Core Warming of Coronavirus Disease 2019 Patients Undergoing Mechanical Ventilation: A Pilot Study.

Fever is a recognized protective factor in patients with sepsis, and growing data suggest beneficial effects on outcomes in sepsis with elevated temperature, with a recent pilot randomized controlled trial (RCT) showing lower mortality by warming afebrile sepsis patients in the intensive care unit (ICU). The objective of this prospective single-site RCT was to determine if core warming improves respiratory physiology of mechanically ventilated patients with coronavirus disease 2019 (COVID-19), allowing earlier weaning from ventilation, and greater overall survival. A total of 19 patients with mean age of 60.5 (±12.5) years, 37% female, mean weight 95.1 (±18.6) kg, and mean body mass index 34.5 (±5.9) kg/m2 with COVID-19 requiring mechanical ventilation were enrolled from September 2020 to February 2022. Patients were randomized 1:1 to standard of care or to receive core warming for 72 hours through an esophageal heat exchanger commonly utilized in critical care and surgical patients. The maximum target temperature was 39.8°C. A total of 10 patients received usual care and 9 patients received esophageal core warming. After 72 hours of warming, the ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO2/FiO2) ratios were 197 (±32) and 134 (±13.4), cycle thresholds were 30.8 (±6.4) and 31.4 (±3.2), ICU mortalities were 40% and 44%, 30-day mortalities were 30% and 22%, and mean 30-day ventilator-free days were 11.9 (±12.6) and 6.8 (±10.2) for standard of care and warmed patients, respectively (p = NS). This pilot study suggests that core warming of patients with COVID-19 undergoing mechanical ventilation is feasible and appears safe. Optimizing time to achieve febrile-range temperature may require a multimodal temperature management strategy to further evaluate effects on outcome. ClinicalTrials.gov Identifier: NCT04494867.

Myocardial Infarction Can Be Safely Excluded by High-sensitivity Troponin I Testing 3 Hours After Emergency Department Presentation.

BACKGROUND: The accuracy and speed by which acute myocardial infarction (AMI) is excluded are an important determinant of emergency department (ED) length of stay and resource utilization. While high-sensitivity troponin I (hsTnI) >99th percentile (upper reference level [URL]) represents a "rule-in" cutpoint, our purpose was to evaluate the ability of the Beckman Coulter hsTnI assay, using various level-of-quantification (LoQ) cutpoints, to rule out AMI within 3 hours of ED presentation in suspected acute coronary syndrome (ACS) patients. METHODS: This multicenter evaluation enrolled adults with >5 minutes of ACS symptoms and an electrocardiogram obtained per standard care. Exclusions were ST-segment elevation or chronic hemodialysis. After informed consent was obtained, blood samples were collected in heparin at ED admission (baseline), ≥1 to 3, ≥3 to 6, and ≥6 to 9 hours postadmission. Samples were processed and stored at -20°C within 1 hour and were tested at three independent clinical laboratories on an immunoassay system (DxI 800, Beckman Coulter). Analytic cutpoints were the URL of 17.9 ng/L and two LoQ cutpoints, defined as the 10 and 20% coefficient of variation (5.6 and 2.3 ng/L, respectively). A criterion standard MI diagnosis was adjudicated by an independent endpoint committee, blinded to hsTnI, and using the universal definition of MI. RESULTS: Of 1,049 patients meeting the entry criteria, and with baseline and 1- to 3-hour hsTnI results, 117 (11.2%) had an adjudicated final diagnosis of AMI. AMI patients were typically older, with more cardiovascular risk factors. Median (IQR) presentation time was 4 (1.6-16.0) hours after symptom onset, although AMI patients presented ~0.5 hour earlier than non-AMI. Enrollment and first blood draw occurred at a mean of ~1 hour after arrival. To evaluate the assay's rule-out performance, patients with any hsTnI > URL were considered high risk and were excluded. The remaining population (n = 829) was divided into four LoQ relative categories: both hsTnI < LoQ (Lo-Lo cohort); first hsTnI < LoQ and 2nd > LoQ (Lo-Hi cohort); first > LoQ and second < LoQ (Hi-Lo cohort); or both > LoQ (Hi-Hi cohort). In patients with any hsTnI result <20% CV LoQ (Groups 1-3), n = 231 (23.9% ruled out), AMI negative predictive value (NPV) was 100% (95% confidence interval [CI] = 98.9% to 100%). In patients with any hsTnI below the 10% LoQ, n = 611 (58% rule out), AMI NPV was 100% (95% CI = 99.5% to 100%). Of the Hi-Hi cohort (i.e., no hsTnI below the 10% LoQ, but both < URL), there were four AMI patients, NPV was 98.2% (95% CI = 95.4% to 99.3%), and sensitivity was 96.6. CONCLUSIONS: Patients presenting >3 hours after the onset of suspected ACS symptoms, with at least two Beckman Coulter Access hsTnI < URL and at least one of which is below either the 10 or the 20% LoQ, had a 100% NPV for AMI. Two hsTnI values 1 to 3 hours apart with both < URL, but also >LoQ had inadequate sensitivity and NPV.

