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Benjamin C Sun

Publications and source records attributed to Benjamin C Sun.

12 recordsLinked to original sources
PubMed2007

Evaluation of a modified prediction instrument to identify significant pediatric intracranial injury after blunt head trauma.

STUDY OBJECTIVE: We evaluate the effect of a modification of the University of California-Davis Pediatric Head Injury Rule on the ability of the decision instrument for pediatric head injury to predict clinically important intracranial injury in an external cohort. METHODS: We analyzed data prospectively recorded in 1,666 pediatric patients enrolled in the derivation set of the National Emergency X-Radiography Utilization Study II (NEXUS II). Treating physicians at 21 emergency departments recorded the presence or absence of clinical predictors on all patients who received a head computed tomography (CT) scan after experiencing blunt head trauma. Predictors included 3 exact elements of the University of California-Davis Rule (abnormal mental status, signs of skull fracture, and scalp hematoma in children < or = 2 years of age), some with different wording, and 2 modified elements with new definitions (the presence of high-risk vomiting or severe headache, rather than any vomiting or headache). RESULTS: A significant intracranial injury was identified by CT in 138 (8.3%) patients. Sensitivity of the modified instrument to detect significant intracranial injury was 90.4% (95% confidence interval [CI] 85.4% to 95.4%); 13 children with such an injury were misclassified as low risk. Specificity of the modified instrument was 42.7% (95% CI 40.1% to 45.3%). CONCLUSION: In the NEXUS II cohort, a modified version of the University of California-Davis Rule misclassified a substantial proportion of pediatric patients with clinically important blunt head injury. Although we cannot evaluate the exact University of California-Davis Rule, we demonstrate that using stricter definitions of "headache" and "vomiting" and different wording than in the original study may have unintended or negative consequences. We emphasize the importance of careful attention to precise definitions of clinical predictors when a decision instrument is used.

Adolescent↗
PubMed2007

External validation of the San Francisco Syncope Rule.

STUDY OBJECTIVE: We externally validate the ability of the San Francisco Syncope Rule to accurately identify syncope patients who will experience a 7-day serious clinical event. METHODS: Patients who presented to a single academic emergency department (ED) between 8 am and 10 pm with syncope or near-syncope were prospectively enrolled. Treating physicians recorded the presence or absence of all San Francisco Syncope Rule risk factors. Patients were contacted by telephone at 14 days for a structured interview. A 3-physician panel, blinded to the San Francisco Syncope Rule score, reviewed ED medical records, hospital records, and telephone interview forms to identify predefined serious clinical events. The primary outcome was the ability of the San Francisco Syncope Rule to predict any 7-day serious clinical event. A secondary outcome was the ability of the San Francisco Syncope Rule to predict 7-day serious clinical events that were not identified during the initial ED evaluation. RESULTS: Of 592 eligible patients, 477 (81%) provided informed consent. Direct telephone contact or admission/outpatient records were successfully obtained for 463 (97%) patients. There were 56 (12%) patients who had a serious 7-day clinical event, including 16 (3%) who received a diagnosis after the initial ED evaluation. Sensitivity and specificity of the San Francisco Syncope Rule for the primary outcome were 89% (95% confidence interval [CI] 81% to 97%) and 42% (95% CI 37% to 48%), respectively, and 69% (95% CI 46% to 92%) and 42% (95% CI 37% to 48%), respectively, for the secondary outcome. Estimates of sensitivity were minimally affected by missing data and most optimistic assumptions for missing follow-up information. CONCLUSION: In this external validation cohort, the San Francisco Syncope Rule had a lower sensitivity and specificity than in previous reports.

Adult↗
PubMed2006

Effects of hospital closures and hospital characteristics on emergency department ambulance diversion, Los Angeles County, 1998 to 2004.

