Journal Reviews

Black patients with isolated long-bone fractures were less likely than white patients to receive analgesics in the ED, according to this study from Emory University in Atlanta.

All ED patients who presented with new isolated long-bone fractures were included in the 40-month study. Ethnic identifiers were removed from the medical records, and analgesic administration was recorded. Participants in the study included 127 black and 90 white patients. White patients were significantly more likely to receive ED analgesics, despite similar records of pain complaints in the medical record.

"We cannot be certain that some aspect of ethnicity, or an unmeasured confounder such as the presence of friends or family, might influence black patients’ expression of pain to physicians and nurses," said the researchers.

However, the medical records contained detailed notation of pain complaints in nearly identical proportions in black and white patients, they noted. "Our findings suggest that it is not the failure of physicians to assess pain, but the failure to administer analgesics," the researchers said.

Moody-Williams JD, Linzer J, Stern A, et al. Twenty-four hour access to emergency care for children in managed care. Ann Emerg Med 1999; 34:761-767.

This article assessed approaches used by managed care organizations (MCOs) to control the flow of patients to the ED. The article is part of the white paper series published by the Emergency Medical Services for Children (EMSC) Managed Care Task Force, formed by the Washington DC-based EMSC National Resource Center.

Telephone triage personnel at MCOs may lack expertise in pediatric emergencies and thus be unable to correctly assess a child’s condition and need for emergency care, the researchers said. Educating plan members about the proper use of emergency services can be confusing, and MCOs lay too great a burden of responsibility on the parents to distinguish life-threatening symptoms from those that only require prompt attention by a primary care physician, they added. The panel made several recommendations to address issues of access to the ED, as follows:

• Make 911 universally accessible to everyone facing a true emergency.

• Ensure that children are permitted access to facilities that are best equipped to provide pediatric care.

• Ensure provision of pediatric specialty/subspecialty care, without prior approval, for patients in EDs.

• Ensure that any definitions of conditions requiring emergency care address parents/caregivers’ concerns.

• Promote pediatric emergency preparedness at alternative care sites such as freestanding urgent care facilities.

• Develop methods to accommodate language barriers during triage and in member information.

Hollander JE, McCracken G, Johnson S, et al. Emergency department observation of poisoned patients: How long is necessary? Acad Emerg Med 1999; 6:887-894.

A significant percentage of overdose patients who are medically cleared after six hours of observation can be identified within two to four hours of presentation, reports this study from the University of Pennsyl vania in Philadelphia. The study looked at 260 patients with potentially toxic oral ingestions that occurred less than six hours before the patients presented to the ED. Data were collected at presentation and two, four, and six hours later, including signs and symptoms, laboratory determinations, and suicide risk.

At two or four hours, physicians were asked whether they thought the patient was safe for medical clearance. No patient who was believed to be safe for medical clearance at two or four hours had a complication within the six-hour period. That finding suggests asymptomatic patients with selected acute ingestions can be released from observation in less than six hours. However, the results of the present study should not be applied to patients who have ingested long-acting medications or poisons who present with delayed clinical symptoms, noted the researchers.