What is the risk of returning to the emergency department within 30 days for patients diagnosed with substance-induced psychosis?

OBJECTIVES: The primary objective of this study was to measure the risk of return Emergency Department (ED) visits in patients presenting to the ED with a diagnosis of substance-induced psychosis. Secondary objectives included: (1) describing the characteristics of patients returning within 30 days to the ED with substance-induced psychosis, and (2) identifying risk factors associated with such ED return. METHODS: At two urban sites from January 1, 2018 to December 31, 2019, we included consecutive patients presenting to the ED with substance-induced psychosis defined by their ED discharge diagnosis of psychosis and clinical evidence of substance use. We described ED resources utilized by this patient population including ED time and disposition then subsequently described return visits within 30 days and characteristics among those patients who returned. RESULTS: We identified 611 unique patients presenting with substance-induced psychosis, with 813 total ED visits. The median age was 35 years (IQR 28-45), 71.4% (n = 436) were male, and 44.8% (n = 274) were homeless. The median ED length of stay was 619 min (IQR 313-898), and 48.4% (n = 296) were admitted to hospital. Forty percent of patients (n = 237) returned to the ED within 30 days of the index substance-induced psychosis visit, 116 (18.9%) returning more than once. Of these return visits, 74 (31.2%) were for recurrent substance-induced psychosis. Younger age, female gender, no opioid use, and no prior history of bipolar disorder were identified as common characteristics among those returning to the ED with substance-induced psychosis. CONCLUSIONS: In ED patients with substance-induced psychosis, nearly half of all patients were admitted to hospital, 40% had a 30 days return ED visit, and one-third of those were for substance-induced psychosis. We identified clinically relevant factors common to those returning with recurrent substance-induced psychosis.

RéSUMé: OBJECTIFS: L'objectif principal de cette étude était de mesurer le risque de retour aux urgences chez les patients se présentant aux urgences avec un diagnostic de psychose induite par une substance. Les objectifs secondaires comprenaient : 1) décrire les caractéristiques des patients qui retournent aux urgences dans les 30 jours avec une psychose induite par la substance, et 2) déterminer les facteurs de risque associés à ce retour aux urgences. MéTHODES: Dans deux sites urbains, du 1er janvier 2018 au 31 décembre 2019, nous avons inclus des patients consécutifs se présentant aux urgences avec une psychose induite par une substance, définie par leur diagnostic de psychose à la sortie des urgences et des preuves cliniques de consommation de substances. Nous avons décrit les ressources des urgences utilisées par cette population de patients, notamment le temps passé aux urgences et les dispositions prises, puis nous avons décrit les visites de retour dans les 30 jours et les caractéristiques des patients qui sont revenus. RéSULTATS: Nous avons identifié 611 patients uniques présentant une psychose induite par une substance, avec un total de 813 visites aux urgences. L'âge médian était de 35 ans (IQR 28-45), 71,4 % (n = 436) étaient des hommes et 44,8 % (n = 274) étaient sans domicile fixe. La durée médiane du séjour aux urgences était de 619 minutes (IQR 313-898), et 48,4 % (n = 296) ont été hospitalisés. Quarante pour cent des patients (n = 237) sont retournés aux urgences dans les 30 jours suivant la visite de référence pour une psychose due à une substance, 116 (18,9 %) y étant retournés plus d'une fois. Parmi ces visites de retour, 74 (31,2 %) concernaient une psychose récurrente induite par une substance. Un âge plus jeune, le sexe féminin, l'absence de consommation d'opioïdes et d'antécédents de troubles bipolaires ont été identifiés comme des caractéristiques communes chez les personnes revenant aux urgences pour une psychose induite par une substance. CONCLUSIONS: Chez les patients des urgences souffrant de psychose due à une substance, près de la moitié des patients ont été hospitalisés, 40 % sont revenus aux urgences dans les 30 jours, dont un tiers pour une psychose due à une substance. Nous avons identifié des facteurs cliniquement pertinents communs à ceux qui reviennent avec une psychose récurrente induite par une substance.

One-year mortality of emergency department patients with substance-induced psychosis.

