Does sex matter? Effect of screener sex in intimate partner violence screening.

STUDY HYPOTHESIS: The sex of the individual performing screening affects the willingness of adult male and female ED patients to disclose incidents of intimate partner violence (IPV). METHODS: We performed a prospective cross-sectional survey at an urban academic medical center. A consecutive sample of adults who presented to the ED from 7:00 am to 00:00 am, 7 days/wk, over an 8-week period, were screened for IPV by 26 trained research assistants (42.3% female; mean age 23 years; 3.8% African American, 53.8% white). Intimate partner violence was detected using a 4-item tool to measure both physical and psychological abuse within the past 6 months. Comparison of medical history and disposition was performed using chi2 tests and t tests. Regression analysis was performed to determine the association of sex and screening outcomes, controlling for patient and screener age and race. RESULTS: A total of 2853 patients participated (63.0% female; mean age, 36 years; 67.5% African American, 22.9% white). During the study 48 female patients (2.7%) and 21 male patients (2.0%) reported incidents of IPV within the past 6 months. The sex of the screener was not associated with the screening outcomes for male (odds ratio, 0.98; CI, 0.35-2.72) or female patients (odds ratio, 0.90; CI, 0.45-1.82). CONCLUSIONS: Sex of the screener does not appear to affect disclosure of IPV. These results support the continuation of existing screening practices and call for IPV detection at multiple stages throughout patient care.

Application of the TIMI risk score in ED patients with cocaine-associated chest pain.

OBJECTIVE: The TIMI risk score has been validated as a risk stratification tool in emergency department (ED) patients with potential acute coronary syndrome. The goal of this study was to assess its ability to predict adverse cardiovascular outcomes in cocaine-associated chest pain. METHODS: This was a prospective cohort study of ED patients with chest pain with cocaine use. Data included demographics, medical history, and TIMI risk score. The main outcomes were acute myocardial infarction, revascularization, or death within 30 days of ED presentation. RESULTS: There were 261 patient visits. Patients were 43.2+8 years old, 73% male, 92% black, and 75% smokers. There were 33 patients with the composite outcome. The incidence of 30-day outcomes according to TIMI score is as follows: TIMI 0, 3.7% (95% CI, 0.1-8.3); TIMI 1, 13.2% (5.7-20.7); TIMI 2, 17.1% (4.3-29.8); TIMI 3, 21.4% (4.4-38.4); TIMI 4, 20.0% (0.1-43.6); TIMI 5/6, 50.0% (0.1-100). CONCLUSIONS: The TIMI risk score has no clinically useful predictive value in patients with cocaine-associated chest pain.

Prospective validation of the Thrombolysis in Myocardial Infarction Risk Score in the emergency department chest pain population.

STUDY OBJECTIVE: The Thrombolysis in Myocardial Infarction (TIMI) risk score is a 7-item tool derived from trials of patients with unstable angina/non-ST segment elevation myocardial infarction for risk stratification with respect to outcomes. It has been retrospectively evaluated in emergency department (ED) patients with potential acute coronary syndrome but has not been prospectively validated in this patient population. To validate the use of the TIMI risk score in the ED, we prospectively assess its potential utility in a broad ED chest pain patient population. METHODS: This was a prospective observational cohort study of consecutive ED chest pain patients enrolled from July 2003 until October 2004. Data included demographics, medical and cardiac history, and components of the TIMI risk score. Investigators followed the hospital course daily for admitted patients, and 30-day follow-up was performed on hospitalized and discharged patients. The main outcome was death, acute myocardial infarction, or revascularization as stratified by TIMI risk score at 30 days. RESULTS: There were 1,481 eligible patient visits; 30-day follow-up was completed on 1,458 (98.4%) patients. Patients had mean age of 53.2+/-14 years and were 40% men, 66% black, and 30% white. Myocardial infarction occurred in 95 patients. The incidence of each TIMI risk factor was age greater than 65 years 21%, known coronary stenosis 18%, 3 or more risk factors 26%, ST-segment deviation 6%, 2 or more anginal events in the previous 24 hours 33%, aspirin use in the previous 7 days 35%, and elevated markers 6%. The incidence of 30-day death, acute myocardial infarction, and revascularization according to TIMI score is as follows: TIMI 0, 1.7% (95% confidence interval [CI] 0.42 to 2.95); TIMI 1, 8.2% (95% CI 5.27 to 11.04); TIMI 2, 8.6% (95% CI 5.02 to 12.08); TIMI 3, 16.8% (95% CI 10.91 to 22.62); TIMI 4, 24.6% (95% CI 16.38 to 32.77); TIMI 5, 37.5% (95% CI 21.25 to 53.75); and TIMI 6, 33.3% (95% CI 0 to 100). This relationship was highly significant. CONCLUSION: Among ED patients with chest pain, the TIMI risk score does correlate with outcome. However, in our study the TIMI risk score failed to stratify these patients into discrete groups according to risk score. Also, patients with the lowest risk as defined by a TIMI score of zero had a 1.7% incidence of adverse events. Therefore, the TIMI risk score should not be used in isolation to determine disposition of ED chest pain patients.

The impact of trauma activations on the care of emergency department patients with potential acute coronary syndromes.

