Performance of the European Society of Cardiology 0/1-hour algorithm with high-sensitivity cardiac troponin T at 90 days among patients with known coronary artery disease.

BACKGROUND: The European Society of Cardiology (ESC) 0/1-h high sensitivity troponin T (hs-cTnT) algorithm does not differentiate risk based on known coronary artery disease (CAD: prior myocardial infarction [MI], coronary revascularization, or ≥ 70% coronary stenosis). We recently evaluated its performance among patients with known CAD at 30-days, but little is known about its longer-term risk prediction. The objective of this study is to determine and compare the performance of the algorithm at 90-days among patients with and without known CAD. METHODS: We performed a pre-planned subgroup analysis of the STOP-CP cohort, which prospectively enrolled ED patients ≥21 years old with symptoms suggestive of ACS without ST-elevation on initial ECG across 8 US sites (1/25/2017-9/6/2018). Participants with 0- and 1-h hs-cTnT measures (Roche, Basel, Switzerland) were stratified into rule-out, observe, and rule-in groups using the ESC 0/1-h algorithm. Algorithm performance was tested among patients with or without known CAD, as determined by the treating provider. The primary outcome was cardiac death or MI at 90-days. Fisher's exact tests were used to compare 90-day event and rule-out rates between patients with and without known CAD. Negative predictive values (NPVs) for 90-day cardiac death or MI with exact 95% confidence intervals were calculated and compared using Fisher's exact test. RESULTS: The STOP-CP study accrued 1430 patients, of which 31.4% (449/1430) had known CAD. Cardiac death or MI at 90 days was more common in patients with known CAD than in those without [21.2% (95/449) vs. 10.0% (98/981); p < 0.001]. Using the ESC 0/1-h algorithm, 39.6% (178/449) of patients with known CAD and 66.1% (648/981) of patients without known CAD were ruled-out (p < 0.001). Among rule-out patients, 90-day cardiac death or MI occurred in 3.4% (6/178) of patients with known CAD and 1.2% (8/648) without known CAD (p = 0.09). NPV for 90-day cardiac death or MI was 96.6% (95%CI 92.8-98.8) among patients with known CAD and 98.8% (95%CI 97.6-99.5) in patients without known CAD (p = 0.09). CONCLUSION: Patients with known CAD who were ruled-out using the ESC 0/1-h hs-cTnT algorithm had a high rate of missed 90-day cardiac events, suggesting that the ESC 0/1-h hs-cTnT algorithm may not be safe for use among patients with known CAD. TRIAL REGISTRATION: High-Sensitivity Cardiac Troponin T to Optimize Chest Pain Risk Stratification (STOP-CP; ClinicalTrials.gov: NCT02984436; https://clinicaltrials.gov/ct2/show/NCT02984436).

Derivation and validation of a high sensitivity troponin-T HEART pathway.

BACKGROUND: The HEART Pathway is widely used for chest pain risk stratification but has yet to be optimized for high sensitivity troponin T (hs-cTnT) assays. METHODS: We conducted a secondary analysis of STOP-CP, a prospective cohort study enrolling adult ED patients with symptoms suggestive of acute coronary syndrome at 8 sites in the United States (US). Patients had a 0- and 1-hour hs-cTnT measured and a HEAR score completed. A derivation set consisting of 729 randomly selected participants was used to derive a hs-cTnT HEART Pathway with rule-out, observation, and rule-in groups for 30-day cardiac death or myocardial infarction (MI). Optimal baseline and 1-hour troponin cutoffs were selected using generalized cross validation to achieve a negative predictive value (NPV) >99% for rule out and positive predictive value (PPV) >60% or maximum Youden index for rule-in. Optimal 0-1-hour delta values were derived using generalized cross validation to maximize the NPV for the rule-out group and PPV for the rule-in group. The hs-cTnT HEART Pathway performance was validated in the remaining cohort (n = 723). RESULTS: Among the 1452 patients, 30-day cardiac death or MI occurred in 12.7% (184/1452). Within the derivation cohort the optimal hs-cTnT HEART Pathway classified 36.5% (266/729) into the rule-out group, yielding a NPV of 99.2% (95% CI: 98.2-100) for 30-day cardiac death or MI. The rule-in group included 15.4% (112/729) with a PPV of 55.4% (95% CI: 46.2-64.6). In the validation cohort, the hs-cTnT HEART Pathway ruled-out 37.6% (272/723), of which 2 had 30-day cardiac death or MI, yielding a NPV of 99.3% (95% CI: 98.3-100). The rule-in group included 14.5% (105/723), yielding a PPV of 57.1% (95% CI: 47.7-66.6). CONCLUSIONS: A novel hs-cTnT HEART Pathway with serial 0- and 1-hour hs-cTnT measures has high NPV and moderate PPV for 30-day cardiac death or MI.