OBJECTIVES: Psychosis is a well established complication of non-prescription drug use. We sought to measure the 1-year mortality of emergency department patients with substance-induced psychosis (SIP). METHODS: This study was a multi-centre, retrospective electronic medical records review of patients presenting to the ED with substance-induced psychosis (SIP). We interrogated the hospital ED database from Jan 1, 2018 and Jan 1, 2019 to identify consecutive patients. All patients were followed for one year from index visit, and classified as alive/dead at that time. Patients were included in the study if they met the following criteria: 1) ED discharge diagnosis of psychosis NOS and a positive urine drugs of abuse screen (UDAS) or the patient verbally endorsed drug use, or 2) Mental disorder due to drug use and "disorganized thought", "bizarre behavior" or "delusional behavior" documented in the chart and one or more of the following criteria: a) arrival with police, b) mental health certification, c) physical restraints, d) chemical restraints. We excluded patients who were not British Columbia residents, since we were unable to ascertain if they were alive or dead at 1 year from their index ED visit. Primary statistical analysis was logistic regression for risk of death in 1 year, based on plausible risk factors, selected a priori. RESULTS: We identified 813 presentations for SIP (620 unique patients). The median age of the entire cohort was 35 years (IQR 28-44), and 69.5% (n = 565) were male. Thirty five patients (4.3%; 95% CI 3.2-5.9) had died one year after their initial presentation to the ED for SIP. Separate multivariable logistic regression analyses, controlling for age, demonstrated schizophrenia (OR 4.2, 95% CI 1.8-11.1) significantly associated with increased 1-year mortality. CONCLUSIONS: In our study of patients presenting to the ED with SIP, the 1-year mortality was 4.3%. Controlling for age, schizophrenia was a notable risk factor for increased 1-year mortality.

qSOFA does not predict bacteremia in patients with severe manifestations of sepsis.

BACKGROUND: Bloodstream infections in septic patients may be missed due to preceding antibiotic therapy prior to obtaining blood cultures. We leveraged the FABLED cohort study to determine if the quick Sequential Organ Failure Assessment (qSOFA) score could reliably identify patients at higher risk of bacteremia in patients who may have false negative blood cultures due to previously administered antibiotic therapy. METHODS: We conducted a multi-centre diagnostic study among adult patients with severe manifestations of sepsis. Patients were enrolled in one of seven participating centres between November 2013 and September 2018. All patients from the FABLED cohort had two sets of blood cultures drawn prior to the administration of antimicrobial therapy, as well as additional blood cultures within 4 hours of treatment initiation. Participants were categorized according to qSOFA score, with a score ≥2 being considered positive. RESULTS: Among 325 patients with severe manifestations of sepsis, a positive qSOFA score (defined as a score ≥2) on admission was 58% sensitive (95% CI 48% to 67%) and 41% specific (95% CI 34% to 48%) for predicting bacteremia. Among patients with negative post-antimicrobial blood cultures, a positive qSOFA score was 57% sensitive (95% CI 42% to 70%) and 42% specific (95% CI 35% to 49%) to detect patients who were originally bacteremic prior to the initiation of therapy. CONCLUSIONS: Our results suggest that the qSOFA score cannot be used to identify patients at risk for occult bacteremia due to the administration of antibiotics pre-blood culture.

HISTORIQUE: Les infections sanguines peuvent rester non diagnostiquées chez les patients septiques avant l'obtention des cultures sanguines, en raison d'une antibiothérapie antérieure. Les chercheurs ont puisé dans l'étude de cohorte FABLED pour déterminer si le score rapide de l'évaluation séquentielle d'insuffisance des organes (Sequential Organ Failure Assessment, qSOFA) pourrait dépister les patients à plus haut risque de bactériémie avec fiabilité, malgré la possibilité de cultures sanguines faussement négatives en raison d'une antibiothérapie antérieure. MÉTHODOLOGIE: Les chercheurs ont réalisé une étude diagnostique multicentrique chez des patients adultes ayant de graves manifestations de sepsis. Les patients ont été inscrits dans l'un des sept centres participants entre novembre 2013 et septembre 2018. Tous les patients de l'étude de cohorte FABLED avaient subi deux séries de cultures sanguines avant de recevoir une thérapie antimicrobienne, de même qu'une autre série de cultures sanguines dans les quatre heures suivant le début du traitement. Les participants ont été classés en fonction de leur score de qSOFA, un score d'au moins 2 étant considéré comme positif. RÉSULTATS: Chez les 325 patients ayant de graves manifestations de sepsis, un score de qSOFA positif (défini comme un score d'au moins 2) à l'admission était sensible à 58 % (IC à 95 %, 48 % à 67 %) et spécifique à 41 % (IC à 95 %, 34 % à 48 %) pour prédire la bactériémie. Chez les patients dont les cultures sanguines étaient négatives après la prise d'antimicrobiens, un score de qSOFA positif était sensible à 57 % (IC à 95 %, 42 % à 70 %) et spécifique à 42 % (IC à 95 %, 35 % à 49 %) pour dépister les patients atteints d'une bactériémie avant le début du traitement. CONCLUSIONS: Selon les résultats, le score de qSOFA ne peut pas être utilisé pour dépister les patients à risque de bactériémie occulte à cause de l'administration d'antibiotiques avant la culture sanguine.

Neither Blood Culture Positivity nor Time to Positivity Is Associated With Mortality Among Patients Presenting With Severe Manifestations of Sepsis: The FABLED Cohort Study.