Esophageal Heat Transfer for Patient Temperature Control and Targeted Temperature Management.

Controlling patient temperature is important for a wide variety of clinical conditions. Cooling to normal or below normal body temperature is often performed for neuroprotection after ischemic insult (e.g. hemorrhagic stroke, subarachnoid hemorrhage, cardiac arrest, or other hypoxic injury). Cooling from febrile states treats fever and reduces the negative effects of hyperthermia on injured neurons. Patients are warmed in the operating room to prevent inadvertent perioperative hypothermia, which is known to cause increased blood loss, wound infections, and myocardial injury, while also prolonging recovery time. There are many reported approaches for temperature management, including improvised methods that repurpose standard supplies (e.g., ice, chilled saline, fans, blankets) but more sophisticated technologies designed for temperature management are typically more successful in delivering an optimized protocol. Over the last decade, advanced technologies have developed around two heat transfer methods: surface devices (water blankets, forced-air warmers) or intravascular devices (sterile catheters requiring vascular placement). Recently, a novel device became available that is placed in the esophagus, analogous to a standard orogastric tube, that provides efficient heat transfer through the patient's core. The device connects to existing heat exchange units to allow automatic patient temperature management via a servo mechanism, using patient temperature from standard temperature sensors (rectal, Foley, or other core temperature sensors) as the input variable. This approach eliminates vascular placement complications (deep venous thrombosis, central line associated bloodstream infection), reduces obstruction to patient access, and causes less shivering when compared to surface approaches. Published data have also shown a high degree of accuracy and maintenance of target temperature using the esophageal approach to temperature management. Therefore, the purpose of this method is to provide a low-risk alternative method for controlling patient temperature in critical care settings.

A Novel Approach for the Administration of Medications and Fluids in Emergency Scenarios and Settings.

The available routes of administration commonly used for medications and fluids in the acute care setting are generally limited to oral, intravenous, or intraosseous routes, but in many patients, particularly in the emergency or critical care settings, these routes are often unavailable or time-consuming to access. A novel device is now available that offers an easy route for administration of medications or fluids via rectal mucosal absorption (also referred to as proctoclysis in the case of fluid administration and subsequent absorption). Although originally intended for the palliative care market, the utility of this device in the emergency setting has recently been described. Specifically, reports of patients being treated for dehydration, alcohol withdrawal, vomiting, fever, myocardial infarction, hyperthyroidism, and cardiac arrest have shown success with administration of a wide variety of medications or fluids (including water, aspirin, lorazepam, ondansetron, acetaminophen, methimazole, and buspirone). Device placement is straightforward, and based on the observation of expected effects from the medication administrations, absorption is rapid. The rapidity of absorption kinetics are further demonstrated in a recent report of the measurement of phenobarbital pharmacokinetics. We describe here the placement and use of this device, and demonstrate methods of pharmacokinetic measurements of medications administered by this method.

