Emergency Department Referral of Patients With Chest Pain for Noninvasive Cardiac Testing and 2-Year Clinical Outcomes.

BACKGROUND: Noninvasive cardiac testing (NICT) has been associated with decreased long-term risks of major adverse cardiac events (MACEs) among emergency department patients at high coronary risk. It is unclear whether this association extends to patients without evidence of myocardial injury on initial ECG and cardiac troponin testing. METHODS: A retrospective cohort study was conducted of patients presenting with chest pain between 2013 and 2019 to 21 emergency departments within an integrated health care system in Northern California, excluding patients with ST-segment-elevation myocardial infarction or myocardial injury by serum troponin testing. To account for confounding by indication, we grouped patient encounters by the NICT referral rate of the initially assigned emergency physician relative to local peers within discrete time periods. The primary outcome was MACE within 2 years. Secondary outcomes were coronary revascularization and MACE, inclusive of all-cause mortality. Associations between the NICT referral group (low, intermediate, or high) and outcomes were assessed using risk-adjusted proportional hazards methods with censoring for competing events. RESULTS: Among 144 577 eligible patient encounters, the median age was 58 years (interquartile range, 48-68) and 57% were female. Thirty-day NICT referral was 13.0%, 19.9%, and 27.8% in low, intermediate, and high NICT referral groups, respectively, with a good balance of baseline covariates between groups. Compared with the low NICT referral group, there was no significant decrease in the adjusted hazard ratio of MACE within the intermediate (adjusted hazard ratio, 1.08 [95% CI, 1.02-1.14]) or high (adjusted hazard ratio, 1.05 [95% CI, 0.99-1.11]) NICT referral groups. Results were similar for MACE, inclusive of all-cause mortality, and coronary revascularization, as well as subgroup analyses stratified by estimated risk (history, electrocardiogram, age, risk factors, troponin [HEART] score: percent classified as low risk, 48.2%; moderate risk, 49.2%; and high risk, 2.7%). CONCLUSIONS: Increases in NICT referrals were not associated with changes in the hazard of MACE within 2 years following emergency department visits for chest pain without evidence of acute myocardial injury. These findings further highlight the need for evidence-based guidance regarding the appropriate use of NICT in this population.

An all-inclusive model for predicting invasive bacterial infection in febrile infants age 7-60 days.

BACKGROUND: Invasive bacterial infections (IBIs) in febrile infants are rare but potentially devastating. We aimed to derive and validate a predictive model for IBI among febrile infants age 7-60 days. METHODS: Data were abstracted retrospectively from electronic records of 37 emergency departments (EDs) for infants with a measured temperature >=100.4 F who underwent an ED evaluation with blood and urine cultures. Models to predict IBI were developed and validated respectively using a random 80/20 dataset split, including 10-fold cross-validation. We used precision recall curves as the classification metric. RESULTS: Of 4411 eligible infants with a mean age of 37 days, 29% had characteristics that would likely have excluded them from existing risk stratification protocols. There were 196 patients with IBI (4.4%), including 43 (1.0%) with bacterial meningitis. Analytic approaches varied in performance characteristics (precision recall range 0.04-0.29, area under the curve range 0.5-0.84), with the XGBoost model demonstrating the best performance (0.29, 0.84). The five most important variables were serum white blood count, maximum temperature, absolute neutrophil count, absolute band count, and age in days. CONCLUSION: A machine learning model (XGBoost) demonstrated the best performance in predicting a rare outcome among febrile infants, including those excluded from existing algorithms. IMPACT: Several models for the risk stratification of febrile infants have been developed. There is a need for a preferred comprehensive model free from limitations and algorithm exclusions that accurately predicts IBIs. This is the first study to derive an all-inclusive predictive model for febrile infants aged 7-60 days in a community ED sample with IBI as a primary outcome. This machine learning model demonstrates potential for clinical utility in predicting IBI.

CA FIRST (California Febrile Infant Risk Stratification Tool) Algorithm Development in a Learning Health System.

