Should COVID-19 symptoms be used to cohort patients in the emergency department? A retrospective analysis.

OBJECTIVE: To determine how cohorting patients based on presenting complaints affects risk of nosocomial infection in crowded Emergency Departments (EDs) under conditions of high and low prevalence of COVID-19. METHODS: This was a retrospective analysis of presenting complaints and PCR tests collected during the COVID-19 epidemic from 4 EDs from a large hospital system in Bronx County, NY, from May 1, 2020 to April 30, 2021. Sensitivity, specificity, positive and negative predictive value (PPV, NPV) were calculated for a symptom screen based on the CDC list of COVID-19 symptoms: fever/chills, shortness of breath/dyspnea, cough, muscle or body ache, fatigue, headache, loss of taste or smell, sore throat, nasal congestion/runny nose, nausea, vomiting, and diarrhea. PPV was calculated for varying values of prevalence. RESULTS: There were 80,078 visits with PCR tests. The sensitivity of the symptom screen was 64.7% (95% CI: 63.6, 65.8), specificity 65.4% (65.1, 65.8). PPV was 16.8% (16.5, 17.0) and NPV was 94.5% (94.4, 94.7) when the observed prevalence of COVID-19 in the ED over the year was 9.7%. The PPV of fever/chills, cough, body and muscle aches and nasal congestion/runny nose were each approximately 25% across the year, while diarrhea, nausea, vomiting and headache were less predictive, (PPV 4.7%-9.6%) The combinations of fever/chills, cough, muscle/body aches, and shortness of breath had PPVs of 40-50%. The PPV of the screen varied from 3.7% (3.6, 3.8) at 2% prevalence of COVID-19 to 44.3% (44.0, 44.7) at 30% prevalence. CONCLUSION: The proportion of patients with a chief complaint of COVID-19 symptoms and confirmed COVID-19 infection was exceeded by the proportion without actual infection. This was true when prevalence in the ED was as high as 30%. Cohorting of patients based on the CDC's list of COVID-19 symptoms will expose many patients who do not have COVID-19 to risk of nosocomially acquired COVID-19. EDs should not use the CDC list of COVID-19 symptoms as the only strategy to minimize exposure.

A prospective observational study evaluating the use of remote patient monitoring in ED discharged COVID-19 patients in NYC.

OBJECTIVES: We investigated whether continuous remote patient monitoring (RPM) could significantly reduce return Emergency Department (ED) revisits among coronavirus disease 2019 (COVID-19) patients discharged from the emergency Department. MATERIALS AND METHODS: A prospective observational study was conducted from a total of 2833 COVID-19 diagnosed patients who presented to the Montefiore Medical Center ED between September 2020-March 2021. Study patients were remotely monitored through a digital platform that was supervised 24/7 by licensed healthcare professionals. Age and time-period matched controls were randomly sampled through retrospective review. The primary outcome was ED revisit rates among the two groups. RESULTS: In our study, 150 patients enrolled in the RPM program and 150 controls were sampled for a total of 300 patients. Overall, 59.1% of the patients identified as Hispanic/Latino. The RPM group had higher body mass index (BMI) (29 (25-35) vs. 27 (25-31) p-value 0.020) and rates of hypertension (50.7% (76) vs. 35.8% (54) p-value 0.009). There were no statistically significant differences in rates of ED revisit between the RPM group (8% (12)) and control group (9.3% (14)) (OR: 0.863; 95% CI:0.413-1. 803; p- 0.695). DISCUSSION AND CONCLUSION: Our study explored the impact of continuous monitoring versus intermittent monitoring for reducing ED revisits in a largely underrepresented population of the Bronx. Our study demonstrated that continuous remote patient monitoring showed no significant difference in preventing ED revisits compared to non-standardized intermittent monitoring. However, potential other acute care settings where RPM may be useful for identifying high-risk patients for early interventions warrant further study.

An expanded HIV screening strategy in the Emergency Department fails to identify most patients with undiagnosed infection: insights from a blinded serosurvey.

Screening for HIV in Emergency Departments (EDs) is recommended to address the problem of undiagnosed HIV. Serosurveys are an important method for estimating the prevalence of undiagnosed HIV and can provide insight into the effectiveness of an HIV screening strategy. We performed a blinded serosurvey in an ED offering non-targeted HIV screening to determine the proportion of patients with undiagnosed HIV who were diagnosed during their visit. The study was conducted in a high-volume, urban ED and included patients who had blood drawn for clinical purposes and had sufficient remnant specimen to undergo deidentified HIV testing. Among 4752 patients not previously diagnosed with HIV, 1403 (29.5%) were offered HIV screening and 543 (38.7% of those offered) consented. Overall, undiagnosed HIV was present in 12 patients (0.25%): six among those offered screening (0.4%), and six among those not offered screening (0.2%). Among those with undiagnosed HIV, two (16.7%) consented to screening and were diagnosed during their visit. Despite efforts to increase HIV screening, more than 80% of patients with undiagnosed HIV were not tested during their ED visit. Although half of those with undiagnosed HIV were missed because they were not offered screening, the yield was further diminished because a substantial proportion of patients declined screening. To avoid missed opportunities for diagnosis in the ED, strategies to further improve implementation of HIV screening and optimize rates of consent are needed.

