[display_podcast]

Date: October 8th, 2015

Guest Skeptic: Meghan Groth (@EMPharmGirl). Meghan is the emergency medicine pharmacy specialist at the University of Vermont Medical Center in Burlington, Vermont and an adjunct professor of pharmacy at the Albany College of Pharmacy and Health Sciences.

Case: A 26-year-old male presents to your emergency department with complaints of a painful, reddened area on his right arm. He has no significant past medical history, surgical history, or social history, but reports that he has an allergic reaction to penicillin and cephalosporin antibiotics.

On exam, you find an abscess approximately 6cm in diameter with surrounding cellulitis. After performing an incision and drainage, you contemplate sending the patient home with a prescription for antibiotic therapy.

The patient expresses to you that he’s seen cases of MRSA (methicillin-resistant Staphylococcus aureus) reported on the news and is worried this may be involved in his infection. 

Background: Skin and soft tissue infections (SSTIs) are a common reason for visits to the emergency department, hospital admissions, and may result in considerable morbidity and mortality.

Classically, it has been thought that beta-hemolytic Streptococci are the causative organisms for cellulitis and Staph species are commonly implicated in cases of skin abscesses.

More recently, MRSA has been recognized as a common cause of SSTIs.

Clinical Question: For patients with uncomplicated skin infections, is clindamycin superior to trimethoprim-sulfamethoxazole?

Reference: Miller LG, et al. Clindamycin versus trimethoprim-sulfamethoxazole for uncomplicated skin infections. NEJM 2015

* Population: Adult and paediatric patients aged six months to 85 years with at least two of the following for 24 hours or more: erythema, swelling/induration, local warmth, purulent drainage, and tenderness to pain/palpation.

* Exclusions: (supplementary index that was three pages long) Body site involvement requiring special management (e.g. perirectal, genital, or hand), human or animal bites, high fever, immunosuppression, diabetes, chronic renal failure, morbid obesity, surgical site infections, or receipt of antibiotics within 14 days that included anti-staphylococcal activity, residence in a long term care facility, cancer, or major surgery in the previous 12 months.

* Intervention: Clindamycin 300 mg PO TID x 10 days (or weight-based paediatric dose)

* Comparison: TMP-SMX 160-800 mg x 10 days BID (or weight-based paediatric dose)

* Outcome:

* Primary Outcome: Clinical cure at the test of cure (TOC) visit (7-10 days after completion of antibiotic course).

* Secondary Outcome: Patients were also evaluated at the end of treatment at 30 days post 10 day antibiotic course (day 40) for symptom resolution and for medication-related adverse effects.

Authors’ Conclusions: “We found no significant differences between the efficacy of clindamycin and that of TMP-SMX for the treatment of uncomplicated skin infections in children and adults with few or no major coexisting conditions.”

Quality Check for Randomized Clinical Trials:

* The study population included or focused on those in the ED. No.  Patients were recruited from urgent care clinics, emergency departments, and clinics affiliated with the four medical centers involved.

* The patients were adequately randomized. Yes

* The randomization process was concealed. Yes

* The patients were analyzed in the groups to which they were randomized. Yes

* The study patients were recruited consecutively (i...

[display_podcast]

Date: September 22nd, 2015

Guest Skeptic: Dr. Marcel Emond is an Associate professor, Laval University. Emergency physician the level one trauma centre in Quebec City. Research Director of the Canadian Emergency Team Initiative (CETI). Marcel is also the lead for SGEM Global French.

If you are interested in evidence based medicine, shortening the KT window down to less than one year, speak another language and always wanted to podcast then contact me at [email protected] with global in the subject line to discuss joining the SGEM Global Team.

Case: A 48-year-old man presents to the emergency department with acute lumbar pain after trying to lift a heavy garbage can. He says his pain is ten out of ten despite taking ibuprofen. He does not have any “red flags” and you are considering how to safely and effectively address his pain.

Background: Oligoanalgesia is defined as the lack of or inadequate pain control. There are many studies showing this is a big problem in the emergency department (Wilson and Pendleton, Motov and Khan) with some groups of patients being at greater risk for oligoanalgesia (elderly, women, mentally ill, certain ethnic groups, insurance status and children).

