Evolution of methodology and reporting of emergency medicine quantitative research over a 20-year period.

OBJECTIVE: We aimed to determine trends over time in article origin, and article and methodology characteristics. METHOD: We examined original research articles published every fifth year over a 20-year period (1997-2017) in six emergency medicine (EM) journals (Ann Emerg Med, Acad Emerg Med, Eur J Emerg Med, Emerg Med J, Am J Emerg Med, Emerg Med Australas). Explicit data extraction of 21 article characteristics was undertaken. These included regional contributions, specific article items and research methodology. RESULTS: 2152 articles were included. Over the study period, the proportional contributions from the USA and the UK steadily fell while those from Australasia, Europe and 'other' countries increased (p<0.001). All specific article items increased (p<0.01). Institutional Review Board/Ethics Committee approval and conflicts of interest were almost universal by 2017. There were substantial increases in the reporting of keywords and authorship contributions. The median (IQR) number of authors increased from 4 (2) in 1997 to 6 (3) in 2017 (p<0.001) and the proportion of female first authors increased from 24.3% to 34.2% (p<0.01). Multicentre and international collaborations, consecutive sampling, sample size calculations, inferential biostatistics and the reporting of CIs and p values all increased (p<0.001). There were decreases in the use of convenience sampling and blinding (p<0.001). The median (IQR) study sample size increased from 148 (470) to 349 (2225) (p<0.001). CONCLUSION: Trends over time are apparent within the EM research literature. The dominance in contributions from the US and UK is being challenged. There is more reporting of research accountability and greater rigour in both research methodology and results presentation.

Urine cultures at the onset of febrile neutropenia rarely impact antibiotic management in asymptomatic adult cancer patients.

PURPOSE: There is a paucity of data regarding the utility of routine urine cultures in adults with febrile neutropenia (FN) without urinary symptoms receiving protocolised antibiotics. This is reflected by inconsistent recommendations in international and regional FN guidelines. We addressed this issue by retrospectively reviewing the impact of routine urine cultures on antibiotic management in haematology cancer inpatients at a tertiary hospital. METHODS: All haematology inpatients over a 5-year period (2011-2015) were retrospectively reviewed for episodes of FN (neutrophil count < 0.5 × 109/L and fever > 37.5 °C). For each episode, demographic data, urinary tract symptoms and signs (absence of which was termed 'asymptomatic'), urinalysis and urine culture results, antibiotic therapy and duration, and patient outcomes were collected. A urine culture was considered positive if > 105 colony forming units (CFU)/L were detected. Empiric antibiotic therapy for FN consisted of intravenous piperacillin/tazobactam in stable patients, with the addition of vancomycin and a single dose of gentamicin if systemically compromised. RESULTS: Four hundred and thirty-three episodes of FN were identified in 317 patients. Urine cultures were performed in 362 (84%) episodes. Cultures were positive in 9 of 48 (19%) symptomatic episodes versus 8 of 314 (2.5%) asymptomatic episodes (RR = 7.4, p < 0.0001). A change in antibiotic management due a positive urine culture occurred in only 5 episodes (1.4%): 3 of 48 (6.3%) symptomatic and 2 of 314 (0.6%) asymptomatic episodes respectively (RR = 9.8, p = 0.01). CONCLUSION: Routine urine cultures in FN patients without urinary symptoms who are already receiving protocolised broad spectrum antibiotics rarely impact subsequent antibiotic management.

Determination of the best early warning scores to predict clinical outcomes of patients in the emergency department.

OBJECTIVE: Early warning scores (EWS) are used to predict patient outcomes. We aimed to determine which of 13 EWS, based largely on emergency department (ED) vital sign data, best predict important clinical outcomes. METHOD: We undertook a prospective cohort study in a metropolitan, tertiary-referral ED in Melbourne, Australia (February-April 2018). Patient demographics, vital signs and management data were collected while the patients were in the ED and EWS were calculated using each EWS criteria. Outcome data were extracted from the medical record (2-day, 7-day and 28-day inhospital mortality, clinical deterioration within 2 days, intensive care unit (ICU) admission within 2 days, admission to hospital). Area under the receiver operator characteristic (AUROC; 95% CIs) curves were used to evaluate the predictive ability of each EWS for each outcome. RESULTS: Of 1730 patients enrolled, 690 patients were admitted to the study hospital. Most EWS were good or excellent predictors of 2-day mortality. When considering the point estimates, the VitalPac EWS was the most strongly predictive (AUROC: 0.96; 95% CI: 0.92 to 0.99). However, when considering the 95% CIs, there was no significant difference between the highest performing EWS. The predictive ability for 7-day and 28-day mortality was generally less. No EWS was a good predictor for clinical deterioration (AUROC range: 0.54-0.70), ICU admission (range: 0.51-0.72) or admission to hospital (range: 0.51-0.68). CONCLUSION: Several EWS have excellent predictive ability for 2-day mortality and have the potential to risk stratify patients in ED. No EWS adequately predicted clinical deterioration, admission to either ICU or the hospital.

