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To explore current practices and decision making regarding antimicrobial prescribing among emergency department (ED) clinical providers.
We conducted a survey of ED providers recruited from 8 sites in 3 cities. Using purposeful sampling, we then recruited 21 providers for in-depth interviews. Additionally, we observed 10 patient-provider interactions at one of the ED sites. SAS 9.3 was used for descriptive and predictive statistics. Interviews were audio recorded, transcribed, and analyzed using a thematic, constructivist approach with consensus coding using NVivo 10.0. Field and interview notes collected during the observational study were aligned with themes identified through individual interviews.
Of 150 survey respondents, 76% agreed or strongly agreed that antibiotics are overused in the ED, while half believed they personally did not overprescribe. Eighty-nine percent used a smartphone or tablet in the ED for antibiotic prescribing decisions. Several significant differences were found between attending and resident physicians. Interview analysis identified 42 codes aggregated into the following themes: (1) resource and environmental factors that affect care; (2) access to and quality of care received outside of the ED consult; (3) patient-provider relationships; (4) clinical inertia; and (5) local knowledge generation. The observational study revealed limited patient understanding of antibiotic use. Providers relied heavily upon diagnostics and provided limited education to patients. Most patients denied a priori expectations of being prescribed antibiotics.
Patient, provider, and healthcare system factors should be considered when designing interventions to improve antimicrobial stewardship in the ED setting.
Infect Control Hosp Epidemiol 2014;35(9):1114-1125
Sukhjit S. Takhar, Assistant Clinical Professor of Emergency Medicine, Faculty Division of Infectious Diseases, University of California, San Francisco, UCSF Fresno Medical Education Program, Fresno, CA,
Gregory J. Moran, Professor of Medicine, David Geffen School of Medicine at UCLA, Department of Emergency Medicine and Division of Infectious Diseases, Olive View–UCLA Medical Center, Los Angeles, CA
Animal and human bites are a common problem in the United States, and approximately half of all Americans will be bitten by an animal or another human during their lifetime. Caring for patients with animal or human bites focuses on treating the acute traumatic injuries and preventing the potential infectious complications.
Dog bites account for 80–90% of all bites seen in emergency departments. Accurate statistics on dog bite injuries are difficult to obtain because the majority of victims do not seek medical attention. Dog bites account for 0.3–1.1% of all emergency visits. A Centers for Disease Control and Prevention (CDC) analysis of the National Electronic Injury Surveillance System (NEISS) estimates that in 2001 there were 368,245 people who were treated in U.S. emergency departments for dog-bite related injuries – a rate of 129.3 per 100,000. Of the victims, 42% were younger than 14 years, with the highest injury rate seen in boys between the ages of 5 and 9 years. There are approximately 20 deaths each year in the United States as a result of dog attacks.
Dog bites occur more often during the summer, on weekends, and in the afternoon. Most dog bites are committed by younger dogs and larger breeds such as Rottweilers, pit bulls, Huskies, and German shepherds. The victim often knows the animal and the majority of attacks are provoked.
To describe the outcomes of electroencephalography requested by general adult psychiatry over a 12-month period.
187 electroencephalograms (EEGs) were performed. In 71%, the request was to look for evidence of epilepsy. In 22%, it was to determine whether there was organic brain dysfunction. In only one patient was unequivocal evidence of an epileptic focus found. A further 11 patients demonstrated a liability to epilepsy. In none of the 33 patients where aggression was mentioned on the request form were any diagnostic features found.
The yield of EEG in psychiatry is low. To diagnose epilepsy, clinicians should continue to rely on the clinical history of attacks and not the EEG. The presence of aggression is rarely associated with meaningful EEG changes.
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