Diagnostic Performance of High-Sensitivity Cardiac Troponin T Strategies and Clinical Variables in a Multisite US Cohort.

BACKGROUND: European data support the use of low high-sensitivity troponin (hs-cTn) measurements or a 0/1-hour (0/1-h) algorithm for myocardial infarction to exclude major adverse cardiac events (MACEs) among patients in the emergency department with possible acute coronary syndrome. However, modest US data exist to validate these strategies. This study evaluated the diagnostic performance of an initial hs-cTnT measure below the limit of quantification (LOQ: 6 ng/L), a 0/1-h algorithm, and their combination with history, ECG, age, risk factors, and initial troponin (HEART) scores for excluding MACE in a multisite US cohort. METHODS: A prospective cohort study was conducted at 8 US sites, enrolling adult patients in the emergency department with symptoms suggestive of acute coronary syndrome and without ST-elevation on ECG. Baseline and 1-hour blood samples were collected, and hs-cTnT (Roche; Basel, Switzerland) was measured. Treating providers blinded to hs-cTnT results prospectively calculated HEART scores. MACE (cardiac death, myocardial infarction, and coronary revascularization) at 30 days was adjudicated. The proportion of patients with initial hs-cTnT measures below the LOQ and risk according to a 0/1-h algorithm was determined. The negative predictive value (NPV) was calculated for both strategies when used alone or with a HEART score. RESULTS: Among 1462 participants with initial hs-cTnT measures, 46.4% (678 of 1462) were women and 37.1% (542 of 1462) were Black with an age of 57.6±12.9 (mean±SD) years. MACEs at 30 days occurred in 14.4% (210 of 1462) of participants. Initial hs-cTnT measures below the LOQ occurred in 32.8% (479 of 1462), yielding an NPV of 98.3% (95% CI, 96.7-99.3) for 30-day MACEs. A low-risk HEART score with an initial hs-cTnT below the LOQ occurred in 20.1% (294 of 1462), yielding an NPV of 99.0% (95% CI, 97.0-99.8) for 30-day MACEs. A 0/1-h algorithm was complete in 1430 patients, ruling out 57.8% (826 of 1430) with an NPV of 97.2% (95% CI, 95.9-98.2) for 30-day MACEs. Adding a low HEART score to the 0/1-h algorithm ruled out 30.8% (441 of 1430) with an NPV of 98.4% (95% CI, 96.8-99.4) for 30-day MACEs. CONCLUSIONS: In a prospective multisite US cohort, an initial hs-cTnT below the LOQ combined with a low-risk HEART score has a 99% NPV for 30-day MACEs. The 0/1-h hs-cTnT algorithm did not achieve an NPV >99% for 30-day MACEs when used alone or with a HEART score. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02984436.

Emergency department evaluation, treatment, and functional outcomes among patients presenting with low back pain.