BACKGROUND: Sepsis is a leading cause of morbidity, mortality, and health care costs worldwide. METHODS: We conducted a multicenter, prospective cohort study evaluating the yield of blood cultures drawn before and after empiric antimicrobial administration among adults presenting to the emergency department with severe manifestations of sepsis. Enrolled patients who had the requisite blood cultures drawn were followed for 90 days. We explored the independent association between blood culture positivity and its time to positivity in relation to 90-day mortality. RESULTS: Three hundred twenty-five participants were enrolled; 90-day mortality among the 315 subjects followed up was 25.4% (80/315). Mortality was associated with age (mean age [standard deviation] in those who died was 72.5 [15.8] compared with 62.9 [17.7] years among survivors; P < .0001), greater Charlson Comorbidity Index (2 [interquartile range {IQR}, 1-3] vs 1 [IQR, 0-3]; P = .008), dementia (13/80 [16.2%] vs 18/235 [7.7%]; P = .03), cancer (27/80 [33.8%] vs 47/235 [20.0%]; P = .015), positive quick Sequential Organ Failure Assessment score (57/80 [71.2%] vs 129/235 [54.9%]; P = .009), and normal white blood cell count (25/80 [31.2%] vs 42/235 [17.9%]; P = .02). The presence of bacteremia, persistent bacteremia after antimicrobial infusion, and shorter time to blood culture positivity were not associated with mortality. Neither the source of infection nor pathogen affected mortality. CONCLUSIONS: Although severe sepsis is an inflammatory condition triggered by infection, its 90-day survival is not influenced by blood culture positivity nor its time to positivity. CLINICAL TRIALS REGISTRATION: NCT01867905.

Real-world Time to Positivity of 2 Widely Used Commercial Blood Culture Systems in Patients With Severe Manifestations of Sepsis: An Analysis of the FABLED Study.

BACKGROUND: Of all microbiological tests performed, blood cultures have the most impact on patient care. Timely results are essential, especially in the management of sepsis. While there are multiple available blood culture systems on the market, they have never been compared in a prospective study in a critically ill population. METHODS: We performed an analysis of the FABLED study cohort to compare culture results and time to positivity (TTP) of 2 widely used blood culture systems: BacT/Alert and BACTEC. In this multisite prospective study, patients with severe manifestations of sepsis had cultures drawn before antibiotics using systematic enrollment criteria and blood drawing methodology allowing for minimization of pre-analytical biases. RESULTS: We enrolled 315 patients; 144 had blood cultures (47 positive) with BacT/Alert and 171 with BACTEC (53 positive). Patients whose blood cultures were processed using the BacT/Alert system were younger (median, 64 vs 70 years; P = .003), had a higher proportion of HIV (9.03% vs 1.75%; P = .008) and a lower qSOFA (P = .003). There were no statistically significant differences in the most commonly identified bacterial species. TTP was shorter for BACTEC (median [interquartile range {IQR}], 12.5 [10-14] hours) compared with BacT/Alert (median [IQR], 17 [14-21] hours; P < .0001). CONCLUSIONS: In this large prospective multi-centre study comparing the two blood culture systems among patients with severe manifestations of sepsis, and using a rigorous pre-analytical methodology, the BACTEC system yielded positive culture results 4.5 hours earlier than BacT/Alert. These results apply to commonly isolated bacteria. However, our study design did not allow direct comparison of TTP for unusual pathogens nor of clinical sensitivity between systems. More research is needed to determine the clinical implications of this finding.

Public access defibrillators: Gender-based inequities in access and application.

AIM: While public access automated external defibrillator (AED) programs appear to improve outcomes in out-of-hospital cardiac arrest (OHCA) it is unclear if men and women benefit equally. We examined gender-based differences in OHCA location to determine what proportion were potentially eligible for public access AED application, and if patient gender was associated with AED utilization. METHODS: We analyzed data from the Resuscitation Outcomes Consortium registry (2011-2015). We compared differences in OHCA locations by gender. We fit multivariate logistic regression models, restricted to public location OHCAs and public-location cases with bystander intervention, to calculate the association between gender and public access AED application. RESULTS: Among 61 473 cases, 34% were female and 50% had bystander resuscitation. The incidence of public OHCA was 8.8% for women and 18% for men (risk difference 9.2%, 95% CI 8.7-9.7%). Women had significantly fewer OHCAs on roadways, in public buildings, places of recreation, and farms, but more in homes, non-acute healthcare facilities, and residential institutions. Female gender was associated with a lower odds of AED application in public OHCA (adjusted OR 0.76, 95% CI 0.64-0.90) and public-location cases with bystander interventions (adjusted OR 0.83, 95% CI 0.71-0.99). CONCLUSION: Women had fewer OHCA in public locations that may have public access AEDs. Even among public location OHCA with bystander interventions, women were less likely to have public access AED applied. Initiatives to optimize AED locations and to engage the public with gender-specific resuscitation training may improve outcomes in women with OHCA.

