Differences in Out-of-Hospital Cardiac Arrest Outcomes Among 5 Racial/Ethnic Groups.

OBJECTIVE: Out-of-hospital cardiac arrest (OHCA) is a major health problem and one of the leading causes of death in adults older than 40. Multiple prior studies have demonstrated survival disparities based on race/ethnicity, but most of these focus on a single racial/ethnic group. This study evaluated OHCA variables and outcomes among on 5 racial/ethnic groups. METHODS: This is a retrospective review of data for adult patients in the Cardiac Arrest Registry to Enhance Survival (CARES) from 3 racially diverse urban counties in the San Francisco Bay Area from May 2009 to October 2021. Stratifying by 5 racial/ethnic groups, we evaluated patient survival outcomes based on patient demographics, emergency medical services response location, cardiac arrest characteristics, and hospital interventions. Adjusted risk ratios were calculated for survival to hospital discharge, controlling for sex, age, response locations, median income of response location, arrest witness, shockable rhythm, and bystander cardiopulmonary resuscitation as well as clustering by census tract. RESULTS: There were 10,757 patient entries analyzed: 42% White, 24% Black, 18% Asian, 9.3% Hispanic, 6.0% Pacific Islander, 0.7% American Indian/Alaska Native, and 0.1% multiple races selected; however, only the first 5 racial/ethnic groups had sufficient numbers for comparison. The adjusted risk ratio for survival to hospital discharge was lower among the 4 racial/ethnic groups compared with the White reference group: Black (0.79, p = 0.003), Asian (0.78 p = 0.004), Hispanic (0.79, p = 0.018), and Pacific Islander (0.78, p = 0.041) groups. The risk difference for positive neurologic outcome was also lower among all 4 racial/ethnic groups compared with the White reference group. CONCLUSIONS: The Black, Asian, Hispanic, and Pacific Islander groups were less likely to survive to hospital discharge from OHCA when compared with the White reference group. No variables were associated with decreased survival across any of these 4 groups.

Association between psoriasis and cardiometabolic comorbidities in a racially and ethnically diverse low-income primary care population.

Psoriasis is associated with cardiometabolic comorbidities, including obesity, diabetes, hyperlipidaemia and hypertension. Many studies that established these associations originated from primarily White and/or relatively affluent populations. To evaluate whether there is a differential risk for cardiometabolic comorbidities in racial/ethnic minorities, we performed a cross-sectional analysis comparing cardiometabolic comorbidities between those with and without psoriasis in a racially and ethnically diverse population of 56 987 low-income patients, stratified by race/ethnicity, and assessed whether race/ethnicity acts as an effect modifier for cardiometabolic comorbidities. We found that psoriasis was statistically significantly associated with obesity, diabetes, hyperlipidaemia and hypertension. The association of psoriasis with comorbidities did not differ significantly by race/ethnicity; thus, we did not find evidence of effect modification. However, our diverse, low-income population had an extremely high baseline prevalence of cardiometabolic comorbidities compared with previous populations studied. Our results suggest education and intervention regarding modifiable risk factors are particularly important among vulnerable populations.

Association of an Emergency Critical Care Program With Survival and Early Downgrade Among Critically Ill Medical Patients in the Emergency Department.

OBJECTIVES: To determine whether implementation of an Emergency Critical Care Program (ECCP) is associated with improved survival and early downgrade of critically ill medical patients in the emergency department (ED). DESIGN: Single-center, retrospective cohort study using ED-visit data between 2015 and 2019. SETTING: Tertiary academic medical center. PATIENTS: Adult medical patients presenting to the ED with a critical care admission order within 12 hours of arrival. INTERVENTIONS: Dedicated bedside critical care for medical ICU patients by an ED-based intensivist following initial resuscitation by the ED team. MEASUREMENTS AND MAIN RESULTS: Primary outcomes were inhospital mortality and the proportion of patients downgraded to non-ICU status while in the ED within 6 hours of the critical care admission order (ED downgrade <6 hr). A difference-in-differences (DiD) analysis compared the change in outcomes for patients arriving during ECCP hours (2 pm to midnight, weekdays) between the preintervention period (2015-2017) and the intervention period (2017-2019) to the change in outcomes for patients arriving during non-ECCP hours (all other hours). Adjustment for severity of illness was performed using the emergency critical care Sequential Organ Failure Assessment (eccSOFA) score. The primary cohort included 2,250 patients. The DiDs for the eccSOFA-adjusted inhospital mortality decreased by 6.0% (95% CI, -11.9 to -0.1) with largest difference in the intermediate illness severity group (DiD, -12.2%; 95% CI, -23.1 to -1.3). The increase in ED downgrade less than 6 hours was not statistically significant (DiD, 4.8%; 95% CI, -0.7 to 10.3%) except in the intermediate group (DiD, 8.8%; 95% CI, 0.2-17.4). CONCLUSIONS: The implementation of a novel ECCP was associated with a significant decrease in inhospital mortality among critically ill medical ED patients, with the greatest decrease observed in patients with intermediate severity of illness. Early ED downgrades also increased, but the difference was statistically significant only in the intermediate illness severity group.