Prospective study of a non-restrictive decision rule for acute aortic syndrome.

OBJECTIVES: To determine the impact of a non-restrictive clinical decision rule on CT utilization for Emergency Department patients suspected of having an acute aortic syndrome (AAS). METHODS: We prospectively assessed the performance of a previously described, collaboratively designed, non-restrictive clinical decision rule for AAS. Emergency Department patients with suspected AAS were stratified into low and high-risk groups based on decision rule results, from July 2013-August 2014. Patients with acute trauma, prior AAS or aortic surgery were excluded. CT dose reduction protocols were concurrently implemented as a quality improvement measure. Bivariate analysis was performed to compare the prospective cohort with the historical derivation cohort for CT utilization rates, results of CT, AAS incidence and radiation exposure. The performance of the clinical decision rule was evaluated. RESULTS: Compared with the historic cohort, the study cohort demonstrated a lower CT utilization rate [0.344% (427/124,093) versus 0.477% (1465/306,961), (p<0.001)], a trend toward higher CT diagnostic yield [4.4% (19/427) versus 2.7% (40/1465), (p=0.08)]. AAS incidence was similar [0.015% (19/124,093) versus 0.013% (40/306,961), (p=0.57)]. The mean effective radiation dose was markedly lower [12±5.5mSv versus 43±20mSv, (p<0.0001)]. The clinical decision rule correctly stratified only 56% (10/18) of patients with AAS as high-risk. CONCLUSIONS: A non-restrictive, collaboratively designed, clinical decision rule for Emergency Department patients with suspected AAS performed poorly in risk-stratifying patients for AAS. However, its implementation was associated with a significant and safe decrease in CT utilization.

Effect of a Single Dose of Oral Opioid and Nonopioid Analgesics on Acute Extremity Pain in the Emergency Department: A Randomized Clinical Trial.

Importance: The choice of analgesic to treat acute pain in the emergency department (ED) lacks a clear evidence base. The combination of ibuprofen and acetaminophen (paracetamol) may represent a viable nonopioid alternative. Objectives: To compare the efficacy of 4 oral analgesics. Design, Settings, and Participants: Randomized clinical trial conducted at 2 urban EDs in the Bronx, New York, that included 416 patients aged 21 to 64 years with moderate to severe acute extremity pain enrolled from July 2015 to August 2016. Interventions: Participants (104 per each combination analgesic group) received 400 mg of ibuprofen and 1000 mg of acetaminophen; 5 mg of oxycodone and 325 mg of acetaminophen; 5 mg of hydrocodone and 300 mg of acetaminophen; or 30 mg of codeine and 300 mg of acetaminophen. Main Outcomes and Measures: The primary outcome was the between-group difference in decline in pain 2 hours after ingestion. Pain intensity was assessed using an 11-point numerical rating scale (NRS), in which 0 indicates no pain and 10 indicates the worst possible pain. The predefined minimum clinically important difference was 1.3 on the NRS. Analysis of variance was used to test the overall between-group difference at P = .05 and 99.2% CIs adjusted for multiple pairwise comparisons. Results: Of 416 patients randomized, 411 were analyzed (mean [SD] age, 37 [12] years; 199 [48%] women; 247 [60%] Latino). The baseline mean NRS pain score was 8.7 (SD, 1.3). At 2 hours, the mean NRS pain score decreased by 4.3 (95% CI, 3.6 to 4.9) in the ibuprofen and acetaminophen group; by 4.4 (95% CI, 3.7 to 5.0) in the oxycodone and acetaminophen group; by 3.5 (95% CI, 2.9 to 4.2) in the hydrocodone and acetaminophen group; and by 3.9 (95% CI, 3.2 to 4.5) in the codeine and acetaminophen group (P = .053). The largest difference in decline in the NRS pain score from baseline to 2 hours was between the oxycodone and acetaminophen group and the hydrocodone and acetaminophen group (0.9; 99.2% CI, -0.1 to 1.8), which was less than the minimum clinically important difference in NRS pain score of 1.3. Adverse events were not assessed. Conclusions and Relevance: For patients presenting to the ED with acute extremity pain, there were no statistically significant or clinically important differences in pain reduction at 2 hours among single-dose treatment with ibuprofen and acetaminophen or with 3 different opioid and acetaminophen combination analgesics. Further research to assess adverse events and other dosing may be warranted. Trial Registration: clinicaltrials.gov Identifier: NCT02455518.

Diphenhydramine as Adjuvant Therapy for Acute Migraine: An Emergency Department-Based Randomized Clinical Trial.