Blood Culture Results Before and After Antimicrobial Administration in Patients With Severe Manifestations of Sepsis: A Diagnostic Study.

Background: Administering antimicrobial agents before obtaining blood cultures could potentially decrease time to treatment and improve outcomes, but it is unclear how this strategy affects diagnostic sensitivity. Objective: To determine the sensitivity of blood cultures obtained shortly after initiation of antimicrobial therapy in patients with severe manifestations of sepsis. Design: Patient-level, single-group, diagnostic study. (ClinicalTrials.gov: NCT01867905). Setting: 7 emergency departments in North America. Participants: Adults with severe manifestations of sepsis, including systolic blood pressure less than 90 mm Hg or a serum lactate level of 4 mmol/L or more. Intervention: Blood cultures were obtained before and within 120 minutes after initiation of antimicrobial treatment. Measurements: Sensitivity of blood cultures obtained after initiation of antimicrobial therapy. Results: Of 3164 participants screened, 325 were included in the study (mean age, 65.6 years; 62.8% men) and had repeated blood cultures drawn after initiation of antimicrobial therapy (median time, 70 minutes [interquartile range, 50 to 110 minutes]). Preantimicrobial blood cultures were positive for 1 or more microbial pathogens in 102 of 325 (31.4%) patients. Postantimicrobial blood cultures were positive for 1 or more microbial pathogens in 63 of 325 (19.4%) patients. The absolute difference in the proportion of positive blood cultures between pre- and postantimicrobial testing was 12.0% (95% CI, 5.4% to 18.6%; P < 0.001). Sensitivity of postantimicrobial culture was 52.9% (CI, 42.8% to 62.9%). When the results of other microbiological cultures were included, microbial pathogens were found in 69 of 102 (67.6% [CI, 57.7% to 76.6%]) patients. Limitation: Only a proportion of screened patients were recruited. Conclusion: Among patients with severe manifestations of sepsis, initiation of empirical antimicrobial therapy significantly reduces the sensitivity of blood cultures drawn shortly after treatment initiation. Primary Funding Source: Vancouver Coastal Health, St. Paul's Hospital Foundation Emergency Department Support Fund, the Fonds de recherche Santé-Québec, and the Maricopa Medical Foundation.

Prehospital Analgesia With Intranasal Ketamine (PAIN-K): A Randomized Double-Blind Trial in Adults.

STUDY OBJECTIVE: We compare intranasal ketamine with intranasal placebo in providing pain reduction at 30 minutes when added to usual paramedic care with nitrous oxide. METHODS: This was a randomized double-blind study of out-of-hospital patients with acute pain who reported a verbal numeric rating scale (VNRS) pain score greater than or equal to 5. Exclusion criteria were younger than 18 years, known ketamine intolerance, nontraumatic chest pain, altered mental status, pregnancy, and nasal occlusion. Patients received usual paramedic care and were randomized to receive either intranasal ketamine or intranasal saline solution at 0.75 mg/kg. The primary outcome was the proportion of patients with VNRS score reduction greater than or equal to 2 at 30 minutes. Secondary outcomes were pain reduction at 15 minutes, patient-reported comfort, satisfaction scores, nitrous oxide consumption, and incidence of adverse events. RESULTS: One hundred twenty subjects were enrolled. Seventy-six percent of intranasal ketamine patients versus 41% of placebo patients reported a greater than or equal to 2-point VNRS reduction at 30 minutes (difference 35%; 95% confidence interval 17% to 51%). Median VNRS reduction at 15 minutes was 2.0 and 1.0 and at 30 minutes was 3.0 and 1.0 for ketamine and placebo, respectively. Improved comfort at 15 and 30 minutes was reported for 75% versus 57% and 61% versus 46% of ketamine and placebo patients, respectively. Sixty-two percent of patients (95% confidence interval 49% to 73%) versus 20% (95% confidence interval 12% to 32%) reported adverse events with ketamine and placebo, respectively. Adverse events were minor, with no patients requiring physical or medical intervention. CONCLUSION: Added to nitrous oxide, intranasal ketamine provides clinically significant pain reduction and improved comfort compared with intranasal placebo, with more minor adverse events.

Intraosseous Vascular Access Is Associated With Lower Survival and Neurologic Recovery Among Patients With Out-of-Hospital Cardiac Arrest.

