Improving Timeliness of Antibiotic Administration Using a Provider and Pharmacist Facing Sepsis Early Warning System in the Emergency Department Setting: A Randomized Controlled Quality Improvement Initiative.

OBJECTIVES: Results of pre-post intervention studies of sepsis early warning systems have been mixed, and randomized clinical trials showing efficacy in the emergency department setting are lacking. Additionally, early warning systems can be resource-intensive and may cause unintended consequences such as antibiotic or IV fluid overuse. We assessed the impact of a pharmacist and provider facing sepsis early warning systems on timeliness of antibiotic administration and sepsis-related clinical outcomes in our setting. DESIGN: A randomized, controlled quality improvement initiative. SETTING: The main emergency department of an academic, safety-net healthcare system from August to December 2019. PATIENTS: Adults presenting to the emergency department. INTERVENTION: Patients were randomized to standard sepsis care or standard care augmented by the display of a sepsis early warning system-triggered flag in the electronic health record combined with electronic health record-based emergency department pharmacist notification. MEASUREMENTS AND MAIN RESULTS: The primary process measure was time to antibiotic administration from arrival. A total of 598 patients were included in the study over a 5-month period (285 in the intervention group and 313 in the standard care group). Time to antibiotic administration from emergency department arrival was shorter in the augmented care group than that in the standard care group (median, 2.3 hr [interquartile range, 1.4-4.7 hr] vs 3.0 hr [interquartile range, 1.6-5.5 hr]; p = 0.039). The hierarchical composite clinical outcome measure of days alive and out of hospital at 28 days was greater in the augmented care group than that in the standard care group (median, 24.1 vs 22.5 d; p = 0.011). Rates of fluid resuscitation and antibiotic utilization did not differ. CONCLUSIONS: In this single-center randomized quality improvement initiative, the display of an electronic health record-based sepsis early warning system-triggered flag combined with electronic health record-based pharmacist notification was associated with shorter time to antibiotic administration without an increase in undesirable or potentially harmful clinical interventions.

Emergency department contrast practices for abdominal/pelvic computed tomography-a national survey and comparison with the american college of radiology appropriateness criteria(®).

BACKGROUND: Controversy exists regarding the need for contrast agents for emergency abdominal computed tomography (CT). OBJECTIVES: We surveyed United States (US) academic Emergency Departments (EDs) to document national practice. We hypothesized variable contrast use for abdominal/pelvic CT, including variance from the American College of Radiology's (ACR) Appropriateness Criteria(®), an evidence-based guideline. METHODS: A survey was sent to physician leaders of US academic EDs, defined as primary site of an Emergency Medicine residency program. Respondents were asked about their institutions' use of oral, intravenous (i.v.), and rectal contrast for various abdominal/pelvic CT indications. Responses were compared with the approach given the highest appropriateness rating by the American College of Radiology. RESULTS: One hundred and six of 152 (70%) surveys were completed. Intravenous contrast was the most frequently cited contrast. At least 90% of respondents reported using i.v. contrast in 12 of 18 indications. Oral contrast use was more variable. In no indication did ≥90% of respondents indicate use of oral contrast, and in only two indications did ≥90% avoid its use. Rectal contrast was rarely used. The most common indications for which no contrast agent was used were suspected renal colic (79%), viscus perforation (19%), penetrating abdominal trauma (18%), and blunt abdominal trauma (15%). CONCLUSIONS: Contrast practices for abdominal/pelvic CT vary nationally, according to a survey of US academic EDs. For multiple indications, the contrast practices of a substantial number of respondents deviated from those recommendations given the highest clinical appropriateness rating by the American College of Radiology.

Customizing anaphylaxis guidelines for emergency medicine.

