Variation in Fluid and Vasopressor Use in Shock With and Without Physiologic Assessment: A Multicenter Observational Study.

OBJECTIVES: To characterize the association between the use of physiologic assessment (central venous pressure, pulmonary artery occlusion pressure, stroke volume variation, pulse pressure variation, passive leg raise test, and critical care ultrasound) with fluid and vasopressor administration 24 hours after shock onset and with in-hospital mortality. DESIGN: Multicenter prospective cohort study between September 2017 and February 2018. SETTINGS: Thirty-four hospitals in the United States and Jordan. PATIENTS: Consecutive adult patients requiring admission to the ICU with systolic blood pressure less than or equal to 90 mm Hg, mean arterial blood pressure less than or equal to 65 mm Hg, or need for vasopressor. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: Of 1,639 patients enrolled, 39% had physiologic assessments. Use of physiologic assessment was not associated with cumulative fluid administered within 24 hours of shock onset, after accounting for baseline characteristics, etiology and location of shock, ICU types, Acute Physiology and Chronic Health Evaluation III, and hospital (beta coefficient, 0.04; 95% CI, -0.07 to 0.15). In multivariate analysis, the use of physiologic assessment was associated with a higher likelihood of vasopressor use (adjusted odds ratio, 1.98; 95% CI, 1.45-2.71) and higher 24-hour cumulative vasopressor dosing as norepinephrine equivalent (beta coefficient, 0.37; 95% CI, 0.19-0.55). The use of vasopressor was associated with increased odds of in-hospital mortality (adjusted odds ratio, 1.88; 95% CI, 1.27-2.78). In-hospital mortality was not associated with the use of physiologic assessment (adjusted odds ratio, 0.86; 95% CI, 0.63-1.18). CONCLUSIONS: The use of physiologic assessment in the 24 hours after shock onset is associated with increased use of vasopressor but not with fluid administration.

Development of a Core Clinical Dataset to Characterize Serious Illness, Injuries, and Resource Requirements for Acute Medical Responses to Public Health Emergencies.

OBJECTIVES: In developed countries, public health systems have become adept at rapidly identifying the etiology and impact of public health emergencies. However, within the time course of clinical responses, shortfalls in readily analyzable patient-level data limit capabilities to understand clinical course, predict outcomes, ensure resource availability, and evaluate the effectiveness of diagnostic and therapeutic strategies for seriously ill and injured patients. To be useful in the timeline of a public health emergency, multi-institutional clinical investigation systems must be in place to rapidly collect, analyze, and disseminate detailed clinical information regarding patients across prehospital, emergency department, and acute care hospital settings, including ICUs. As an initial step to near real-time clinical learning during public health emergencies, we sought to develop an "all-hazards" core dataset to characterize serious illness and injuries and the resource requirements for acute medical response across the care continuum. SUBJECTS: A multidisciplinary panel of clinicians, public health professionals, and researchers with expertise in public health emergencies. DESIGN: Group consensus process. INTERVENTIONS: The consensus process included regularly scheduled conference calls, electronic communications, and an in-person meeting to generate candidate variables. Candidate variables were then reviewed by the group to meet the competing criteria of utility and feasibility resulting in the core dataset. MEASUREMENTS AND MAIN RESULTS: The 40-member panel generated 215 candidate variables for potential dataset inclusion. The final dataset includes 140 patient-level variables in the domains of demographics and anthropometrics (7), prehospital (11), emergency department (13), diagnosis (8), severity of illness (54), medications and interventions (38), and outcomes (9). CONCLUSIONS: The resulting all-hazard core dataset for seriously ill and injured persons provides a foundation to facilitate rapid collection, analyses, and dissemination of information necessary for clinicians, public health officials, and policymakers to optimize public health emergency response. Further work is needed to validate the effectiveness of the dataset in a variety of emergency settings.

A randomized trial exploring the effect of a telephone call follow-up on care plan compliance among older adults discharged home from the emergency department.

