Why Won't Emergency Physicians Discharge Patients With a Low HEART Score From an Observation Unit Without Further Evaluation?

BACKGROUND: The History, Electrocardiogram, Age, Risk Factors, Troponin (HEART) score is a prospectively validated risk stratification tool for patients presenting to the emergency department (ED) with chest pain. Data demonstrate that patients with low HEART scores (0-3) can be safely discharged from the ED. ED physicians, however, may be reluctant to discharge patients based on the score. OBJECTIVE: To identify specific factors why ED physicians are reluctant to discharge patients with low-risk HEART scores from an ED observation unit (EDOU) without further evaluation. METHODS: This was a single-center prospective, cross-sectional analysis of ED patients from an urban ED placed in an EDOU for evaluation of chest pain, from July 1, 2016, to August 31, 2016. ED physicians completed a questionnaire that included documentation of patient HEART score and if the patient would or would not be a good candidate for outpatient stress testing or follow-up within 72 hours without further EDOU testing or consultant evaluation. Providers selected reasons why patients were not a good candidate for outpatient stress testing/follow-up. RESULTS: There were 279 patient questionnaires completed, 42% (117/279) had a HEART score of 0-3. Within this group, 54.7% (64/117) of the patients were identified as not being good candidates for outpatient stress testing/follow-up within 72 hours because of concerns for poor follow-up (n = 14), concerning risk factors (n = 14), concerning symptoms (n = 11), and other (n = 7). CONCLUSIONS: ED physicians in this urban ED felt that over half of patients with a low-risk HEART score were not good candidates for discharge from the EDOU without further evaluation due to poor follow-up, concerning risk factors or symptoms, or coexisting conditions.

A 90-second magnetocardiogram using a novel analysis system to assess for coronary artery stenosis in Emergency department observation unit chest pain patients.

BACKGROUND: Magnetocardiography (MCG) has been shown to non-invasively detect coronary artery stenosis (CAS). Emergency department (ED) patients with possible acute coronary syndrome (ACS) are commonly placed in an observation unit (OU) for further evaluation. Our objective was to compare a novel MCG analysis system with stress testing (ST) and/or coronary angiography (CA) in non-high risk EDOU chest pain patients. METHODS: This is a prospective pilot study of non-high risk EDOU chest pain patients evaluated with ST and/or CA that underwent a resting 90-second MCG scan between August 2017 and February 2018. A positive MCG scan was defined as having current dipole deviations with dispersion or splitting during the repolarization phase. ST, CA and major adverse cardiac events (MACE) 30 days and 6 months post-discharge assessed. RESULTS: Of 101 study patients, mean age was 56 years and 53.6% were male. MCG scan sensitivity with 95% CI was 27.3% [7.3%, 60.7%], specificity 77.8% [67.5%, 85.6%], PPV 13.0% [3.4%, 34.7%] and NPV 89.7% [80.3%, 95.2%] compared to ST, and 33.3% [7.5%, 70.7%], 78.3% [68.4%, 86.2%], 13% [5.2%, 29.0%] and 92.3% [88.2%, 95.1%] respectively compared to ST and CA. No patients had positive ST, CA or MACE 30 days and 6 months post-discharge. CONCLUSION: This pilot study suggests a resting 90-second MCG scan shows promise in evaluating EDOU chest pain patients for CAS and warrants further study as an alternative testing modality to identify patients safe for discharge. Larger studies are needed to assess accuracy of MCG using this novel analysis system.

Use of Extracorporeal Membrane Oxygenation and Surgical Embolectomy for Massive Pulmonary Embolism in the Emergency Department.

BACKGROUND: Massive pulmonary embolism (PE) carries significant morbidity and mortality with current standard of care modalities. CASE REPORT: We present the case of a 63-year-old male status post abdominal surgery 2 weeks before presenting to the emergency department with a massive pulmonary embolism and subsequent acute cardiopulmonary failure. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Here we describe a case of extracorporeal membrane oxygenation (ECMO) deployed in the emergency department as a bridge to embolectomy to successfully treat massive pulmonary embolism. This provided the opportunity to establish a "Code ECMO" protocol and algorithm for PE with cardiopulmonary instability so that patients can be rapidly triaged to the appropriate treatment modality.

Care of Respiratory Conditions in an Observation Unit.

In adults, respiratory disorders are the second most frequent diagnoses treated in emergency department observation units (EDOUs) and account for the most frequent indication for placement of pediatric patients into an EDOU. With appropriate patient selection, chronic obstructive pulmonary disease exacerbations, and community-acquired pneumonia can be managed in the EDOU. EDOU management results in equivalent or better outcomes than inpatient care with decreased length of stay, increased patient satisfaction, lower cost and in some studies decreased mortality. Evidence-based protocols are important to ensure appropriate patients are placed in the EDOU, standardize best practice interventions, and guide disposition decisions.