BACKGROUND: Most episodes of anaphylaxis are managed in emergency medical settings, where the cardinal signs and symptoms often differ from those observed in the allergy clinic. Data suggest that low recognition of anaphylaxis in the emergency setting may relate to inaccurate coding and lack of a standard, practical definition. OBJECTIVE: Develop a simple, consistent definition of anaphylaxis for emergency medicine providers, supported by clinically relevant consensus statements. DISCUSSION: Definitions of anaphylaxis and criteria for diagnosis from current anaphylaxis guidelines were reviewed with regard to their utilization in emergency medical settings. The agreed-upon working definition is: Anaphylaxis is a serious reaction causing a combination of characteristic findings, and which is rapid in onset and may cause death. It is usually due to an allergic reaction but can be non-allergic. The definition is supported by Consensus Statements, each with referenced discussion. For a positive outcome, quick diagnosis and treatment of anaphylaxis are critical. However, even in the emergency setting, the patient may not present with life-threatening symptoms. Because mild initial symptoms can quickly progress to a severe, even fatal, reaction, the first-line treatment for any anaphylaxis episode--regardless of severity--is intramuscular injection of epinephrine into the anterolateral thigh; delaying its administration increases the potential for morbidity and mortality. When a reaction appears as "possible anaphylaxis," it is generally better to err on the side of caution and administer epinephrine. CONCLUSION: We believe that this working definition and the supporting Consensus Statements are a first step to better management of anaphylaxis in the emergency medical setting.

Disparities in Emergency Department Naloxone and Buprenorphine Initiation.

INTRODUCTION: Prescribing of buprenorphine and naloxone in the emergency department (ED) has been shown to be an effective intervention. The purpose of this study was to determine the frequency of prescribing of naloxone and buprenorphine and the sub-groups that may be more or less likely to receive treatment. METHODS: We used a national electronic health record database to identify patients with opioid poisoning or overdose presenting between January 2019-December 2021. Patients who were prescribed naloxone or buprenorphine were identified in this dataset and then further segmented based on self-identified gender, age, racial and ethnic identity, income categories, and social vulnerability index in order to identify sub-groups that may be less likely to be prescribed treatment. RESULTS: We found 74,004 patients in the database whom we identified as presenting to the ED with an opioid poisoning or overdose. Overall, 22.8% were discharged with a prescription for naloxone, while 0.9% of patients were discharged with buprenorphine products. Patients were less likely to receive naloxone prescriptions if they were female, White or Pacific Islander, non-Hispanic, not between the ages of 18-65, and non-English speaking. We found the same pattern for buprenorphine prescriptions except that the results were not significant for ethnicity and English-speaking. CONCLUSION: Despite evidence supporting its use, buprenorphine is not prescribed from the ED in a substantial proportion of patients. Naloxone is prescribed to a higher percentage, although still a minority of patients receive it. Some sub-groups are disadvantaged in the prescribing of these products. Further study may assist in improving the prescribing of these therapies.

Initiation of Medication for Alcohol Use Disorder for Inpatients with Alcohol Withdrawal Syndromes.

OBJECTIVE: Medications for alcohol use disorder (MAUD) are thought to be underused in the United States. This study reviewed data from a national database to determine the frequency of prescribing MAUD for patients admitted to the hospital or discharged with alcohol withdrawal syndromes (AWS). METHOD: We searched for hospital admissions from 2019 to 2021 in the Epic Cosmos database associated with an active diagnosis of AWS. We then searched for patients prescribed medications approved for therapy. We reviewed 197,375 admissions with an active diagnosis of AWS. RESULTS: There was an increasing percentage of admissions for AWS from 2019 to 2021. Overall, only 7% of patients were prescribed MAUD at discharge. Naltrexone was the most prescribed MAUD. Women, non-African Americans, Latinos, and patients under 65 were more likely to be prescribed MAUD. CONCLUSIONS: Many patients with AWS during admission are not prescribed MAUD at the time of discharge.

The effectiveness and adverse events of morphine versus fentanyl on a physician-staffed helicopter.

