External Validation of a Tool to Identify Low-Risk Patients With Isolated Subdural Hematoma and Preserved Consciousness.

STUDY OBJECTIVE: The SafeSDH Tool was derived to identify patients with isolated (no other type of intracranial hemorrhage) subdural hematoma who are at very low risk of neurologic deterioration, neurosurgical intervention, or death. Patients are low risk by the tool if they have none of the following: use of anticoagulant or nonaspirin antiplatelet agent, Glasgow Coma Score (GCS) <14, more than 1 discrete hematoma, hematoma thickness >5 mm, or midline shift. We attempted to externally validate the SafeSDH Tool. METHODS: We performed a retrospective chart review of patients aged ≥16 with a GCS ≥13 and isolated subdural hematoma who presented to 1 of 6 academic and community hospitals from 2005 to 2018. The primary outcome, a composite of neurologic deterioration (seizure, altered mental status, or symptoms requiring repeat imaging), neurosurgical intervention, discharge on hospice, and death, was abstracted from discharge summaries. Hematoma thickness, number of hematomas, and midline shift were abstracted from head imaging reports. Anticoagulant use, antiplatelet use, and GCS were gathered from the admission record. RESULTS: The validation data set included 753 patients with isolated subdural hematoma. Mortality during the index admission was 2.1%; 26% of patients underwent neurosurgical intervention. For the composite outcome, sensitivity was 99% (95% confidence interval [CI] 97 to 100), and specificity was 31% (95% CI 27 to 35). The tool identified 162 (21.5%) patients as low risk. Negative likelihood ratio was 0.03 (95% CI 0.01 to 0.11). CONCLUSION: The SafeSDH Tool identified patients with isolated subdural hematoma who are at low risk for poor outcomes with high sensitivity. With prospective validation, these low-risk patients could be safe for management in less intensive settings.

Can tablet video-based telehealth assessment of the abdomen safely determine the need for abdominal imaging? A pilot study.

Objective: There is limited evidence on the reliability of video-based physical examinations. We aimed to evaluate the safety of a remote physician-directed abdominal examination using tablet-based video. Methods: This was a prospective observational pilot study of patients >19 years old presenting with abdominal pain to an academic emergency department July 9, 2021-December 21, 2021. In addition to usual care, patients had a tablet video-based telehealth history and examination by an emergency physician who was otherwise not involved in the visit. Both telehealth and in-person clinicians were asked about the patient's need for abdominal imaging (yes/no). Thirty-day chart review searched for subsequent ED visits, hospitalizations, and procedures. Our primary outcome was agreement between telehealth and in-person clinicians on imaging need. Our secondary outcome was potentially missed imaging by the telehealth physicians leading to morbidity or mortality. We used descriptive and bivariate analyses to examine characteristics associated with disagreement on imaging needs. Results: Fifty-six patients were enrolled; the median age was 43 years (interquartile range: 27-59), 31 (55%) were female. The telehealth and in-person clinicians agreed on the need for imaging in 42 (75%) of the patients (95% confidence interval [CI]: 62%-86%), with moderate agreement with Cohen's kappa ((k = 0.41, 95% CI: 0.15-0.67). For study patients who had a procedure within 24 hours of ED arrival (n = 3, 5.4%, 95% CI: 1.1%-14.9%) or within 30 days (n = 7, 12.5%, 95% CI: 5.2%-24.1%), neither telehealth physicians nor in-person clinicians missed timely imaging. Conclusion: In this pilot study, telehealth physicians and in-person clinicians agreed on the need for imaging for the majority of patients with abdominal pain. Importantly, telehealth physicians did not miss the identification of imaging needs for patients requiring urgent or emergent surgery.

Can video-based telehealth examinations of the abdomen safely determine the need for imaging?