OBJECTIVES: Low back pain (LBP) leads to more than 4.3 million emergency department (ED) visits annually. Despite the number of ED visits for LBP, emergency medicine societies have not established clear guidelines for the evaluation and care of these patients. This study aims to describe patterns in the evaluation, treatment, and outcomes of patients presenting to an urban, academic ED for atraumatic LBP. METHODS: We prospectively identified a convenience sample of patients presenting with LBP to the University of Utah Hospital ED between January 2017 and June 2018. We collected baseline demographic information and calculated the Patient-Reported Outcomes Measurement Information System Physical Function Short Form 12a (PROMIS PFSF-12a) score to assess patient function and mobility (50 = average PROMIS PFSF-12a score, with higher scores indicating better function). We contacted patients 6 weeks after the ED visit to assess outpatient follow-up and functional outcomes. RESULTS: Over the 18-month study period, 103 patients presented with a chief complaint of LBP and agreed to participate in the study. Average age of the cohort was 48.5 years (SD = 18.3) and 55 (53.4%) were female. Notably, 61 patients (59.2%) had been seen previously in the ED for LBP and 32 (31.1%) had received an opioid for LBP in the preceding 3 months. In the ED, 35.9% of patient received an opioid while 18.5% had an opioid prescription at discharge. While in the ED, 37 (35.9%) had an x-ray and 47 (45.6%) underwent computed tomography or magnetic resonance imaging. At 6-week follow-up, 22 of 68 (32.4%) patients reported having missed work due to pain. PROMIS PFSF-12a score improved from 32.2 ("low" range) at time of ED visit to 42.0 ("low-average" range) at the 6-week follow up. Regarding outpatient follow-up after the ED visit, 22 patients (21.4%) saw a primary care provider, 12 patients (17.8%) saw orthopedics or neurosurgery, and 8 patients (11.8%) attended physical therapy. CONCLUSIONS: Patients receiving ED care for LBP had a significant improvement in PROMIS PFSF-12a scores 6 weeks after the ED but return to function continued to lag despite interventions. Imaging patterns, medication prescriptions, and outpatient follow-up varied widely, emphasizing the needs for clear guidelines and treatment pathways for ED patients with LBP.

Cancer pain management in the emergency department: a multicenter prospective observational trial of the Comprehensive Oncologic Emergencies Research Network (CONCERN).

PURPOSE: Many patients with cancer seek care for pain in the emergency department (ED). Prospective research on cancer pain in this setting has historically been insufficient. We conducted this study to describe the reported pain among cancer patients presenting to the ED, how pain is managed, and how pain may be associated with clinical outcomes. METHODS: We conducted a multicenter cohort study on adult patients with active cancer presenting to 18 EDs in the USA. We reported pain scores, response to medication, and analgesic utilization. We estimated the associations between pain severity, medication utilization, and the following outcomes: 30-day mortality, 30-day hospital readmission, and ED disposition. RESULTS: The study population included 1075 participants. Those who received an opioid in the ED were more likely to be admitted to the hospital and were more likely to be readmitted within 30 days (OR 1.4 (95% CI: 1.11, 1.88) and OR 1.56 (95% CI: 1.17, 2.07)), respectively. Severe pain at ED presentation was associated with increased 30-day mortality (OR 2.30, 95% CI: 1.05, 5.02), though this risk was attenuated when adjusting for clinical factors (most notably functional status). CONCLUSIONS: Patients with severe pain had a higher risk of mortality, which was attenuated when correcting for clinical characteristics. Those patients who required opioid analgesics in the ED were more likely to require admission and were more at risk of 30-day hospital readmission. Future efforts should focus on these at-risk groups, who may benefit from additional services including palliative care, hospice, or home-health services.

Cost-effectiveness of managing low-risk pulmonary embolism patients without hospitalization. The low-risk pulmonary embolism prospective management study.

