Faculty Bibliography

BACKGROUND: Given that orbital fractures are found in only one of every eight patients receiving computed tomography for acute orbital trauma, we sought to prospectively identify clinical predictors of orbital fracture that may obviate the need for exposing low-risk patients to ionizing radiation. METHODS: Prospective cohort study conducted from July 2007 through October 2009 at two urban emergency departments. Consecutive patients undergoing computed tomography for acute blunt orbital trauma were evaluated on 15 clinical findings before imaging. The primary outcome of interest was presence of any acute orbital fracture. The secondary outcome was a fracture requiring emergent operative intervention. Multivariable logistic regression analysis with multiple imputation was used to derive a predictive risk score. RESULTS: A total of 2,262 patients with acute orbital trauma were enrolled. Median age was 38 years with male predominance (68.3%). Acute orbital fractures were found in 360 patients (15.9%). The derived risk score included orbital rim tenderness, periorbital emphysema, subconjunctival hemorrhage, pain with extraocular movement, impaired extraocular movement, and epistaxis. Across 10 multiply imputed data sets, a mean of 660 patients (29.2%) lacked all six equally weighted predictors, of which 6.3% (95% confidence interval, 4.3-8.2) experienced an acute orbital fracture and only 0.5% (95% confidence interval, 0.0-1.0) required emergent operative intervention. CONCLUSION: Six clinical predictors identify patients with blunt orbital trauma at increased risk for acute orbital fracture. A risk score of 0 identifies patients at very low risk for emergent operative intervention. Multicenter studies are needed to validate these findings and derive a clinical decision instrument to reduce orbital imaging without compromising patient safety. LEVEL OF EVIDENCE: Diagnostic study, level II.

Background: Having a usual source of primary care is known to improve health. Currently only two-thirds of ED patients have a usual source of care outside the ED, far short of Healthy People 2020's target of 84%. Prior attempts to link ED patients with primary care have had mixed results. Objectives: To determine if an intervention directly linking low-acuity patients with a primary care clinic at the time of an ED visit could lead to future primary care linkage. Methods: DESIGN: Pseudo-randomized controlled trial. SETTING: Urban safety-net hospital. SUBJECTS: Adults presenting to the ED 1/07-1/08 for select problems a layperson would identify as low-acuity. Patients were excluded if they arrived by EMS, had a PCP outside our hospital, were febrile, or the triage nurse felt they needed ED care. Consecutive patients were enrolled weekday business hours when the primary care clinic was open. Patients were assigned to usual care in the ED if a provider was ready to see them before they had completed the baseline study survey. Otherwise they were offered the intervention if a clinic slot was available. INTERVENTION: Patients agreeing to the intervention were escorted to a primary care clinic in the same hospital building. They were assigned a personal physician and given an overview of clinic services. A patient navigator ensured patients received timely same-day care. Intervention group patients could refuse the intervention and instead remain in the ED for care. Both clinic and ED patients were given follow-up clinic appointments, or a phone number to call for one, as per usual provider practice. ANALYSIS: The main outcome measure was primary care linkage, defined as having one or more primary care clinic visits within a year of the index ED visit for patients with no prior PCP. Results: 1,292 patients were potentially eligible and 853 were enrolled (662 intervention and 191 controls). Groups had similar baseline characteristics. Nearly 75% in both groups had no prior PCP. Using an intention to treat analysis, 50.3% of intervention group patients with no prior PCP achieved successful linkage (95%CI 45.7-54.9%) vs. 36.9% of the control group (95%CI 28.9-45.4%). Conclusion: A point-of-care program offering low-acuity ED patients the opportunity to instead be seen at the hospital's primary care clinic resulted in increased future primary care linkage compared to standard ED referral practices

Evidence from Europe suggests establishing out-of-hospital, uncontrolled donation after circulatory determination of death (UDCDD) protocols has potential to substantially increase organ availability. The study objective was to derive an out-of-hospital UDCDD protocol that would be acceptable to New York City (NYC) residents. Participatory action research and the SEED-SCALE process for social change guided protocol development in NYC from July 2007 to September 2010. A coalition of government officials, subject experts and communities necessary to achieve support was formed. Authorized NY State and NYC government officials and their legal representatives collaboratively investigated how the program could be implemented under current law and regulations. Community stakeholders (secular and religious organizations) were engaged in town hall style meetings. Ethnographic data (meeting minutes, field notes, quantitative surveys) were collected and posted in a collaborative internet environment. Data were analyzed using an iterative coding scheme to discern themes, theoretical constructs and a summary narrative to guide protocol development. A clinically appropriate, ethically sound UDCDD protocol for out-of-hospital settings has been derived. This program is likely to be accepted by NYC residents since the protocol was derived through partnership with government officials, subject experts and community participants