OBJECTIVES: Older patients discharged from the emergency department (ED) have difficulty comprehending discharge plans and are at high risk of adverse outcomes. The authors investigated whether a postdischarge telephone call-mediated intervention by a nurse would improve discharge care plan adherence, specifically by expediting post-ED visit physician follow-up appointments and/or compliance with medication changes. The second objectives were to determine if this telephone call intervention would reduce return ED visits and/or hospitalizations within 35 days of the index ED visit and to determine potential cost savings of this intervention. METHODS: This was a 10-week randomized, controlled trial among patients aged 65 and older discharged to home from an academic ED. At 1 to 3 days after each patient's index ED visit, a trained nurse called intervention group patients to review discharge instructions and assist with discharge plan compliance; placebo call group patients received a patient satisfaction survey call, while the control group patients were not called. Data collection calls occurred at 5 to 8 days and 30 to 35 days after the index ED visits for all three groups. Chi-square or Fisher's exact tests were performed for categorical data and the Kruskal-Wallis test examined group differences in time to follow-up. RESULTS: A total of 120 patients completed the study. Patients were 60% female and 72% white, with a mean age of 75 years (standard deviation [SD] ± 7.58 years). Intervention patients were more likely to follow up with medical providers within 5 days of their ED visits than either the placebo or the control group patients (54, 20, and 37%, respectively; p = 0.04). All groups performed well in medication acquisition and comprehension of medication indications and dosage. There were no differences in return visits to the ED or hospital within 35 days of the index ED visit for intervention patients, compared to placebo or control group patients (22, 33, and 27%, respectively; p = 0.41). An economic analysis showed an estimated 70% chance that this intervention would reduce total costs. CONCLUSIONS: Telephone call follow-up of older patients discharged from the ED resulted in expedited follow-up for patients with their primary care physicians. Further study is warranted to determine if these results translate into improved patient outcomes, decreased return ED visits or hospital admissions, and cost savings resulting from this intervention.

Disasters; the 2010 Haitian earthquake and the evacuation of burn victims to US burn centers.

Response to the 2010 Haitian earthquake included an array of diverse yet critical actions. This paper will briefly review the evacuation of a small group of patients with burns to burn centers in the southeastern United States (US). This particular evacuation brought together for the first time plans, groups, and organizations that had previously only exercised this process. The response to the Haitian earthquake was a glimpse at what the international community working together can do to help others, and relieve suffering following a catastrophic disaster. The international response was substantial. This paper will trace one evacuation, one day for one unique group of patients with burns to burn centers in the US and review the lessons learned from this process. The patient population with burns being evacuated from Haiti was very small compared to the overall operation. Nevertheless, the outcomes included a better understanding of how a larger event could challenge the limited resources for all involved. This paper includes aspects of the patient movement, the logistics needed, and briefly discusses reimbursement for the care provided.

Nursing home revenue source and information availability during the emergency department evaluation of nursing home residents.

OBJECTIVES: Lack of access to medical information for nursing home residents during emergency department (ED) evaluation is a barrier to quality care. We hypothesized that the quantity of information available in the ED differs based on the funding source of the resident's nursing home. DESIGN: Cross-sectional observational study. SETTING: Single academic ED. PARTICIPANTS: Participants were 128 skilled nursing facility (SNF) residents age 65 or older from 12 SNFs. MEASUREMENTS: Emergency physicians documented knowledge of 9 essential information items. SNFs were categorized as accepting or not accepting Medicaid. RESULTS: Questionnaires were completed for 128 patients, of whom 95 (74%) were from 1 of 8 Medicaid-funded SNFs and 33 (26%) were from 1 of 4 SNFs not accepting Medicaid. Patients from SNFs accepting Medicaid were younger (79 versus 87, P < .001) and less frequently white (62% versus 97%, P < .001). The mean number of 9 possible information items available was lower for patients from SNFs that accept Medicaid (7.13 versus 8.15, P < .001). Emergency providers also reported lower satisfaction regarding access to information for residents from SNFs that accept Medicaid (P < .05). The association between residence in an SNF that accepts Medicaid and lower ED information scores remained after linear regression with clustering by SNF controlling for age, gender, and race. The most common source of information for residents from both types of SNFs was transfer papers from the SNF. CONCLUSION: Less information is available to ED providers for patients from SNFs that accept Medicaid than for residents from SNFs that do not accept Medicaid. Further study is needed to examine this information gap.