STUDY OBJECTIVE: We seek to determine the effect of intraosseous over intravenous vascular access on outcomes after out-of-hospital cardiac arrest. METHODS: This secondary analysis of the Resuscitation Outcomes Consortium Prehospital Resuscitation Using an Impedance Valve and Early Versus Delayed (PRIMED) study included adult patients with nontraumatic out-of-hospital cardiac arrests treated during 2007 to 2009, excluding those with any unsuccessful attempt or more than one access site. The primary exposure was intraosseous versus intravenous vascular access. The primary outcome was favorable neurologic outcome on hospital discharge (modified Rankin Scale score ≤3). We determined the association between vascular access route and out-of-hospital cardiac arrest outcome with multivariable logistic regression, adjusting for age, sex, initial emergency medical services-recorded rhythm (shockable or nonshockable), witness status, bystander cardiopulmonary resuscitation, use of public automated external defibrillator, episode location (public or not), and time from call to paramedic scene arrival. We confirmed the results with multiple imputation, propensity score matching, and generalized estimating equations, with study enrolling region as a clustering variable. RESULTS: Of 13,155 included out-of-hospital cardiac arrests, 660 (5.0%) received intraosseous vascular access. In the intraosseous group, 10 of 660 patients (1.5%) had favorable neurologic outcome compared with 945 of 12,495 (7.6%) in the intravenous group. On multivariable regression, intraosseous access was associated with poorer out-of-hospital cardiac arrest survival (adjusted odds ratio 0.24; 95% confidence interval 0.12 to 0.46). Sensitivity analyses revealed similar results. CONCLUSION: In adult out-of-hospital cardiac arrest patients, intraosseous vascular access was associated with poorer neurologic outcomes than intravenous access.

Implementation of an emergency department atrial fibrillation and flutter pathway improves rates of appropriate anticoagulation, reduces length of stay and thirty-day revisit rates for congestive heart failure.

OBJECTIVES: An evidence-based emergency department (ED) atrial fibrillation and flutter (AFF) pathway was developed to improve care. The primary objective was to measure rates of new anticoagulation (AC) on ED discharge for AFF patients who were not AC correctly upon presentation. METHODS: This is a pre-post evaluation from April to December 2013 measuring the impact of our pathway on rates of new AC and other performance measures in patients with uncomplicated AFF solely managed by emergency physicians. A standardized chart review identified demographics, comorbidities, and ED treatments. The primary outcome was the rate of new AC. Secondary outcomes were ED length of stay (LOS), referrals to AFF clinic, ED revisit rates, and 30-day rates of return visits for congestive heart failure (CHF), stroke, major bleeding, and death. RESULTS: ED AFF patients totalling 301 (129 pre-pathway [PRE]; 172 post-pathway [POST]) were included; baseline demographics were similar between groups. The rates of AC at ED presentation were 18.6% (PRE) and 19.7% (POST). The rates of new AC on ED discharge were 48.6 % PRE (95% confidence interval [CI] 42.1%-55.1%) and 70.2% POST (62.1%-78.3%) (20.6% [p<0.01; 15.1-26.3]). Median ED LOS decreased from 262 to 218 minutes (44 minutes [p<0.03; 36.2-51.8]). Thirty-day rates of ED revisits for CHF decreased from 13.2% to 2.3% (10.9%; p<0.01; 8.1%-13.7%), and rates of other measures were similar. CONCLUSIONS: The evidence-based pathway led to an improvement in the rate of patients with new AC upon discharge, a reduction in ED LOS, and decreased revisit rates for CHF.

A Case Report of Tadalafil-Associated Fixed Drug Eruption.

Tadalafil is a drug approved for use in erectile dysfunction, but increasingly being used recreationally. There have only been scant case reports on tadalafil causing fixed drug eruption (FDE). Patients who use tadalafil recreationally are less likely to seek medical attention and the diagnosis can often be missed, given the difficulty in diagnosis. However, clinical examination together with a detailed medication history can provide clinicians with good evidence of the association without invasive biopsies. We discuss a 37-year-old male who developed FDE after 2 separate exposures to tadalafil used for recreational purpose. The scar from the first reaction served as a landmark for the second exposure. His lesions resolved 2 days after the initial presentation. The Naranjo adverse drug reaction probability scale (score = 9) indicates a definite adverse drug reaction to tadalafil. We hope to raise awareness of this drug reaction with this case report.

Prehospital sodium bicarbonate use could worsen long term survival with favorable neurological recovery among patients with out-of-hospital cardiac arrest.