ACADEMIC EMERGENCY MEDICINE 2011; 18:313-316 (c) 2011 by the Society for Academic Emergency Medicine ABSTRACT: Objectives: In preparation for development of a clinical decision rule (CDR) to promote more efficient use of computed tomography (CT) for diagnosing orbital fractures, the authors sought to estimate the annual incidence of orbital fractures in emergency departments (EDs) and the usage of CT to make these diagnoses. The authors also sought to evaluate a mandatory electronic data collection instrument (EDCI) administered to providers to facilitate CDR data collection. Methods: National estimates were made by analyzing the 2007 National Hospital Ambulatory Medical Care Survey (NHAMCS) database, while hospital billing system and coding data were used to make local estimates. An EDCI was integrated into the CT ordering system such that providers had to complete the form to perform a CT. Because the EDCI had to be filled out for every CT ordered, data collection efficiency was measured by compliance (counting the number of unrealistic data collection instrument answers) and by timing a convenience sample of providers completing the EDCI. Results: Out of 116.8 million ED visits in the United States in 2007, 4.1 million patients were treated for injuries of the eye and face. Of those, 820,252 patients underwent CT imaging, with 102,999 patients (12.5%) diagnosed with an orbital fracture. In our local hospital system with 122,500 annual ED visits, 752 CTs of orbits were performed, with 172 (23%) orbital fractures. The EDCI compliance rate was 94.9% and took less than 5 minutes to complete. Conclusions: National and local data demonstrate a low yield for CT imaging in identifying orbital fractures. Data collection using a mandatory EDCI linked to computerized provider order entry can provide prospective, consecutive patient data that are needed to develop a CDR for the selective use of CT imaging in orbital trauma. Such a decision rule could increase the efficiency in diagnosing orbital fractures, thereby improving patient care, reducing radiation exposure, and decreasing costs. ACADEMIC EMERGENCY MEDICINE 2011; 18:1-4 (c) 2011 by the Society for Academic Emergency Medicine

Background: Significant variation and inefficiency exist in ordering computed tomography (CT) imaging for detecting orbital fractures in patients presenting with acute orbital trauma. Clinical decision rules (CDRs) can help improve diagnostic accuracy, decrease resource utilization, and limit exposure of radiosensitive organs (such as the globe) to ionizing radiation. Objectives: To derive a CDR that is highly predictive of acute orbital fracture in ED patients presenting with acute orbital trauma. (Figure Presented). Methods: Prospective cohort study conducted from July 2007- October 2009 at two urban hospitals. Consecutive patients with acute orbital trauma undergoing CT were enrolled using a mandatory electronic data collection instrument (EDCI) integrated into the computerized order system. Physicians evaluated patients on 15 clinical findings prior to CT. The main outcome was any acute orbital bone fracture identified in the final CT report. The CDR was derived using multivariate logistic regression with multiple imputation to determine which findings were most predictive for acute orbital fracture. Results: of 3,123 EDCIs completed, 2,549 (81.6%) were for patients suffering traumatic injury. Compliance with the EDCI was high (95.0%) resulting in 2,422 complete forms. For EDCIs with missing data, we used multiple imputation so that all surveys could be used for CDR derivation. Median age was 39 with male predominance (68.8%). CT results were available for all patients, with 408 (16.0%) having acute orbital fractures. Majority of injuries were caused by fist to orbit (36.7%) or fall (32.9%). The CDR with the highest predictive value was selected; cross-validation and regression diagnostics were performed to ensure calibration and confirm model fit. Patients lacking any of the equally-weighted six exam findings (Table 1) had a 6.4% (95% CI 4.7-8.4) prevalence of acute orbital fracture. Patients with four or more exam findings had a fracture prevalence of 44.7% (Figure 1). Conclusion: The CDR derived in this study identifies six exam findings highly predictive for acute orbital fracture; however, with a prevalence of 6.4% in the 0 score group, the CDR is not sufficiently sensitive to rule out'' fracture. Subsequent study using fractures of clinical importance as the outcome may yield a more sensitive CDR. Table 1: Orbital Fracture Risk Score (Table Pesented)

Background: Emergency medical servies (EMS) systems improve outcomes for a subset of patients in need of emergent care. Unfortunately, much of the world's population does not have access to EMS. Unique challenges hinder developing nations' ability to provide this service. In October 2002, the West African nation of Gabon introduced its EMS system in Libreville, yet few access it. Objectives: To identify barriers to EMS access among Libreville residents. Methods: In this qualitative study, we interviewed a convenience sample of patients and family members who presented to the emergency department (ED) at Jeanne Ebori Hospital, a public teaching facility in Libreville, Gabon, in October 2009. Eligible subjects were ill enough to require hospital admission, but arrived by means other than EMS. Subjects were excluded if under 21, unable to speak French, or medically unstable without family present. Questions explored subjects' knowledge of and attitudes toward EMS, including perceptions about access and need. Audio- recorded interviews were conducted in French and transcribed in English by a bilingual team member. Two trained investigators organized the relevant text into themes and theoretical constructs using an iterative coding strategy. Data were collected until achieving theoretical saturation. Results: We achieved theoretical saturation at 27 subjects (22 patients and 5 family members). Two additional subjects were approached, but did not participate in the study; one refused participation, one did not speak French. Subjects recognize EMS may save lives. However, subjects rarely call EMS, because they are unaware of how to access it (e.g., lack the phone number), habitually use other transport modes, and have no means to pay. Subjects are frustrated by difficulty in contacting EMS and prolonged response times. Subjects also indicate that people often have no phone to call EMS and that poor neighborhoods are hard to access due to lack of roads and safety concerns. Conclusion: Barriers to EMS access among Libreville residents have been identified. Future policy may be directed to establish means for payment, station vehicles throughout the city to decrease response times, and improve infrastructure to allow better vehicle access. Public outreach should be considered to improve community awareness of the EMS system. Future work will be undertaken to design and evaluate reform based on these results to improve access to EMS in Libreville