STUDY OBJECTIVE: More than 1 million patients present to US emergency departments (EDs) annually seeking care for acute migraine. Parenteral antihistamines have long been used in combination with antidopaminergics such as metoclopramide to treat acute migraine in the ED. High-quality data supporting this practice do not exist. We determine whether administration of diphenhydramine 50 mg intravenously+metoclopramide 10 mg intravenously results in greater rates of sustained headache relief than placebo+metoclopramide 10 mg intravenously. METHODS: This was a randomized, double-blind, clinical trial comparing 2 active treatments for acute migraine in an ED. Eligible patients were adults younger than 65 years presenting with an acute moderate or severe headache meeting International Classification of Headache Disorders-2 migraine criteria. Patients were stratified according to presence or absence of allergic symptoms. The primary outcome was sustained headache relief, defined as achieving a headache level of mild or none within 2 hours of medication administration and maintaining this level of relief without use of any additional headache medication for 48 hours. Secondary efficacy outcomes included mean improvement on a 0 to 10 verbal scale between baseline and 1 hour, the frequency with which subjects indicated they would want the same medication the next time they present to the ED with migraine, and the ED throughput time. Sample size calculation using a 2-sided α of .05, a ß of .20, and a 15% difference between study arms determined the need for 374 patients. An interim analysis was conducted when data were available for 200 subjects. RESULTS: Four hundred twenty patients were approached for participation. Two hundred eight eligible patients consented to participate and were randomized. At the planned interim analysis, the data and safety monitoring board recommended that the study be halted for futility. Baseline characteristics were comparable between the groups. Fourteen percent (29/208) of the sample reported allergic symptoms. Of patients randomized to diphenhydramine, 40% (40/100) reported sustained relief at 48 hours, as did 37% (38/103) of patients randomized to placebo (95% confidence interval [CI] for difference of 3%: -10% to 16%). One hour after medication administration, patients randomized to diphenhydramine improved by a mean of 5.1 on the 0 to 10 scale versus 4.8 for those randomized to placebo (95% CI for difference of 0.3: -0.6 to 1.1). Eighty-five percent (84/99) of the patients in the diphenhydramine arm reported they would want the same medication combination during a subsequent ED visit, as did 76% (77/102) of those who received placebo (95% CI for difference of 9%: -2% to 20%). Median ED length of stay was 122 minutes (interquartile range 84 to 180 minutes) in the diphenhydramine group and 139 minutes (interquartile range 90 to 235 minutes) in the placebo arm. Rates of adverse effects, including akathisia, were comparable between the groups. CONCLUSION: Intravenous diphenhydramine, when administered as adjuvant therapy with metoclopramide, does not improve migraine outcomes.

Temperature measurement in the adult emergency department: oral, tympanic membrane and temporal artery temperatures versus rectal temperature.

OBJECTIVE: The objective was to compare agreement between three non-invasive measures of temperature and rectal temperatures and to estimate the sensitivity and specificity of these measures to detect a rectal temperature of 38°C or higher. METHODS: We conducted a study of the diagnostic accuracy of oral, tympanic membrane (TM) and temporal artery (TA) thermometry to measure fever in an urban emergency department (ED). Data were collected from adult patients who received rectal temperature measurement. Bland-Altman analysis was performed; sensitivity, specificity and 95% CIs were calculated. RESULTS: 987 patients were enrolled. 36% of the TM and TA readings differed by 0.5°C or more from rectal temperatures, 50% of oral temperatures. TM measures were most precise-the SD of the difference from rectal was 0.4°C TM, and 0.6°C for oral and TA (p<0.001). The sensitivities of a 38°C cutpoint on oral, TM and TA measures to detect a rectal temperature of 38°C or higher were: 37.0%, 68.3% and 71.1%, respectively (oral vs TM and TA p<0.001). The corresponding specificities were 99.4%, 98.2% and 92.3% (oral, TM and TA) with oral specificity significantly higher than the other two methods (p<0.01). TM and TA cutpoints of 37.5°C provided greater than 90% sensitivity to detect fever with specificity of 90% and 72%, respectively. CONCLUSIONS: None of the non-invasive methods met benchmarks for diagnostic accuracy using the criterion of 38°C to detect rectal temperature of 38°C. A TM cutpoint of 37.5°C provides maximum diagnostic accuracy of the three non-invasive measures.

Naproxen With Cyclobenzaprine, Oxycodone/Acetaminophen, or Placebo for Treating Acute Low Back Pain: A Randomized Clinical Trial.