There is little evidence on the reliability of the video-based telehealth physical examinations. Our objective was to evaluate the feasibility of a physician-directed abdominal examination using telehealth. This was a prospective, blinded observational study of patients >19 years of age presenting with abdominal pain to a large, academic emergency department. In addition to their usual care, patients had a video-based telehealth examination by an emergency physician early in the visit. We compared the in-person and telehealth providers' decisions on imaging. Thirty patients were enrolled and providers' recommendations for imaging were YES (telehealth: 18 (60%); in-person: 22 (73%)), UNSURE (telehealth: 9 (30%); in-person: 2 (7%)) and NO (telehealth: 6 (20%); in-person: 3 (10%)). There were 20 patients for whom both telehealth and in-person providers were not unsure; of these, 16 (80%, 95% confidence interval 56.3-94.3%) patients had a provider agreement on the need for imaging. While the use of video-based telehealth may be feasible for patients seeking emergency department care for abdominal pain, further study is needed to determine how it may be safely deployed. Currently, caution should be exercised when evaluating the need for abdominal imaging remotely.

Cerebral Fat Embolism After a Fall.

BACKGROUND: Cerebral fat embolism is a rare diagnosis that can occur after significant long bone trauma. Most patients have evidence of pulmonary involvement, but this case involved a patient with a pure neurologic manifestation of a fat embolism. CASE REPORT: An 89-year-old woman presented to the emergency department as a transfer from an outside hospital with a diagnosis of air embolism after an episode of altered mental status and expressive aphasia. A secondary review of the patient's computed tomography angiography head imaging uncovered a cerebral fat embolism as the cause of the patient's acute neurologic event. The cerebral fat embolism was likely from a remote sacral fracture 6 weeks prior. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: When a patient presents with a concern for a stroke-like symptoms and a cerebral fat embolism is diagnosed, a thorough examination of the patient must be performed to identify the primary fracture site. Geriatric long bone fractures have well-known significant morbidity and mortality. An associated cerebral fat embolism can increase that mortality and morbidity and prompt diagnosis is important.

The Utility of Computed Tomography Angiogram in Patients with Mild Traumatic Subarachnoid Hemorrhage.

BACKGROUND: Aneurysmal subarachnoid hemorrhage (aSAH) and traumatic subarachnoid hemorrhage (tSAH) differ significantly in their mortality and management. Although computed tomography angiography (CTA) is critical to guide timely interventions in aSAH, it lacks recognized benefit in assessing tSAH. Despite this, CTA commonly is included in tSAH evaluation. OBJECTIVE: Determine if any clinically significant cerebral aneurysms are identified on CTA in emergency department (ED) patients with a tSAH. METHODS: Retrospective observational study of consecutive blunt head trauma patients ages ≥ 16 years with Glasgow Coma Scale score (GCS) ≥ 13 who presented to an academic ED (100,000 annual visits) over a 7-year period. Those included had a CT-diagnosed SAH and underwent head CTA. The primary endpoint was the detection of any clinically significant brain aneurysms. RESULTS: There were 297 patients that met the inclusion criteria. Twenty-six patients (8.8%) had an incidental aneurysm discovered; one underwent elective outpatient intervention. Aneurysm-positive patients were more likely to be female (69.2% vs. 46.9%, p = 0.003), age 60 years or older (80.8% vs. 52.4%, p = 0.005), and be on anticoagulation (42.3% vs. 28.0%, p = 0.03). There were no differences between the aneurysm-positive and -negative patients with respect to GCS, history of hypertension, or mechanism of injury. CONCLUSIONS: In this 7-year retrospective chart review, CTA in patients with tSAH and GCS ≥ 13 did not reveal any clinically relevant cerebral aneurysms. One incidental aneurysm later underwent outpatient neurovascular intervention. In the absence of specific clinical concerns, CTA has minimal value in well-appearing patients with a tSAH.

External Validation of a Tool to Predict Neurosurgery in Patients with Isolated Subdural Hematoma.