BACKGROUND: Sodium bicarbonate (SB) is widely used for resuscitation in out-of- hospital cardiac arrest (OHCA); however, its effect on long term outcomes is unclear. METHODS: From 2005-2016, we prospectively conducted a province-wide population-based observational study including adult non-traumatic OHCA patients managed by paramedics. SB was administered by paramedics based on their clinical assessments. To examine the association of SB administration and survival and favorable neurological outcome to hospital discharge, defined as modified Rankin scale of 3 or less, we performed a multivariable logistic regression analysis: (1) within propensity score matched comparison groups, and; (2) within the full cohort with missing variables addressed by multiple imputation techniques. RESULTS: Of 15 601 OHCA patients, 13,865 were included in this study with 5165 (37.3%) managed with SB. In the SB treated group, 118 (2.3%) patients survived and 62 (1.2%) had favorable neurological outcomes to hospital discharge, compared to 1699 (19.8%) and 831 (10.6%) in the non-SB treated group, respectively. In the 1:1 propensity matched cohort including 5638 OHCA patients, SB was associated with decreased probability of outcomes (adjusted OR for survival: 0.64, 95% CI 0.45-0.91, and adjusted OR for favorable neurological outcome: 0.59, 95% CI 0.39-0.88, respectively). The association remained consistent in the multiply imputed cohort (adjusted OR 0.48, 95 CI 0.36-0.64, and adjusted OR 0.54, 95% CI 0.38-0.76, respectively). CONCLUSIONS: In OHCA patients, prehospital SB administration was associated with worse survival rate and neurological outcomes to hospital discharge.

External Validation of the Universal Termination of Resuscitation Rule for Out-of-Hospital Cardiac Arrest in British Columbia.

STUDY OBJECTIVE: The Universal Termination of Resuscitation Rule (TOR Rule) was developed to identify out-of-hospital cardiac arrests eligible for field termination of resuscitation, avoiding futile transportation to the hospital. The validity of the rule in emergency medical services (EMS) systems that do not routinely transport out-of-hospital cardiac arrest patients to the hospital is unknown. We seek to validate the TOR Rule in British Columbia. METHODS: This study included consecutive, nontraumatic, adult, out-of-hospital cardiac arrests treated by EMS in British Columbia from April 2011 to September 2015. We excluded patients with active do-not-resuscitate orders and those with missing data. Following consensus guidelines, we examined the validity of the TOR Rule after 6 minutes of resuscitation (to approximate three 2-minute cycles of resuscitation). To ascertain rule performance at the different time junctures, we recalculated TOR Rule classification accuracy at subsequent 1-minute resuscitation increments. RESULTS: Of 6,994 consecutive, adult, EMS-treated, out-of-hospital cardiac arrests, overall survival was 15%. At 6 minutes of resuscitation, rule performance was sensitivity 0.72, specificity 0.91, positive predictive value 0.98, and negative predictive value 0.36. The TOR Rule recommended care termination for 4,367 patients (62%); of these, 92 survived to hospital discharge (false-positive rate 2.1%; 95% confidence interval 1.7% to 2.5%); however, this proportion steadily decreased with later application. The TOR Rule recommended continuation of resuscitation in 2,627 patients (38%); of these, 1,674 died (false-negative rate 64%; 95% confidence interval 62% to 66%). Compared with 6-minute application, test characteristics at 30 minutes demonstrated nearly perfect positive predictive value (1.0) and specificity (1.0) but a lower sensitivity (0.46) and negative predictive value (0.25). CONCLUSION: In this cohort of adult out-of-hospital cardiac arrest patients, the TOR Rule applied at 6 minutes falsely recommended care termination for 2.1% of patients; however, this decreased with later application. Systems using the TOR Rule to cease resuscitation in the field should consider rule application at points later than 6 minutes.

Epinephrine use in older patients with anaphylaxis: Clinical outcomes and cardiovascular complications.

BACKGROUND: There is little data describing the differences in epinephrine (epi) administration and cardiac complications among older and younger patients with anaphylaxis. METHODS: This retrospective cohort study was conducted at two urban emergency departments (ED) over a 5 year-period, and included adults who met a pre-specified criteria for anaphylaxis. Patients ≥50years of age were defined as "older". Univariate logistic regression was performed to compare the difference in frequency of epi administration between the "older" and "younger" groups. Among those who received epi, the proportion of patients who received doses exceeding the recommended maximum and who had pre-specified cardiovascular complications were compared between the two groups, stratified further by route of administration. RESULTS: Of 2995 allergy-related visits, 492 met criteria for anaphylaxis, including 122 (24.8%) older patients. Older patients were less likely to receive epi injection (36.1% vs. 60.5%). Of those who received epi, older patients were more likely to receive excessive dose of epi (7/44, 15.9% vs 2/225, 0.9%, unadjusted OR 20.7, 95% CI 3.8-211.7). Four (4/44, 9.1%) older patients experienced cardiovascular complications, compared to 1/225 (0.4%) in the younger group (unadjusted OR 22.4, 95% CI 2.1-1129.8). When examining only intra-muscular epinephrine, 1/31 older patients had cardiac complications, compared to 1/186 in the younger group. CONCLUSION: Older patients with anaphylaxis were less likely to receive epi injection. Intramuscular epi appears safe in this population; however, the use of intravenous epi should be avoided in older patients due to the potential of developing serious cardiac complications.

H1-antihistamines Reduce Progression to Anaphylaxis Among Emergency Department Patients With Allergic Reactions.