Temperature modulation with an esophageal heat transfer device - a pediatric swine model study.

BACKGROUND: An increasing number of conditions appear to benefit from control and modulation of temperature, but available techniques to control temperature often have limitations, particularly in smaller patients with high surface to mass ratios. We aimed to evaluate a new method of temperature modulation with an esophageal heat transfer device in a pediatric swine model, hypothesizing that clinically significant modulation in temperature (both increases and decreases of more than 1°C) would be possible. METHODS: Three female Yorkshire swine averaging 23 kg were anesthetized with inhalational isoflurane prior to placement of the esophageal device, which was powered by a commercially available heat exchanger. Swine temperature was measured rectally and cooling and warming were performed by selecting the appropriate external heat exchanger mode. Temperature was recorded over time in order to calculate rates of temperature change. Histopathology of esophageal tissue was performed after study completion. RESULTS: Average swine baseline temperature was 38.3°C. Swine #1 exhibited a cooling rate of 3.5°C/hr; however, passive cooling may have contributed to this rate. External warming blankets maintained thermal equilibrium in swine #2 and #3, demonstrating maximum temperature decrease of 1.7°C/hr. Warming rates averaged 0.29°C/hr. Histopathologic analysis of esophageal tissue showed no adverse effects. CONCLUSIONS: An esophageal heat transfer device successfully modulated the temperature in a pediatric swine model. This approach to temperature modulation may offer a useful new modality to control temperature in conditions warranting temperature management (such as maintenance of normothermia, induction of hypothermia, fever control, or malignant hyperthermia).

The role of prehospital electrocardiograms in the recognition of ST-segment elevation myocardial infarctions and reperfusion times.

BACKGROUND: Clinical outcomes in ST-segment elevation myocardial infarction (STEMI) are related to reperfusion times. Given the benefit of early recognition of STEMI and resulting ability to decrease reperfusion times and improve mortality, current prehospital recommendations are to obtain electrocardiograms (ECGs) in patients with concern for acute coronary syndrome. OBJECTIVES: We sought to determine the effect of wireless transmission of prehospital ECGs on STEMI recognition and reperfusion times. We hypothesized decreased reperfusion times in patients in whom prehospital ECGs were obtained. METHODS: We conducted a retrospective, observational study of patients who presented to our suburban, tertiary care, teaching hospital emergency department with STEMI on a prehospital ECG. RESULTS: Ninety-nine patients underwent reperfusion therapy. Patients with prehospital ECGs had a mean time to angioplasty suite of 43 min (95% confidence interval [CI] 31-54). Compared to patients with no prehospital ECG, mean time to angioplasty suite was 49 min (95% CI 41-57), p = 0.035. Patients with prehospital STEMI identification and catheterization laboratory activation had a mean time to angioplasty suite of 33 min (95% CI 25-41), p = 0.007. Patients with prehospital ECGs had a mean door-to-balloon time of 66 min (95% CI 53-79), whereas the control group had a mean door-to-balloon time of 79 min (95% CI 67-90), p = 0.024. Patients with prehospital STEMI identification and catheterization laboratory activation had a mean door-to-balloon time of 58 min (95% CI 48-68), p = 0.018. CONCLUSIONS: Prehospital STEMI identification allows for prompt catheterization laboratory activation, leading to decreased reperfusion times.

Emergency Department Crowding is Associated with Reduced Satisfaction Scores in Patients Discharged from the Emergency Department.