OBJECTIVE: Evaluate the cost-effectiveness and difference in length-of-stay when patients in the ED diagnosed with low-risk pulmonary embolism (PE) are managed with early discharge or observation. METHODS: Single cohort prospective management study from January 2013 to October 2016 of patients with PE diagnosed in the ED and evaluated for a primary composite endpoint of mortality, recurrent venous thromboembolism, and/or major bleeding event at 90 days. Low-risk patients had a PE Severity Index score < 86, no evidence of proximal deep vein thrombosis on venous compression ultrasonography of both lower extremities, and no evidence of right heart strain on echocardiography. Patients were managed either in the ED or in the hospital on observation status. Primary outcomes were total length of stay, total encounter costs, and 30-day costs. RESULTS: 213 patients were enrolled. 13 were excluded per the study protocol. Of the remaining 200, 122 were managed with emergency department observation (EDO) and 78 with hospital observation (HO). One patient managed with EDO met the composite outcome due to a major bleeding event on day 61. The mean length of stay for EDO was 793.4 min (SD -169.7, 95% CI:762-823) and for HO was 1170 (SD -211.4, 95% CI:1122-1218) with a difference of 376.8 (95% CI: 430-323, p < 0.0001). Total encounter mean costs for EDO were $1982.95 and $2759.59 for HO, with a difference of $776.64 (95% CI: 972-480, p > 0.0001). 30-day total mean costs for EDO were $2864.14 and $3441.52 for HO, with a difference of $577.38 (95% CI: -1372-217, p = 0.15). CONCLUSIONS: Patients with low-risk PE managed with ED-based observation have a shorter length of stay and lower total encounter costs than patients managed with Hospital-based observation.

Accuracy of Parental-Reported Tetanus Vaccination Status for Children With Lacerations.

OBJECTIVES: The aim of this study was to determine whether emergency department (ED) providers are able to accurately assess whether a child with a laceration needs tetanus prophylaxis. METHODS: We conducted an 8-month prospective cross-sectional study of children presenting with a laceration to a pediatric ED. We asked ED providers whether tetanus prophylaxis was necessary. An ED pharmacist accessed the Utah Statewide Immunization Information System (USIIS), and we assessed the accuracy of the ED provider's determination of necessary tetanus prophylaxis compared with USIIS records. RESULTS: Among 375 patients aged 5 months to 17 years, ED providers made an inaccurate assessment of necessary tetanus prophylaxis in 33 cases (8.8%; 95% confidence interval [CI], 6.3%-12.1%). Emergency department providers would have inappropriately administered tetanus prophylaxis in 5 cases (1.3%; 95% CI, 0.5%-3.2%) and would have missed the need for tetanus prophylaxis in 28 cases (7.5%; 95% CI, 5.2%-10.6%). Emergency department providers were more likely to provide an inaccurate recommendation in older children (8.3 vs 4.8 years; P < 0.001), in patients with a dirty wound (45.5% vs 11.7%; P < 0.001), and in children who had fewer than 3 vaccines recorded in the USIIS (54.5% vs 1.2%; P < 0.001). CONCLUSIONS: Emergency department providers may inaccurately assess the need for tetanus prophylaxis in children. Special attention should be paid to cases of dirty wounds and cases in which fewer than 3 tetanus-containing vaccines have been given.

Pediatric Appendicitis: Association of Chief Complaint With Missed Appendicitis.

OBJECTIVES: We evaluated the association between the emergency department (ED) triage chief complaint and rate of missed appendicitis in children. METHODS: We performed a retrospective chart review of patients who presented to a pediatric ED and were diagnosed with appendicitis over 5 years (July 1, 2009 to June 30, 2014). We reviewed the medical record for any additional ED visits in the 7 days preceding the diagnosis of appendicitis. Triage chief complaints were classified as "suggestive of appendicitis" (abdominal pain, right lower quadrant pain, or rule out appendicitis) or "nonspecific" (fever, vomiting, dehydration, etc). We evaluated the association between triage chief complaint and missed diagnosis of appendicitis. RESULTS: We reviewed 1680 patients with appendicitis. In 67 (4%) cases, patients had at least 1 additional ED visit during the week preceding the diagnosis of appendicitis. When comparing those diagnosed with appendicitis at their initial ED visit to those diagnosed after multiple visits, we found no difference in age (9.9 vs 10.1 years, P = 0.665), sex (55.7% vs 49.3% male, P = 0.291), white blood cell count (14.4 vs 12.3 × 103/L, P = 0.115), or presence of fever (19.9% vs 19.4%, P = 0.920). Of patients with a triage chief complaint that was suggestive of appendicitis, 3.8% were missed on their initial ED visit versus 8.8% of those with a nonspecific triage chief complaint (odds ratio, 2.46; 95% confidence interval, 1.1-5.6). CONCLUSIONS: A triage chief complaint less suggestive of appendicitis was associated with a higher rate of missed appendicitis in a pediatric ED. Our findings further confirm the potential impact of anchoring bias by a triage chief complaint when attempting to diagnose appendicitis.