Assessment of temporal trends in mortality with implementation of a statewide ST-segment elevation myocardial infarction (STEMI) regionalization program.

STUDY OBJECTIVE: Although regionalized care for ST-segment elevation myocardial infarction (STEMI) has improved the use of timely reperfusion therapy, its effect on patient outcomes has been difficult to assess. Our objective is to explore temporal trends in STEMI mortality with the implementation of a statewide STEMI regionalization program (Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments [RACE]). METHODS: We compared trends in inpatient mortality among STEMI patients treated at North Carolina (NC) hospitals participating in the RACE program, relative to those not participating, using state inpatient claims data. Using Medicare claims data, we compared trends in 30-day mortality among Medicare beneficiaries in NC with those nationally. Logistic models with random effects were used to evaluate the association of the program with mortality. RESULTS: From 2005 to 2007, inpatient mortality for 6,565 STEMI patients treated at NC hospitals participating in RACE decreased from 11.6% to 10.1% (risk difference -1.5%; 95% confidence interval [CI] -3.0% to 0.04%), whereas inpatient mortality among 5,850 STEMI patients treated at NC nonparticipating hospitals decreased from 10.2% to 8.6% (risk difference -1.6%; 95% CI -3.1% to 0.10%); (adjusted odds ratio 1.28; 95% CI 0.88 to 1.85 for temporal differences between groups). During the same period, 30-day STEMI mortality among Medicare beneficiaries decreased from 22.7% to 21.4% in NC (risk difference -1.28%; 95% CI -3.60% to 1.03%) and from 22.3% to 21.6% nationally (risk difference -0.71%, 95% CI -1.13% to -0.29%; adjusted odds ratio 0.99, 95% CI 0.85 to 1.15 for temporal differences between regions). CONCLUSION: The initiation of a statewide STEMI collaborative care model was associated with a reduction in mortality rates according to claims data, yet these changes were similar to those seen nationally. Further study is needed to evaluate regionalized systems of STEMI care and to determine the role of claims data to evaluate population-based STEMI outcomes.

Use of emergency department transcranial Doppler assessment of reperfusion after intravenous tPA for ischemic stroke.

BACKGROUND: Thrombolysis with intravenous recombinant tissue plasminogen activator (IV-tPA) has been associated with significant improvements in clinical outcomes when initiated within 3 h of symptom onset. Although adjunctive therapies for acute stroke have been developed, challenges remain in identifying appropriate patients and therapeutic end-point measurements. OBJECTIVE: To describe the use of transcranial Doppler (TCD) monitoring in the Emergency Department (ED) to guide the decision for advanced reperfusion strategies after failure of IV-tPA. CASE REPORT: A 75-year-old man presented to the ED within 50 min after the acute onset of right-sided hemiparesis and aphasia. After administration of IV-tPA, there was no immediate improvement in neurological symptoms. TCD performed in the ED demonstrated persistent left middle cerebral artery (MCA) occlusion. Based on this information, the patient received intra-arterial tPA followed by mechanical thrombectomy of the MCA occlusion, resulting in clinical improvement of the patient's right hemiparesis and aphasia. CONCLUSION: TCD is a feasible assessment tool for use in the ED to aid in diagnosis and to guide treatment decisions in patients with acute ischemic stroke, including those not responding to IV-tPA therapy.

Interest survey and guide to medical school admissions for SOF medics.

The University of North Carolina at Chapel Hill and the Special Warfare Training Group, Airborne (SWTG)(A) at Fort Bragg, NC began a bilateral partnership in 2009 to enhance medical training, care and innovation in austere environments. As a result of this partnership, instructors from the Joint Special Operations Training Center have been completing month-long rotations in the North Carolina Jaycee Burn Center and University of North Carolina Hospitals. This rotation has been successful and prompted us to assess the interest of Special Operation Forces (SOF) medics is in pursuing careers in healthcare, especially medical school. We surveyed the Special Forces Medical Sergeant (SFMS) listserve on Army Knowledge Online (AKO) to collect these data. This article will review SFMS survey responses and offer information on how to negotiate medical school admissions.

Perspective: The case for research justice: inclusion of patients with limited English proficiency in clinical research.

