Academic emergency medicine : official journal of the Society for Academic Emergency Medicine
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Clinical decision rules have been validated for estimation of pretest probability in patients with suspected pulmonary embolism (PE). However, many clinicians prefer to use clinical gestalt for this purpose. The authors compared the unstructured clinical estimate of pretest probability for PE with two clinical decision rules. ⋯ The unstructured clinical estimate of low pretest probability for PE compares favorably with the Canadian score and the Charlotte rule. Interobserver agreement for the unstructured estimate is moderate.
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Although rare, HIV transmission is one of the most feared consequences of sexual assault. While availability of medications to prevent HIV transmission (HIV nonoccupational postexposure prophylaxis [HIV nPEP]) is increasing, little is known about emergency department (ED) prescribing practices and patient adherence to treatment recommendations. ⋯ HIV nPEP was offered to less than half of sexual assault patients, and few completed treatment. Further studies are needed to evaluate and improve appropriateness of HIV nPEP administration and follow-up.
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This article uses a case report and discussion to demonstrate the concept of active and latent failures, and the "systems approach" to the reduction of adverse events in medicine. The case involves an inadvertently misplaced and retained guidewire during femoral vein catheterization using the Seldinger technique, and the subsequent failure to identify the guidewire in the chest despite several chest radiographs and a computed tomography (CT) scan read by radiologists, emergency physicians, and intensivists. This event reveals active failures in the performance of the Seldinger technique, latent failures in the design of the catheter kit, and problems with the current system of interpretation of radiographs. The authors conclude that the design of the catheter kit and the Seldinger technique should be critically examined from a human factors standpoint and that radiographic interpretation is still heavily subject to human error.
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Multicenter Study Clinical Trial
Refining Emergency Severity Index triage criteria.
The Emergency Severity Index (ESI) version 3 is a five-level triage acuity scale with demonstrated reliability and validity. Patients are rated from ESI level 1 (highest acuity) to ESI level 5 (lowest acuity). Clinical experience has demonstrated two levels of ESI level 2 patients: those who require immediate intervention and those who are stable to wait for at least ten minutes. Studies have found that few patients are rated ESI level 1, and it has been suggested that revisions to the ESI might result in appropriate reclassification of some sickest level 2 patients as level 1. The purpose of this study was to identify level 2 patients who might be reclassified as level 1 patients. ⋯ Specific clinical findings at triage for a subset of ESI level 2 patients were associated with immediate delivery of lifesaving interventions. Revisions to the ESI level 1 criteria may be beneficial.