Spontaneous pneumothorax resulting in tension physiology.

Spontaneous pneumothorax (SP) is a relatively common pathology in emergency medicine; however, scant information is published regarding SPs developing tension physiology in the literature. Risk factors for spontaneous pneumothorax include smoking, family history, and underlying lung disease such as chronic obstructive lung disease (COPD), cystic fibrosis, tuberculosis, among others. Treatment often involves conservative management, needle aspiration, catheter placement, or tube thoracostomy. Tension pneumothorax, however, is a life threatening condition requiring emergent intervention. Case reports have demonstrated large SPs with midline shift but without tension physiology as patients largely remained hemodynamically stable. We report the case of an 18-year-old male presenting to the Emergency Department (ED) with a SP that rapidly developed tension physiology with mediastinal shift and hypotension resolved by needle decompression and CT placement.

Impact of altitude-adjusted hypoxia on the Pulmonary Embolism Rule-out Criteria.

BACKGROUND: The Pulmonary Embolism Rule-out Criteria (PERC) defines hypoxia as an oxygen saturation (O2 sat) < 95%. Utilizing this threshold for hypoxia at a significant elevation above sea level may lead to an inflated number of PERC-positive patients and unnecessary testing. The aim of this study was to determine the effect of an altitude-adjusted O2 sat on PERC's sensitivity and the potential impact on testing rates. METHODS: At the University of Utah Emergency Department (ED) (elevation: 4980 ft/1518 m), we prospectively enrolled a convenience sample of patients presenting with chest pain and/or shortness of breath. We calculated PERC utilizing triage vital signs and baseline clinical variables and noted the diagnosis of acute PE during the ED visit. We adjusted the PERC O2 sat threshold to <90% to account for altitude to determine the potential impact on outcomes and decision tool performance. RESULTS: Of 3024 study patients, 1.9% received the diagnosis of an acute PE in the ED, resulting in a sensitivity of 96.6% for the traditional PERC (95% CI: 88.1%-99.6%). Utilizing a definition of hypoxia of <90%, the sensitivity of the altitude-adjusted PERC rule was 94.8% (95% CI: 85.6%-98.9%). Assuming that imaging would not have been pursued for PERC-negative patients, the altitude-adjusted PERC rule would have reduced the overall rate of advanced imaging by 2.7% (95% CI: 1.8%-4.1%). CONCLUSION: Adjusting the PERC O2 sat threshold for altitude may result in decreased rates of advanced imaging for PE without a substantial change in the sensitivity of the PERC rule.

Emergency department visits for electric scooter-related injuries after introduction of an urban rental program.

