safety incident reporting system in our emergency radiology section over an 8-year period. Electronic incident reporting system of our institute was searched for the variables in emergency radiology. All reports from April 2006 to June 2014 were included and deindentified.

Effects of Performance Feedback Reports on Adherence to Evidence-Based Guidelines in Use of CT for Evaluation of Pulmonary Embolism in the Emergency Department: A Randomized Trial.

Objective: The purpose of this study was to assess whether implementing emergency department (ED) physician performance feedback reports improves adherence to evidence-based guidelines for use of CT for evaluation of pulmonary embolism (PE) beyond that achieved with clinical decision support (CDS) alone.

Subjects And Methods: This prospective randomized controlled trial was conducted from January 1, 2012, to December 31, 2013, at an urban level 1 adult trauma center ED. Attending physicians were stratified into quartiles by use of CT for evaluation of PE in 2012 and were randomized to receive quarterly feedback reporting or not, beginning January 2013.

Prevalence and Clinical Import of Thoracic Injury Identified by Chest Computed Tomography but Not Chest Radiography in Blunt Trauma: Multicenter Prospective Cohort Study.

Study Objective: Chest computed tomography (CT) diagnoses more injuries than chest radiography, so-called occult injuries. Wide availability of chest CT has driven substantial increase in emergency department use, although the incidence and clinical significance of chest CT findings have not been fully described. We determine the frequency, severity, and clinical import of occult injury, as determined by changes in management.

Shared Decision-making in the Emergency Department: Respecting Patient Autonomy When Seconds Count.

Shared decision-making (SDM), a collaborative process in which patients and providers make health care decisions together, taking into account the best scientific evidence available, as well as the patient's values and preferences, is being increasingly advocated as the optimal approach to decision-making for many health care decisions. The rapidly paced and often chaotic environment of the emergency department (ED), however, is a unique clinical setting that offers many practical and contextual challenges. Despite these challenges, in a recent survey emergency physicians reported there to be more than one reasonable management option for over 50% of their patients and that they take an SDM approach in 58% of such patients.

Sternal fracture in the age of pan-scan.

Study Objective: Widespread chest CT use in trauma evaluation may increase the diagnosis of minor sternal fracture (SF), making former teaching about SF obsolete. We sought to determine: (1) the frequency with which SF patients are diagnosed by CXR versus chest CT under current imaging protocols, (2) the frequency of surgical procedures related to SF diagnosis, (3) SF patient mortality and hospital length of stay comparing patients with isolated sternal fracture (ISF) and sternal fracture with other thoracic injury (SFOTI), and (4) the frequency and yield of cardiac contusion (CC) workups in SF patients.

Methods: We analyzed charts and data of all SF patients enrolled from January 2009 to May 2013 in the NEXUS Chest and NEXUS Chest CT studies, two multi-centre observational cohorts of blunt trauma patients who received chest imaging for trauma evaluation.

The role of nontechnical skills in simulated trauma resuscitation.

Objective: Trauma team training provides instruction on crisis management through debriefing and discussion of teamwork and leadership skills during simulated trauma scenarios. The effects of team leader's nontechnical skills (NTSs) on technical performance have not been thoroughly studied. We hypothesized that team's and team leader's NTSs correlate with technical performance of clinical tasks.

Optimizing diagnostic imaging in the emergency department.

While emergency diagnostic imaging use has increased significantly, there is a lack of evidence for corresponding improvements in patient outcomes. Optimizing emergency department (ED) diagnostic imaging has the potential to improve the quality, safety, and outcomes of ED patients, but to date, there have not been any coordinated efforts to further our evidence-based knowledge in this area. The objective of this article is to discuss six aspects of diagnostic imaging to provide background information on the underlying framework for the 2015 Academic Emergency Medicine consensus conference, "Diagnostic Imaging in the Emergency Department: A Research Agenda to Optimize Utilization.

Effect of Evidence-based Clinical Decision Support on the Use and Yield of CT Pulmonary Angiographic Imaging in Hospitalized Patients.

Purpose: To determine the effect of clinical decision support (CDS) on the use and yield of inpatient computed tomographic (CT) pulmonary angiography for acute pulmonary embolism (PE).

Materials And Methods: This HIPAA-compliant, institutional review board-approved study with waiver of informed consent included all adults admitted to a 793-bed teaching hospital from April 1, 2007, to June 30, 2012. The CDS intervention, implemented after a baseline observation period, informed providers who placed an order for CT pulmonary angiographic imaging about the pretest probability of the study based on a validated decision rule.

Use of Public Data to Target Variation in Providers' Use of CT and MR Imaging among Medicare Beneficiaries.

Purpose: To examine geographic variation in providers' use of diagnostic imaging to identify potential targets for quality improvement initiatives after adjusting for imaging referral across hospital referral regions (HRRs).

Materials And Methods: Using two Centers for Medicare and Medicaid Services datasets, the authors included all claims for beneficiaries enrolled in the Medicare fee-for-service program. Diagnostic imaging procedures were selected on the basis of common procedure coding system codes, excluding interventional procedures.