BACKGROUND: Subdural hematoma (SDH) is the most common form of traumatic intracranial hemorrhage. Orlando and colleagues derived a prediction tool for neurosurgical intervention, the "Orlando Tool," consisting of (a) maximum thickness of hematoma, and (b) presence of acute-on-chronic (AOC) hematoma. This study externally validated the Orlando Tool. METHODS: We performed a retrospective chart review of consecutive patients aged ≥16 years with a Glasgow Coma Scale score ≥13, and a computed tomography-documented isolated, traumatic SDH, who presented to a university-affiliated, urban, 100,000-annual-visit emergency department from 2009-2015. The primary outcome was neurosurgical intervention. Thickness of hematoma and presence of AOC hematoma were abstracted from cranial computed tomography scan reports by 2 trained physician abstractors. RESULTS: A total of 607 patients with isolated SDH were included in the validation dataset. Median hematoma thickness was 6 mm. AOC hematoma was noted in 13% of patients. Mortality was 2.5%, and 15.7% of patients underwent neurosurgery. The Orlando Tool had an area under the curve of 0.93 in the validation, comparable to 0.94 reported in their derivation set. At the prespecified cutoff of 9.96% risk, the tool had a 88% (95% CI, 80-94) sensitivity in the validation cohort compared with 94% in the derivation cohort. The specificity of 82% (95% CI, 78-85) was comparable with 84% in the derivation group. Negative likelihood ratio was 0.14 (95% CI, 0.08-0.25), compared with 0.09 in derivation. CONCLUSIONS: The Orlando Tool accurately predicts neurosurgical intervention in patients with isolated, traumatic SDH and preserved consciousness.

Unscheduled return visits to the emergency department with ICU admission: A trigger tool for diagnostic error.

BACKGROUND: It is believed that patients who return to the Emergency Department (ED) and require admission are thought to represent failures in diagnosis, treatment or discharge planning. Screening readmission rates or patients who return within 72 h have been used in ED Quality Assurance efforts. These metrics require significant effort in chart review and only rarely identify care deviations. OBJECTIVE: This study was conducted to evaluate the yield of reviewing ED return visits that resulted in an ICU admission. This study was conducted to evaluate the yield of reviewing ED return visits that resulted in an ICU admission. We planned to assess if the return visits with ICU admission were associated with deviations in care, and secondarily, to understand the common causes of error in this group. METHODS: Retrospective review of patients presenting to a university affiliated ED between January 1, 2005 and December 31, 2015 and returned within 14 days requiring ICU admission. RESULTS: From 1,106,606 ED visits, 511 patients returned within 14 days and were admitted to an ICU. 223 patients returned for a reason related to the index visit (43.6%). Of these related returns, 31 (13.9%) had a deviation in care on the index visit. When a standard diagnostic process of care framework was applied to these 31 cases, 47.3% represented failures in the initial diagnostic pathway. CONCLUSION: Reviewing 14-day returns leading to ICU admission, while an uncommon event, has a higher yield in the understanding of quality issues involving diagnostic as well as systems errors.

Seizure frequency in patients with isolated subdural hematoma and preserved consciousness.

Background: Seizures are a complication of subdural hematoma (SDH), and there is substantial variability in the use of seizure prophylaxis for patients with SDH. However, the incidence of seizures in patients with SDH without severe neurotrauma is not clear. The objective of this study was to assess the frequency of and factors associated with seizures in patients with isolated SDH (iSDH) without severe neurotrauma. Methods: In this retrospective, observational study, we identified adults with Glasgow Coma Score (GCS) ≥13 and computed tomography (CT)-documented iSDH. The primary outcome was clinical seizure frequency. Seizure medication use was also assessed. Fisher's exact test and logistic regression were used to assess association. Results: Of 643 patients with iSDH, 14 (2.2%) had seizures during hospitalization. Of 630 patients (98%) not receiving seizure medication prior to SDH, 522 (82.9%) received levetiracetam. Of the patients who received a seizure medication, 12 (2.3%) had a seizure, while of the 121 patients who did not receive seizure medications, 2 (1.9%) had a seizure (p = .49). In multivariable regression, the only variable significantly associated with seizure was thickness of subdural hematoma (OR 1.16, p = .005). Conclusion: In patients with iSDH and preserved consciousness, in-hospital seizures were rare regardless of seizure medications use.