BACKGROUND: Providers in Salt Lake City emergency departments (EDs) anecdotally noted a significant number of electronic scooter (e-scooter)-related injuries since the launch of e-scooter rentals in the downtown area in June 2018. The aim of this study was to quantify and characterize these injuries. METHODS: We reviewed the electronic medical records of the University of Utah ED and the Salt Lake Regional Medical Center ED. Using a broad keyword search for "scooter," we examined all notes for ED visits between June 15-November 15, 2017, and June 15-November 15, 2018, and identified e-scooter related injuries. The 2017 data pre-dated the launch of the e-scooter share programs in Salt Lake City and served as a control period. RESULTS: We noted 8 scooter-related injuries in 2017 and 50 in 2018. Injury types from the 2018 period included: major head injury (8%); major musculoskeletal injury (36%); minor head injury (12%); minor musculoskeletal injury (34%); and superficial soft tissue injury (40%). 24% of patients presented via ambulance and 6% presented as a trauma activation. 16% of patients required hospital admission and 14% had an injury requiring operative repair. 16% reported alcohol intoxication and none of the patients reported wearing a helmet at the time of the injury. CONCLUSION: Since the launch of e-scooter share programs in Salt Lake City, we have seen a substantial increase in e-scooter related trauma in our EDs. Of particular note is the number of patients with major head injuries and major musculoskeletal injuries.

Validation of the Emergency Severity Index (Version 4) for the Triage of Adult Emergency Department Patients With Active Cancer.

BACKGROUND: Patients with active cancer account for a growing percentage of all emergency department (ED) visits and have a unique set of risks related to their disease and its treatments. Effective triage for this population is fundamental to facilitating their emergency care. OBJECTIVES: We evaluated the validity of the Emergency Severity Index (ESI; version 4) triage tool to predict ED-relevant outcomes among adult patients with active cancer. METHODS: We conducted a prespecified analysis of the observational cohort established by the National Cancer Institute-supported Comprehensive Oncologic Emergencies Research Network's multicenter (18 sites) study of ED visits by patients with active cancer (N = 1075). We used a series of χ2 tests for independence to relate ESI scores with 1) disposition, 2) ED resource use, 3) hospital length of stay, and 4) 30-day mortality. RESULTS: Among the 1008 subjects included in this analysis, the ESI distribution skewed heavily toward high acuity (>95% of subjects had an ESI level of 1, 2, or 3). ESI was significantly associated with patient disposition and ED resource use (p values < 0.05). No significant associations were observed between ESI and the non-ED based outcomes of hospital length of stay or 30-day mortality. CONCLUSION: ESI scores among ED patients with active cancer indicate higher acuity than the general ED population and are predictive of disposition and ED resource use. These findings show that the ESI is a valid triage tool for use in this population for outcomes directly relevant to ED care.

Prevalence of pulmonary embolism in patients presenting to the emergency department with syncope.

OBJECTIVES: A recent study reported a high prevalence of pulmonary embolism (PE) among patients admitted with syncope. We sought to determine whether these findings were validated in our patient population. METHODS: We performed a retrospective, secondary analysis of prospectively gathered data from patients presenting with syncope to an academic emergency department (ED) from July 2010 to December 2015. We analyzed baseline information from the time of the ED visit, recorded outcomes during the hospital stay, and contacted patients by phone at least 30days after the ED visit. The primary study outcome was the diagnosis of acute PE in the ED, during inpatient admission or ED observation unit stay, or by patient report over a 30-day follow-up period. RESULTS: Over the 5.5-year study period, 348 patients with syncope agreed to participate in the study. 52% of patients were female [95% confidence interval (CI): 46.6-57.4] and the average age was 48.4years. Of the enrolled patients, 50.1% (CI: 44.8-55.2) underwent further evaluation for syncope beyond the ED stay: 27% (CI: 22.6-31.9) of patients were admitted to an inpatient unit for further work-up and 23.9% (CI: 19.7-28.6) of patients were placed in the ED observation unit. The overall rate of PE among patients presenting to the ED with syncope was 1.4% (CI: 0.6-3.3%). 2 patients (0.6%, CI: 0.2-2.1) were diagnosed with a PE while in the ED. None of the patients were diagnosed with a PE during hospital admission or the observation stay associated with the index ED visit. 3 patients (0.9%, CI: 0.3-2.5) reported they had been diagnosed with a PE during the 30days following their ED visit, two of whom had been admitted to the hospital at the index ED visit but were not diagnosed with a PE at that time. All patients diagnosed with a PE at the time of the ED visit or during the follow-up period were Pulmonary Embolism Rule Out Criteria (PERC) positive and reported shortness of breath in the ED. CONCLUSION: In contrast to a previous study, our findings do not support a high rate of PE among ED patients presenting with syncope.