Patient perceptions of participation in emergency medicine research projects.

OBJECTIVE: To determine if ED research reflects patient expectations. METHOD: A cross-sectional ED patient survey. RESULTS: Three hundred and nine (98.1%, 95% confidence interval [CI] 95.7-99.2) of 315 patients believed that ED research was important. Two hundred and twelve (68.4%, 95% CI 62.9-73.5) would welcome involvement, only 26 (8.4%, 95% CI 5.7-12.3) felt pressured to do so. Two hundred and thirty-one (75.7%, 95% CI 70.5-80.4) and 279 (91.5%, 95% CI 87.6-94.3) believed consent was necessary for observational and experimental studies, respectively. One hundred and one (32.4%, 95% CI 27.3-37.9) disagreed with medical records being accessed without consent. CONCLUSION: Patient expectations are not always consistent with current practice. The expectation of consent prior to record access is worthy of further consideration.

Utility of calcium, magnesium and phosphate testing in the emergency department.

OBJECTIVE: To determine how frequently calcium (Ca), magnesium (Mg) and phosphate (PO4 ) tests change ED patient management. METHODS: We undertook a retrospective observational study in an Australian tertiary referral ED. We enrolled adult patients (aged ≥18 years) who presented between 1 January and 30 June 2017 and who had a serum Ca, Mg or PO4 test ordered and completed during their ED stay. Patient symptoms, medical history, electrolyte levels and ED management changes were extracted from the electronic medical record. RESULTS: Of the 33 120 adults presented during the study period, 1716 (5.2%, 95% confidence interval [CI] 5.0-5.4) had at least one Ca, Mg or PO4 test completed in the ED. This included 4776 individual electrolyte tests, of which 776 (16.2%, 95% CI 15.2-17.3) were abnormal. Fifty-six (7.2% [95% CI 5.5-9.3] of patients with abnormal tests, 1.2% [95% CI 0.9-1.5] of all tests) tests were associated with a change in ED management. Twenty-six out of 1683 (1.5%) Ca levels were low with six (23.1%) management changes; 203 (12.1%) were high with 10 (4.9%) management changes. One hundred and twenty-eight out of 1579 (8.1%) Mg levels were low with 33 (25.8%) management changes; 30 (1.9%) were high with no management changes. Two hundred and twenty-five out of 1514 (14.9%) PO4 levels were low with six (2.7%) management changes; 164 (10.8%) were high with one (0.6%) management change. Fifty (2.9%) patients had management changes despite normal electrolyte levels. CONCLUSION: Ca, Mg and PO4 testing is common. However, the yield of clinically significant abnormal levels is low and patient management is rarely changed. Testing of these electrolytes needs to be rationalised.

Risk variables associated with abnormal calcium, magnesium and phosphate levels among emergency department patients.

OBJECTIVE: The utility of calcium, magnesium and phosphate measurement in the ED is limited. We aimed to determine clinical risk variables for abnormal levels of these electrolytes in order to inform the development of an ordering guideline. METHODS: We performed a retrospective, observational study of patients who presented to a tertiary referral ED between January and June 2017. Adult patients who had serum calcium, magnesium or phosphate tests completed during their ED stay were included. Presenting symptoms and signs, comorbidities, medication use and laboratory values were extracted from the medical record. Patients with missing data items were excluded. Logistic regression models determined clinical risk variables associated with low and high levels of each electrolyte. RESULTS: A total of 33 120 adults presented during the study period. Of the 1679 calcium, 1576 magnesium and 1511 phosphate tests, 228 (13.6%), 158 (10.0%) and 387 (25.6%) were abnormal, respectively. Significant risk variables (P < 0.05) for abnormal levels were: hypocalcaemia - vomiting, perioral numbness, hand/foot spasm, calcium and phosphate supplements and chemotherapy (odds ratio [OR] range 5.9-17.3); hypercalcaemia - female sex, vomiting, polyuria, confusion, hyperparathyroidism, cancer and type 1 diabetes (OR range 2.3-9.7); hypomagnesemia - female sex, proton pump inhibitor use, tacrolimus use, alcohol abuse and type 2 diabetes (OR range 2.2-13.1); hypermagnesemia - lethargy, thiazide use and chronic kidney disease (OR range 4.3-4.5); hypophosphatemia - nausea, seizure and glucocorticoid use (OR range 1.7-2.1); and hyperphosphataemia - polyuria, diuretics and chronic kidney disease (OR range 1.9-5.0). CONCLUSION: A range of demographic, comorbid, medication and clinical variables are associated with abnormal calcium, magnesium and phosphate levels. These findings will inform the development of clinical guidelines to rationalise calcium, magnesium and phosphate testing. Justification may be required for testing patients with no risk variables.