Persons with limited English proficiency (LEP) constitute a growing portion of the U.S. population, yet they are underrepresented in clinical research. This inherently limits the societal benefits of the research and its generalizability to ethnic populations living in the United States. To illustrate the complexity associated with including LEP participants in clinical research, the authors critically evaluated LEP consent requirements posted on the Web sites of 134 academic health centers in March 2008. They found wide variability with regard to consent policies and striking interinstitutional differences in posted IRB policies and attitudes toward consent of LEP patients in research. The authors argue this variation highlights competing concerns between autonomy and justice. Outcomes-based justice requires inclusion of LEP patients in the research, yet the consent process is often resource-intensive and complex. The authors suggest that more uniform and specific guidance from federal agencies for enrollment of LEP patients in clinical research be established and that this guidance explicitly recalibrate the current balance between autonomy and justice. Investigators and institutional review boards should also develop streamlined best practices to reduce unnecessary effort and expense associated with recruitment of LEP individuals. LEP individuals should have fair access to clinical research in order to fully realize individual and societal benefits of their participation and to ensure the generalizability of scientific discovery.

Impact of a statewide ST-segment-elevation myocardial infarction regionalization program on treatment times for women, minorities, and the elderly.

BACKGROUND: Prior studies have demonstrated differences in time to reperfusion for ST-segment-elevation myocardial infarction (STEMI) in women, minorities, and the elderly, relative to their counterparts. Regionalization has been shown to improve overall STEMI treatment times, but its impact on care differences among these important patient subgroups is unknown. The objective of this analysis was to assess the impact of a statewide system of STEMI care (The Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments) on treatment times according to patient sex, race, and age. METHODS AND RESULTS: STEMI treatment times were determined before (July 2005 to September 2005) and after (January 2007 to March 2007) a year-long implementation of coordinated regional treatment protocols. Times in the pre- and postintervention periods were compared by mixed-effects models. A total of 2063 STEMI patients were analyzed: 1140 at percutaneous coronary intervention hospitals and 923 at non-percutaneous coronary intervention hospitals. The Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments was associated with significant improvements in treatment times in women and the elderly, including door-to-ECG, door-to-device, door-in-door-out, and door-to-needle times (all P<0.05). Temporal improvements in treatment times at percutaneous coronary intervention hospitals were not significantly different in blacks than in whites. There was a reduction in baseline treatment disparities in door-to-ECG times in women versus men (4.4-minute reduction in difference; 95% CI, -8.1 to -0.4; P=0.03). After Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments, an age-treatment time gap persisted in the elderly, relative to younger patients. CONCLUSIONS: A statewide STEMI regionalization program was associated with comparable improvement in treatment times for female, black, and elderly patients compared with middle-aged, white male patients. Nevertheless, there remain opportunities to further narrow treatment differences, particularly among the elderly.

The North Carolina EMS Data System: a comprehensive integrated emergency medical services quality improvement program.

BACKGROUND: The EMS Agenda for the Future describes emergency medical services (EMS) as the intersection between public health, public safety, and health care. The most comprehensive method to describe, evaluate, and optimize these systems of care is using a state EMS data system. A centralized EMS data system can be a valuable tool to identify, evaluate, target, and improve EMS service delivery and patient care. Significant barriers, however, still exist to the standardization of EMS data systems and infrastructure nationally. Indeed, there is no comprehensive measurement of EMS service delivery or patient volume at the national level. OBJECTIVE: In this article, we describe the successful development of a fully integrated, statewide EMS data system for quality improvement of EMS service delivery and patient care in North Carolina. The article also provides a platform for linking EMS with emergency physicians, other health care providers, and public health agencies responsible for planning, disease surveillance, and disaster preparedness. RESULTS AND CONCLUSION: The North Carolina EMS Data System represents the successful development of a large, fully integrated, comprehensive statewide EMS database and quality improvement effort. The North Carolina EMS Data System applications include the Prehospital Medical Information System (PreMIS), the Credentialing Information System (CIS), the State Medical Asset Resource Tracking Tool (SMARTT), and the EMS Performance Improvement Toolkits. The system provides a quality and performance improvement program consistent with the idealized EMS design described in the EMS Agenda for the Future. The program has already achieved significant improvements in the quality of EMS service delivery, patient care, and integrated systems of care. Consistent with the goals of the 2007 Institute of Medicine's recommendations for EMS, the linkage of the North Carolina EMS Data System with other health care registries has created an environment that can evaluate larger systems of care and ultimate patient outcomes.