BACKGROUND: Morphine and fentanyl are both frequently used in prehospital trauma patients, but due to limited formulary size, we sought to study whether both drugs should be included. OBJECTIVES: The purpose of this study was to evaluate the effectiveness and safety of fentanyl as compared to morphine for patients requiring analgesic medications for a traumatic injury during transport via a physician-staffed air medical service. METHODS: Trauma patients were grouped by even and odd days (even - morphine 4 mg, odd - fentanyl 50 µg). Patients were excluded based on age (< 18 or > 64 years), hypotension, inability to communicate a pain score (intubated), or known allergy to the study drugs. During the flight, medical crew assessed numeric pain score, vital signs, and incidence of pruritis or nausea. RESULTS: There were 103 patients enrolled in the morphine arm and 97 patients in the fentanyl arm. The mean pain score at the beginning of enrollment was 8.0 ± 2.0 in the morphine arm and 8.0 ± 1.8 in the fentanyl arm. The mean final pain score was 5.8 ± 2.7 in the morphine arm and 5.5 ± 2.4 in the fentanyl arm (n.s. by either t-test or non-parametric testing). There was no significant difference in analgesia between fentanyl and morphine. There were no significant differences in the incidence of pruritis or vomiting between the two groups. Average transport time was 37 ± 8 min in the morphine group, and 43 ± 11 min in the fentanyl group. Average number of morphine doses was 3 ± 1.2. For fentanyl, average number of doses was 3 ± 1.3. CONCLUSION: In our study, there was not a significant difference in analgesic effectiveness between morphine and fentanyl. There was no significant difference in the incidence of adverse effects between the two drugs. Our study suggests that either drug can be used safely with equivalent effectiveness.

Safety of induction at standard doses of buprenorphine for inpatients with opioid use disorder.

Patients with opioid use disorder (OUD) are commonly admitted to various inpatient services where treatment can be started. The typical initiation of buprenorphine involves delay of treatment until withdrawal symptoms occur, however, those symptoms may interfere with other medical therapy. The purpose of this study was to evaluate the safety and efficacy of initiation of buprenorphine for inpatients with OUD.We reviewed the charts of 99 patients for whom the inpatient addiction medicine consult service was contacted over a 15-month period from January 2020 to identify those patients started on buprenorphine. We abstracted data on toxicology results, prior use of buprenorphine, and Clinical Opioid Withdrawal Scale (COWS) and pain scores before and after the administration of buprenorphine.There was no significant difference in COWS classification post treatment based on ancillary or non use of full agonist therapy. There was no significant change in COWS scores based on prior buprenorphine or methadone use. 5% of patients developed moderate withdrawal (COWS score 12-24) after the initiation of buprenorphine. Twenty of the study patients (20%) developed a 2-point increase in pain scores after the initiation of buprenorphine. SUMMARY: The initiation of buprenorphine for inpatients rarely results in a significant increase in withdrawal symptoms. A larger percent of patients may have an increase in pain scores which would need to be managed. Further prospective work on this subject is warranted.

The time dependence of antithrombin initiation in patients with non-ST-segment elevation acute coronary syndromes: subgroup analysis from the ACUITY trial.