Diagnostic accuracy of point-of-care ultrasonography for intussusception in children: A systematic review and meta-analysis.

OBJECTIVES: Ileocolic intussusception can be challenging to diagnose due to vague complaints, but rapid diagnosis and treatment can help prevent morbidity and mortality. Prior research has focused on radiologic ultrasound, with more recent studies focusing on point-of-care ultrasonography (POCUS). This systematic review and meta-analysis assesses the diagnostic accuracy of POCUS for children with suspected ileocolic intussusception. METHODS: PubMed, Embase, CINAHL, LILACS, the Cochrane databases, Google Scholar, conference abstracts, and bibliographies of selected articles were searched for studies evaluating the accuracy of POCUS for the diagnosis of intussusception in children. Data were dual extracted into a predefined worksheet, and quality analysis was performed with the QUADAS-2 tool. Data were summarized, and a meta-analysis was performed. RESULTS: Eleven studies (n = 2400 children) met our inclusion criteria. Overall, 14.4% of children had intussusception. POCUS was 95.1% (95% CI: 90.3% to 97.2%) sensitive and 98.1% (95% CI: 95.8% to 99.2%) specific with a positive likelihood ratio of 50 (95% CI: 23 to 113) and a negative likelihood ratio of 0.05 (95% CI: 0.03 to 0.09). CONCLUSIONS: POCUS has excellent diagnostic accuracy for intussusception in children presenting to the emergency department.

Is AVPU comparable to GCS in critical prehospital decisions? - A cross-sectional study.

BACKGROUND: Advanced Trauma Life Support field triage utilizes the Glasgow Coma Scale (GCS) to assess the level of consciousness. However, prehospital care providers in low- and middle-income countries (LMICs) often use the Alert, Verbal, Pain, and Unresponsive (AVPU) scale to assess the level of consciousness. This study aimed to determine whether prehospital AVPU categorization correlates with mortality rates in trauma victims, similarly to GCS. METHODS: In this cross-sectional study conducted between November 2015 and January 2016, we enrolled a convenience sample of prehospital trauma-related field activations. The primary outcome measure was the probability of death within 48 h for each category of AVPU. RESULTS: In a convenience sample of 4514 activations, 1606 (35.6%) met exclusion criteria, four did not have AVPU, and four did not have GCS, leaving 2900 (64.2%) trauma activations with both AVPU and GCS available for analysis. Forty-eight-hour follow-up data were available for 2184 (75.3%) activations out of these 2900. The 48-h mortality rates for each category of AVPU were 1.1% (Alert), 4.3% (Verbal), 17.9% (Pain), 53.2% (Unresponsive); and, for each GCS-based injury severity category, they were 0.9% (Mild, GCS 13-15), 8.1% (Moderate, GCS 9-12), 43.5% (Severe, GCS ≤ 8). Overall, there was a statistically significant difference in GCS for each category of AVPU (p < 0.001) except between patients responding to verbal commands and those responding to pain (p = 0.18). The discriminative ability of AVPU (AUC 79.7% (95% CI 73.4-86.1)) and GCS (AUC 81.5% (95% CI 74.8-88.2)) for death within 48-h following hospital drop-off were comparable. CONCLUSION: EMT assessments of AVPU and GCS relate to each other, and AVPU predicts mortality at 48 h. Future studies using AVPU to assess the level of consciousness in prehospital trauma protocols may simplify their global application without impacting the overall quality of care.