STUDY OBJECTIVE: Trauma systems improve the care of trauma patients; however, it is possible that prioritizing the emergency care of trauma patients might adversely affect other potentially ill patients requiring the same resources. We seek to determine whether the presence of a concurrent trauma activation negatively affects processes of care and outcomes for patients with potential acute coronary syndromes. METHODS: Patients who presented to the emergency department (ED) with a potential acute coronary syndrome from July 2003 to June 2004 were stratified according to whether they presented concurrently with a trauma activation. Structured data collection included demographics, medical history, and daily tracking of inhospital course. Thirty-day follow-up was performed. The main outcome was a composite of inhospital cardiovascular complications and 30-day death and myocardial infarction. Secondary outcomes were time from triage to ECG acquisition, transfer to an evaluation room, return of laboratory results, disposition decision, and actual disposition. RESULTS: Patients who presented concurrently with (n=357) or not concurrently with (n=1,235) a trauma activation were similar with respect to demographic characteristics, cardiac risk factors, and TIMI risk score. The unadjusted incidence of 30-day adverse cardiovascular events between potential acute coronary syndrome patients who presented with and without a concurrent trauma activation was 6.2% versus 3.6% (unadjusted odds ratio 1.74 [95% confidence interval (CI) 1.03 to 2.93]). After adjustment for measures of patient acuity (triage classification, TIMI risk score) and ED volume (total patient care hours and ED activity), concurrent trauma activation was independently associated with increased rate of 30-day cardiovascular complications (odds ratio 1.72; 95% CI 1.01 to 2.92). CONCLUSION: The presence of a concurrent trauma activation at the time of presentation of a patient with potential acute coronary syndrome was associated with an increased incidence of 30-day adverse cardiovascular events. Although trauma activations improve the care of trauma patients, they may be associated with a negative impact on the care of other patients requiring contemporaneous resources.

Relationship between a clear-cut alternative noncardiac diagnosis and 30-day outcome in emergency department patients with chest pain.

BACKGROUND: Accurate identification of patients with acute coronary syndromes (ACSs) in the emergency department (ED) remains problematic. Studies have not been able to identify a cohort of patients that are safe for immediate ED discharge; however, prior studies have not examined the utility of a clear-cut alternative noncardiac diagnosis. OBJECTIVES: To compare the 30-day event rate in ED chest pain patients who were diagnosed with a clear-cut alternative noncardiac diagnosis with the 30-day event rate in the cohort of patients in whom a definitive diagnosis could not be made in the ED. METHODS: This was a prospective cohort study of consecutive ED patients with potential ACS. Data included demographics, medical and cardiac history, laboratory and electrocardiogram results, and whether or not the treating physician ascribed the condition to a clear-cut alternative noncardiac diagnosis. The main outcome was death, acute myocardial infarction (AMI), or revascularization within 30 days, as determined by phone follow-up or medical record review. RESULTS: The investigators enrolled 1,995 patients in the ED who had potential ACSs. Overall, 77 had a final hospital diagnosis of AMI (4%). Within 30 days, 73 patients received revascularization (4%), and 26 died (1%). There were 599 (30%) patients given a clear-cut alternative noncardiac diagnosis. Comparing the patients with a clear-cut alternative noncardiac diagnosis with those without an obvious noncardiac diagnosis, the presence of a clear-cut alternative noncardiac diagnosis was associated with a reduced risk of an in-hospital triple-composite endpoint (death, MI, and revascularization), with a risk ratio of 0.32 (95% confidence interval [CI] = 0.19 to 0.55) and 30-day triple-composite endpoint with a risk ratio of 0.45 (95% CI = 0.29 to 0.69); however, patients with a clear-cut alternative noncardiac diagnosis still had a 4% event rate at 30 days (95% CI = 2.4% to 5.6%). CONCLUSIONS: In the ED chest pain patient, the presence of a clear-cut alternative noncardiac diagnosis reduces the likelihood of a composite outcome of death and cardiovascular events within 30 days. However, it does not reduce the event rate to an acceptable level to allow ED discharge of these patients.

The impact of a concurrent trauma alert evaluation on time to head computed tomography in patients with suspected stroke.

BACKGROUND: Emergency department (ED) overcrowding threatens quality of care by delaying the time to diagnosis and treatment of patients with time-sensitive diseases, such as acute stroke. OBJECTIVE: The authors hypothesized that the presence of a trauma alert evaluation would impede the time to head computed tomography (hCT) in patients with stroke-like symptoms. METHODS: This was a secondary analysis of prospectively collected data on patients with potential stroke who received an hCT in an urban trauma center ED from January 1, 2004, to November 30, 2004. Structured data collection included historical and examination items, National Institutes of Health (NIH) stroke scale score, laboratory and radiographic results, and final diagnosis. Admitted patients were followed in hospital. Patients who presented within one hour following a trauma evaluation were compared with patients who presented without concurrent trauma for triage time until completion of hCT. Chi-square, t-tests, and 95% confidence intervals (95% CIs) were used for comparisons. RESULTS: The 171 patients enrolled had a mean (+/- standard deviation) age of 60.7 (+/- 7) years; 60% were female; and 58% were African American. Of these, 72 patients had a significant cerebrovascular event (38 [22%] ischemic stroke, 25 [15%] transient ischemic attack, seven [4%] intracranial hemorrhage, one [0.6%] subarachnoid hemorrhage, and one [0.6%] subdural hematoma). The remaining diagnoses included 4.6% migraine, 2.3% seizure, 2.9% syncope, 2.3% Bell's palsy, and 2.9% vertigo. There was no significant difference in time to hCT in patients who presented during a trauma activation and those who did not (99 minutes [interquartile range (IQR) = 24-156] vs. 101 minutes [IQR = 43-151.5]; p = 0.537). In subgroup analysis of patients with a significant cerebrovascular event, times to hCT were also similar (24 minutes [IQR = 12-99] vs. 61 minutes [IQR = 15-126]; p = 0.26). CONCLUSIONS: In the authors' institution, the presence of concurrent trauma evaluation does not delay CT imaging of patients with potential stroke.