IMPORTANCE: Low back pain (LBP) is responsible for more than 2.5 million visits to US emergency departments (EDs) annually. These patients are usually treated with nonsteroidal anti-inflammatory drugs, acetaminophen, opioids, or skeletal muscle relaxants, often in combination. OBJECTIVE: To compare functional outcomes and pain at 1 week and 3 months after an ED visit for acute LBP among patients randomized to a 10-day course of (1) naproxen + placebo; (2) naproxen + cyclobenzaprine; or (3) naproxen + oxycodone/acetaminophen. DESIGN, SETTING, AND PARTICIPANTS: This randomized, double-blind, 3-group study was conducted at one urban ED in the Bronx, New York City. Patients who presented with nontraumatic, nonradicular LBP of 2 weeks' duration or less were eligible for enrollment upon ED discharge if they had a score greater than 5 on the Roland-Morris Disability Questionnaire (RMDQ). The RMDQ is a 24-item questionnaire commonly used to measure LBP and related functional impairment on which 0 indicates no functional impairment and 24 indicates maximum impairment. Beginning in April 2012, a total of 2588 patients were approached for enrollment. Of the 323 deemed eligible for participation, 107 were randomized to receive placebo and 108 each to cyclobenzaprine and to oxycodone/acetaminophen. Follow-up was completed in December 2014. INTERVENTIONS: All participants were given 20 tablets of naproxen, 500 mg, to be taken twice a day. They were randomized to receive either 60 tablets of placebo; cyclobenzaprine, 5 mg; or oxycodone, 5 mg/acetaminophen, 325 mg. Participants were instructed to take 1 or 2 of these tablets every 8 hours, as needed for LBP. They also received a standardized 10-minute LBP educational session prior to discharge. MAIN OUTCOMES AND MEASURES: The primary outcome was improvement in RMDQ between ED discharge and 1 week later. RESULTS: Demographic characteristics were comparable among the 3 groups. At baseline, median RMDQ score in the placebo group was 20 (interquartile range [IQR],17-21), in the cyclobenzaprine group 19 (IQR,17-21), and in the oxycodone/acetaminophen group 20 (IQR,17-22). At 1-week follow-up, the mean RMDQ improvement was 9.8 in the placebo group, 10.1 in the cyclobenzaprine group, and 11.1 in the oxycodone/acetaminophen group. Between-group difference in mean RMDQ improvement for cyclobenzaprine vs placebo was 0.3 (98.3% CI, -2.6 to 3.2; P = .77), for oxycodone/acetaminophen vs placebo, 1.3 (98.3% CI, -1.5 to 4.1; P = .28), and for oxycodone/acetaminophen vs cyclobenzaprine, 0.9 (98.3% CI, -2.1 to 3.9; P = .45). CONCLUSIONS AND RELEVANCE: Among patients with acute, nontraumatic, nonradicular LBP presenting to the ED, adding cyclobenzaprine or oxycodone/acetaminophen to naproxen alone did not improve functional outcomes or pain at 1-week follow-up. These findings do not support use of these additional medications in this setting. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01587274.

Design and implementation of the hospital airway resuscitation trial.

Guidelines for the management of in-hospital cardiac arrest resuscitation are often drawn from evidence generated in out-of-hospital cardiac arrest populations and applied to the in-hospital setting. Approach to airway management during resuscitation is one example of this phenomenon, with the recommendation to place either a supraglottic airway or endotracheal tube when performing advanced airway management during in-hospital cardiac arrest based mainly in clinical trials conducted in the out-of-hospital setting. The Hospital Airway Resuscitation Trial (HART) is a pragmatic cluster-randomized superiority trial comparing a strategy of first choice supraglottic airway to a strategy of first choice endotracheal intubation during resuscitation from in-hospital cardiac arrest. The design includes a number of innovative elements such as a highly pragmatic design drawing from electronic health records and a novel primary outcome measure for cardiac arrest trials-alive-and-ventilator free days. Many of the topics explored in the design of HART have wide relevance to other trials in in-hospital cardiac arrest populations.

A randomized trial of intravenous ketorolac versus intravenous metoclopramide plus diphenhydramine for tension-type and all nonmigraine, noncluster recurrent headaches.

STUDY OBJECTIVE: We compare metoclopramide 20 mg intravenously, combined with diphenhydramine 25 mg intravenously, with ketorolac 30 mg intravenously in adults with tension-type headache and all nonmigraine, noncluster recurrent headaches. METHODS: In this emergency department (ED)-based randomized, double-blind study, we enrolled adults with nonmigraine, noncluster recurrent headaches. Patients with tension-type headache were a subgroup of special interest. Our primary outcome was a comparison of the improvement in pain score between baseline and 1 hour later, assessed on a 0 to 10 verbal scale. We defined a between-group difference of 2.0 as the minimum clinically significant difference. Secondary endpoints included need for rescue medication in the ED, achieving headache freedom in the ED and sustaining it for 24 hours, and patient's desire to receive the same medication again. RESULTS: We included 120 patients in the analysis. The metoclopramide/diphenhydramine arm improved by a median of 5 (interquartile range 3, 7) scale units, whereas the ketorolac arm improved by a median of 3 (IQR 2, 6) (95% confidence interval [CI] for difference 0 to 3). Metoclopramide+diphenhydramine was superior to ketorolac for all 3 secondary outcomes: the number needed to treat for not requiring ED rescue medication was 3 (95% CI 2 to 6); for sustained headache freedom, 6 (95% CI 3 to 20); and for wish to receive the same medication again, 7 (95% CI 4 to 65). Tension-type headache subgroup results were similar. CONCLUSION: For adults who presented to an ED with tension-type headache or with nonmigraine, noncluster recurrent headache, intravenous metoclopramide+diphenhydramine provided more headache relief than intravenous ketorolac.