INTRODUCTION: Emergency department (ED) crowding has been shown to negatively impact patient outcomes. Few studies have addressed the effect of ED crowding on patient satisfaction. Our objective was to evaluate the impact of ED crowding on patient satisfaction in patients discharged from the ED. METHODS: We measured patient satisfaction using Press-Ganey surveys returned by patients that visited our ED between August 1, 2007 and March 31, 2008. We recorded all mean satisfaction scores and obtained mean ED occupancy rate, mean emergency department work index (EDWIN) score and hospital diversion status over each 8-hour shift from data archived in our electronic tracking board. Univariate and multivariate logistic regression analysis was calculated to determine the effect of ED crowding and hospital diversion status on the odds of achieving a mean satisfaction score ≥ 85, which was the patient satisfaction goal set forth by our ED administration. RESULTS: A total of 1591 surveys were returned over the study period. Mean satisfaction score was 77.6 (standard deviation [SD] ±16) and mean occupancy rate was 1.23 (SD ± 0.31). The likelihood of failure to meet patient satisfaction goals was associated with an increase in average ED occupancy rate (odds ratio [OR] 0.32, 95% confidence interval [CI] 0.17 to 0.59, P < 0.001) and an increase in EDWIN score (OR 0.05, 95% CI 0.004 to 0.55, P = 0.015). Hospital diversion resulted in lower mean satisfaction scores, but this was not statistically significant (OR 0.62, 95% CI 0.36 to 1.05). In multivariable analysis controlling for hospital diversion status and time of shift, ED occupancy rate remained a significant predictor of failure to meet patient satisfaction goals (OR 0.34, 95% CI 0.18 to 0.66, P = 0.001). CONCLUSION: Increased crowding, as measured by ED occupancy rate and EDWIN score, was significantly associated with reduced patient satisfaction. Although causative attribution was limited, our study suggested yet another negative impact resulting from ED crowding.

Evaluation of the revised trauma and injury severity scores in elderly trauma patients.

BACKGROUND: Severity-of-illness scoring systems have primarily been developed for, and validated in, younger trauma patients. AIMS: We sought to determine the accuracy of the injury severity score (ISS) and the revised trauma score (RTS) in predicting mortality and hospital length of stay (LOS) in trauma patients over the age of 65 treated in our emergency department (ED). MATERIALS AND METHODS: Using the Illinois Trauma Registry, we identified all patients 65 years and older treated in our level I trauma facility from January 2004 to November 2007. The primary outcome was death; the secondary outcome was overall hospital length of stay (LOS). We measured associations between scores and outcomes with binary logistic and linear regression. RESULTS: A total of 347 patients, 65 years of age and older were treated in our hospital during the study period. Median age was 76 years (IQR 69-82), with median ISS 13 (IQR 8-17), and median RTS 7.8 (IQR 7.1-7.8). Overall mortality was 24%. A higher value for ISS showed a positive correlation with likelihood of death, which although statistically significant, was numerically small (OR=1.10, 95% CI 1.06 to 1.13, P<0.001). An elevated RTS had an inverse correlation to likelihood of death that was also statistically significant (OR=0.48, 95% CI 0.39 to 0.58, P<0.001). Total hospital LOS increased with increasing ISS, with statistical significance decreasing at the highest levels of ISS, but an increase in RTS not confirming the predicted decrease in total hospital LOS consistently across all ranges of RTS. CONCLUSIONS: The ISS and the RTS were better predictors of mortality than hypothesized, but had limited correlation with hospital LOS in elderly trauma patients. Although there may be some utility in these scores when applied to the elderly population, caution is warranted if attempting to predict the prognosis of patients.

Diagnosis of pneumonia in the ED has poor accuracy despite diagnostic uncertainty.