OBJECTIVES: H1-antihistamines (H1a) can be used to treat emergency department (ED) patients with allergic reactions; however, this is inconsistently done, likely because there is no evidence that this therapy has an impact on serious outcomes. Among ED patients initially presenting with allergic reactions, we investigated whether H1a were associated with lower rates of progression to anaphylaxis. METHODS: This was a retrospective cohort study conducted at two urban Canadian EDs from April 1, 2007, to March 31, 2012. We included consecutive adult patients with allergic reactions while excluding those presenting with anaphylaxis, according to prespecified criteria. The primary outcome was the proportion of patients who subsequently developed anaphylaxis during medical care, either by emergency medical services (EMS) or in the ED. A prespecified subgroup analysis excluded patients who received H1a prior to EMS or ED contact. We compared those who received H1a and those who did not and used multivariable regression and propensity score adjustment techniques to compare outcomes. RESULTS: Of 2,376 overall patients included, 1,880 (79.1%) were managed with H1a. Of the latter group, 36 of 1,880 (1.9%) developed anaphylaxis, compared to 17 of 496 (3.4%) in the non-H1a-treated group (adjusted odds ratio [AOR] = 0.34, 95% confidence interval [CI] = 0.17-0.70; number needed to treat [NNT] to benefit = 44.74, 95% CI = 35.36-99.67). In the subgroup analysis of 1,717 patients who did not receive H1a prior to EMS or ED contact, a similar association was observed (AOR = 0.26, 95% CI = 0.10-0.50; NNT to benefit 38.20, 95% CI = 32.58-55.24). CONCLUSIONS: Among ED patient with allergic reactions, H1a administration was associated with a lower likelihood of progression to anaphylaxis. These data indicate that early H1a treatment in the ED or prehospital setting may decrease progression to anaphylaxis.

A pharmacoeconomic study of traditional anticoagulation versus direct oral anticoagulation for the treatment of venous thromboembolism in the emergency department.

OBJECTIVES: Patients with venous thromboembolism (VTE) (deep vein thrombosis [DVT] and pulmonary embolism [PE]) are commonly treated as outpatients. Traditionally, patients are anticoagulated with low-molecular-weight heparin (LMWH) and warfarin, resulting in return visits to the ED. The direct oral anticoagulant (DOAC) medications do not require therapeutic monitoring or repeat visits; however, they are more expensive. This study compared health costs, from the hospital and patient perspectives, between traditional versus DOAC therapy. METHODS: A chart review of VTE cases at two tertiary, urban hospitals from January 1, 2010 to December 31, 2012 was performed to capture historical practice in VTE management, using LMWH/warfarin. This historical data were compared against data derived from clinical trials, where a DOAC was used. Cost minimization analyses comparing the two modes of anticoagulation were completed from hospital and patient perspectives. RESULTS: Of the 207 cases in the cohort, only 130 (63.2%) were therapeutically anticoagulated (international normalized ratio 2.0-3.0) at emergency department (ED) discharge; patients returned for a mean of 7.18 (range: 1-21) visits. Twenty-one (10%) were admitted to the hospital; 4 (1.9%) were related to VTE or anticoagulation complications. From a hospital perspective, a DOAC (in this case, rivaroxaban) had a total cost avoidance of $1,488.04 per VTE event, per patient. From a patient perspective, it would cost an additional $204.10 to $349.04 over 6 months, assuming no reimbursement. CONCLUSIONS: VTE management in the ED has opportunities for improvement. A DOAC is a viable and cost-effective strategy for VTE treatment from a hospital perspective and, depending on patient characteristics and values, may also be an appropriate and cost-effective option from a patient perspective.

Missed Opportunities for HIV Prophylaxis Among Emergency Department Patients With Occupational and Nonoccupational Body Fluid Exposures.