STUDY OBJECTIVE: Antithrombins are among standard treatment agents for patients with non-ST-segment elevation acute coronary syndromes. We aimed to determine the association between time from emergency department (ED) presentation to treatment with an antithrombin and adverse cardiac events. METHODS: The study cohort was a subgroup of the Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) trial, enrolled from March 1, 2005, to December 5, 2005. The ACUITY trial enrolled patients with moderate- and high-risk non-ST-segment elevation acute coronary syndromes and who were undergoing an early invasive strategy (<72 hours from randomization). All patients received an antithrombin (unfractionated heparin, low-molecular-weight heparin, or bivalirudin), in addition to other agents. A formal ED case report form was introduced in March 2005. Time from presentation to antithrombin initiation was evaluated as a continuous variable in hours. The endpoints were defined as major ischemic events (death, myocardial infarction, unplanned revascularization) or major bleeding within 30 days, or inhospital major bleeding. Logistic regression was used to adjust for demographics, severity of disease, comorbidities, and treatment differences. RESULTS: Of the 2,722 patients enrolled with an ED case report form, complete time data were available in 2,632 (96%). Median time to antithrombin administration was 4.87 hours (interquartile range 2.67 to 9.83). After multivariable analysis, there was no association of major ischemic events with log time (hours) to antithrombin treatment (adjusted odds ratio [OR] 0.99; 95% confidence interval [CI] 0.97 to 1.01). There was an increase in major bleeding at 30 days and inhospital major bleeding complications with longer log time (hours) to antithrombin initiation (adjusted OR 1.44, 95% CI 1.15 to 1.80; OR 1.43, 95% CI 1.13 to 1.83, respectively). CONCLUSION: In this study of patients with non-ST-segment elevation acute coronary syndromes who were undergoing an early invasive management strategy, we were unable to demonstrate an association between adverse ischemic outcomes with the timing of antithrombin administration. However, there was an increase in bleeding outcomes as time to antithrombin administration increased.

Nicotine Patch Prescription Fulfillment Rates for Emergency Department Patients.

INTRODUCTION: Smoking cessation has significant health benefits, and the emergency department (ED) can be an important venue for smoking cessation counseling. Nicotine replacement therapy with transdermal patches has been shown to be associated with smoking cessation in a variety of studies. This study evaluated fulfillment rates for prescriptions for nicotine replacement transdermal patches (NRT-P) from the ED. METHODS: We conducted a retrospective review of all patients receiving a prescription for a NRT-P product from January 2018-October 2019. Charts were reviewed to gather data including age, gender, presence of chronic heart or lung problems, and health insurance. We assessed the fulfillment rate of prescriptions using the Surescripts system, which is a functionality within our electronic health record system that queries participating pharmacies. Statistical analysis was conducted to determine associations between fill rates and the other variables collected from charts. RESULTS: We had follow-up on 500 patients prescribed nicotine patches. Of those patients, 44% filled their prescriptions. Those who filled their prescriptions were more likely to be female and have a history of chronic lung disease. Self-pay patients were least likely to fill their prescriptions. Overall, we had evidence of smoking cessation in 13% of patients. CONCLUSION: This study found that a substantial proportion of patients fail to fill their NRT-P prescriptions. Further work on means of enhancing fulfillment rates is warranted.

Levalbuterol versuss levalbuterol plus ipratropium in the treatment of severe acute asthma.

BACKGROUND: The National Asthma Education and Prevention Program (NAEPP) Expert Panel Report 3 guidelines advise the addition of ipratropium bromide to short-acting ß-agonist therapy for the treatment of patients with severe acute asthma exacerbation. METHODS: This was a prospective, double-blind, randomized, controlled study involving 141 adults, presenting to two EDs with acute severe asthma exacerbation. Patients were treated using a standardized pathway with levalbuterol plus ipratropium or levalbuterol alone. Primary outcomes were changes from baseline in the percentage of predicted forced expiratory volume in 1 second (FEV1) at 30 minutes and 60 minutes after completion of treatment. Secondary outcomes included hospitalization and relapse rates. Occurrence of adverse events was recorded. RESULTS: Sixty-seven patients in the levalbuterol plus ipratropium group and 74 patients in the levalbuterol group completed the study. Overall, there was no significant difference in the improvement in percent predicted FEV1 between the two groups at 30 minutes [difference in change between study groups at 30 minutes: 1% (95% CI: ?3 to 2%) or at 60 minutes: 3% (95% CI: 1-6%)] No difference was noted in hospitalization rates between the treatment groups [combination therapy group, 33%; single therapy group, 47%, difference: -14% (95% CI: -30 to 20%)]. Post-hoc analysis revealed that patients receiving ipratropium in addition to levalbuterol were 1.5 times more likely to experience side effects (palpitations) than patients treated with levalbuterol alone (RR 1.5; 95% CI: 1.2-1.9) No differences in relapse rates were noted between the groups. Post-hoc analysis revealed more side effects in patients receiving levalbuterol plus ipratropium. CONCLUSION: We were unable to demonstrate superiority of adding ipratropium to levalbuterol in alleviating obstruction as measured by FEV1 or in decreasing the need for hospitalization among adult patients presenting to the ED with acute severe asthma exacerbation.