SARS COV-2 anti-nucleocapsid and anti-spike antibodies in an emergency department healthcare worker cohort: September 2020 - April 2021.

BACKGROUND: Emergency department (ED) workers have an increased seroprevalence of SARS-CoV-2 antibodies. However, breakthrough infections in ED workers have led to a reduced workforce within a strained healthcare system. By measuring levels of IgG antibodies to the SARS-CoV-2 nucleocapsid and spike antigens in ED workers, we determined the incidence of infection and described the course of antibody levels. We also measured the antibody response to vaccination and examined factors associated with immunogenicity. METHODS: We conducted a prospective cohort study of ED workers conducted at a single ED from September 2020-April 2021. IgG antibodies to the SARS-CoV-2 nucleocapsid antigen were measured at baseline, 3, and 6 months, and IgG antibodies to the SARS-CoV-2 spike antigen were measured at 6 months. RESULTS: At baseline, we found 5 out of 139 (3.6%) participants with prior infection. At 6 months, 4 of the 5 had antibody results below the test manufacturer's positivity threshold. We identified one incident case of SARS-COV-2 infection out of 130 seronegative participants (0.8%, 95% CI 0.02-4.2%). In 131 vaccinated participants (125 BNT162b2, 6 mRNA-1273), 131 tested positive for anti-spike antibodies. We identified predictors of anti-spike antibody levels: time since vaccination, prior COVID-19 infection, age, and vaccine type. Each additional week since vaccination was associated with an 11.1% decrease in anti-spike antibody levels. (95% CI 6.2-15.8%). CONCLUSION: ED workers experienced a low incidence of SARS-CoV-2 infection and developed antibodies in response to vaccines and prior infection. Antibody levels decreased markedly with time since infection or vaccination.

Natural language processing of head CT reports to identify intracranial mass effect: CTIME algorithm.

BACKGROUND: The Mortality Probability Model (MPM) is used in research and quality improvement to adjust for severity of illness and can also inform triage decisions. However, a limitation for its automated use or application is that it includes the variable "intracranial mass effect" (IME), which requires human engagement with the electronic health record (EHR). We developed and tested a natural language processing (NLP) algorithm to identify IME from CT head reports. METHODS: We obtained initial CT head reports from adult patients who were admitted to the ICU from our ED between 10/2013 and 9/2016. Each head CT head report was labeled yes/no IME by at least two of five independent labelers. The reports were then randomly divided 80/20 into training and test sets. All reports were preprocessed to remove linguistic and style variability, and a dictionary was created to map similar common terms. We tested three vectorization strategies: Term Frequency-Inverse Document frequency (TF-IDF), Word2Vec, and Universal Sentence Encoder to convert the report text to a numerical vector. This vector served as the input to a classification-tree-based ensemble machine learning algorithm (XGBoost). After training, model performance was assessed in the test set using the area under the receiver operating characteristic curve (AUROC). We also divided the continuous range of scores into positive/inconclusive/negative categories for IME. RESULTS: Of the 1202 CT reports in the training set, 308 (25.6%) reports were manually labeled as "yes" for IME. Of the 355 reports in the test set, 108 (30.4%) were labeled as "yes" for IME. The TF-IDF vectorization strategy as an input for the XGBoost model had the best AUROC:-- 0.9625 (95% CI 0.9443-0.9807). TF-IDF score categories were defined and had the following likelihood ratios: "positive" (TF-IDF score > 0.5) LR = 24.59; "inconclusive" (TF-IDF 0.05-0.5) LR = 0.99; and "negative" (TF-IDF < 0.05) LR = 0.05. 82% of reports were classified as either "positive" or "negative". In the test set, only 4 of 199 (2.0%) reports with a "negative" classification were false negatives and only 8 of 93 (8.6%) reports classified as "positive" were false positives. CONCLUSION: NLP can accurately identify IME from free-text reports of head CTs in approximately 80% of records, adequate to allow automatic calculation of MPM based on EHR data for many applications.

Risk Factors for Peri-intubation Cardiac Arrest in a Pediatric Emergency Department.