Preliminary development of a clinical decision rule for acute aortic syndromes.

OBJECTIVE: Patients with suspected acute aortic syndromes (AAS) often undergo computed tomography (CT) with negative results. We sought clinical and diagnostic criteria to identify low-risk patients, an initial step in developing a clinical decision rule. METHODS: We retrospectively identified all adults presenting to our emergency department (ED) from January 1, 2006, to August 1, 2010, who underwent CT angiography for suspected AAS without prior trauma or AAS. A total of 1465 patients met inclusion criteria; a retrospective case-controlled review (ratio 1:4) was conducted. Cases were diagnosed with aortic dissection, intramural hematoma, penetrating atherosclerotic ulcer, or ruptured aneurysm. RESULTS: Of the patients who underwent CT, 2.7% (40/1465) had an AAS; 2 additional cases were diagnosed after admission (ED miss rate, 5% [2/42]). Patients with AAS were significantly older than controls (66 vs 59 years; P = .008). Risk factors included abnormal chest radiograph (sensitivity, 79% [26/33]; specificity, 82% [113/137]) and acute chest pain (sensitivity, 83% [29/35]; specificity, 71% [111/157]). None of the 19 patients with resolved pain upon ED presentation had AAS. These data support a 2-step rule: first screen for ongoing pain; if present, screen for acute chest pain or an abnormal chest radiograph. This approach achieves a 54% (84/155) reduction in CT usage with a sensitivity for AAS of 96% (95% confidence interval, 89%-100%), negative predictive value of 99.8% (99.4%-100%), and a false-negative rate of 1.7% (1/84). CONCLUSIONS: Our results demonstrate a need to safely identify patients at low risk for AAS who can forgo CT. We developed a preliminary 2-step clinical decision rule, which requires validation.

One-week and 3-month outcomes after an emergency department visit for undifferentiated musculoskeletal low back pain.

STUDY OBJECTIVE: Nearly 3 million patients present to US emergency departments (EDs) annually with undifferentiated musculoskeletal low back pain. Little is known about short- and longer-term outcomes in this group. We seek to describe the pain and functional outcomes 1 week and 3 months after discharge in a sample of ED patients presenting with undifferentiated musculoskeletal low back pain. METHODS: We used a prospective observational descriptive cohort design, enrolling ED patients with a chief complaint of low back pain classified as musculoskeletal in origin by the ED attending physician. We defined low back pain as pain originating in the posterior back between the tips of the scapulae and upper buttocks and excluded any patient with a traumatic back injury occurring within the previous month. We interviewed patients in the ED and then by telephone follow-up 1 week and 3 months after ED discharge, using a scripted closed-question data collection instrument. Our primary outcome was functional limitation attributable to low back pain assessed with a validated scale. Secondary outcomes included pain and analgesic use during the 24 hours before each follow-up telephone call. RESULTS: During a 9-month period beginning in July 2009, we approached 894 patients, of whom 556 were enrolled. We obtained follow-up on 97% of our sample at 1 week and 92% at 3 months. One week after ED discharge, 70% (95% confidence interval [CI] 66% to 74%) of patients reported back pain-related functional impairment, 59% (95% CI 55% to 63%) reported moderate or severe low back pain, and 69% (95% CI 65% to 73%) reported analgesic use within the previous 24 hours. Three months after ED discharge, 48% (95% CI 44% to 52%) of patients reported functional impairment, 42% (95% CI 38% to 46%) reported moderate or severe pain, and 46% (95% CI 44% to 50%) reported analgesic use within the previous 24 hours. CONCLUSION: There is substantial short- and longer-term morbidity and ongoing analgesic use among patients who present to an ED with undifferentiated musculoskeletal low back pain.

Dosing and titration of intravenous opioid analgesics administered to ED patients in acute severe pain.