To raise awareness about oligoanalgeisa, the Joint Commission made pain the “fifth vital sign” in 2001. American physicians started being evaluated and compensated by means of patient satisfaction with emergency department pain control on factor. This provided misguided incentives for giving out opioids.

There are some disturbing trends reported by the Center for Disease Control (CDC) over the last few years. Between 1991 and 2010, prescriptions for opioid analgesics increased from about 75 million to 210 million according to the National Institute of Drug Abuse (NIDA).

This was followed by an increase in abuse and overdose. The CDC estimates that narcotic pain relievers now cause or contribute to nearly three out of four prescription drug overdoses and about 15,000 deaths per year

In October 2012, American College of Emergency Physicians (ACEP) published practice guidelines regarding opioid including these Level C recommendations:

* Physicians should avoid the routine prescribing of outpatient opioids for a patient with an acute exacerbation of chronic non-cancer pain seen in the emergency department.

* The Prescriber should consider the patient’s risk for opioid misuse, abuse or diversion.

* If opioids are prescribed on discharge, the prescription should be for the lowest practical dose for a limited duration.

If you want to watch a YouTube video that combines ACEP recommendations with a Taylor Swift song then check out Michael Barton’s parody video called We are Never (Giving you Drugs in the ER).

Besides abuse, there are other well know limitations to using opioids including: allergy, respiratory depression, hypotension, nausea and vomiting.

[display_podcast]

Date: August 14th, 2015

Guest Skeptic: Dr. Rick Malthaner is the Director of Thoracic Surgery Research, Professor of Surgery, Epidemiology and Biostatistics at the Schulich School of Medicine and Dentistry, Western University, Canada.

Case: A 25-year-old female was allegedly stabbed while standing on the corner minding her own business. She was found unconscious (Glasgow Coma Scale 7) and was intubated by the EMS. On arrival in your emergency department, the vitals are stable, but there is decreased air entry on the right side. You skillfully insert a right chest tube and get back 100 ml of blood. You review the post insertion chest tube x-ray and are somewhat disappointed by the position of your tube. It is hitting the mediastinum and curling back on itself and there is persistent white-out on the right.

Background: The “B” of the ABCs is really “Chest Tube”. Chest tubes didn’t become the standard of care for pneumothorax and hemothorax until the 1950s. The idea of draining the chest has been around since Hippocrates (460-370 B.C.) where he used tin tubes, linen, wine, and oil to drain empyemas.

The first mention of chest tubes for trauma was in the 1200s when a knight named Gawan used a tube of bark from a branch of a linden tree to treat a tension hemopneumothorax in another knight who sustained an injury during a joust.

Controversy existed over whether chest wounds should be left open or closed for the next few centuries. In the 17th and 18th century the importance of removing retained blood led to the practice of wound sucking. This was often done by the drummers of the military who sucked the wounds and then applied compresses and bandages.

During the wars of the last century there was debate over drainage systems versus repeated aspirations versus suture closure of open chest wounds. The mortality from chest wounds in World War I was 56%. Repeated chest thoracenteses was the treatment of choice for hemothorax and endorsed by NATO in 1958.

Plastic chest tubes were introduced in 1961 and closed thoracostomy and underwater seal drainage become common during the Vietnam War. The mortality rate dropped to 2.9%.

Current chest tubes are made from clear vinyl or silastic. They have multiple side holes and have centimeter markings to denote depth of insertion. A radiopaque strip allows visualization on chest x-ray. The principle of evacuation of pus, air, blood, and fluid from the pleural cavity that originated in ancient Greece remains the standard to this day.

* Triangle of Safety: The triangle of safety is bordered by the anterior axillary line (pectoris major) and posterior axillary line (latissimus dorsi) and the 5th intercostal space (roughly the level of the nipple in a thin male). The only muscles you need to go through are the serratus anterior and intercostals. The only structure of significance is the long thoracic nerve. If injured it will produce a winged scapula. This is rare. This the first choice for chest tube insertion in trauma.

Question#1: In a trauma patient, how clinically useful is a chest X-ray (CXR) after putting in the chest tube?