OBJECTIVES: Cardiac arrest is a significant complication of emergent endotracheal intubation (ETI) within the pediatric population. No studies have evaluated risk factors for peri-intubation cardiac arrest (PICA) in a pediatric emergency department (ED) setting. This study identified risk factors for PICA among patients undergoing emergent ETI in a pediatric ED. METHODS: We performed a nested case-control study within the cohort of children who underwent emergent ETI in our pediatric ED during a 9-year period. Cases were children with PICA within 20 minutes of ETI. Controls (4 per case) were randomly selected children without PICA after ETI. We analyzed potential risk factors based on published data and physiologic plausibility and created a simple risk model using univariate results, model fit statistics, and clinical judgment. RESULTS: In the cohort of patients undergoing ETI, PICA occurred in 21 of 543 subjects (3.9%; 95% confidence interval [CI], 2.2-5.9%), with return of spontaneous circulation in 16 of 21 (76.2%; 95% CI, 52.8-91.8%) and survival to discharge in 12 of 21 (57.1%; 95% CI, 34.0-78.2%). On univariate analysis, cases were more likely to be younger, have delayed capillary refill time, systolic or diastolic hypotension, hypoxia, greater than one intubation attempt, no sedative or paralytic used, and pulmonary disease compared with controls. Our 4-category risk model for PICA combined preintubation hypoxia (or an unobtainable pulse oximetry value) and younger than 1 year. The area under the receiver operating characteristic curve for this model was 0.87 (95% CI, 0.77-0.97). CONCLUSIONS: Hypoxia (or an unobtainable pulse oximetry value) was the strongest predictor for PICA among children after emergent ETI in our sample. A simple risk model combining pre-ETI hypoxia and younger than 1 year showed excellent discrimination in this sample. Our results require independent validation.

Pupillary unrest, opioid intensity, and the impact of environmental stimulation on respiratory depression.

Opioid-induced respiratory depression (OIRD) confers significant morbidity, but its onset can be challenging to recognize. Pain or stimulation effects of conversation may mask or attenuate common clinical manifestations of OIRD. We asked whether pupillary unrest could provide an objective signal of opioid exposure, and whether this signal would be independent from the confounding influence of extrinsic stimulation. We conducted a cross-over trial of healthy volunteers using identical remifentanil infusions separated by a washout period; in both, pupillary unrest in ambient light (PUAL) was measured at 2.5-min intervals. During one infusion, investigators continuously engaged the subject in conversation, while in the other, a quiet environment was maintained; measures of respiratory depression were compared under each condition. We tested PUAL's relationship to estimated opioid concentration under quiet conditions, measured PUAL's discrimination of lower versus higher opioid exposure using receiver operating characteristic (ROC) analysis, and assessed the effect of stimulation on PUAL versus opioid using mixed effects regression. Respiratory depression occurred more frequently under quiet conditions (p < 0.0001). Under both conditions, PUAL declined significantly over the course of the remifentanil infusion and rose during recovery (p < 0.0001). PUAL showed excellent discrimination in distinguishing higher versus absent-moderate opioid exposure (AUROC = 0.957 [0.929 to 0.985]), but was unaffected by interactive versus quiet conditions (mean difference, interactive - quiet = - 0.007, 95% CI - 0.016 to 0.002). PUAL is a consistent indicator of opioid effect, and distinguishes higher opioid concentrations independently of the stimulating effects of conversational interaction. Under equivalent opioid exposure, conversational interaction delayed the onset and minimized the severity of OIRD.Clinical trial registration: NCT04301895.

Identification of Generalized Convulsive Status Epilepticus from Emergency Medical Service Records: A Validation Study of Diagnostic Coding.