Introduction There is considerable variation in the approach to infants presenting to the emergency department (ED) with fever. The authors' primary aim was to develop a robust set of algorithms using community ED data to inform modifications of broader clinical guidance. Methods The authors report the development of California Febrile Infant Risk Stratification Tool (CA FIRST) using key components of the Roseville Protocol (ROS) and American Academy of Pediatrics (AAP) Clinical Practice Guideline (CPG). Expanded guidance was derived using a retrospective analysis of a cohort of 3527 febrile infants aged 7-90 days presenting to any Kaiser Permanente Northern California ED between 2010 and 2019 who underwent a core febrile infant evaluation. Results Melding ROS and AAP CPG algorithms in infants 7-60 days old, CA FIRST Algorithms had comparable performance characteristics to ROS and AAP CPG. CA FIRST enhancements included guidance on febrile infants 61-90 days old, high-risk infants, infants with bronchiolitis, and infants who received immunizations within the prior 48 hours. This retrospective analysis revealed that of 235 febrile infants 22-90 days old with respiratory syncytial virus and 221 who had fever in the 48 hours following vaccination, there were no cases of invasive bacterial infection. Discussion CA FIRST is a set of 13 algorithms providing a thoughtful and flexible approach to the febrile infant while minimizing unnecessary interventions. Conclusions CA FIRST Algorithms empower clinicians to manage most febrile infants. Algorithms are being modified as new data become available, imparting useful and ever-current educational information within a learning health care system.

Clinical decision support to Optimize Care of patients with Atrial Fibrillation or flutter in the Emergency department: protocol of a stepped-wedge cluster randomized pragmatic trial (O'CAFÉ trial).

BACKGROUND: Management of adults with atrial fibrillation (AF) or atrial flutter in the emergency department (ED) includes rate reduction, cardioversion, and stroke prevention. Different approaches to these components of care may lead to variation in frequency of hospitalization and stroke prevention actions, with significant implications for patient experience, cost of care, and risk of complications. Standardization using evidence-based recommendations could reduce variation in management, preventable hospitalizations, and stroke risk. METHODS: We describe the rationale for our ED-based AF treatment recommendations. We also describe the development of an electronic clinical decision support system (CDSS) to deliver these recommendations to emergency physicians at the point of care. We implemented the CDSS at three pilot sites to assess feasibility and solicit user feedback. We will evaluate the impact of the CDSS on hospitalization and stroke prevention actions using a stepped-wedge cluster randomized pragmatic clinical trial across 13 community EDs in Northern California. DISCUSSION: We hypothesize that the CDSS intervention will reduce hospitalization of adults with isolated AF or atrial flutter presenting to the ED and increase anticoagulation prescription in eligible patients at the time of ED discharge and within 30 days. If our hypotheses are confirmed, the treatment protocol and CDSS could be recommended to other EDs to improve management of adults with AF or atrial flutter. TRIAL REGISTRATION: ClinicalTrials.gov NCT05009225 .  Registered on 17 August 2021.

CT Use Reduction In Ostensive Ureteral Stone (CURIOUS).

INTRODUCTION: Computed tomography (CT) is performed in over 90% of patients diagnosed with ureteral stones, but only 10% of patients presenting to the emergency department (ED) with acute flank pain are hospitalized for a clinically important stone or non-stone diagnosis. Hydronephrosis can be accurately detected using point-of-care ultrasound and is a key predictor of ureteral stone and risk of subsequent complications. The absence of hydronephrosis is insufficient to exclude a stone. We created a sensitive clinical decision rule to predict clinically important ureteral stones. We hypothesized that this rule could identify patients at low risk for this outcome. METHODS: We conducted a retrospective cohort study in a random sample of 4000 adults who presented to one of 21 Kaiser Permanente Northern California EDs and underwent a CT for suspected ureteral stone from 1/1/2016 to 12/31/2020. The primary outcome was clinically important stone, defined as stone resulting in hospitalization or urologic procedure within 60 days. We used recursive partition analysis to generate a clinical decision rule predicting the outcome. We estimated the C-statistic (area under the curve), plotted the receiver operating characteristic (ROC) curve for the model, and calculated sensitivity, specificity, and predictive values of the model based on a risk threshold of 2%. RESULTS: Among 4000 patients, 354 (8.9%) had a clinically important stone. Our partition model resulted in four terminal nodes with risks ranging from 0.4% to 21.8%. The area under the ROC curve was 0.81 (95% CI 0.80, 0.83). Using a 2% risk cut point, a clinical decision tree including hydronephrosis, hematuria, and a history of prior stones predicted complicated stones with sensitivity 95.5% (95% CI 92.8%-97.4%), specificity 59.9% (95% CI 58.3%-61.5%), positive predictive value 18.8% (95% CI 18.1%-19.5%), and negative predictive value 99.3% (95% CI 98.8%-99.6%). CONCLUSIONS: Application of this clinical decision rule to imaging decisions would have led to 63% fewer CT scans with a miss rate of 0.4%. A limitation was the application of our decision rule only to patients who underwent CT for suspected ureteral stone. Thus, this rule would not apply to patients who were thought to have ureteral colic but did not receive a CT because ultrasound or history were sufficient for diagnosis. These results could inform future prospective validation studies.