Reference: Kong et al. What is the yield of routine chest radiography following tube thoracostomy for trauma? Injury 2015

* Population: Adults presenting or referred to a trauma centre who had a CXR after tube thoracostomy

* Group A: No CXR prior to tube insertion

* Group B: CXR prior to tube insertion with clinical concerns

* Group C: CXR prior to tube insertion without clinical concerns

* Excluded: Patients without complete data set

* Intervention: CXR following tube thoracostomy

* Comparison: None

* Outcome: Yield of post CXR tube insertion influencing clinical management

[display_podcast]

Date: September 10th, 2015

Guest Skeptic: Daniel McCollum. Daniel is an Assistant Residency Director at Georgia Regents University in Augusta, GA. He loves craft beer, evidence based medicine, and Batman. 

Case: A 53 year-old man presents with left sided chest pain that started 90 minutes ago. The pain radiates to his left arm and he has nausea without vomiting. The pain began while he was doing yard work and he has never had pain like this before. His initial ECG is unremarkable.

Background: Only about 5% of all consecutive patients presenting with acute chest pain will have a ST elevated myocardial infarction (STEMI) (Apple et al). These are the easy ones to diagnose and manage. This leaves the other 95% of chest pain patients. These are the hard ones.

We need to figure out who will rule-in vs. rule-out for acute myocardial infarction (AMI). This is where cardiac biomarkers play a major role.There have been many biomarkers used over the last 60 years to try to identify patients with acute myocardial infarction.

The first practical test utilized, as a cardiac marker was serum glutamic oxaloacetic transaminase (SGOT) that is now called aspartate amino-transferase (AST). Since the late 1990‘s the cardiac marker of choice has changed from CK-MB to Troponin.

A limitation of current troponin assays is that they can take 3-4 hours to rise. This means the diagnosis of Non-STEMI can take many hours of continued monitoring with serial blood sampling.

Ruling out AMI takes time, uses resources, contributes to overcrowding, and causes patient anxiety. High sensitivity troponin assays are all the rage now and used in many emergency departments. They offer very high sensitivity but are less specific than prior troponin assays.

There is limited evidence from studies that the use of high sensitivity troponins may allow for the safe discharge of patients more rapidly from the emergency department than what is possible with traditional troponin assays.

Clinical Question: Is it possible to rule in/rule out acute myocardial infarction in the emergency department with high sensitivity troponin T and ECG in one hour?

Reference: Reichlin et al. Prospective validation of a 1-hour algorithm
to rule-out and rule-in acute myocardial infarction using a high-sensitivity cardiac troponin T assay. CMAJ 2015

* Population: Patients presenting to the emergency department within twelve hours of onset of non-trauamtic chest pain or symptoms suggestive of AMI. This was part of an ongoing study in Switzerland, Spain and Italy (Advantageous Predictors of Acute Coronary Syndromes Evaluation [APACE] Study).

* Excluded: Kidney failure requiring dialysis or STEMI

* Intervention: High Sensitivity Troponin T at time zero and one hour with ECG

* Comparison: Two independent cardiologists (ED presentation to 90-day follow-up, including patient history, physical exam, coronary angiography, echocardiography, follow-up data, and serial high sensitivity troponin T measurements).

* Outcome: Acute myocardial infarction (negative predictive value, positive predictive value and area under the curve.

Authors’ Conclusions: “This rapid strategy incorporating high-sensitivity cardiac troponin T baseline values and absolute changes within the first hour substantially accelerated the management of suspected acute MI by allowing safe rule-out as well as accurate rule-in of acute MI in 3 out of 4 patients.”

Quality Checklist for A Diagnostic Study:

* The clinical problem is well defined? Yes.

[display_podcast]

Date: September 8th, 2015

Guest Skeptic: Dr. Anthony Crocco is a Pediatric Emergency Physician and is the Medical Director & Division Head of the Division of Pediatric Emergency at McMaster’s Children’s Hospital. I often refer to him as a PedsEM Super Hero but the SGEMers probably know him for his RANThony’s on YouTube.

Season#3 finished with an SGEM#126 Hot Off the Press featuring Dr. Jeff Kline discussing outpatient management of venous thromboembolism. We are going to kick off Season#4 with another SGEM HOP from Academic Emergency Medicine.

SGEM Hot Off the Press Process:

* We select a paper that has been accepted by the editors at Academic Emergency Medicine that is about to be published.

* The SGEM then put a skeptical eye upon the manuscript using a modified BEEM critical appraisal tool.

* One of the authors is then invited to discuss their work on the SGEM.