Rapid Discharge After Interfacility Transfer for Mild Traumatic Intracranial Hemorrhage: Frequency and Associated Factors.

INTRODUCTION: Traumatic intracranial hemorrhage (TIH), brain injury with radiographic hemorrhage, is a common emergency department (ED) presentation, and encompasses a wide range of clinical syndromes. Patients with moderate and severe neurotrauma (Glasgow Coma Scale [GCS] < 13) with intracranial hemorrhage require care at a trauma center with neurosurgical capabilities. However, many patients with mild traumatic intracranial hemorrhage (mTIH), defined as radiographic bleeding and GCS ≥ 13, do not require operative intervention or intensive care unit monitoring, but are still routinely transferred to tertiary care centers. We hypothesized that a significant proportion of patients are managed non-operatively and are discharged within 24 hours of admission. METHODS: This was a retrospective, observational study of consecutive patients age ≥ 16 years, GCS ≥ 13 who were transferred to an urban, medical school-affiliated, 100,000 annual visit ED over a seven-year period with blunt isolated mTIH. The primary outcome was discharge within 24 hours of admission. We measured rates of neurosurgical intervention, computed tomography hemorrhage progression, and neurologic deterioration as well as other demographic and clinical variables. RESULTS: There were 1079 transferred patients with isolated mTIH. Of these, 92.4% were treated non-operatively and 35.8% were discharged within 24 hours of presentation to the tertiary ED. Patient characteristics associated with rapid discharge after transfer include a GCS of 15 (odds ratio [OR] 2.9, 95% confidence interval [CI], 1.9 - 4.4), subdural hematoma ≤ 6mm (OR 3.1, 95% CI, 2.2 - 4.5) or the presence of an isolated subarachnoid hemorrhage (OR 1.7, 95% CI, 1.3 - 2.4). Of patients with length of stay < 24 hours, 79.8% were discharged directly from the ED or ED observation unit. CONCLUSION: Patients transferred to tertiary care centers are frequently discharged after brief observation without intervention. Risk can be predicted by clinical and radiographic data. Further prospective research is required to determine a safe cohort of patients who could be managed at community sites.

A natural language processing algorithm to extract characteristics of subdural hematoma from head CT reports.

PURPOSE: Subdural hematoma (SDH) is the most common form of traumatic intracranial hemorrhage, and radiographic characteristics of SDH are predictive of complications and patient outcomes. We created a natural language processing (NLP) algorithm to extract structured data from cranial computed tomography (CT) scan reports for patients with SDH. METHODS: CT scan reports from patients with SDH were collected from a single center. All reports were based on cranial CT scan interpretations by board-certified attending radiologists. Reports were then coded by a pair of physicians for four variables: number of SDH, size of midline shift, thickness of largest SDH, and side of largest SDH. Inter-rater reliability was assessed. The annotated reports were divided into training (80%) and test (20%) datasets. Relevant information was extracted from text using a pattern-matching approach, due to the lack of a mention-level gold-standard corpus. Then, the NLP pipeline components were integrated using the Apache Unstructured Information Management Architecture. Output performance was measured as algorithm accuracy compared to the data coded by the two ED physicians. RESULTS: A total of 643 scans were extracted. The NLP algorithm accuracy was high: 0.84 for side of largest SDH, 0.88 for thickness of largest SDH, and 0.92 for size of midline shift. CONCLUSION: A NLP algorithm can structure key data from non-contrast head CT reports with high accuracy. The NLP is a potential tool to detect important radiographic findings from electronic health records, and, potentially, add decision support capabilities.

Is repeat head CT necessary in patients with mild traumatic intracranial hemorrhage.