BACKGROUND: Generalized convulsive status epilepticus (GCSE) is a neurologic emergency demanding prehospital identification and treatment. Evaluating real-world practice requires accurately identifying the target population; however, it is unclear whether emergency medical services (EMS) documentation accurately identifies patients with GCSE. OBJECTIVE: To evaluate the validity of EMS diagnostic impressions for GCSE. METHODS: This was an analysis of electronic medical records of a California county EMS system from 2013 to 2018. We identified all cases with a primary diagnostic impression of "seizure-active," "seizure-post," or "seizure-not otherwise specified (NOS)" and within each diagnostic category, we randomly selected 75 adult and 25 pediatric records. Two authors reviewed the provider narrative of these 300 charts to determine a clinical seizure diagnosis according to prespecified definitions. We calculated a kappa for interrater reliability of the clinical diagnosis. We then calculated the positive predictive value (PPV), sensitivity, and specificity of an EMS diagnosis of "seizure-active" diagnosis for identifying GCSE. Sensitivity and specificity calculations were weighted according to the distribution of seizure cases in the overall population. We performed a descriptive analysis of records with an incorrect EMS diagnosis of GCSE or seizure. RESULTS: Of 38,995 total records for seizure, there were 3401 (8.7%) seizure-active cases, 12,478 (32.0%) seizure-NOS cases, and 23,116 (59.4%) seizure-post cases. An EMS diagnosis of "seizure-active" had a PPV of 65.0% (95% CI 54.8-74.3), sensitivity of 54.6% (95% confidence interval [CI] 39.3-69.0), and specificity of 96.6% (95% CI 95.1-97.6) for capturing GCSE. Limiting the case definition to patients who received an EMS diagnosis of "seizure-active" and were treated with a benzodiazepine increased the PPV (80.2%; 95% CI 69.9-88.2) and specificity (99.3%; 95% CI 98.7-99.6) while the sensitivity decreased (25.1%; 95% CI 17.0-35.3). Across the 300 records reviewed, there were 19 (6.3%) patients who had a non-seizure related diagnosis including non-epileptic spells (7 records), altered mental status (8 records), tremors (2 records), anxiety (1 record), and stroke (1 record). CONCLUSIONS: EMS diagnostic impressions have reasonable PPV and specificity but low sensitivity for GCSE. Improved coding algorithms and training will allow for improved benchmarking, quality improvement, and research about this neurologic emergency.

SARS-CoV-2 IgG Seropositivity and Acute Asymptomatic Infection Rate among Firefighter First Responders in an Early Outbreak County in California.

Objective: Firefighter first responders and other emergency medical services (EMS) personnel have been among the highest risk healthcare workers for illness during the SARS-CoV-2 pandemic. We sought to determine the rate of seropositivity for SARS-CoV-2 IgG antibodies and of acute asymptomatic infection among firefighter first responders in a single county with early exposure in the pandemic. Methods: We conducted a cross-sectional study of clinically active firefighters cross-trained as paramedics or EMTs in the fire departments of Santa Clara County, California. Firefighters without current symptoms were tested between June and August 2020. Our primary outcomes were rates of SARS-CoV-2 IgG antibody seropositivity and SARS-CoV-2 RT-PCR swab positivity for acute infection. We report cumulative incidence, participant characteristics with frequencies and proportions, and proportion positive and associated relative risk (with 95% confidence intervals). Results: We enrolled 983 out of 1339 eligible participants (response rate: 73.4%). Twenty-five participants (2.54%, 95% CI 1.65-3.73) tested positive for IgG antibodies and 9 (0.92%, 95% CI 0.42-1.73) tested positive for SARS-CoV-2 by RT-PCR. Our cumulative incidence, inclusive of self-reported prior positive PCR tests, was 34 (3.46%, 95% CI 2.41-4.80). Conclusion: In a county with one of the earliest outbreaks in the United States, the seroprevalence among firefighter first responders was lower than that reported by other studies of frontline health care workers, while the cumulative incidence remained higher than that seen in the surrounding community.

eccSOFA: SOFA illness severity score adapted to predict in-hospital mortality in emergency critical care patients.