Mortality Following Diagnosis of Nontraumatic Intracerebral Hemorrhage Within an Integrated "Hub-and-Spoke" Neuroscience Care Model: Is Spoke Presentation Noninferior to Hub Presentation?

BACKGROUND: Practice guidelines recommend that patients with intracerebral hemorrhage (ICH) be treated in units with acute neuroscience care experience. However, most hospitals in the United States lack this degree of specialization. We sought to examine outcome differences for patients with nontraumatic ICH presenting to centers with and without advanced neuroscience care specialization. METHODS: This was a retrospective study of adult patients presenting with nontraumatic ICH between 1/1/2011 and 9/30/2020 across 21 medical centers within Kaiser Permanente Northern California, an integrated care system that employs a "hub-and-spoke" model of neuroscience care in which two centers service as neuroscience "hubs" and the remaining 19 centers service as referral "spokes." Patients presenting to spokes can receive remote consultation (including image review) by neurosurgical or neurointensive care specialists located at hubs. The primary outcome was 90-day mortality. We used hierarchical logistic regression, adjusting for ICH score components, comorbidities, and demographics, to test a hypothesis that initial presentation to a spoke medical center was noninferior to hub presentation [defined as an odds ratio (OR) with an upper 95% confidence interval (CI) limit of 1.24 or less]. RESULTS: A total of 6978 patients were included, with 6170 (88%) initially presenting to spoke medical centers. The unadjusted 90-day mortality for patients initially presenting to spoke versus hub medical centers was 32.2% and 32.7%, respectively. In adjusted analysis, presentation to a spoke medical center was neither noninferior nor inferior for 90-day mortality risk (OR 1.21, 95% CI 0.84-1.74). Sensitivity analysis excluding patients admitted to general wards or lacking continuous health plan insurance during the follow-up period trended closer to a noninferior result (OR 0.99, 95% CI 0.69-1.44). CONCLUSIONS: Within an integrated "hub-and-spoke" neuroscience care model, the risk of 90-day mortality following initial presentation with nontraumatic ICH to a spoke medical center was not conclusively noninferior compared with initial presentation to a hub medical center. However, there was also no indication that care for selected patients with nontraumatic ICH within medical centers lacking advanced neuroscience specialization resulted in significantly inferior outcomes. This finding may support the safety and efficiency of a "hub-and-spoke" care model for patients with nontraumatic ICH, although additional investigations are warranted.

Using AAP Guidelines for Managing Febrile Infants Without C-Reactive Protein and Procalcitonin.

BACKGROUND AND OBJECTIVES: In 2021, the American Academy of Pediatrics (AAP) published the Clinical Practice Guideline (CPG) for management of well-appearing, febrile infants 8 to 60 days old. For older infants, the guideline relies on several inflammatory markers, including tests not rapidly available in many settings like C-reactive protein (CRP) and procalcitonin (PCT). This study describes the performance of the AAP CPG for detecting invasive bacterial infections (IBI) without using CRP and PCT. METHODS: This retrospective cohort study included infants aged 8 to 60 days old presenting to Kaiser Permanente Northern California emergency departments between 2010 and 2019 with temperatures ≥38°C who met AAP CPG inclusion criteria and underwent complete blood counts, blood cultures, and urinalyses. Performance characteristics for detecting IBI were calculated for each age group. RESULTS: Among 1433 eligible infants, there were 57 (4.0%) bacteremia and 9 (0.6%) bacterial meningitis cases. Using absolute neutrophil count >5200/mm3 and temperature >38.5°C as inflammatory markers, 3 (5%) infants with IBI were misidentified. Sensitivities and specificities for detecting infants with IBIs in each age group were: 8 to 21 days: 100% (95% confidence interval [CI] 83.9%-100%) and 0% (95% CI 0%-1.4%); 22 to 28 days: 88.9% (95% CI 51.8%-99.7%) and 40.4% (95% CI 33.2%- 48.1%); and 29 to 60 days: 93.3% (95% CI 77.9%-99.2%) and 32.1% (95% CI 29.1%- 35.3%). Invasive interventions were recommended for 100% of infants aged 8 to 21 days; 58% to 100% of infants aged 22 to 28 days; and 0% to 69% of infants aged 29 to 60 days. CONCLUSIONS: When CRP and PCT are not available, the AAP CPG detected IBI in young, febrile infants with high sensitivity but low specificity.