BACKGROUND: In 2007, the Centers for Medicare and Medicaid Services created a measure known as "diagnostic uncertainty" in emergency department (ED) pneumonia admissions. This documentation excludes the antibiotic timing measure, as pressure to quickly diagnose pneumonia may serve to reduce overall accuracy. STUDY OBJECTIVES: The objective of the study was to determine the correlation between ED and final discharge diagnosis of pneumonia and measure the effect of invoking the diagnostic uncertainty documentation on accuracy. METHODS: We retrospectively reviewed all ED pneumonia admissions among adults from July to October 2008. We analyzed the effect of invoking the diagnostic uncertainty documentation in the ED by comparing against final outcomes. We then performed a multivariate analysis to adjust for the potential effects of sex, age, Emergency Severity Index (ESI) score, weekend arrival, and level of ED-attending physician staffing. RESULTS: Of 401 patients who were admitted with pneumonia, 297 (74%) had a discharge diagnosis of pneumonia, with 72 (18%) of those diagnoses being the primary outcome. Diagnostic uncertainty documentation was used in 11% (45/401). This documentation did not significantly alter the odds of a primary pneumonia discharge diagnosis (odds ratio, 0.68; 95% confidence interval, 0.28-1.7) but did reduce the odds of pneumonia being diagnosed (odds ratio, 0.43; 95% confidence interval, 0.23-0.81). Sex, age, day of week, and (ESI) score remained nonsignificant predictors. CONCLUSIONS: Correlation between ED and discharge diagnosis of pneumonia was limited. Use of diagnostic uncertainty documentation decreased the likelihood of a hospital discharge diagnosis of pneumonia. Further analysis of the effects of artificially imposed time constraints on ED diagnoses appears warranted.

Therapeutic hypothermia induction via an esophageal route--a computer simulation.

OBJECTIVES: Mild therapeutic hypothermia has been shown to improve outcomes after adult cardiac arrest but remains underused. Development of easier methods than currently exist to induce therapeutic hypothermia may help increase use of this treatment. We developed a mathematical model to evaluate the potential to induce mild therapeutic hypothermia through the esophagus. METHODS: Using a finite element mathematical modeling software package incorporating Pennes Bioheat equation, we predicted the changes in body temperature that would occur with placement of an esophageal cooling device containing recirculating chilled water at 10°C. RESULTS: Patient temperature under the simulated conditions decreased from 37°C to 33°C in approximately 40 minutes. Distribution of body temperature was not uniform in our model, with the skin surface and extremities showing a greater temperature decrease than in the patient's core. CONCLUSIONS: Our computer simulations suggest that inducing mild therapeutic hypothermia via an esophageal route is feasible.

Crowding does not adversely affect time to percutaneous coronary intervention for acute myocardial infarction in a community emergency department.

STUDY OBJECTIVE: Multiple studies have linked emergency department (ED) crowding to delays in patient care, such as treatment with antibiotics and analgesics. Multiple studies have also demonstrated the benefit of timely percutaneous coronary intervention for patients with acute ST-segment elevation myocardial infarction (STEMI). We therefore study whether increased occupancy rates in our community ED might correlate with delays in door-to-balloon time for patients with acute STEMI who are referred for emergency percutaneous coronary intervention. METHODS: This study was a single-institution prospective observational study. For every patient arriving in our ED from June 2007 through October 2009 with acute STEMI treated with percutaneous coronary intervention, we measured the ED occupancy rate on arrival and the door-to-balloon time and determined the correlation between these variables in univariate and multivariate analyses controlling for patient characteristics, occupancy rate, times to ECG and catheter laboratory activation, and the availability of the catheterization laboratory team (in-house versus on-call). RESULTS: During the study period, 210 patients were treated with emergency percutaneous coronary intervention in accordance with the hospital protocol. For these patients, the mean ED occupancy rate at arrival was 127% (range 28% to 214%). The mean time to balloon inflation was 65 minutes (range 25 to 142 minutes). The time to balloon inflation did not significantly change with increasing occupancy rate in univariate analysis (Spearman's correlation -0.02; 95% confidence interval -0.13 to 0.11) or in multivariate analysis, with the only significant variable being the availability of the catheterization laboratory team in house, which was associated with reduced time to balloon inflation. CONCLUSION: Times to achieve emergency percutaneous coronary intervention for acute STEMI do not correlate positively with crowding as measured by the occupancy rate in our ED.

Induction of therapeutic hypothermia via the esophagus: a proof of concept study.