BACKGROUND: Patients with traumatic intracranial hemorrhage (TIH) frequently receive repeat head CT scans (RHCT) to assess for progression of TIH. The utility of this practice has been brought into question, with some studies suggesting that in the absence of progressive neurologic symptoms, the RHCT does not lead to clinical interventions. METHODS: This was a retrospective review of consecutive patients with CT-documented TIH and GCS ≥ 13 presenting to an academic emergency department from 2009 to 2013. Demographic, historical, and physical exam variables, number of CT scans during admission were collected with primary outcomes of: neurological decline, worsening findings on repeat CT scan, and the need for neurosurgical intervention. RESULTS: Of these 1126 patients with mild traumatic intracranial hemorrhage, 975 had RHCT. Of these, 54 (5.5% (4.2-7.2 95 CI) had neurological decline, 73 (7.5% 5.9-9.3 95 CI) had hemorrhage progression on repeat CT scan, and 58 (5.9% 4.5-7.6 95 CI) required neurosurgical intervention. Only 3 patients (0.3% 0.1-0.9% 95 CI) underwent neurosurgical intervention due to hemorrhage progression on repeat CT scan without neurological decline. In this scenario, the number of RHCT scans needed to be performed to identify this one patient is 305. CONCLUSIONS: RHCT after initial findings of TIH and GCS ≥ 13 leading to a change to operative management in the absence of neurologic progression is a rare event. A protocol that includes selective RHCT including larger subdural hematomas or patients with coagulopathy (vitamin K inhibitors and anti-platelet agents) may be a topic for further study.

Utilization of head CT during injury visits to United States emergency departments: 2012-2015.

INTRODUCTION: Studies have shown increasing utilization of head computed tomography (CT) imaging of emergency department (ED) patients presenting with an injury-related visit. Multiple initiatives, including the Choosing Wisely™ campaign and evidence-based clinical decision support based on validated decision rules, have targeted head CT use in patients with injuries. Therefore, we investigated national trends in the use of head CT during injury-related ED visits from 2012 to 2015. METHODS: This was a secondary analysis of data from the annual United States (U.S.) National Hospital Ambulatory Medical Care Survey from 2012 to 2015. The study population was defined as injury-related ED visits, and we sought to determine the percentage in which a head CT was ordered and, secondarily, to determine both the diagnostic yield of clinically significant intracranial findings and hospital characteristics associated with increased head CT utilization. RESULTS: Between 2012 and 2015, 12.25% (95% confidence interval [CI] 11.48-13.02%) of injury-related visits received at least one head CT. Overall head CT utilization showed an increased trend during the study period (2012: 11.7%, 2015: 13.23%, p = 0.09), but the results were not statistically significant. The diagnostic yield of head CT for a significant intracranial injury over the period of four years was 7.4% (9.68% in 2012 vs. 7.67% in 2015, p = 0.23). CONCLUSIONS: Head CT use along with diagnostic yield has remained stable from 2012 to 2015 among patients presenting to the ED for an injury-related visit.

72h returns: A trigger tool for diagnostic error.

BACKGROUND: Patients who return to the Emergency Department (ED) within 72h of discharge are often used for ED Quality Assurance efforts, however little is known about the yield of this kind of review and the types of errors it identifies. Our objective was to identify the prevalence, types and severity of errors in these cases. METHODS: Retrospective review of patients who presented to an urban, university affiliated ED between 10/1/2012-9/30/2015 who returned within 72 h requiring hospital admission. RESULTS: There were 413,167 ED visits during the study period with 2001 (0.48%) patients who returned within 72h and were admitted to the hospital. An event requiring further investigation was identified in 59 (2.95%) of these patients and 50 (2.49%) of them were deemed to represent a deviation from optimal care. Of these, 48 (96%) represented diagnostic error. When a standard diagnostic process of care framework was applied to these, the majority of cases represented failures in the initial diagnostic pathway (29 cases, 60.4%). When Error Severity Codes were applied, 16 (32%) resulted in minor harm and 34 (68%) resulted in major harm or death. CONCLUSION: Screening of 72h ED returns has low yield in identifying suboptimal care, with less than 3% of cases representing deviations from standard care. Of these, the majority represent cognitive errors in the diagnostic pathway. These reviews may be useful as a tool for Ongoing Professional Practice Evaluation of individual clinicians, however likely serve less value in identifying systems issues contributing to unsafe care.