Platelet aspirin resistance in ED patients with suspected acute coronary syndrome.

BACKGROUND: Platelet aspirin resistance is reported to be as high as 45%. The prevalence of emergency department (ED) platelet aspirin resistance in suspected acute coronary syndrome (ACS) is not described. Our purpose was to determine the prevalence of platelet aspirin resistance. METHODS: We determined platelet aspirin resistance in a convenience sample of ED suspected ACS patients. Eligible patients had longer than 10 minutes of chest pain or an ischemic equivalent. Two hours after receiving 325 mg of aspirin, blood was assessed for platelet function (Accumetrics, San Diego, CA). Definitions are as follows: aspirin resistance, at least 550 aspirin reaction units; positive troponin T, greater than 0.1 ng/mL; significant coronary lesion, at least 70% stenosis. The composite end point was prospectively defined as a 30-day revisit, positive cardiac catheterization, or hospital length of stay (LOS) longer than 3 days. RESULTS: Of 200 patients, 50.5% were male, 50.0% were black, troponin T was positive in 7.5%, cardiac catheterization was done in 10.5%, and 33.3% had a significant stenosis. Final diagnoses were noncardiac in 83.4%, stable angina in 8.0%, and unstable angina in 8.5%. Overall, 6.5% were resistant to aspirin; and high-risk patients trended to more aspirin resistance than non-high-risk patients (23.1% [3] vs 9.1% [17]; P value 95% confidence interval [CI], -0.0929 to 0.373). One-month follow-up found ED revisits in 12.5% of aspirin-resistant vs 4.9% of non-aspirin-resistant patients (95% CI, -0.114 to 0.182) and rehospitalization in 12.5% of resistant patients vs 4.3% of nonresistant patients (P value 95% CI, -0.108 to 0.187). Although LOS was similar at index admission, if rehospitalized, LOS was 6.5 for aspirin-resistant patients vs 3.2 days in nonresistant patients (P < .0001). CONCLUSION: This first report of platelet aspirin resistance in patients presenting to the ED with suggested ACS finds that it is present in 6.5% of patients.

Impact of intravenous loop diuretics on outcomes of patients hospitalized with acute decompensated heart failure: insights from the ADHERE registry.

The optimal use of diuretics in decompensated heart failure remains uncertain. We analyzed data from the ADHERE registry to look at the impact of diuretic dosing. 62,866 patients receiving <160 mg and 19,674 patients > or =160 mg of furosemide were analyzed. The patients receiving the lower doses had a lower risk for in-hospital mortality, ICU stay, prolonged hospitalization, or adverse renal effects. These findings suggest that future studies should evaluate strategies for minimizing exposure to high doses of diuretics.

Observation unit management of acute decompensated heart failure.

Acute decompensated heart failure (ADHF) is a common illness presenting to the emergency department (ED) that is amenable to observation unit (OU) treatment. As the number of baby boomers continues to grow and the incidence of heart failure increases, the financial implications of ADHF treatment will become more prominent. Obtaining institutional support and developing a good working relationship with cardiology colleagues is vital to creating workable ADHF protocols for whichever type of OU an institution decides to use.

Venous thromboembolism prophylaxis in hospitalized heart failure patients.