Salivary protein changes in response to acute stress in medical residents performing advanced clinical simulations: a pilot proteomics study.

CONTEXT: Quantitative changes of salivary proteins due to acute stress were detected. OBJECTIVE: To explore protein markers of stress in saliva of eight medical residents who performed emergency medicine simulations. MATERIALS AND METHODS: Saliva was collected before the simulations, after the simulations, and following morning upon waking. Proteins were separated by sodium dodecyl sulphate-polyacrylamide gel electrophoresis (SDS-PAGE), identified by mass spectrometry (MS), and relatively quantified by densitometry. RESULTS: Salivary alpha-amylase and S-type cystatins significantly increased, while the ∼26 kDa and low-molecular weight (MW) (<10 kDa) SDS-PAGE bands exhibited changes after stress. DISCUSSION AND CONCLUSION: Alpha-amylase and cystatins are potential salivary markers of acute stress, but further validation should be performed using larger sample populations.

Follow-up CT pulmonary angiograms in patients with acute pulmonary embolism.

Computed tomographic (CT) angiography is associated with a non-negligible lifetime attributable risk of cancer. The risk is considerably greater for women and younger patients. Recognizing that there are risks from radiation, the purpose of this investigation was to assess the frequency of follow-up CT angiograms in patients with acute pulmonary embolism. This was a retrospective cohort study of patients aged ≥18 years with acute pulmonary embolism seen in three emergency departments from January 2013 to December 2014. Records of all patients were reviewed for at least 14 months. Pulmonary embolism was diagnosed by CT angiography in 600 patients. At least one follow-up CT angiogram in 1 year was obtained in 141 of 600 (23.5 %). Two follow-ups in 1 year were obtained in 40 patients (6.7 %), 3 follow-ups were obtained in 15 patients (2.5 %), and 4 follow-ups were obtained in 3 patients (0.5 %). Among young women (aged ≤29 years) with pulmonary embolism, 10 of 21 (47.6 %) had at least 1 follow-up and 4 of 21 (19.0 %) had 2 or more follow-ups in 1 year. Among all patients, recurrent pulmonary embolism was diagnosed in 15 of 141 (10.6 %) on the first follow-up CT angiogram and in 6 of 40 (15.0 %) on the second follow-up. Follow-up CT angiograms were obtained in a significant proportion of patients with pulmonary embolism, including young women, the group with the highest risk. Alternative options might be considered to reduce the hazard of radiation-induced cancer, particularly in young women.

Home Treatment of Pulmonary Embolism in the Era of Novel Oral Anticoagulants.

BACKGROUND: Outpatient therapy of patients with acute pulmonary embolism has been shown to be safe in carefully selected patients. Problems related to the injection of low-molecular-weight heparin at home can be overcome by use of novel oral anticoagulants. The purpose of this investigation is to assess the prevalence of home treatment in the era of novel oral anticoagulants. METHODS: This was a retrospective cohort study of patients aged ≥18 years with acute pulmonary embolism seen in 5 emergency departments from January 2013 to December 2014. RESULTS: Pulmonary embolism was diagnosed in 983 patients. Among these, 237 were considered ineligible for home treatment because of instability or hypoxia. Home treatment was selected for 13 of 746 (1.7%) patients who were potentially eligible. Anticoagulant treatment for those treated at home was low-molecular-weight heparin or warfarin in 9 (69.2%) and novel oral anticoagulants in 4 (30.8%). Hospitalization was chosen for 733 of 746 (98.3%). Discharge in ≤2 days was in 119 patients (16.2%). Treatment of these patients was low-molecular-weight heparin or warfarin in 76 (63.9%), novel oral anticoagulants in 34 (28.6%), and in 9 (7.6%), anticoagulants were not given because of metastatic cancer or treatment was not known. CONCLUSION: Even in the era of novel oral anticoagulants, the vast majority of patients with acute pulmonary embolism were hospitalized, and only a small proportion were discharged in ≤2 days. Although home treatment has been found to be safe in carefully selected patients, and scoring systems have been derived to identify those at low risk of adverse events, home treatment was infrequently selected.

Home treatment of deep venous thrombosis in the era of new oral anticoagulants.

This is a retrospective cohort study of adults with a primary diagnosis of deep venous thrombosis (DVT) unaccompanied by pulmonary embolism (PE), seen in 4 emergency departments in 2013 and part of 2014. The purpose was to assess the prevalence of home treatment of DVT in the present era of new oral anticoagulants. Among 96 patients with DVT and no PE, 85 (88.5%) were hospitalized and 11 (11.5%) were discharged to home. Most of the patients discharged to home received low-molecular-weight heparin, 9 (81.8%) of 11. None were prescribed new oral anticoagulants. Early discharge in ≤2 days occurred 28 (32.9%) of 85 patients. Most (64.3%) received enoxaparin and/or warfarin at early discharge. Rivaroxaban was prescribed in 7 (25.0%) of those discharged in ≤2 days. We conclude that in some emergency departments, patients with DVT are uncommonly discharged to home even though new oral anticoagulants are available.

