Objectives Blood culture contamination is a common problem in the emergency department (ED) that leads to unnecessary patient morbidity and health care costs. The study objective was to develop and evaluate the effectiveness of a quality improvement (QI) intervention for reducing blood culture contamination in an ED. Methods The authors developed a QI intervention to reduce blood culture contamination in the ED and then evaluated its effectiveness in a prospective interrupted times series study. The QI intervention involved changing the technique of blood culture specimen collection from the traditional clean procedure, to a new sterile procedure, with standardized use of sterile gloves and a new materials kit containing a 2% chlorhexidine skin antisepsis device, a sterile fenestrated drape, a sterile needle, and a procedural checklist. The intervention was implemented in a university-affiliated ED and its effect on blood culture contamination evaluated by comparing the biweekly percentages of blood cultures contaminated during a 48-week baseline period (clean technique), and 48-week intervention period (sterile technique), using segmented regression analysis with adjustment for secular trends and first-order autocorrelation. The goal was to achieve and maintain a contamination rate below 3%. Results During the baseline period, 321 out of 7,389 (4.3%) cultures were contaminated, compared to 111 of 6,590 (1.7%) during the intervention period (p < 0.001). In the segmented regression model, the intervention was associated with an immediate 2.9% (95% CI = 2.2% to 3.2%) absolute reduction in contamination. The contamination rate was maintained below 3% during each biweekly interval throughout the intervention period. Conclusions A QI assessment of ED blood culture contamination led to development of a targeted intervention to convert the process of blood culture collection from a clean to a fully sterile procedure. Implementation of this intervention led to an immediate and sustained reduction of contamination in an ED with a high baseline contamination rate.

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Study objective Induction doses of etomidate during rapid sequence intubation (RSI) cause transient adrenal dysfunction, but its clinical significance on trauma patients is uncertain. Ketamine has emerged as an alternative for RSI induction. Among adult trauma patients emergently intubated, we compared clinical outcomes among those induced with etomidate and ketamine. Methods The study entailed a retrospective evaluation of a four-year (January 2011–December 2014) period spanning an institutional protocol switch from etomidate to ketamine as the standard induction agent for adult trauma patients undergoing RSI in the ED of an academic Level I trauma center. The primary outcome was hospital mortality evaluated with multivariable logistic regression adjusted for age, vital signs, and injury severity and mechanism. Secondary outcomes included intensive care unit (ICU)-free days and ventilator-free days (VFD) evaluated with multivariable ordered logistic regression using the same covariates. Results The analysis included 968 patients, including 526 with etomidate and 442 with ketamine. Hospital mortality was 20.4% among patients induced with ketamine compared to 17.3% among those induced with etomidate (aOR: 1.41; 95% CI: 0.92, 2.16). Patients induced with ketamine had similar ICU-free-days (aOR: 0.80; 95% CI: 0.63, 1.00) and VFDs (aOR: 0.96; 95% CI: 0.76, 1.20) as compared to patients induced with etomidate. Conclusion In this analysis spanning an institutional protocol switch from etomidate to ketamine as the standard RSI induction agent for adult trauma patients, patient-centered outcomes were similar for patients who received etomidate and ketamine.

Study Objective-Atrial fibrillation (AF) affects over 2 million people in the United States and accounts for nearly 1% of emergency department (ED) visits. Physicians have little information to guide risk stratification of patients with symptomatic AF and admit more than 65%. Our aim was to assess whether data available in the ED management of symptomatic AF can estimate a patient's risk of experiencing a 30-day adverse event.Methods-We systematically reviewed the electronic medical records of all ED patients presenting with symptomatic AF between August 2005 and July 2008. Predefined adverse outcomes included 30-day ED return visit, unscheduled hospitalization, cardiovascular complication or death. We performed multivariable logistic regression to identify predictors of 30-day adverse events. The model was validated using 300 bootstrap replications.Results-During the 3-year study period, 914 patients accounted for 1228 ED visits. Eighty patients were excluded for non-AF related complaints and 2 patients had no follow-up recorded. Of 832 eligible patients, 216 (25.9%) experienced at least one of the 30-day adverse events. Increasing age (odds ratio [OR] Conclusion-In ED patients with symptomatic AF, increased age, inadequate ED ventricular rate control, dyspnea, smoking, and beta-blocker treatment were associated with an increased risk of a 30-day adverse event.

Introduction: Recent position statements from health care organizations have placed a strong emphasis on continuous quality improvement (CQI). CQI finds many of its roots in kaizen, which emphasizes small, low-cost, low-risk improvements. Based on the successful Kaizen Programs at organizations such as Toyota, the authors thought the emergency department (ED) would be an ideal environment to benefit from such a program.