OBJECTIVES: The objectives were to describe the dose of opioids and incidence of titration for management of acute pain in emergency department patients and, secondarily, to assess the association between change in pain and dose. METHODS: Data from control groups of 2 randomized clinical trials were analyzed. Patients 21 to 64 years with acute pain judged to warrant intravenous (i.v.) opioids were eligible. We calculated the mean weight-based dose of i.v. opioids, distribution of dose, proportion of patients receiving additional i.v. opioids, and 95% confidence intervals. We compared these statistics to 3 recommendations: 0.1 mg/kg morphine, 10 mg morphine, and titration to analgesic effect. We used multiple linear regression to assess the association between change in pain measured on a numerical rating scale and dose. RESULTS: There were 281 patients with an initial median pain score of 10 (interquartile range: 8, 10). Mean weight-based dose of i.v. opioids was 0.08 mg/kg (0.07, 0.08 mg/kg). A total of 268 patients (95.4% [92.2%, 97.5%]) received less than 10 mg i.v. morphine equivalents; 7 patients (2.5% [1.0%, 5.0%]) received additional opioids. There was a weak association between change in pain in the 15, 30, and 60 minutes after the initial bolus and dose: b = 0.22 (0.07, 0.37), b = 0.17 (0.02, 0.32), and b = 0.12 (-0.03, 0.28), respectively, after adjustment for baseline pain. CONCLUSION: Analgesic practice did not conform to recommended doses or regimens. There was only a weak association between change of pain and dose in the range of doses given. These findings suggest that oligoanalgesia continues to be a problem despite improvements over the past 20 years.

Predicting 7-day and 3-month functional outcomes after an ED visit for acute nontraumatic low back pain.

BACKGROUND: Recent work has shown that two-thirds of patients report functional disability 1 week after an emergency department (ED) visit for nontraumatic musculoskeletal low back pain (LBP). Nearly half of these patients report functional disability 3 months later. Identifying high-risk predictors of functional disability at each of these 2 time points will allow emergency clinicians to provide individual patients with an evidence-based understanding of their risk of protracted symptoms. OBJECT: The aim of the present study was to determine whether 5 high-risk features previously identified in various primary care settings predict poor functional outcomes among patients in the ED. The hypothesized predictors are as follows: LBP-related functional disability at baseline, radicular signs, depression, a work-related injury, or a history of chronic or recurrent LBP before the index episode. METHODS: We conducted a prospective observational cohort study of patients in the ED with a chief complaint of nontraumatic LBP, which the ED attending physician classified as musculoskeletal. We interviewed patients in the ED before discharge and performed a baseline assessment of functional disability using the 24-item Roland-Morris questionnaire. We also trichotomized the patient's baseline history of LBP into chronic (defined as 30 straight days with continuous LBP or a history of acute exacerbations more frequently than once per week); episodic (acute exacerbations more frequently than once per year but less frequently than once per week), or rarely/never (less frequently than once per year or no history of LBP). We performed telephone follow-up 1 week and 3 months after ED discharge using a scripted closed-question data collection instrument. The primary outcome was any functional limitation attributable to LBP at 1 week and 3 months, defined as a score greater than zero on the Roland-Morris questionnaire. We used logistic regression, adjusted for age, sex, and educational level, to assess the independent association between functional disability and each of the 5 hypothesized predictors listed above. RESULTS: We approached 894 patients for participation and included 556. We obtained follow-up on 97% and 92% of our sample at 1 week and 3 months, respectively. Two of the 5 hypothesized variables predicted functional disability at both time points: higher baseline Roland-Morris score (odds ratio [OR], 4.3; 95% confidence interval [CI], 2.6-6.9) and chronic LBP (OR, 2.3; 95% CI, 1.1-4.8) were associated with 7-day functional disability. These same 2 variables predicted functional disability 3 months after ED discharge-higher baseline Roland-Morris score (OR, 2.3; 95% CI, 1.4-3.9) and chronic LBP (OR, 2.8; 95% CI, 1.5-5.2). The remaining 3 hypothesized predictors (depression, radicular signs, and on-the-job injury) did not predict functional outcome at either time point. CONCLUSIONS: Patients in the ED with worse baseline functional impairment and a history of chronic LBP are 2 to 4 times most likely to have poor short- and longer-term outcomes.

Metoclopramide for acute migraine: a dose-finding randomized clinical trial.

STUDY OBJECTIVE: Intravenous metoclopramide is effective as primary therapy for acute migraine, but the optimal dose of this medication is not yet known. The objective of this study is to compare the efficacy and safety of 3 different doses of intravenous metoclopramide for the treatment of acute migraine. METHODS: This was a randomized, double-blind, dose-finding study conducted on patients who presented to our emergency department (ED) meeting International Classification of Headache Disorders criteria for migraine without aura. We randomized patients to 10, 20, or 40 mg of intravenous metoclopramide. We coadministered diphenhydramine to all patients to prevent extrapyramidal adverse effects. The primary outcome was improvement in pain on an 11-point numeric rating scale at 1 hour. Secondary outcomes included sustained pain freedom at 48 hours and adverse effects. RESULTS: In this study, 356 patients were randomized. Baseline demographics and headache features were comparable among the groups. At 1 hour, those who received 10 mg of intravenous metoclopramide improved by a mean of 4.7 numeric rating scale points (95% confidence interval [CI] 4.2 to 5.2 points); those who received 20 mg improved by 4.9 points (95% CI 4.4 to 5.4 points), and those who received 40 mg improved by 5.3 points (95% CI 4.8 to 5.9 points). Rates of 48-hour sustained pain freedom in the 10-, 20-, and 40-mg groups were 16% (95% CI 10% to 24%), 20% (95% CI 14% to 28%), and 21% (95% CI 15% to 29%), respectively. The most commonly occurring adverse event was drowsiness, which impaired function in 17% (95% CI 13% to 21%) of the overall study population. Akathisia developed in 33 patients. Both drowsiness and akathisia were evenly distributed across the 3 arms of the study. One month later, no patient had developed tardive dyskinesia. CONCLUSION: Twenty milligrams or 40 mg of metoclopramide is no better for acute migraine than 10 mg of metoclopramide.