BACKGROUND: Venous thromboembolism (VTE) is a concerning problem for hospitalized heart failure (HF) patients. Current recommendations are that all hospitalized New York Heart Association Class III or IV HF patients should receive VTE prophylaxis. Our purpose was to describe the rate of use and the characteristics of patients receiving VTE prophylaxis in the Acute Decompensated Heart Failure National Registry (ADHERE). METHODS AND RESULTS: HF hospitalization episodes in ADHERE were analyzed. Patients were excluded from analysis if they were receiving Coumadin or intravenous heparin, had elevated troponin levels, underwent cardiac catheterization or dialysis before or during hospitalization, or were initially admitted to the intensive care unit. VTE prophylaxis was defined as low-molecular-weight or subcutaneous unfractionated heparin administered at any time during hospitalization and intravenous vasoactive therapy was defined as any inotrope, inodilator, or vasodilator. Chi-square, analysis of variance, and Wilcoxon tests were used for univariate and multivariate analyses. Logistic regression was used to evaluate outcomes. A total of 155,073 entries were evaluated, with 71,376 eligible for VTE prophylaxis; 21,847 (31%) received VTE prophylaxis. VTE prophylaxis patients were more often African American (28% versus 21%) or admitted from the emergency department (84% versus 79%), compared with those who did not receive VTE prophylaxis (both P < .0001). Medical history and initial presentation characteristics were similar, except edema, which was more likely in VTE prophylaxis patients (71% versus 66%, P < .0001). Patients receiving VTE prophylaxis more often received an intravenous vasoactive agent (23% versus 18%), angiotensin-converting enzyme inhibitor (61% versus 54%), or beta-blocker (63% versus 58%) during their hospitalization and were more likely discharged on an angiotensin-converting enzyme inhibitor (53% versus 49%) or beta-blocker (57% versus 54%) than non-VTE prophylaxis patients, all P < .0001. VTE prophylaxis patients were more often admitted to the intensive care unit (4.8% versus 2.5%, P < .0001) and had longer median hospital stays (4.2 versus 3.8 days, P < .0001). Mortality was similar between cohorts (3.0% versus 2.9%, P = .69). CONCLUSIONS: Despite recommendations that all hospitalized New York Heart Association III and IV CHF patients receive venous thromboembolic disease prophylaxis, less than one third of eligible patients receive this guideline recommended therapy.

Bronchodilator therapy in acute decompensated heart failure patients without a history of chronic obstructive pulmonary disease.

STUDY OBJECTIVE: Inhaled bronchodilators are often used in the emergency department (ED) before a definitive diagnosis is made. We evaluated the association between inhaled bronchodilators and outcomes in acute decompensated heart failure patients without chronic obstructive pulmonary disease. METHODS: We conducted an analysis of the Acute Decompensated Heart Failure National Registry Emergency Module registry of patients with a principal discharge diagnosis of acute decompensated heart failure enrolled at 76 academic or community EDs. Dichotomous outcomes (mortality, ED discharges, ICU admission, ED i.v. vasodilator use, new dialysis, ED or in patient endotracheal intubation, ED BiPAP, and asymptomatic at discharge) in patients without a history of chronic obstructive pulmonary disease who were given bronchodilators were compared to those who were not given bronchodilators using logistic regression; odds ratios (ORs) and 95% confidence intervals (CIs) were calculated; and propensity score adjustments were made. RESULTS: Of the 10,978 patients enrolled, 7299 (66.5%) did not have a history of chronic obstructive pulmonary disease. Bronchodilators were administered by the EMS or in the ED to 2317 (21%) patients. Patients without chronic obstructive pulmonary disease given bronchodilators were more likely to receive ED i.v. vasodilators (28.4% vs. 16.9%; propensity adjusted OR 1.40 [95% CI 1.18-1.67]) and in-patient mechanical ventilation (6.0% vs. 2.4%; propensity adjusted OR 1.69 [95% CI 1.21-2.37]) than patients without chronic obstructive pulmonary disease who were not given bronchodilators. Hospital mortality in patients without chronic obstructive pulmonary disease was similar regardless of bronchodilator treatment (3.4% vs. 2.6%, propensity adjusted OR 1.02 [95% CI 0.67, 1.56]). CONCLUSION: Many acute decompensated heart failure patients without a history of chronic obstructive pulmonary disease receive inhaled bronchodilators. Bronchodilator use was associated with a greater need for aggressive interventions and monitoring, and this may reflect an adverse effect of bronchodilators or it may be a marker for patients with more severe disease.