BACKGROUND: Induction of hypothermia (a 4 °C decrease from baseline) improves outcomes in adult cardiac arrest and neonatal hypoxic ischemic encephalopathy, and may benefit other conditions as well. Methods used to implement or prevent hypothermia typically require skin contact with blankets or pads or intravascular access with catheter devices. The study was to evaluate the potential to induce mild therapeutic hypothermia via an esophageal route in a porcine model. METHODS: Single-animal proof-of-concept study of a prototype esophageal device in a 70 kg Yorkshire swine. We measured the rate of temperature change after placement of a prototype device to induce hypothermia via the esophagus, and compared this rate to known temperature changes that occur under similar laboratory conditions without a hypothermic device. RESULTS: Swine temperature decreased from a starting temperature of 37.8 °C to 33.8 °C (achieving the goal of a 4 °C decrease) in 175 minutes, resulting in a cooling rate of 1.37 °C/h. Histopathology of the esophagus showed normal tissue without evidence of injury. CONCLUSION: A prototype of an esophageal cooling device induced hypothermia effectively in a large single-swine model.

Correlation between impedance cardiography and B-type natriuretic peptide levels in dyspneic patients.

BACKGROUND: Both serum measurements of B-type natriuretic peptide (BNP) and impedance cardiography (ICG) are used to evaluate patients for congestive heart failure (CHF) in the Emergency Department (ED), but the agreement between the data obtained by these two methods remains uncertain. STUDY OBJECTIVES: We sought to measure the correlation between BNP levels and ICG measurements in patients presenting to the ED with dyspnea, and compare the diagnostic accuracy of each method in diagnosing CHF. METHODS: We performed a prospective observational study of a convenience sample of patients presenting to the ED with dyspnea and being evaluated for CHF as a cause of their symptoms. An ICG measurement was obtained on each patient and the correlation between BNP level and the ICG parameters cardiac index (CI), systemic vascular resistance (SVR), and thoracic fluid content (TFC) was measured. To further quantify the diagnostic accuracy of ICG and BNP, we then constructed receiver operating characteristic curves based on discharge diagnosis of CHF and compared the area under the curve (AUC) of each test. RESULTS: Out of 54 patients enrolled, correlation was poor between BNP and CI (Spearman's ρ = -.07, p = 0.64) and between BNP and SVR (Spearman's ρ = -.10, p = 0.46), but moderate between BNP and TFC (Spearman's ρ = .32, p = 0.02); a wide degree of scatter was seen in all correlations. BNP levels showed the best diagnostic accuracy for a discharge diagnosis of CHF, with an AUC of .77 (95% confidence interval .59-.95), whereas CI had an AUC of .72 (95% confidence interval .55-.88). CONCLUSION: We found limited correlation between BNP levels and ICG parameters, suggesting that, in our population, the two tests may not consistently give similar information. BNP level and CI both provided only fair diagnostic accuracy for discharge diagnosis of CHF.

Comparison of severity of illness scoring systems in the prediction of hospital mortality in severe sepsis and septic shock.

BACKGROUND: New scoring systems, including the Rapid Emergency Medicine Score (REMS), the Mortality in Emergency Department Sepsis (MEDS) score, and the confusion, urea nitrogen, respiratory rate, blood pressure, 65 years and older (CURB-65) score, have been developed for emergency department (ED) use in various patient populations. Increasing use of early goal directed therapy (EGDT) for the emergent treatment of sepsis introduces a growing population of patients in which the accuracy of these scoring systems has not been widely examined. OBJECTIVES: To evaluate the ability of the REMS, MEDS score, and CURB-65 score to predict mortality in septic patients treated with modified EGDT. MATERIALS AND METHODS: Secondary analysis of data from prospectively identified patients treated with modified EGDT in a large tertiary care suburban community hospital with over 85,000 ED visits annually and 700 inpatient beds, from May 2007 through May 2008. We included all patients with severe sepsis or septic shock, who were treated with our modified EGDT protocol. Our major outcome was in-hospital mortality. The performance of the scores was compared by area under the ROC curves (AUCs). RESULTS: A total of 216 patients with severe sepsis or septic shock were treated with modified EGDT during the study period. Overall mortality was 32.9%. Calculated AUCs were 0.74 [95% confidence interval (CI): 0.67-0.81] for the MEDS score, 0.62 (95% CI: 0.54-0.69) for the REMS, and 0.59 (95% CI: 0.51-0.67) for the CURB-65 score. CONCLUSION: We found that all three ED-based systems for scoring severity of illness had low to moderate predictive capability. The MEDS score demonstrated the largest AUC of the studied scoring systems for the outcome of mortality, although the CIs on point estimates of the AUC of the REMS and CURB-65 scores all overlap.