Evidence-based perspectives on pay for performance and quality of patient care and outcomes in emergency medicine.

Pay for performance is gaining momentum as a means to improve the quality of clinical care. Recently, the Centers for Medicare & Medicaid Services has expanded pay for performance initiatives to incorporate 9 emergency care metrics, including indicators for cardiac, pneumonia, and stroke care. The American College of Cardiology and American Heart Association (ACC/AHA) have published methodology for the selection and creation of performance measures for quantifying the quality of cardiovascular care. The purpose of this study is to grade each of the 9 Physician Quality Reporting Initiative emergency medicine process measures according to the ACC/AHA criteria related to clinical evidence (yes, no, indeterminate). Five of the 9 recently selected metrics in emergency medicine do not appear to meet all of the ACC/AHA criteria for measurement selection. Several of the metrics, including aspirin for acute myocardial infarction (mean hospital adherence 94.7%; SD 6.7%) and pulse oximetry for community-acquired pneumonia (mean 99.4%; SD 2.0%), already have high levels of performance nationally, which raises uncertainty about the overall cost-effectiveness of quality improvement interventions for these measures. Formal methodology needs to be established for future selection of performance measures for quality improvement programs in emergency care. These performance measures should focus on unique aspects of emergency and acute care, including recognition and treatment of time-sensitive life-threatening conditions, assessment of patients with undifferentiated signs and symptoms, and care of all-inclusive geographically based patient populations. In key emergency therapeutic areas, the evidence linking treatment and improved patient outcomes will require additional study before inclusion in pay for performance programs. New research initiatives are needed to assess the effect of timely administration of emergency department interventions on patient outcomes.

Challenges in enrollment of minority, pediatric, and geriatric patients in emergency and acute care clinical research.

STUDY OBJECTIVE: Emergency department (ED) -based clinical research has the potential to include patient populations that are typically underrepresented in clinical research. The objective of this study is to assess how emergency clinical care and research processes, informed consent, and patient demographic factors (age, sex, and ethnicity/race) affect enrollment and consent in clinical research in the ED. METHODS: This was an analysis of prospectively collected data of all patients (aged 2 to 101 years) eligible for one of 7 clinical research studies from February 2005 to April 2007 in an academic ED. We measured rates of enrollment and consent in the clinical studies. RESULTS: One thousand two hundred two of the 4418 patients screened for participation in 7 clinical studies were clinically eligible for enrollment. Of the 868 patients who were able to provide a voluntary decision regarding consent, 639 (73.6%) agreed to participate; an overall enrollment rate of 53.2%. The mean age of patients enrolled was 51.8 years (range 3 to 98 years). Black patients (49.2% enrollment) and Latino patients (18.4% enrollment) were less likely to be enrolled in comparison with white patients (58.3% enrollment) (adjusted odds ratio [OR] of enrollment for blacks=0.64; 95% confidence interval [CI] 0.50 to 0.82; adjusted OR of enrollment for Latinos=0.16; 95% CI 0.08 to 0.33). Enrollment rates were lower among pediatric (40.0%) and geriatric patients (49.1%) in comparison with adult patients ages 18 to 64 years (55.5%) (adjusted OR of enrollment for pediatric patients=0.70, 95% CI 0.34 to 1.43; adjusted OR of enrollment for geriatric patients=0.69, 95% CI 0.53 to 0.90). Unique issues contributing to underenrollment included challenges in consent among pediatric and elderly patients, language issues in Latino patients, reduced voluntary consent rates among black patients, and perhaps underuse of minimal risk waivers. CONCLUSION: In a large academic ED, minority, pediatric, and geriatric patients were less likely to be enrolled in acute care clinical research studies than middle-aged whites. Enrollment and consent strategies designed to enhance research participation in these important patient populations may be necessary to address disparities in the development and application of evidence-based emergency and acute care.