* We podcast the review on iTunes and on the SGEM blog shortly after publication inviting the SGEMers to respond on the blog, via Twitter or Facebook.

* A summary of the review including the top social media feedback is then published in a subsequent issue of AEM.

Case: A ten-year-old girl is a restrained rear-seat passenger in a motor vehicle collision.  The driver of the other car was texting and ran a red light at low city speeds, “T-boning” her vehicle on her side.  There was minimal intrusion into the vehicle space.

The girl presents to the emergency department via EMS with a c-spine collar and on a spine board.  She is alert, appropriate and in no distress.  Her exam is normal, including no evidence of abdominal wall trauma, tenderness or nausea/vomiting.  The remainder of her exam is normal.

Given the mechanism of the injury you are concerned about blunt abdominal trauma.  You wonder if you should do a CT abdomen, but are also concerned about the risk of radiation.  You heard of a study in 2013 that developed a clinical decision instrument for this very question, but don’t know if you should use that, or trust your own ‘gut feeling‘.

Background: The leading cause of death in children is trauma. Blunt torso trauma makes up a significant portion of the mortality statistics. CT scanning has become a routine method for identifying children with intra-abdominal injuries. The amount of radiation being delivered to these vulnerable patients and the risks of developing radiation-induced malignancy has raised concern. There is evidence that clinical suspicion is not accurate in identifying children with intra-abdominal injuries. In addition, there is wide variation on the use of abdominal CT and over utilization in children with low pre-test probability of clinically important injuries.

Clinical Question: How well do clinicians identify children suffering from blunt torso trauma who have intra-abdominal injuries compared to an established clinical prediction rule?

Reference: Mahajan P et al. Comparison of clinical suspicion versus a clinical prediction rule in identifying children at risk for intra-abdominal injuries after blunt torso trauma.  Sept 2015 AEM .

[display_podcast]

Date: September 8th, 2015

Today was the first day back to school for my children so what better time to launch Season#4 of the SGEM. We had a great summer that included white water rafting on the Ottawa river, a visit to Niagara Falls, catching a Toronto Blue Jays game, watching a few outdoor movies, a trip to Halifax and many more adventures. I hope all the SGEMers had some great time off  with family and friends.

Listeners know that the goal of the SGEM is to cut the knowledge translation window down from over ten years to less than one year. We use social media to accomplish this goal.

Today I have one of the most exciting announcements ever made on the SGEM. It has been hinted about in past episodes but today is the day. Today I am announcing the SGEM Global project.

SGEMers have come to expect a weekly dose of medical skepticism. It is typically delivered as an evidenced based review of a recently published paper. The critical appraisal is performed using a validated and reliable method. The review is then is uploaded to the SGEM blog and podcasted for free on iTunes.

The SGEM is part of the FOAM movement. FOAM stands for Free Open Access to Medical Education. FOAM was started in 2012 to provide medical education for free to anyone, anywhere and anytime. It’s goal …to make the world a better place.

FOAM is a wonderful initiative. You might be wondering how SGEM Global could make it even better? How could it be possible? What could SGEM Global do to improve on such an amazing concept?

Before I spill the beans, let me remind everyone that it can take an average of 17 years for 14% of high quality clinically relevant information to reach the patients’ bedside.

It was Pathman and company who created a beautiful model to illustrate the problem visually. He called his model the leaky pipe. Pathman et al described seven leaks in a pipe between the reservoir of knowledge and the patient. The seven leaks all started with “A” and include:

SGEM Global will focus in the first of the “A’s” – Awareness.

How can patients get the best emergency care if their providers are not even aware of the literature? Patients deserve excellent emergency care from the time they call 911, during transportation, in the emergency department, in-patient (ICU/CCU) and to discharge. It takes a team (EMS, PA, NPs, RNs, MDs, Pharmacist, administration) all working together based on the best information for patients to get the best care.

However, the SGEM blog is published in English and I podcast the SGEM episodes in English. Do you see the problem? It reminded me of a Simpsons episode where Homer says ” ? Who needs that? I’m never going to England”.

The FOAM world has some great resources like Life in the Fast Lane out of Australia and Academic Life in Emergency Medicine. But a limitation of these great resources is that they are provided in English.

The SGEM often does critical appraisals of systematic reviews. One of the things we look for in the methods section is any language restriction. A weakness of these systematic reviews is the search strategy. They will often only include studies published in English. They specifically exclude non-English papers.