Occupancy rates and emergency department work index scores correlate with leaving without being seen.

OBJECTIVE: TWO CROWDING METRICS ARE OFTEN USED TO MEASURE EMERGENCY DEPARTMENT (ED) CROWDING: the occupancy rate and the emergency department work index (EDWIN) score. To evaluate these metrics for applicability in our community ED, we sought to measure their correlation with the number of patients who left without being seen (LWBS) and determine if either, or both, correlated with our daily LWBS rate. We hypothesized a statistically significant positive correlation between the number of patients who LWBS and both crowding metrics. METHODS: We performed a retrospective observational study by reviewing data on all patients who LWBS from December 1, 2007, to February 29, 2008. Occupancy rates and EDWIN scores were obtained through our electronic patient tracking board. We identified LWBS status by searching the final disposition entered into our electronic medical record. We measured the correlation between each crowding metric averaged over each 24-hour day and the number of patients who LWBS per 24-hour day using Spearman's rank correlation, and created receiver operator characteristic (ROC) curves to quantify the discriminatory power of occupancy rate and EDWIN score for predicting more than two patients per day who LWBS. RESULTS: We identified 1,193 patients who LWBS during the study period, including patients who registered but then left the waiting room (733), as well as those who left before: registration (71), triage (75), seeing a physician (260), or final disposition (54). The number of patients who LWBS per day ranged from one to 30, with a mean of 13 and median of 11 (IQR 6 to 19). The daily number of patients who LWBS showed a positive correlation with the average daily occupancy rate (Spearman's rho = 0.771, p = 0.01) and with average daily EDWIN score (Spearman's rho = 0.67, p< .001). Area under the ROC curve for occupancy rate was .97 (95% CI .93 to 1.0) and for EDWIN score was .94 (95% CI .89 to 1.0). CONCLUSION: Average daily occupancy rates and EDWIN scores both correlate positively with, and have excellent discriminatory power for, the number of patients who LWBS in our ED; however, the scale of our EDWIN scores differs from that obtained at other institutions. For studies of crowding, occupancy rate may be the more useful metric due to its ease of calculation.

A comparison of the effects of etomidate and midazolam on hospital length of stay in patients with suspected sepsis: a prospective, randomized study.

STUDY OBJECTIVE: Etomidate, a widely used induction agent for rapid sequence intubation in the emergency department (ED), causes measurable adrenal suppression after a single bolus dose. The clinical significance of this adrenal suppression in patients with sepsis remains controversial. We seek to determine the difference in hospital length of stay between patients with suspected sepsis who receive either etomidate or midazolam during intubation in our ED. METHODS: We performed a prospective, double-blind, randomized study of patients with suspected sepsis who were intubated in our ED during an 18-month period. Eligible patients who were critically ill and were suspected of having sepsis were randomized to receive either etomidate or midazolam before intubation. RESULTS: A total of 122 patients were enrolled; 59 received midazolam and 63 received etomidate. Two patients in the etomidate group were lost to follow-up. Patient baseline characteristics were similar between groups. There were no significant differences in median hospital length of stay (9.5 versus 7.3 days), ICU length of stay (4.2 versus 3.1 days), or ventilator days (2.8 versus 2.1) between patients who received midazolam and those who received etomidate, respectively. Inhospital mortality was 21 of 59 (36%; 95% confidence interval 24% to 49%) for patients who received midazolam and 26 of 61 (43%; 95% confidence interval 30% to 56%) for patients who received etomidate. For patients who survived to hospital discharge, the median length of stay was 11.3 days in the midazolam group versus 11.8 days in the etomidate group; for patients who died, the median length of stay was 2.9 days in the midazolam group versus 3.3 days in the etomidate group. CONCLUSION: Patients with suspected sepsis and who received a single bolus dose of etomidate for rapid sequence intubation showed no significant increase in hospital length of stay compared with patients who received a single bolus dose of midazolam.