BACKGROUND: Boarding of ICU patients in the ED is increasing. Illness severity scores may help emergency physicians stratify risk to guide earlier transfer to the ICU and assess pre-ICU interventions by adjusting for baseline mortality risk. Most existing illness severity scores are based on data that is not available at the time of the hospital admission decision or cannot be extracted from the electronic health record (EHR). We adapted the SOFA score to create a new illness severity score (eccSOFA) that can be calculated at the time of ICU admission order entry in the ED using EHR data. We evaluated this score in a cohort of emergency critical care (ECC) patients at a single academic center over a period of 3 years. METHODS: This was a retrospective cohort study using EHR data to assess predictive accuracy of eccSOFA for estimating in-hospital mortality risk. The patient population included all adult patients who had a critical care admission order entered while in the ED of an academic medical center between 10/24/2013 and 9/30/2016. eccSOFA's discriminatory ability for in-hospital mortality was assessed using ROC curves. RESULTS: Of the 3912 patients whose in-hospital mortality risk was estimated, 2260 (57.8%) were in the low-risk group (scores 0-3), 1203 (30.8%) in the intermediate-risk group (scores 4-7), and 449 (11.5%) in the high-risk group (scores 8+). In-hospital mortality for the low-, intermediate, and high-risk groups was 4.2% (95%CI: 3.4-5.1), 15.5% (95% CI 13.5-17.6), and 37.9% (95% CI 33.4-42.3) respectively. The AUROC was 0.78 (95%CI: 0.75-0.80) for the integer score and 0.75 (95% CI: 0.72-0.77) for the categorical eccSOFA. CONCLUSIONS: As a predictor of in-hospital mortality, eccSOFA can be calculated based on variables that are commonly available at the time of critical care admission order entry in the ED and has discriminatory ability that is comparable to other commonly used illness severity scores. Future studies should assess the calibration of our absolute risk predictions.

Effect of emergency critical care nurses and emergency department boarding time on in-hospital mortality in critically ill patients.

STUDY HYPOTHESIS: We hypothesized that establishing a program of specialized emergency critical care (ECC) nurses in the ED would improve mortality of ICU patients boarding in the ED. METHODS: This was a retrospective before-after cohort study using electronic health record data at an academic medical center. We compared in-hospital mortality between the pre- and post-intervention periods and between non-prolonged (≤6 h) boarding time and prolonged (>6 h) boarding time. In-hospital mortality was stratified by illness severity (eccSOFA category) and adjusted using logistic regression. RESULTS: Severity-adjusted in-hospital mortality decreased from 12.8% pre-intervention to 12.3% post-intervention (-0.5% (95% CI, -3.1% to 2.1%), which was not statistically significant. This was despite a concurrent increase in ED and hospital crowding. The proportion of ECC patients downgraded to a lower level of care while still in the ED increased from 6.4% in the pre-intervention period to 17.0% in the post-intervention period. (+10.6%, 8.2% to 13.0%, p < 0.001). Severity-adjusted mortality was 12.8% in the non-prolonged group vs. 11.3% in the prolonged group (p = 0.331). CONCLUSIONS: During the post-intervention period, there was a significant increase in illness severity, hospital congestion, ED boarding time, and downgrades in the ED, but no significant change in mortality. These findings suggest that ECC nurses may improve the safety of boarding ICU patients in the ED. Longer ED boarding times were not associated with higher mortality in either the pre- or post-intervention periods.

The ulnar artery: A site suitable for arterial cannulation in pediatric patients.

BACKGROUND: Historically, the ulnar artery has rarely been considered for arterial cannulation as it is less easily palpated than the radial artery. With the current routine use of ultrasound in pediatric patients, the ulnar is as accessible as the radial and could be viewed as an equivalent site for cannulation. AIMS: The purpose of this study was to compare ulnar and radial artery suitability for arterial cannulation in pediatric patients using 2-dimensional ultrasound. METHODS: We examined the ulnar and radial arteries of pediatric patients aged birth to 6 years who were scheduled to undergo general anesthesia. Following anesthesia induction, the investigators positioned the patient's wrist to 30-45 degrees of extension and obtained images of the ulnar and radial arteries in the transverse and longitudinal planes. Assessments of the arteries' anterior-posterior diameter, cross-sectional area and depth were made by visual inspection at the time of image acquisition and by electronic caliper measurement of recorded images. RESULTS: In 108 patients, mean anterior-posterior diameter of the ulnar artery was larger than the radial artery in the transverse view, longitudinal view, and cross-sectional area in 63.6%, 59.4%, and 60.4% of patients (p = .002, .004, and .006, respectively). Mean ulnar artery size was, on average, larger than the radial artery by 7.7%, 8.1%, and 12.9% in the transverse AP diameter, longitudinal AP diameter, and cross-sectional area (95% CI 3.1-12.4%; 3.2-13.0%; 4.4-21.5%). The investigator's visual evaluation of vessel size at the bedside showed substantial agreement with the measured cross-sectional area (linear-weighted kappa of 0.73). In a subset of 13 patients age <24 months, the mean depth of the ulnar artery was 2.13 mm compared to 1.65 mm for the radial artery (difference -0.48 mm 95% CI 1.08-0.12). CONCLUSIONS: The ulnar artery was larger than the radial artery in 60% of pediatric patients thus may offer an arterial cannulation site advantage due to its larger size. The use of 2-dimensional ultrasound examination allows accurate assessment of upper extremity distal arteries in order to optimize site selection for arterial cannulation in pediatric patients.