So turning that skeptical/critical eye on my own project, I realized the SGEM only disseminates in English. This represents a major limitation, barrier or leak in the KT pipe.

[display_podcast]

Date: August 26th, 2015

This will be the last of the SGEM Xtra summer content. The next episode will launch Season#4 with a super big announcement. Very excited about the new initiative and I think it will take the SGEM to the next level of knowledge translation. The goal is always to cut that KT window down from over ten years to less than one year. This new initiative will accomplish this on a global level.

We have hinted about this special project before on the SGEM.  I even promised Chris Carpenter it would knock his socks off. Many more of you may not be wearing socks after hearing the announcement. In fact, once you have heard about the super big SGEM surprise, tweet me pictures of you without socks.

Until then enjoy the fourth of the fabulous #FOAMed speakers lighting the way in Edmonton earlier this year as part of the Canadian Association of Emergency Physicians (CAEP) meeting.

Chris Bond: Chris is an EM physician and clinical lecturer at the University of Calgary. His interests include knowledge translation, FOAMed, and all things food and wine related. Make sure you check out his great blog called SOCMOB (Standing on the Corner Minding My Own Business).

FOAM: Consolidation, Integration and the Future

How to keep up with FOAMed, a discussion of quality assurance/quality metrics within FOAM and efforts to develop and implement a FOAM curriculum.

You can watch Chris give his talk on YouTube and download a PDF copy of his slides.

That is it for the sumner Xtra content on the SGEM. Season#4 will start in September and I can’t wait to get pictures of SGEMers without their socks on.

The SGEM is on Facebook so if you would please like our page that would be great. You can follow the SGEM on twitter @TheSGEM. And if you would please take a few seconds to give the SGEM a rating on iTunes.

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

[display_podcast]

Date: August 22nd, 2015

SGEMers have become familiar with Paediatric Emergency Medicine Super Hero Dr. Anthony Crocco. He has been on the SGEM many times discussing the best paediatric emergency care. Anthony is also well know for his YouTube videos. There are now three RANThonys: Fever Phobia, Cough Medication and Pain Control.

Anthony launched his own evidence based medicine website earlier this year called SketchyEBM. This blog is another summer SGEM Xtra that will highlight this great new #FOAMed resource.

Five Questions for SketchyEBM:

* Give me your elevator pitch for SketchyEBM?

* Where did you get the idea for SketchyEBM?

* What are your goals for SketchyEBM?

* What content will people find on SketchyEBM?

* What other topics will you be covering on SketchyEBM?

If you are a program director, you need to check out SketchyEBM. If you are a student wanting to learn various EBM concepts, you need to check this website out. If you are running a Journal Club, you need to check this website out. Anyone interested in cutting the KT window down from over ten years to less than one year should check out SketchyEBM.

Skeptics’ Guide to Emergency Medicine Season#4:

Season#4 of the SGEM will be starting very soon. However, we need your help in selecting the articles to be reviewed. Please click on Hot or Not to vote. Those articles rated highly by SGEMers will go through a structured critical review process. If you think there is an article we should consider reviewing then SUBMIT it to Hot or Not.

The first episode on Season#4 will be another Hot off the Press paper just published in Academic Emergency Medicine. Anthony will be moderating this episode of SGEM HOP instead of Chris Carpenter because we are reviewing a paediatric trauma paper.

An exciting component of the SGEM HOP is that the best social media feedback gets published in a future AEM paper. Help us show how social media can shorten the KT window and engage an audience.

SketchyEBM tag line “Always draw your own conclusions”.

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

[display_podcast]

Date: August 15th, 2015

This is another SGEM Xtra. Season#4 will be starting soon in September trying to cut that knowledge translation window down from over ten years to less than one year with critical appraisals of the recent literature.

Until then we have some more FOAMed goodness from the Canadian Association of Emergency Physician meeting that was held in Edmonton earlier this year.

It was my pleasure to host the #FOAMed track at the CAEP meeting. There were four amazing speakers Lighting the Way in Edmonton including Lauren Westafer.

Lauren Westafer (@LWestafer): Lauren is currently the Chief Resident at Baystate Medical Center, FOAMcast co-host with Jeremy Faust, author of The Short Coat blog, and the Knowledge to Action Fellow. Lauren is passionate about Free Open Access Medical education, dissemination and implementation science, and metacognition.

