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The abstracts and commentaries in this issue were prepared by editorial bozrd memberrs fo the YearBook of Emergency Medicine. These selections will appear in the 2008 volume. To order a copy ofthe entire 2008 Year Book of Emergency Medicine, call Mosby’s toll-free number 800-453-4351 or314-453-4351 outside the United States.Commentaries appearing in Annals of Emergency Medicine may undergo additional editing by theAnnals abstract editor.

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right © 2008 by Mosby, Inc.

The Effect of Emergency Department Expansion onEmergency Department Overcrowding

Han JH, Zhou C, France DJ, et al(Vanderbilt Univ, Nashville, TM)Acad Emerg Med. 2007;14:338-343.

Objectives: To examine the effects of emergency department(ED) expansion on ambulance diversion at an urban, academicLevel 1 trauma center.

Methods: This was a pre-post study performed usingadministrative data from the ED and hospital electronicinformation systems. On April 19, 2005, the adult EDexpanded from 28 to 53 licensed beds. Data from a 5-monthpre-expansion period (November 1, 2004, to March 1, 2005)and a 5-month postexpansion period (June 1, 2005, to October31, 2005) were included for this analysis. ED and waiting roomstatistics as well as diversion status were obtained. Total EDlength of stay (LOS) was defined as the time from patientregistration to the time leaving the ED. Admission hold LOSwas defined as the time from the inpatient bed request to thetime leaving the ED for admitted patients. Mean differences(95% confidence interval [CI]) in total time spent onambulance diversion per month, diversion episodes per month,and duration per diversion episode were calculated. Anaccelerated failure time model was performed to test if EDexpansion was associated with a reduction in ambulancediversion while adjusting for potential confounders.

Results: From pre-expansion to postexpansion, daily patientvolume increased but ED occupancy decreased. There was nosignificant change in the time spent on ambulance diversion permonth (mean difference, 10.9 hours; 95% CI � �74.0 to95.8), ambulance diversion episodes per month (two episodesper month; 95% CI � �4.2 to 8.2), and duration ofambulance diversion per episode (0.3 hours; 95% CI � �4.0 to3.5). Mean (�/�SD) total LOS increased from 4.6 (�/�1.9)to 5.6(�/�2.3) hours, and mean (�/�SD) admission holdLOS also increased from 3.0 (�/�0.2) to 4.1 (�/�0.2) hours.The proportion of patients who left without being seen was3.5% and 2.7% (p � 0.06) in the pre-expansion andpostexpansion periods, respectively. In the accelerated failuretime model, ED expansion did not affect the time to the next

ulance diversion episode.

Annals of Emergency Medicine

Conclusions: An increase in ED bed capacity did not affectambulance diversion. Instead, total and admission hold LOSincreased. As a result, ED expansion appears to be aninsufficient solution to improve diversion without addressingother bottlenecks in the hospital.

Comment: If you build it, they will come. But, once they come,will you have anywhere to put them? This study is additional proofto the concept that ED overcrowding is a multi-factorial problemwith no simple solution. And, it is likely that the weight of thecontributing factors varies between EDs and hospitals. As thepopulation ages, ED overcrowding will likely become a greaterproblem. Solutions will need to include increases in the readyavailability of inpatient beds and staffing, alternatives to admission(for example, cardiac CTs rather than admission for a rule out andstress test in low risk chest pain), and mechanisms to divert patientswith non-urgent care needs from the ED when it is busy. Inaddition, there is a great need for development of models to identifywhen an ED/Hospital is nearing the point of requiring diversion sothat measures like calling in additional ED/inpatient staffing,prompting early discharges, etc, can be implemented before the EDis in crisis mode.

S. L. Werner, MD

doi:10.1016/j.annemergmed.2008.02.001

Clinical Prediction Rule for Identifying Children WithCerebrospinal Fluid Pleocytosis at Very Low Risk ofBacterial Meningitis

Nigrovic LE, for the Pediatric Emergency Medicine CollaborativeResearch Committee of the American Academy of Pediatrics(Harvard Med School; et al).JAMA 2007;297:52-60

Context: Children with cerebrospinal fluid (CSF) pleocytosisare routinely admitted to the hospital and treated withparenteral antibiotics, although few have bacterial meningitis.We previously developed a clinical prediction rule, the BacterialMeningitis Score, that classifies patients at very low risk ofbacterial meningitis if they lack all of the following criteria:positive CSF Gram stain, CSF absolute neutrophil count

(ANC) of at least 1000 cells/microL, CSF protein of at least 80

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