Evaluation of a Low-risk Mild Traumatic Brain Injury and Intracranial Hemorrhage Emergency Department Observation Protocol.

OBJECTIVES: Among emergency physicians, there is wide variation in admitting practices for patients who suffered a mild traumatic brain injury (TBI) with an intracranial hemorrhage (ICH). The purpose of this study was to evaluate the effects of implementing a protocol in the emergency department (ED) observation unit for patients with mild TBI and ICH. METHODS: This retrospective cohort study was approved by the institutional review board. Study subjects were patients ≥ 18 years of age with an International Classification of Diseases code corresponding to a traumatic ICH and admitted to an ED observation unit (EDOU) of an urban, academic Level I trauma center between February 1, 2015, and January 31, 2017. Patient data and discharge disposition were abstracted from the electronic health record, and imaging data, from the final neuroradiologist report. To measure kappa, two abstractors independently collected data for presence of neuro deficit from a 10% random sample of the medical charts. Using a multivariable logistic regression model with a propensity score of the probability of placement in the EDOU before and after protocol implementation as a covariate, we sought to determine the pre-post effects of implementing a protocol on the composite outcome of admission to the floor, intensive care unit, or operating room from the EDOU and the proportion of patients with worsening findings on repeat computed tomography (CT) head scan in the EDOU. RESULTS: A total of 379 patients were identified during the study period; 83 were excluded as they were found to have no ICH on chart review. Inter-rater reliability kappa statistic was 0.63 for 30 charts. Among the 296 patients who remained eligible and comprised the study population, 143 were in the preprotocol period and 153 after protocol implementation. The EDOU protocol was associated with an independently statistically significant decreased odds ratio (OR) for admission or worsening ICH on repeat CT scan (OR = 0.45, 95% confidence interval [CI] = 0.25-0.82, p = 0.009) in the observation unit. After a stay in the EDOU, 26% (37/143) of patients required an inpatient admission before implementation of the protocol and 13% (20/153) of patients required an inpatient admission after protocol implementation. There was no statistically significant difference in log transformed EDOU length of stay (LOS) between the groups after adjusting for propensity score (p = 0.34). CONCLUSIONS: While there was no difference in EDOU LOS, implementing a low-risk mild TBI and ICH protocol in the EDOU may decrease the rate of inpatient admissions from the EDOU. A protocol-driven observation unit may help physicians by standardizing eligibility criteria and by providing guidance on management. As the propensity score method limits our ability to create a straightforward predictive model, a future larger study should validate the results.

A Decision Instrument to Identify Isolated Traumatic Subdural Hematomas at Low Risk of Neurologic Deterioration, Surgical Intervention, or Radiographic Worsening.

OBJECTIVES: Subdural hematoma (SDH) is the most common form of traumatic intracranial hemorrhage. Severity of disease in patients with SDH varies widely. It was hypothesized that a decision rule could identify patients with SDH who are at very low risk for neurologic decline, neurosurgical intervention, or radiographic worsening. METHODS: Retrospective chart review of consecutive patients age ≥ 16 with Glasgow Coma Score (GCS) ≥ 13 and computed tomography (CT)-documented isolated SDH presenting to a university-affiliated, urban, 100,000-annual-visit ED from 2009 to 2015. Demographic, historical, and physical examination variables were collected. Primary outcome was a composite of neurosurgical intervention, worsening repeat CT, and neurologic decline. Univariate analysis was performed and statistically important variables were utilized to create a logistic regression model. RESULTS: A total of 644 patients with isolated SDH were reviewed, 340 in the derivation group and 304 in the validation set. Mortality was 2.2%. A total 15.5% of patients required neurosurgery. A decision instrument was created: patients were low risk if they had none of the following factors-SDH thickness ≥ 5mm, warfarin use, clopidogrel use, GCS < 14, and presence of midline shift. This model had a sensitivity of 98.6% for the composite endpoint, specificity of 37.1%, and a negative likelihood ratio of 0.037. In the validation cohort, sensitivity was 96.3%, specificity was 31.5%, and negative likelihood ratio was 0.127. CONCLUSION: Subdural hematomas are amenable to risk stratification analysis. With prospective validation, this decision instrument may aid in triaging these patients, including reducing the need for transfer to tertiary centers.