(Un)Learning in Medicine – Easing the Grieving Process with FOAM

A Harvard Medical School’s former Dean (Charles Sidney Burwell) proclaimed to his students half a century ago, “Half of what we are going to teach you is wrong, and half of it is right. Our problem is that we don’t know which half is which”. Ease the denial, the anger, the sadness of hearing that what you were taught is no longer accurate with FOAM. This isn’t your favorite brew, rather Free Open Access Medical education (FOAM), which can allow one to increase cognitive flexibility by staying up to date with evidence based medicine and peer discussions. It’s yoga for your brain.

You can watch Lauren give her talk on YouTube and download a PDF copy of her slides.

The SGEM is on Facebook so if you would please like our page that would be great. You can follow the SGEM on twitter @TheSGEM. And if you would please take a few seconds to give the SGEM a rating on iTunes.

There was a keener contest winner last week from Chris Carpenters guest hosting a SGEM Xtra episode on Preventing Older Adult Falls from the Emergency Department.

Mike Butterfield from Tampa Florida won a cool skeptical prize. He knew The Hurricane was a biopic movie about Rubin “Hurricane” Carter staring Denzel Washington and was filmed in Peterson New Jersey

That’s all for today but don’t panic. The SGEM will be back in September with more critical reviews, Hot off the Press, SGEM Classics and SGEM Journal Clubs.

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

 

[display_podcast]

Date: Summer 2015

Guest Skeptic: Dr. Julie Gyi and Dr. Jordan Jeong. Emergency medicine residents at St. Joseph’s Regional Medical Center in Paterson, New Jersey.

Guest Host: Dr. Chris Carpenter @SAEMEBM. Associate Professor, Emergency Medicine. Director, Evidence Based Medicine, Washington University. C0-Author of Evidence Based Emergency Care- Diagnostic, Testing and Clinical Decision Rules.

Case: An 80 year old female presents with left wrist pain following a fall. You diagnose and treat a Colles fracture with no other acute injuries, but at discharge her family wonders if she is at significant risk for further falls and, if so, how to prevent them?

Background: Falls don’t just happen in hospitals and nursing homes. About one in three older adults who live at home suffer a standing level fall every year.

That is over eight million non-fatal falls in the U.S. alone every year. Almost 800,000 fallers present to U.S. EDs annually. This has an estimated yearly cost of $68 billion.

Ground level falls are the number one cause of geriatric-trauma related mortality. The ACEP/SAEM/ENA/AGS Geriatric Emergency Department Guidelines make the following recommendations regarding falls prevention:

* “It is the policy of the Geriatric ED to initiate a comprehensive evaluation for geriatric patients presenting after a fall or for those who may be at high risk for a future fall. Patients will be evaluated for injuries, including those injuries that may be ‘occult’ in the geriatric population. Furthermore, patients will be evaluated for causes of and risk factors for falls. Patients will be assessed prior to disposition for safety with the goal to prevent further injury and falls.”

More information on geriatric falls can be found on SGEM#89 Preventing Falling to Pieces.

Clinical Question: Do older adults receive guideline-directed evaluation in the emergency department following a standing level fall?

Reference: Tirrell G et al. Evaluation of Older Adult Patients with Falls in the Emergency Department: Discordance with National Guidelines. Acad Emerg Med 2015

* Population: Geriatric adults presenting to one academic emergency department after a standing level fall.

* Intervention: Adherence to American Geriatric Society fall prevention guidelines and/or ACEP Geriatric Emergency Department Guidelines recommendations for fall assessment and management

* Comparison: No comparison group (observational study)

* Outcome: Proportion of cases in which history and physical exam incorporated elements of either the American Geriatric Society (AGS) or the American College of Emergency Physician (ACEP) Guideline recommendations for falls

Author’s Conclusions: “The current ED evaluation of older adult fallers is discordant with general and ED-specific fall guidelines. Future studies are warranted to investigate ways to successfully implement fall evaluation guidelines.”

Quality Checklist for Observational Trials:

* Did the study address a clearly focused issue? Yes. Randomly selected subset of patients who presented to the ED for falls in 2012, identified via medical record review using ICD-9 codes for accidental fall, excluding patients transferred from another ED.