STUDY OBJECTIVE: We assess the effects of nearby hospital closures and other hospital characteristics on emergency department (ED) ambulance diversion. METHODS: The study design was a retrospective, multiple interrupted time series with control group. We studied all ambulance-receiving hospitals with EDs in Los Angeles County from 1998 to 2004. The main outcome measure was monthly ambulance diversion hours because of ED saturation. RESULTS: Our sample included 80 hospitals, of which 9 closed during the study period. There were increasing monthly diversion hours over time, from an average of 57 hours (95% confidence interval [CI] 51 to 63 hours) in 1998 to 190 hours (95% CI 180 to 200 hours) in 2004. In multivariate modeling, hospital closure increased ambulance monthly diversion hours by an average of 56 hours (95% CI 28 to 84 hours) for 4 months at the nearest ED. County-operated hospitals had 150 hours (95% CI 90 to 200 hours) and trauma centers had 48 hours (95% CI 9 to 87 hours) more diversion than other hospitals. Diversion hours for a given facility were positively correlated with diversion hours of the nearest ED (0.3; 95% CI 0.28 to 0.32). There was a significant and positive interaction between diversion hours of the nearest ED and time, suggesting that the effects of an adjacent facility's diversion hours increased during the study period. CONCLUSION: Hospital closure was associated with a significant but transient increase in ambulance diversion for the nearest ED. The temporal trend toward more diversion hours, as well as increasing effects of the nearest facility's diversion hours over time, implies that the capacity to absorb future hospital closures is declining.

Adolescent↗
PubMed2005

Direct medical costs of syncope-related hospitalizations in the United States.

Little is known about the costs of syncope-related admissions in the United States. A nationally representative sample of hospital discharges and reported charges was analyzed, and costs were estimated using Medicare cost-to-charge ratios. A conservative estimate of total annual costs for syncope-related hospitalizations was $2.4 billion (95% confidence interval [CI] $2.2 to $2.6 billion), with a mean cost of $5,400 (95% CI $5,100 to $5,600) per hospitalization. Efforts to safely decrease syncope-related admissions may result in substantial costs savings.

Adolescent↗
PubMed2004

Inconsistent electrocardiographic testing for syncope in United States emergency departments.

The electrocardiogram has diagnostic and prognostic value in the evaluation of syncope, and consensus guidelines suggest routine electrocardiographic testing. An analysis of a nationally representative survey suggests that electrocardiographic testing is performed inconsistently in patients presenting with syncope to United States emergency departments, even in high-risk patients, such as the elderly and hospitalized. Variation in electrocardiographic testing represents an opportunity to improve the care of patients presenting with syncope to emergency departments.

Adolescent↗
PubMed2004

A patient education intervention does not improve satisfaction with emergency care.

STUDY OBJECTIVE: We determine whether a patient education intervention based on a previously validated model increases satisfaction with emergency department (ED) care. METHODS: A single-page patient education form was distributed on alternating 2-week time blocks for 8 weeks at the triage desk of a single academic ED. Alert, discharged patients were administered an exit interview assessing satisfaction on a 5-point ordinal scale. Secondary outcomes included patient satisfaction measured on a bivariate scale, willingness to return, and process of care indicators previously demonstrated to be associated with satisfaction. Exclusion criteria included air or ground transport to the ED, inability to speak English or Spanish, and refusal to participate. Differences in patient satisfaction and other outcomes were adjusted for predefined covariates, including age, sex, triage severity, race, language, location in ED, total ED length of stay, and time to room, using multivariable logistic regression. RESULTS: Of 1,934 patients discharged during study periods, 1,233 (64%) were approached and 860 (44%) were enrolled. There were no important covariate differences between the control and intervention groups. There was no important correlation between intervention and patient satisfaction on univariate (odds ratio [OR] 0.840; 95% confidence interval [CI] 0.650 to 1.086) and multivariate analysis (OR 0.874; 95% CI 0.672 to 1.136). There were no important correlations between the intervention and secondary outcomes on multivariate analysis. CONCLUSION: A triage-based, patient education intervention did not significantly improve patient satisfaction or performance on predictors of satisfaction at the study site.

Academic Medical Centers↗
PubMed2004

Characteristics and admission patterns of patients presenting with syncope to U.S. emergency departments, 1992-2000.