The Effect of Chest Compression Location and Occlusion of the Aorta in a Traumatic Arrest Model.

BACKGROUND: Recent evidence demonstrates that closed chest compressions directly over the left ventricle (LV) in a traumatic cardiac arrest (TCA) model improve hemodynamics and return of spontaneous circulation (ROSC) when compared with traditional compressions. Resuscitative endovascular balloon occlusion of the aorta (REBOA) also improves hemodynamics and controls hemorrhage in TCA. We hypothesized that chest compressions located over the LV would result in improved hemodynamics and ROSC in a swine model of TCA using REBOA. MATERIALS AND METHODS: Transthoracic echo was used to mark the location of the aortic root (traditional location) and the center of the LV on animals (n = 26), which were randomized to receive chest compressions in one of the two locations. After hemorrhage, ventricular fibrillation was induced to simulate TCA. After a period of 10 min of ventricular fibrillation, basic life support (BLS) with mechanical cardiopulmonary resuscitation was initiated and performed for 10 min followed by advanced life support for an additional 10 min. REBOA balloons were inflated at 6 min into BLS. Hemodynamic variables were averaged during the final 2 min of the BLS and advanced life support periods. Survival was compared between this REBOA cohort and a control group without REBOA (no-REBOA cohort) (n = 26). RESULTS: There was no significant difference in ROSC between the two REBOA groups (P = 0.24). Survival was higher with REBOA group versus no-REBOA group (P = 0.02). CONCLUSIONS: There was no difference in ROSC between LV and traditional compressions when REBOA was used in this swine model of TCA. REBOA conferred a survival benefit regardless of compression location.

Patient safety and quality outcomes for ED patients admitted to alternative care area inpatient beds.

BACKGROUND: Inpatient hallway beds are one solution to mitigate emergency department (ED) crowding due to boarding of admitted patients. Alternative Care Areas (AltCA) beds are located in inpatient hallways, cardiac catheterization lab, and endoscopy. We examined whether AltCA beds were associated with increased risk of patient safety and quality outcomes: transfer to Intensive Care Unit (ICU), mortality, hospital-acquired infections (HAI), falls, and 72-hour hospital readmission. METHODS: Retrospective cohort study of patients age >18 years admitted from the ED to non-ICU beds at an urban, academic hospital. AltCA bed exclusion criteria: dementia, frequent respiratory interventions, contact or airborne isolation, psychiatric admission, and inability to ambulate. The study periods were: pre-intervention 9/1/2014-3/31/2015, transition 9/1/2015-3/31/2016, and post-intervention 9/1/2016-3/31/2017. Data analysis used unadjusted and multivariable analyses which controlled for age, sex, race, ethnicity, insurance, ED triage Emergency Service Index (ESI) level, and telemetry order. RESULTS: The study included 16,801 patients, with 622 (3.7%) patients in AltCA beds. AltCA beds had younger patients than standard inpatient beds, 57.7 years and 61.7 years; fewer telemetry order, 48.4% and 59.3%; and fewer ESI level 2, 16.1% and 26.2%. AltCA beds had shorter hospital LOS than standard inpatient beds, 2.7 days and 3.4 days. AltCA beds had decreased risk of transfer to ICU -10.6 (95%CI: -18.3, -2.8) and HAI -13.4 (95%CI: -20.3, -6.5) compared to standard inpatient beds. CONCLUSION: Patients in AltCA beds did not have increased risk of patient safety and quality outcomes but rather decreased risk of transfer to ICU and HAI than standard inpatient beds.