STUDY OBJECTIVE: Exposures to HIV are frequently managed in the emergency department (ED) for assessment and potential initiation of HIV postexposure prophylaxis. Despite established guidelines, it is unclear whether patients with a nonoccupational exposure are managed similarly to patients with an occupational exposure. METHODS: This retrospective study used an administrative database to identify consecutive patients at a single ED with a discharge diagnosis of "blood or body fluid exposure" without sexual assault from April 1, 2007 to June 30, 2013. Patient exposure details and physician management were ascertained according to predefined guidelines. The primary outcome was the proportion of patients with high-risk exposures who were correctly given HIV prophylaxis; the secondary outcome was the proportion of patients with low-risk exposures who were correctly not given HIV prophylaxis. Other outcomes included the proportion of patients who had a baseline HIV test in the ED, the proportion who followed up with an HIV test within 6 months, and the number of seroconversions in this group. All outcomes were compared between nonoccupational and occupational exposure. RESULTS: Of 1,972 encounters, 1,358 patients (68.9%) had an occupational exposure and 614 (31.1%) had a nonoccupational exposure. In the occupational exposure group, 190 patients (14.0%) were deemed high risk, with 160 (84.2%; 95% confidence interval [CI] 78.1% to 88.9%) appropriately given prophylaxis. In the nonoccupational exposure group, 287 patients (46.7%) had a high-risk exposure, with 208 (72.5%; 95% CI 66.8% to 77.5%) given prophylaxis, for a difference of 11.7% (95% CI 3.8% to 19.1%). For low-risk exposures, appropriate management of both occupational and nonoccupational exposure was similar (92.4% versus 93.0%). At the index ED visit, 90.5% of occupational exposure patients and 76.7% of nonoccupational exposure patients received HIV testing, for a difference of 13.8% (95% CI 10.1% to 17.7%). At 6 months, 25.4% of patients with an occupational exposure and 35.0% of patients with a nonoccupational exposure had a follow-up test, for a difference of -9.6% (95% CI -14.2% to -5.1%). Of patients who had follow-up testing within 6 months, 4 of 215 (1.9%) in the nonoccupational exposure group tested newly positive for HIV, whereas 0 of 345 (0%) in the occupational exposure group tested positive. CONCLUSION: For ED patients with blood or body fluid exposures, those with high-risk nonoccupational exposures were not given HIV prophylaxis nearly twice as often as those with high-risk occupational exposure. Although 6-month follow-up testing rates were low, 1.9% of high-risk nonoccupational exposure patients seroconverted.

Comparing the prognosis of those with initial shockable and non-shockable rhythms with increasing durations of CPR: Informing minimum durations of resuscitation.

AIM: There is little data to inform the appropriate duration of resuscitation attempts for out-of-hospital cardiac arrest (OHCA). We assessed the relationship of elapsed duration since commencement of resuscitation and outcomes, highlighting differences between initial shockable and non-shockable rhythms. METHODS: We examined consecutive adult non-traumatic EMS-treated OHCA in a single health region. We plotted the time-dependent accrual of patients with ROSC, as well as dynamic estimates of outcomes as a function of duration from commencement of professional resuscitation, and compared subgroups dichotomized by initial rhythm. Logistic regression tested the association between time-to-ROSC and outcomes. RESULTS: Of 1627 adult EMS-treated cases of OHCA, 1617 patients were included; 14% survivors and 10% with favorable neurological outcomes. Time-to-ROSC (per minute increase) was independently associated with survival in those with initial shockable (aOR 0.95, 95% CI 0.92-0.97) and non-shockable (aOR 0.83; 95% CI 0.78-0.88) rhythms. Similar associations were seen with favorable neurologic outcome. The elapsed duration at which the probability of survival fell below 1% was 48 and 15 min in the shockable and non-shockable groups, respectively. Median time-to-termination of resuscitation was 36 and 26 min in the shockable and non-shockable groups, respectively. CONCLUSION: The subgroup of initial shockable rhythms showed a less pronounced association of time-to-ROSC with outcomes, and demonstrated higher resilience for neurologically intact survival after prolonged periods of resuscitation. This data can guide minimum durations of resuscitation, however should not be considered as evidence for termination of resuscitation as survival in this cohort may have been improved with longer resuscitation attempts.

Association between mental health apprehensions by police and monthly income assistance (welfare) payments.

OBJECTIVE: Social misconduct, increased police activity, and increased emergency department (ED) use are associated with monthly income assistance (welfare) payments. The relation, if any, between welfare payments and mental health and addictions presentations to the ED requiring police involvement remains unknown. Our purpose was to determine if a relation exists between mental health apprehensions (MHAs) by police and monthly welfare cheque distribution, and the association between monthly payments and mental health and substance-related ED presentations. METHOD: The Vancouver Police administrative database was analyzed during an 81-week period (June 8, 2011, to December 25, 2012). Comparisons were made between the numbers of MHAs by police during the week following welfare payment to those during nonpayment weeks. The weekly number of mental health and substance-related ED presentations were also analyzed during the study period. MHAs were analyzed continuously, and compared using the 2-tailed t test. RESULTS: During the study period, 4009 MHAs occurred (range 1 to 18 MHAs/day). The mean weekly MHAs during welfare week was 54.6 (95% CI 51.75 to 57.45), compared with 48.6 (95% CI 46.35 to 50.85) during nonpayment weeks (P = 0.004). This translates to 85 MHAs annually related to welfare payments. Total mental health and addictions-related presentations to the ED were also significantly increased in the week following welfare payments (P < 0.001), and could not be solely attributed to increased MHAs by police. CONCLUSION: A statistically significant increase in the number of MHAs by police follows welfare payments. This is superimposed on a significant increase in overall mental health and substance-related ED presentations seen during the same period.