OBJECTIVES: To describe the characteristics and admission patterns of patients with syncope presenting to U.S. emergency departments (EDs). METHODS: The ED portion of the National Hospital Ambulatory Medical Care Survey, 1992-2000, was analyzed. Nationally representative weighted estimates for incidence and admission rates were estimated and stratified by demographic variables. Presence of cardiovascular diagnoses on ED discharge was noted. RESULTS: Of the 865 million ED visits during the nine-year study period, an estimated 6.7 million (0.77%; 95% confidence interval [95% CI] = 0.69% to 0.85%) were related to syncope. Higher incidences of ED visits for syncope were found in elder, female, and non-Hispanic patients compared with their reference groups. The overall admission rate was 32% (95% CI = 28% to 36%). Older, male, and white patients were admitted more frequently than their counterparts. Of patients older than 80 years of age, 58% (95% CI = 49% to 67%) were admitted. Associated cardiovascular International Classification of Diseases, Ninth Revision (ICD-9), codes for ischemic, structural, and arrhythmic heart disease were noted in 10% (95% CI = 8% to 13%) of patients, and 66% (95% CI = 56% to 76%) of these patients were admitted. CONCLUSIONS: Syncope is a frequent reason for ED visits and admissions. Elders and patients with associated cardiovascular diagnoses are frequently discharged, and admission practices appear to deviate from consensus panel guidelines.

Adolescent↗
PubMed2003

Indications for long-term assist device placement as bridge to transplantation.

The current indications for long-term mechanical support as bridge to transplantation first require the patient to be a transplant candidate. Often times a patient presents with limited history and refractory cardiogenic shock, where a full transplant work-up for contraindications cannot be safely performed. The use of short-term mechanical support can be used to help filter out many patients who have easily identifiable contraindications to heart transplant. Nevertheless, patients need to be listed for a heart transplant before the implantation of some of these devices. This paradigm needs to be altered, because there are many instances where mechanical support can be used to support a patient for an intervention to "make" them a transplant candidate where they otherwise would not have been. Long-term mechanical support can overcome the cardiac contraindication to the surgical/interventional therapy to "cure" them of the process that would have prevented them from being a good cardiac transplant candidate in the first place. Noncardiac surgical procedures are well tolerated in these patients [11]. The FDA is currently evaluating the Vented Electric Heartmate system for use as destination therapy for patients who are not transplant candidates. Approval for this indication (with a device that is already approved for bridge to transplantation) will allow this paradigm shift. This system could be used in the group who may be good candidates, but not determined. If they were subsequently determined to not be a good surgical candidate, they would be chronically supported with the LVAD as destination therapy.

Equipment Design↗
PubMed2003

An unexpected surgical complication of ventricular assist device implantation identified by transesophageal echocardiography: a case report.

Ventricular assist devices are used for circulatory support for patients with cardiogenic shock and refractory heart failure. Although early and late complications of left ventricular assist devices have been reported, we report a rare surgical complication of a left ventricular assist device implantation. This unexpected surgical complication was accurately identified by transesophageal echocardiography.

Aorta↗
PubMed2003

Predictors and outcomes of frequent emergency department users.

OBJECTIVE: To identify predictors and outcomes associated with frequent emergency department (ED) users. METHODS: Cross-sectional intake surveys, medical chart reviews, and telephone follow-up interviews of patients presenting with selected chief complaints were performed at five urban EDs during a one-month study period in 1995. Frequent use was defined by four or more self-reported, prior ED visits. Multivariate logistic regression identified predictors of frequent ED visitors from five domains (demographics, health status, health access, health care preference, and severity of acute illness). Associations between high use and selected outcomes were assessed with logistic regression models. RESULTS: All study components were completed by 2,333 of 3,455 eligible patients (67.5%). Demographics predicting frequent use included being a single parent, single or divorced marital status, high school education or less, and income of less than $10,000 (1995). Health status predictors included hospitalization in the preceding three months, high ratings of psychological distress, and asthma. Health access predictors included identifying an ED or a hospital clinic as the primary care site, having a primary care physician (PCP), and visiting a PCP in the past month. Choosing the ED for free care was the only health preference predictive of heavy use. Illness severity measures were higher in frequent visitors, although these were not independently predictive in the multivariate model. Outcomes correlated with heavy use include increased hospital admissions, higher rates of ED return visits, and lower patient satisfaction, but not willingness to return to the ED or follow-up with a doctor. CONCLUSIONS: Frequent ED visits are associated with socioeconomic distress, chronic illness, and high use of other health resources. Efforts to reduce ED visits require addressing the unique needs of these patients in the emergency and primary care settings.

Acute Disease↗