Practice Variation in the Diagnosis of Aneurysmal Subarachnoid Hemorrhage: A Survey of US and Canadian Emergency Medicine Physicians.

BACKGROUND AND AIMS: Spontaneous subarachnoid hemorrhage (SAH) from a brain aneurysm, if untreated in the acute phase, leads to loss of functional independence in about 30% of patients and death in 27-44%. To evaluate for SAH, the American College of Emergency Physicians (ACEP) Clinical Policy recommends obtaining a non-contrast brain computed tomography (CT) scan followed by a lumbar puncture (LP) if the CT is negative. On the other hand, current evidence from prospectively collected data suggests that CT alone may be sufficient to rule out SAH in patients who present within 6 h of symptom onset while anecdotal evidence suggests that CT angiogram (CTA) may be used to detect aneurysms, which are the probable cause of SAH. Since many different options are available to emergency physicians, we examined their practice pattern variation by observing their diagnostic approaches and their adherence to the ACEP Clinical Policy. METHODS: We developed, validated, and distributed a survey to emergency physicians at three practice sites: (1) Stanford Healthcare, California, (2) Intermountain Healthcare (five emergency departments), Utah, and (3) Ottawa General Hospital, Toronto. The survey questions examined physician knowledge on CT and LP's test performance and used case-based scenarios to assess diagnostic approaches, variation in practice, and adherence to guidelines. Results were presented as proportions with 95% CIs. RESULTS: Of the 216 physicians surveyed, we received 168 responses (77.8%). The responses by site were: (1) (n = 38, 23.2%), (2) (n = 70, 42.7%), (3) (n = 56, 34.1%). To the CT and LP test performance question, most physicians indicated that CT alone detects > 90% of SAH in those with a confirmed SAH [n = 150 (89.3%, 95% CI 83.6-93.5]. To the case-based questions, most physicians indicated that they would perform a CTA along with a CT [n = 110 (65.5%, 95% CI 57.8-72.6)], some indicated a LP along with a CT [n = 57, 33.9% 95% CI 26.8-41.6)], and a few indicated both a CTA and a LP [n = 16, 9.5%, 95% CI 5.5-15.0]. We also observed practice site variation in the proportion of physicians who indicated that they would use CTA: (1) (n = 25, 65.8%), (2) (n = 54, 77.1%), and (3) (n = 28, 50.0%) (p = 0.006). CONCLUSIONS: Survey responses indicate that physicians use some or all of the imaging tests, with or without LP to diagnose SAH. We observed variation in the use of CTA by site and academic setting and divergence from ACEP Clinical Policy.

Hospitalizations for Autoimmune Hepatitis Disproportionately Affect Black and Latino Americans.

OBJECTIVES: The healthcare burden of autoimmune hepatitis (AIH) in the United States has not been characterized. We previously showed that AIH disproportionately affects people of color in a single hospital system. The current study aimed to determine whether the same disparity occurs nationwide. METHODS: We analyzed hospitalizations with a primary discharge diagnosis corresponding to the ICD-9 code for AIH in the National Inpatient Sample between 2008 and 2012. For each racial/ethnic group, we calculated the AIH hospitalization rate per 100,000 population and per 100,000 all-cause hospitalizations, then calculated a risk ratio compared to the reference rate among whites. We used multivariable logistic regression models to assess for racial disparities and to identify predictors of in-hospital mortality during AIH hospitalizations. RESULTS: The national rate of AIH hospitalization was 0.73 hospitalizations per 100,000 population. Blacks and Latinos were hospitalized for AIH at a rate 69% (P<0.001) and 20% higher (P<0.001) than whites, respectively. After controlling for age, gender, payer, residence, zip code income, region, and cirrhosis, black race was a statistically significant predictor for mortality during AIH hospitalizations (odds ratio (OR) 2.81, 95% confidence interval (CI) 1.43, 5.47). CONCLUSIONS: Hospitalizations for AIH disproportionately affect black and Latino Americans. Black race is independently associated with higher odds of death during hospitalizations for AIH. This racial disparity may be related to biological, genetic, environmental, socioeconomic, and healthcare access and quality factors.