Family history of venous thromboembolism predicts the diagnosis of acute pulmonary embolism in the emergency department.

BACKGROUND: Pulmonary embolism (PE) clinical decision rules do not consider a patient's family history of venous thromboembolism (VTE). We evaluated whether a family history of VTE predicts acute PE in the emergency department (ED). METHODS: Over a 5.5-year study period, we enrolled a prospective convenience sample of patients presenting to an academic emergency department with chest pain and/or shortness of breath. We defined a family history of VTE as a first-degree relative with previous PE or deep vein thrombosis (DVT). We noted outcomes of testing during the patient's ED stay, including the diagnosis of acute PE by either computed tomography (CT) or ventilation/perfusion (VQ) scan. RESULTS: Of the 3024 study patients, 19.4% reported a family history of VTE and 1.9% were diagnosed with an acute PE during the ED visit. Patients with a family history of VTE were more likely to be diagnosed with a PE: 3.2% vs. 1.6% (p = 0.009). 82.3% of patients were Pulmonary Embolism Rule-out Criteria (PERC) positive, and among PERC-positive patients, those with a family history of VTE were more likely to be diagnosed with a PE: 3.6% vs. 1.9% (p = 0.016). Of patients who underwent testing for PE (33.7%), patients with a family history of VTE were more likely to be diagnosed with a PE: 9.4% vs. 4.9% (p = 0.032). CONCLUSION: Patients with a self-reported family history of VTE in a first-degree relative are more likely to be diagnosed with an acute PE in the ED, even among those patients considered to have a higher likelihood of PE.

Cardiology consultation reduces provocative testing rates in an ED observation unit.

BACKGROUND: In evaluating patients with chest pain, emergency department observation units (EDOUs) may use a staffing model in which emergency physicians determine patient testing (EP model) or a model similar to a chest pain unit (CPU) in which cardiologists determine provocative testing (CPU model). METHODS: We performed a prospective study with 30-day telephone follow-up for all chest pain patients placed in our EDOU. Halfway through the study period, our EDOU transitioned from an EP model to a CPU model. We compared provocative testing rates and outcomes between the 2 models. RESULTS: Over the 34-month study period, our EDOU evaluated 1190 patients for chest pain. Patients placed in the EDOU during the 17-month CPU model were more likely to be moderate risk (Thrombolysis in Myocardial Infarction score 3-5) than those during the 17-month EP model: 24.9% vs 18.8%, P = .011. Despite this difference, rates of provocative testing (stress testing or coronary computed tomography) were lower during the CPU model: 47.1% vs 56.5%, P = .001. This reduction was particularly evident among low-risk patients (Thrombolysis in Myocardial Infarction score 0-2): 49.8% vs 58.1%, P = .011. Rates of myocardial infarction, percutaneous coronary intervention, or coronary artery bypass graft were similar between the 2 groups (2.8% vs 3.2%, P = .140). We noted no significant events or missed diagnoses in either group during the 30-day follow-up. CONCLUSION: An EDOU model that used mandatory cardiology consultation resulted in decreased provocative testing, particularly among low-risk chest pain patients. Future research should explore the cost-effectiveness of this model.

ED pharmacist monitoring of provider antibiotic selection aids appropriate treatment for outpatient UTI.