RSV in adult ED patients: Do emergency providers consider RSV as an admission diagnosis?

BACKGROUND: Respiratory Syncytial Virus (RSV) has been recognized for over half a century as a cause of morbidity in infants and children. Over the past 20years, data has emerged linking RSV as a cause of illness in adults resulting in 177,000 annual hospitalizations and up to 14,000 deaths among older adults. OBJECTIVE: Characterize clinical variables in a cohort of adult RSV patients. We hypothesize that emergency physicians do not routinely consider RSV in the differential diagnosis (DDx) of influenza like illness. METHODS: Observational study of all adult inpatients, age≥19, with a positive RSV swab ordered within 48h of their hospital visit, including their emergency department (ED) visit, and who initially presented to a university affiliated urban 100,000 annual visit emergency department from 2007 to 2014. A data collection form was created, and a single trained clinical research assistant abstracted demographic, clinical variables. ED providers were given credit for RSV DDx if an RSV swab was ordered as part of the diagnostic ED workup. RESULTS: 295 consecutive inpatients (mean age=66.5years, range, 19-97, 53% male) were RSV positive during the 7-year study period. 207 cases (70%) were age≥60. 76 (26%) had fever, 86 (29%) had O2sat <92% and 145 (49%) had wheezing. 279 patients required admission, 30 needed ICU stay and overall mortality was 12 patients (4%). Age≥60 was associated with overall mortality (p=0.09). There were 106 (36%) immunocompromised patients (23% transplant, 40% cancer, 33% steroid use) in the cohort. A diagnosis of RSV was considered in the ED in 105 (36%) of patients. Being immunocompromised, having COPD/asthma, O2sat <92, or wheezing did not alert the ED provider to order an RSV test. CONCLUSION: Adults can harbor RSV as this can lead to significant mobility and mortality, especially in individuals who are over the age of 60. RSV is not being considered in the DDx diagnosis, and this was especially surprising in the transplant/immunocompromised subgroups. Given antiviral treatment options, educational efforts should be undertaken to raise awareness of RSV in adults.

Opportunity to reduce transfer of patients with mild traumatic brain injury and intracranial hemorrhage to a Level 1 trauma center.

OBJECTIVE: Current guidelines do not address the disposition of patients with mild traumatic brain injury (TBI) and resultant intracranial hemorrhage (ICH). Emergency medicine clinicians working in hospitals without neurosurgery coverage typically transfer patients with both to a trauma center with neurosurgery capability. Evidence is accruing which demonstrates that the risk of neurologic decompensation depends on the type of ICH and as a result, not every patient may need to be transferred. The purpose of this study was to identify risk factors for admission among patients with mild TBI and ICH who were transferred from a community hospital to the emergency department (ED) of a Level 1 trauma center. METHODS: Study subjects were patients ≥18years of age who were transferred from a community hospital to the ED of an urban, academic Level 1 trauma center between April 1, 2015 and March 31, 2016, and with an isolated traumatic ICH. Patients who had an epidural hematoma, were deemed to require a trauma center's level of service, were found to have non-traumatic ICHs, or had a Glasgow Coma Scale of <13 were excluded. Using a multivariable logistic regression model, we sought to determine patient factors and Computed Tomography (CT) findings which were associated with admission (to the floor, intensive care unit, or operating room with neurosurgery) of the Level 1 trauma center. RESULTS: 644 transferred patients were identified; 205 remained eligible after exclusion criteria. Presence of warfarin (odds ratio [OR] 4.09, 95% Confidence Interval [CI] 1.64, 10.25, p=0.0026) and a subdural hematoma (SDH) ≥1 cm (OR 6.28, 95% CI 1.24, 31.71, p=0.0263) were independently statistically significant factors predicting admission. Age, sex, GCS, presence of neurologic deficit, aspirin use, clopidogrel use, SDH <1 cm, IPH, and SAH were each independently not significant predictive factors of an admission. CONCLUSIONS: After controlling for factors, transferred patients with mild TBI with a SDH ≥1 cm or on warfarin have a higher odds ratio of requiring inpatient admission to a Level 1 trauma center. While these patients may require admission, there may be opportunities to develop and study a low risk traumatic intracranial hemorrhage protocol, which keeps a subgroup of patients with a mild TBI and resultant ICH at community hospitals with access to a nearby Level 1 trauma center.