Patient variables impacting hospital costs from 2008 to 2010.

BACKGROUND: Studying the variables associated with the increased costs of health care provides valuable insight. METHODS: A review and analysis of the pertinent variables and information collected for 118.3 million hospital admissions recorded as Nationwide Inpatient Samples database was done for the years 2008 to 2010. We used hospital charges as an approximation of costs in the analysis of the patient variables and other factors contributing to hospital costs. RESULTS: The top 5 factors with the most impact on charges were diagnostic category, length of stay, number of procedures, major operating room procedures, and ownership of the hospital. CONCLUSION: The top 5 factors with the most impact on charges were length of stay, number of procedures, major diagnostic category, major operating room procedures, and ownership of the hospital.

A single center experience with retrievable IVC filters.

OBJECTIVE: To evaluate retrievable IVC filters in our institution and assess their retrieval following a well-structured follow up program. DESIGN: Retrospective cohort study. MATERIALS: The medical records of patients implanted with retrievable IVC filters were reviewed. METHODS: All retrievable filter insertions between July 2007 and August 2011 at our institution were reviewed. Data was analyzed for age, gender, indication, complications, retrieval rate, and brand of filter inserted. Statistical analysis was done using SPSS software v19. Chi-square was used to compare discrete data and t-test for continuous data. P < 0.05 was significant. RESULTS: A total of 484 patients were reviewed of which 258 (53.1%) had a complete medical record. And 96 (37.2%) filters were placed as permanent at the time of insertion. An additional 40 (15.5%) filters were converted to permanent (total permanent filters 136; 52.7%). Death was reported in 26 (10%) patients and 96 (37.2%) out of the remaining 232 patients presented for potential retrieval. Also, 73 (28.2%) had an attempt to retrieve the filters, 69 (94.5%) were successful and 4 (5.4%) failed to retrieve. The remaining 23 (8.9%) patients declined retrieval. Filters studied include Celect (38%), Bard (31.4%), Option (26.2%), Tulip (4.1%), and Recovery (0.2%). Bard was more commonly used as a retrievable filter (80.9%). Retrieval on the first attempt was 90.4% (n = 66) successful. Of the remaining seven filters, three were successfully retrieved on a second attempt, and four failed to retrieve due to filter tilt. The success rates of retrieval for Celect and Tulip were significantly lower than for Bard (p = 0.04 and 0.023, respectively). CONCLUSION: Our study showed that a variety of IVC filters can be retrieved successfully with minimal complication rates. In more than half of our patients, IVC filters were used as permanent. Failure of retrieval was most frequently due to filter tilting.

Internal jugular vein hemangioma.

Primary tumors of the major body veins arising intraluminally are rare clinical entities. As such, few cases have been reported in the literature. As a primary tumor, hemangiomas arising in the internal jugular vein are extremely rare, while those arising in the external jugular vein are only slightly more common. We present a case of an internal jugular vein hemangioma that was incidentally discovered during an ultrasound examination performed for the evaluation of the internal carotid arteries. We believe that this is the second case of internal jugular vein hemangioma reported in the English literature.

Fluctuation of spuriously elevated troponin I: a case report.

Serum troponin is a useful laboratory study for the diagnosis of acute myocardial infarction. However, elevations can also be seen in a variety of other diseases processes. Falsely positive troponin values caused by interference with current troponin assays have been reported. We report a unique case that demonstrates the fluctuation of falsely elevated troponin correlating with hemoglobin, serving as a marker of heterophile antibody levels. A 74-year-old gentleman presented to our Emergency Department with a several-day history of increasing shortness of breath associated with a new-onset chest pain and a troponin I level of 77.28 ng/mL. Throughout his stay, fluctuations in measured troponin levels correlated strongly with fluctuations in hemoglobin levels. Several investigations confirmed false elevated troponin levels secondary to heterophile antibody interference. We conclude that hemoglobin trending in our patient represented a surrogate measure of his heterophile antibody titers with time and that fluctuations in these levels correlated with respective fluctuations in the falsely elevated troponin levels.

Penetrating abdominal aortic ulcers: case reports and review of the literature.

Atherosclerotic abdominal aortic ulcers are uncommon in contrast to those of the thoracic aorta. They present with a variety of symptoms. Computed tomography (CT) scans and magnetic resonance imaging (MRI) are the methods of diagnosis. Treatment is made easier with the use of endovascular techniques, which have less mortality and morbidity than open repair. In this paper, we present three cases of penetrating aortic ulcers presenting with abdominal pain. In two of those cases, the diagnosis was made by MRI and missed by CT scan. We present a review of the literature.