OBJECTIVE: We sought to determine whether an emergency department (ED) pharmacist could aid in the monitoring and correction of inappropriate empiric antibiotic selection for urinary tract infections in an outpatient ED population. METHODS: Urine cultures with greater than 100 000 CFU/mL bacteria from the University of Utah Emergency Department over 1 year (October 2011-Sept 2012) were identified using our electronic medical record system. Per ED protocol, an ED pharmacist reviews all cultures and performs a chart review of patient symptoms, diagnosis, and discharge antibiotics to determine whether the treatment was appropriate. A retrospective review of this process was performed to identify how often inappropriate treatment was recognized and intervened on by an ED pharmacist. RESULTS: Of the 180 cultures included, a total of 42 (23%) of empiric discharge treatments were considered inappropriate and required intervention. In 35 (83%) of 42 patients, the ED pharmacist was able to contact the patient and make appropriate changes; the remaining 7 patients were unable to be contacted, and no change could be made in their treatment. CONCLUSION: A chart review of all urine cultures with greater than 100 000 CFU/mL performed by an ED pharmacist helped identify inappropriate treatment in 23% of patients discharged to home with the diagnosis of urinary tract infection. Of these patients who had received inappropriate treatment, an ED pharmacist was able to intervene in 83% of cases. These data highlight the role of ED pharmacists in improving patient care after discharge.

Prospective evaluation of outcomes among geriatric chest pain patients in an ED observation unit.

OBJECTIVE: Because of concerns of high admission rates and adverse events in geriatric patients, hospitals may exclude this group from emergency department observation unit (EDOU) chest pain protocols. We sought to evaluate characteristics and outcomes of geriatric chest pain patients treated in an EDOU. METHODS: We performed a prospective, observational study of chest pain patients admitted to our EDOU over a 36-month period. We recorded baseline demographics and risk factors as well as outcomes related to the EDOU stay. We performed 30-day follow-up using telephone contact and review of the electronic medical record. RESULTS: Over the 36-month study period, 1276 chest pain patients agreed to participate in the study. Two hundred seventy-six patients (21.6%) were 65 years and older. Geriatric patients in the EDOU were more likely to report a history of coronary artery disease than nongeriatric patients (27.1% vs 11.6%, P<.001). There were no clinically significant adverse events nor deaths among geriatric patients. The proportion of geriatric patients who experienced myocardial infarction, stent, or coronary artery bypass graft during the EDOU stay or follow-up period was 4.7% vs 2.7% for nongeriatric patients (P=.09). Inpatient admission rates were significantly higher for geriatric patients (15.6% vs 9.7%, P=.006). Similarly, geriatric patients had higher rates of cardiac catheterization than did nongeriatric patients (13.4% vs 7.9%, P=.005). CONCLUSION: Geriatric patients with chest pain may represent a higher-risk group for evaluation in the EDOU. In our experience, however, these patients were safely evaluated in the EDOU setting and their inpatient admission rate fell within generally accepted guidelines.

Predictors of patient adherence to follow-up recommendations after an ED visit.

BACKGROUND: It is unclear whether factors identified during the emergency department (ED) visit predict noncompliance with ED recommendations. STUDY OBJECTIVE: We sought to determine predictors of adherence to medical recommendations after an ED visit. METHODS: We conducted a prospective, observational study at a single urban medical center. Eligible ED patients provided baseline demographic data as well as information regarding insurance status, whether they had a primary care physician (PCP), and the impact of cost of care on their ability to follow medical recommendations. Patients were contacted at least 1 week after the ED visit and answered questions regarding adherence to medical recommendations. RESULTS: Four hundred twenty-two patients agreed to participate in the study. At follow-up, 89.7% of patients reported that they had complied with recommendations made during the ED visit. Patients who were adherent to follow-up recommendations were more likely to have a primary care provider (odds ratio [OR], 2.6; 95% confidence interval [CI], 1.1-6.1), have an annual income of greater than $35000 (OR, 2.9; 95% CI, 1.2-7.2), and report a non-Hispanic ethnicity or race (OR, 2.8; 95% CI, 1.1-7.1). Individuals who reported that cost "sometimes" or "always" impacts their ability to follow their physician's recommendations were significantly less likely to comply with ED recommendations (OR, 2.7; 95% CI, 1.3-5.6). CONCLUSION: Individuals who reported that cost affects their ability to follow their physician's recommendations and those who did not have a PCP were less likely to follow ED recommendations. Identification of predictors of noncompliance during the ED visit may aid in ensuring compliance with ED recommendations.