Post-severe Acute Respiratory Syndrome Coronavirus 2 Monoclonal Antibody Treatment Hospitalizations as a Sentinel for Emergence of Viral Variants in New York City.

We partnered with the US Department of Health and Human Services to treat high-risk, nonadmitted coronavirus disease 2019 (COVID-19) patients with bamlanivimab in the Bronx, New York per Emergency Use Authorization criteria. Increasing posttreatment hospitalizations were observed monthly between December 2020 and March 2021 in parallel to the emergence of severe acute respiratory syndrome coronavirus 2 variants in New York City.

Identifying the minimum clinically significant difference in acute pain in the elderly.

STUDY OBJECTIVE: To identify the minimum clinically significant difference in pain in elderly emergency department (ED) patients. METHODS: This was an observational, prospective study of a convenience sample of patients aged 65 years or older with acute pain. Patients rated their pain on an 11-point numeric rating scale (NRS) on entering the study and every 30 minutes for 2 hours. The arithmetic minimum clinically significant difference was defined as the mean difference between current and preceding NRS scores when the subject described his or her pain as "a little less pain" or "a little more pain." The proportional minimum clinically significant difference was change in NRS in a 30-minute interval divided by the NRS at the beginning of the interval. We used generalized estimating equations to adjust for nonindependence of pain scores and to test trend over time. RESULTS: One hundred ninety-five patients were enrolled (mean age 74 years; 73% women; 51% Hispanic; 33% black). The arithmetic minimum clinically significant difference averaged over all periods was 1.5 (95% confidence interval 1.3 to 1.6), the proportional minimum clinically significant difference was 25% (95% confidence interval 20% to 29%). The arithmetic minimum clinically significant difference unexpectedly decreased over time: 2.1 from baseline to 30 minutes, 1.4 from 30 to 60 minutes, 1.3 from 60 to 90 minutes, and 1.0 from 90 to 120 minutes (P<.001). In contrast, the proportional differences were more stable: 27% from baseline to 30 minutes, 22% from 30 to 60 minutes, 22% from 60 to 90 minutes, and 28% from 90 to 120 minutes (P=.89). CONCLUSION: The arithmetic minimum clinically significant difference in older ED patients was 1.5 NRS units and decreased over time, whereas the proportional change was 25% and more stable.

Treating headache recurrence after emergency department discharge: a randomized controlled trial of naproxen versus sumatriptan.

STUDY OBJECTIVE: Multiple parenteral medications are used to treat migraine and other acute primary headaches in the emergency department (ED). Regardless of specific headache diagnosis, no medication eliminates the frequent recurrence of primary headache after ED discharge. It is uncertain which medication primary headache patients should be given on discharge from an ED. The aim of this study is to compare the efficacy of oral sumatriptan with naproxen for treatment of post-ED recurrent primary headache. METHODS: This was a randomized, double-blind efficacy trial. We randomized patients to either naproxen 500 mg or sumatriptan 100 mg for headache recurrence after ED discharge. Patients were eligible if they received parenteral therapy for an acute exacerbation of a primary headache in the ED. Patients who met established criteria for migraine without aura were designated a priori as a homogenous subgroup of interest. We followed all patients by telephone 48 hours after ED discharge. The primary endpoint was the between-group difference in change in pain intensity during the 2-hour period after ingestion of either 500 mg naproxen or 100 mg sumatriptan. This difference was measured on a validated 11-point (0 to 10) verbal numeric rating scale (NRS). Satisfaction with the medication and adverse effects were also assessed. Patients who met criteria for migraine without aura were analyzed twice according to a priori design: once as a homogenous subgroup and then again combined with all other primary headaches. RESULTS: Of 410 patients randomized, 383 (93%) had outcome data available for analysis. Two hundred eighty (73%; 95% confidence interval [CI] 68% to 77%) reported headache post-ED discharge and 196 (51%; 95% CI 44% to 58%), including 88 with migraine, took the investigational medication provided to them. The naproxen group improved by a mean of 4.3 NRS points, whereas the sumatriptan group improved by 4.1 points (95% CI for difference of 0.2 points: -0.7 to 1.1 points). Findings were virtually identical among the migraine subset (4.3 versus 4.2 NRS points; 95% CI for difference of 0.1 points: -1.3 to 1.5 points). Seventy-one percent (95% CI 62% to 80%) of naproxen patients and 75% (95% CI 66% to 84%) of sumatriptan patients would want to take the same medication the next time. Adverse effect profiles were also comparable. CONCLUSION: In this trial, nearly three quarters of patients reported headache recurrence within 48 hours of ED discharge. Naproxen 500 mg and sumatriptan 100 mg taken orally relieve post-ED recurrent primary headache and migraine comparably. Clinicians should be guided by medication costs, contraindications, and a patient's previous experience with the medication.