Health care-associated pneumonia: identification and initial management in the ED.

Traditionally, pneumonia is categorized by epidemiologic factors into community-acquired pneumonia (CAP), hospital-acquired pneumonia (HAP), and ventilator-associated pneumonia (VAP). Microbiologic studies have shown that the organisms which cause infections in HAP and VAP differ from CAP in epidemiology and resistance patterns. Patients with HAP or VAP are at higher risk for harboring resistant organisms. Other historical features that potentially place patients at a higher risk for being infected with resistant pathogens and organisms not commonly associated with CAP include history of recent admission to a health care facility, residence in a long-term care or nursing home facility, attendance at a dialysis clinic, history of recent intravenous antibiotic therapy, chemotherapy, and wound care. Because these "risk factors" have health care exposure as a common feature, patients presenting with pneumonia having these historical features have been more recently categorized as having health care-associated pneumonia (HCAP). This publication was prepared by the HCAP Working Group, which is comprised of nationally recognized experts in emergency medicine, infectious diseases, and pulmonary and critical care medicine. The aim of this article is to create awareness of the entity known as HCAP and to provide knowledge of its identification and initial management in the emergency department.

Effect of hip abduction and external rotation on femoral vein exposure for possible cannulation.

Femoral vein access is often required during resuscitation efforts and when other routes of intravenous access are difficult. This study evaluated by ultrasound the effect of abduction/external rotation of the hip on venous accessibility. This was a prospective repeated measurement study. The common femoral veins of 25 volunteers were scanned transversely inferior to the inguinal ligament with the leg straight and in external rotation/abduction. The diameter of the vein and percent accessible (not posterior to the femoral artery) were determined. Data were analyzed using repeated measures analysis of variance. The mean percentage of the femoral vein accessible with the leg in external rotation/abduction was greater than with the leg straight (82.6 +/- 20.3 vs. 70.4 +/- 26.3, respectively); p < 0.03. External rotation/abduction of the hip may improve the success rate of femoral vein cannulation by increasing the percentage of the femoral vein accessible.

A brief risk stratification tool to predict functional decline in older adults discharged from emergency departments.

OBJECTIVES: To determine the effectiveness of the six-item Triage Risk Screening Tool (TRST) to assess baseline functional status and predict subsequent functional decline in older community-dwelling adults discharged home from the emergency department (ED). DESIGN: Secondary data analysis of a randomized, controlled trial. SETTING: EDs of two urban academic hospitals. PARTICIPANTS: Six hundred fifty community-dwelling adults aged 65 and older presenting to the ED and discharged home. Patients were categorized a priori as "high risk" if they had cognitive impairment or two or more risk factors on the TRST. MEASUREMENTS: Functional status: summed activity of daily living (ADL) and instrumental activity of daily living (IADL) scores at baseline, 30 days, and 120 days. Self-perceived physical health: standardized physical health component of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36). Functional decline: loss of one or more ADLs and one or more IADLs from ED baseline at 30 and 120 days. Decline in self-perceived physical health: follow-up SF-36 standardized physical health component scores four or more points lower than baseline. RESULTS: TRST scores correlated with baseline ADL impairments, IADL impairments, and self-perceived physical health at all endpoints (P<.001). A TRST score of two or more was moderately predictive of decline in ADLs or IADLs (30-day ADL area under the receiver operating characteristic curve (AUC)=0.64; 95% confidence interval (CI)=0.56-0.72; 120-day ADL AUC=0.66; 95% CI=0.58-0.74) but not perceived physical health. CONCLUSION: The TRST identifies baseline functional impairment in older ED patients and is moderately predictive of subsequent functional decline after an initial ED visit. The TRST provides a valid proxy measure for assessing functional status in the ED and may be useful in identifying high-risk patients who would benefit from referrals for further evaluation or surveillance upon ED discharge.