Identifying patients with mild traumatic intracranial hemorrhage at low risk of decompensation who are safe for ED observation.

BACKGROUND: Patients with traumatic intracranial hemorrhage and mild traumatic brain injury (mTIH) receive broadly variable care which often includes transfer to a trauma center, neurosurgery consultation and ICU admission. However, there may be a low risk cohort of patients who can be managed without utilizing such significant resources. OBJECTIVE: Describe mTIH patients who are at low risk of clinical or radiographic decompensation and can be safely managed in an ED observation unit (EDOU). METHODS: Retrospective evaluation of patients age≥16, GCS≥13 with ICH on CT. Primary outcomes included clinical/neurologic deterioration, CT worsening or need for neurosurgery. RESULTS: 1185 consecutive patients were studied. 814 were admitted and 371 observed patients (OP) were monitored in the EDOU or discharged from the ED after a period of observation. None of the OP deteriorated clinically. 299 OP (81%) had a single lesion on CT; 72 had mixed lesions. 120 patients had isolated subarachnoid hemorrhage (iSAH) and they did uniformly well. Of the 119 OP who had subdural hematoma (SDH), 6 had worsening CT scans and 3 underwent burr hole drainage procedures as inpatients due to persistent SDH without new deficit. Of the 39 OP who had cerebral contusions, 3 had worsening CT scans and one required NSG admission. No patient returned to the ED with a complication. Follow-up was obtained on 81% of OP. 2 patients with SDH required burr hole procedure >2weeks after discharge. CONCLUSIONS: Patients with mTIH, particularly those with iSAH, have very low rates of clinical or radiographic deterioration and may be safe for monitoring in an emergency department observation unit.

A prediction model to identify patients without a concerning intraabdominal diagnosis.

OBJECTIVE: Patients with abdominal diagnoses constitute 5% to 10% of all emergency department (ED) presentations. The goal of this study is to identify which of these patients will have a nonconcerning diagnosis based on demographic, physical examination, and basic laboratory testing. METHODS: Consecutive patients from July 2013 to March 2014 discharged with a gastrointestinal (GI) diagnosis who presented to an urban, university-affiliated ED were identified. The cohort was split into a derivation set and a validation set. Using univariate and multivariable logistic regression analysis, a risk score was created based on the deviation data and then tested on the validation data. RESULTS: There were 8852 patients with a GI diagnosis during the study period. A total of 7747 (87.5%) of them had a nonconcerning diagnosis. The logistic regression model identified 13 variables that predict a concerning GI diagnosis and created a scoring system ranging from 0 to 20. The area under the receiver operating characteristic was 0.81. When dichotomized at greater than or equal to 7 vs less than 7, the risk score has a sensitivity of 91% (95% confidence interval [CI], 88-94), specificity of 46% (95% CI, 44-48), positive predictive value of 17% (95% CI, 15-19) and negative predictive value of 98% (95% CI, 97-99). CONCLUSION: One can determine with a high degree of certainty, based only on an initial evaluation and screening laboratory work (excluding radiology) whether a patient who presents with a GI-related complaint has a nonconcerning diagnosis. This model could be used as a tool to aid in quality assurance when reviewing patients discharged with GI complaints and with future study, as a secondary triage instrument in a crowded ED environment, and aid in resource allocation.