Implementation of an aortic dissection CT protocol with clinical decision support aimed at decreasing radiation exposure by reducing routine abdominopelvic imaging.

Patients suspected of having an acute aortic syndrome in the ED typically undergo CT of the chest/abdomen/pelvis. However, the overwhelming majority of these exams are negative. With the help of clinical decision support, we implemented a new radiologist monitored 'aortic dissection screening protocol' that forgoes routine abdominopelvic imaging in order to reduce radiation dose without compromising diagnostic accuracy. The purpose of the present study is to assess the performance of this protocol. A retrospective analysis was performed to study the effect of the dissection screening protocol on the diagnostic yield, radiation and contrast dose on a total of 835 ED patients who underwent CT scans for suspected aortic dissection over a 48-week study period immediately before and after implementation of the protocol. 3.4% (28/835) of examinations were positive for an acute aortic syndrome over the 48-week study period with no difference in positivity before and after implementation of the 'aortic dissection screening' protocol, 3.0% vs. 3.7%, respectively (p = 0.57). There was a 14.6% reduction in median radiation dose and a 16% decrease in contrast volume utilization for the total ED population who underwent CT for aortic dissection using any protocol in the period after implementation of the 'aortic dissection screening' protocol. Aortic dissection CT in the ED is negative in the overwhelming majority of cases. A monitored 'aortic dissection screening' protocol that initially images the chest only significantly reduced contrast and radiation dose without reducing diagnostic accuracy for ED patients who underwent CT for aortic dissection.

A randomized trial of diphenhydramine as prophylaxis against metoclopramide-induced akathisia in nauseated emergency department patients.

STUDY OBJECTIVE: Akathisia, an adverse effect observed at times after administration of parenteral metoclopramide, is an unpleasant symptom complex characterized by restlessness and agitation. Some try to limit the development of akathisia by coadministering diphenhydramine when using parenteral metoclopramide. The goal of this investigation is to determine whether concomitant administration of diphenhydramine 25 mg decreased the rate of development of akathisia after administration of 10 mg or 20 mg of intravenous metoclopramide. METHODS: This was a randomized, double-blind, factorial design trial. Patients who presented to our emergency department with a primary or secondary chief complaint of nausea were randomized to one of the following 4 groups: (1) metoclopramide 10 mg+diphenhydramine 25 mg; (2) metoclopramide 10 mg+placebo; (3) metoclopramide 20 mg+diphenhydramine 25 mg; (4) metoclopramide 20 mg+placebo. The medications were inserted into a 50-mL bag of normal saline solution and administered as an intravenous drip during 15 minutes. Primary outcome was development of akathisia within 60 minutes of medication administration, as measured by blinded assessors using a short akathisia instrument, or use of rescue medication for treatment of akathisia by blinded clinical staff. Patients were also asked at baseline and 30 minutes later whether they felt restless. RESULTS: Two hundred eighty-nine patients were randomized and 286 patients were included in the final analysis. Within 1 hour of medication administration, 17 of 143 patients randomized to diphenhydramine (12%; 95% confidence interval [CI] 8% to 18%) and 17 of 143 (12%; 95% CI 8% to 18%) randomized to placebo developed akathisia (95% CI for difference of 0%: -8% to 8%). Thirteen of 143 patients randomized to metoclopramide 10 mg (9%; 95% CI 5% to 15%) and 21 of 143 randomized to metoclopramide 20 mg (15%; 95% CI 10% to 22%) developed akathisia (95% CI for difference of 6%: -2% to 14%). In those administered prophylactic diphenhydramine, odds of akathisia relative to placebo were 1.0 (95% CI 0.5 to 2.0). Odds of akathisia in those administered 20 mg of metoclopramide relative to the 10-mg dose were 1.7 (95% CI 0.8 to 3.6). Among patients who received 20 mg of metoclopramide, subjective restlessness was reported by 7 of 72 (9.7%) patients who received diphenhydramine and 14 of 71 (19.7%) patients who received placebo (95% CI for difference of 10%: -2% to 22%). CONCLUSION: Routine prophylaxis with diphenhydramine to prevent akathisia is unwarranted when intravenous metoclopramide is administered over 15 minutes. For patients administered 20 mg of metoclopramide, prophylactic diphenhydramine may decrease subjective restlessness.