ED crowding is associated with an increased time to pneumonia treatment.

OBJECTIVE: We measured the correlation between emergency department (ED) occupancy rate and time to antibiotic administration for patients with pneumonia treated in a community hospital setting. METHODS: We reviewed quality improvement data on patients treated for pneumonia in our ED and admitted over a 5-month period. The outcomes were timeliness of antibiotic therapy (within 4 hours of arrival) and overall time to antibiotic administration. Emergency department crowding was measured as the ED occupancy rate. We calculated (1) the Spearman correlation between occupancy rate at time of patient presentation and the time to antibiotic administration, (2) the odds ratio of receiving antibiotics within 4 hours with increasing ED occupancy, and (3) the ability of the occupancy rate to predict failure of achieving the 4-hour goal with the receiver operating characteristic curve. RESULTS: A total of 334 patients were treated over the study period, of which 262 had complete data available. Occupancy rate ranged from 20% to 245%, and median was 137%. Eighty-one percent received antibiotics within 4 hours; the median time was 150 minutes. Time to antibiotics showed a positive correlation with occupancy rate (Spearman ρ = 0.17, P = .008). An increasing ED occupancy rate was associated with decreased odds of receiving antibiotics within 4 hours (odds ratio, 0.31; 95% confidence interval, 0.13-0.75). Receiver operating characteristic curve area was 0.62 (95% confidence interval, 0.54-0.70; P = .009). CONCLUSION: Emergency department occupancy rate was associated with increased time to antibiotic treatment for patients admitted with pneumonia. Occupancy rate had fair success in predicting failure of treatment within 4 hours.

Etomidate as an induction agent in septic patients: red flags or false alarms?

Despite its widespread use in North America and many other parts of the world, the safety of etomidate as an induction agent for rapid sequence intubation in septic patients is still debated. In this article, we evaluate the current literature on etomidate, review its clinical history, and discuss the controversy regarding its use, especially in sepsis. We address eight questions: (i) When did concern over the safety of etomidate first arise? (ii) What is the mechanism by which etomidate is thought to affect the adrenal axis? (iii) How has adrenal insufficiency in relation to etomidate use been defined or identified in the literature? (iv) What is the evidence that single dose etomidate is associated with subsequent adrenal-cortisol dysfunction? (v) What is the clinical significance of adrenal insufficiency or dysfunction associated with single dose etomidate, and where are the data that support or refute the contention that single-dose etomidate is associated with increased mortality or important post emergency department (ED) clinical outcomes? (vi) How should etomidate's effects in septic patients best be measured? (vii) What are alternative induction agents and what are the advantages and disadvantages of these agents relative to etomidate? (viii) What future work is needed to further clarify the characteristics of etomidate as it is currently used in patients with sepsis? We conclude that the observational nature of almost all available data suggesting adverse outcomes from etomidate does not support abandoning its use for rapid sequence induction. However, because we see a need to balance theoretical harms and benefits in the presence of data supporting the non-inferiority of alternative agents without similar theoretical risks associated with them, we suggest that the burden of proof to support continued widespread use may rest with the proponents of etomidate. We further suggest that practitioners become familiar with the use of more than one agent while awaiting further definitive data.