Advanced imaging use in intensive care units has decreased, resulting in lower charges without negative effects on patient outcomes.

Purpose: There has been both greater recognition and scrutiny of the increased use of advanced imaging. Our aim was to determine whether there has been a change over time in the use of computed tomography (CT), magnetic resonance imaging (MRI), ultrasound (US) modalities in the intensive care units (ICUs).

Materials And Methods: A retrospective review of 75657 admissions to 20 ICUs was conducted.

Impact of clinical decision support on head computed tomography use in patients with mild traumatic brain injury in the ED.

Background: Reduction of unnecessary head computed tomographies (CTs) in patients with mild traumatic brain injury (MTBI) was recently endorsed by American College of Emergency Physicians (ACEP) in the "Choosing Wisely" campaign. We examined the impact of computerized clinical decision support (CDS) on head CT utilization in MTBI emergency department (ED) visits.

Methods: We conducted a 2-year cohort study at a level 1 trauma center and compared our results with the National Hospital Ambulatory Medical Care Survey from 2009 to 2010.

Structured physician order entry for trauma CT: value in improving clinical information transfer and billing efficiency.

Objective: The purpose of this study was to measure the effects of use of a structured physician order entry system for trauma CT on the communication of clinical information and on coding practices and reimbursement efficiency.

Materials And Methods: This study was conducted between April 1, 2011, and January 14, 2013, at a level I trauma center with 59,000 annual emergency department visits. On March 29, 2012, a structured order entry system was implemented for head through pelvis trauma CT, so-called pan-scan CT.

Journal club: Requiring clinical justification to override repeat imaging decision support: impact on CT use.

Objective: The purpose of this study was to determine the impact of requiring clinical justification to override decision support alerts on repeat use of CT.

Subjects And Methods: This before and after intervention study was conducted at a 793-bed tertiary hospital with computerized physician order entry and clinical decision support systems. When a CT order is placed, decision support alerts the orderer if the patient's same body part has undergone CT within the past 90 days.

Assessing 2 D-dimer age-adjustment strategies to optimize computed tomographic use in ED evaluation of pulmonary embolism.

Study Objective: Validate the sensitivity and specificity of 2 age adjustment strategies for d-dimer values in identifying patients at risk for pulmonary embolism (PE) compared with traditional D-dimer cutoff value (500 ng/mL) to decrease inappropriate computed tomography pulmonary angiography (CTPA) use.

Methods: This institutional review board-approved, Health Insurance Portability and Accountability Act-compliant retrospective study included all adult emergency department patients evaluated for PE over a 32-month period (1/1/11-8/30/13). Only patients undergoing CTPA and D-dimer testing were included.

Tracing the evolution of FERM domain of Kindlins.

Kindlin proteins represent a novel family of evolutionarily conserved FERM domain containing proteins (FDCPs) and are members of B4.1 superfamily. Kindlins consist of three conserved protein homologs in vertebrates: Kindlin-1, Kindlin-2 and Kindlin-3.

In silico analysis of missense mutations in LPAR6 reveals abnormal phospholipid signaling pathway leading to hypotrichosis.

Autosomal recessive hypotrichosis is a rare genetic irreversible hair loss disorder characterized by sparse scalp hair, sparse to absent eyebrows and eyelashes, and sparse axillary and body hair. The study, presented here, established genetic linkage in four families showing similar phenotypes to lysophosphatidic acid receptor 6 (LPAR6) gene on chromosome 13q14.11-q21.

Use of CT and MRI in emergency department patients with acute pancreatitis.

Purpose: Assess the utility of CT and MRI in patients with acute pancreatitis (AP) presenting to emergency department (ED).

Materials And Methods: In this Institutional Review Board-approved retrospective study, we identified all patients with AP from March 2012 through February 2013 in ED of a teaching hospital with approximately 60,000 annual visits. Patients were initially identified via ICD-9 code for AP (577.

Mandatory health care insurance is associated with shorter hospital length of stay among critically injured trauma patients.

Background: The implementation of the Affordable Care Act stimulated interest in outcomes of patients in Massachusetts, a state mandating health insurance as of 2006. We sought to determine the impact of an insurance mandate on hospital use and outcomes among trauma intensive care unit (ICU) patients.

Methods: This is a retrospective cohort study of trauma patients admitted to the ICU conducted at an academic, trauma center.

Radiology utilization in the emergency department: trends of the past 2 decades.

Objective: The objective of our study was to assess radiology utilization trends for emergency department (ED) patients from 1993 through 2012.

Materials And Methods: For this retrospective study, we reviewed radiology utilization at a 793-bed quaternary care academic medical center from January 1, 1993, through December 31, 2012, during which time the number of ED patient visits increased from approximately 48,000 to 61,000, and determined the number of imaging studies by modality (radiography, sonography, CT, MRI, other) and associated relative value units (RVUs). We used linear regression to assess for trends in the number of imaging RVUs and imaging accession numbers, our primary and secondary outcomes, respectively.