Higher intensity of 72-h noninvasive cardiac test referral does not improve short-term outcomes among emergency department patients with chest pain.

BACKGROUND: It is unclear whether referral for cardiac noninvasive testing (NIT) following emergency department (ED) chest pain encounters improves short-term outcomes. METHODS: This was a retrospective cohort study of patients presenting with chest pain, without ST-elevation myocardial infarction or myocardial injury by serum troponin testing, between 2013 and 2019 to 21 EDs within an integrated health care system. We examined the association between NIT referral (within 72 h of the ED encounter) and a primary outcome of 60-day major adverse cardiac events (MACE). Secondary outcomes were 60-day MACE without coronary revascularization (MACE-CR) and 60-day all-cause mortality. To account for confounding by indication for NIT, we grouped patient encounters into ranked tertiles of NIT referral intensity based on the likelihood of 72-h NIT referral associated with the initially assigned emergency physician, relative to local peers and within discrete time periods. Associations between NIT referral-intensity tertile and outcomes were assessed using risk-adjusted multivariable logistic regression. RESULTS: Among 210,948 eligible patient encounters, 72-h NIT referral frequency was 11.9%, 18.3%, and 25.9% in low, intermediate, and high NIT referral-intensity encounters, respectively. Compared with the low referral-intensity tertile, there was a higher risk of 60-day MACE within the high referral-intensity tertile (odds ratio [OR] = 1.11, 95% confidence interval [CI] = 1.04 to 1.17) due to more coronary revascularizations without corresponding differences in MACE-CR or all-cause mortality. In analyses stratified by patients' estimated risk (HEART score; 50.5% lower risk, 38.7% moderate risk, 10.8% higher risk), the difference in 60-day MACE was primarily attributable to moderate-risk encounters (OR = 1.15, 95% CI = 1.08 to 1.24), with no differences among either lower- (OR = 1.10, 95% CI = 0.92 to 1.31) or higher- (OR = 1.01, 95% CI = 0.90 to 1.14) risk encounters. CONCLUSION: Higher referral intensity for 72-h NIT was associated with higher risk of coronary revascularization but no difference in adverse events within 60 days. These findings further call into question the urgency of NIT among ED patients without objective evidence of myocardial injury.

Management and Outcomes of Adults Diagnosed with Acute Pulmonary Embolism in Primary Care: Community-Based Retrospective Cohort Study.

BACKGROUND: The management and outcomes of patients diagnosed with acute pulmonary embolism in primary care have not been characterized. OBJECTIVE: To describe 30-day outcomes stratified by initial site-of-care decisions DESIGN: Multicenter retrospective cohort study PARTICIPANTS: Adults diagnosed with acute pulmonary embolism in primary care in a large, diverse community-based US health system (2013-2019) MAIN MEASURES: The primary outcome was a composite of 30-day serious adverse events (recurrent venous thromboembolism, major bleeding, and all-cause mortality). The secondary outcome was 7-day pulmonary embolism-related hospitalization, either initial or delayed. KEY RESULTS: Among 652 patient encounters (from 646 patients), median age was 64 years; 51.5% were male and 70.7% identified as non-Hispanic white. Overall, 134 cases (20.6%) were sent home from primary care and 518 cases (79.4%) were initially referred to the emergency department (ED) or hospital. Among the referred, 196 (37.8%) were discharged home from the ED without events. Eight patients (1.2%; 95% CI 0.5-2.4%) experienced a 30-day serious adverse event: 4 venous thromboemboli (0.6%), 1 major bleed (0.2%), and 3 deaths (0.5%). Seven of these patients were initially hospitalized, and 1 had been sent home from primary care. All 3 deaths occurred in patients with known metastatic cancer initially referred to the ED, hospitalized, then enrolled in hospice following discharge. Overall, 328 patients (50.3%) were hospitalized within 7 days: 322 at the time of the index diagnosis and 6 following initial outpatient management (4 clinic-only and 2 clinic-plus-ED patients). CONCLUSIONS: Patients diagnosed with acute pulmonary embolism in this primary care setting uncommonly experienced 30-day adverse events, regardless of initial site-of-care decisions. Over 20% were managed comprehensively by primary care. Delayed 7-day pulmonary embolism-related hospitalization was rare among the 51% treated as outpatients. Primary care management of acute pulmonary embolism appears to be safe and could have implications for cost-effectiveness and patient care experience.

Predictors of Acute Atrial Fibrillation and Flutter Hospitalization across 7 U.S. Emergency Departments: A Prospective Study.

INTRODUCTION: International rates of hospitalization for atrial fibrillation and flutter (AFF) from the emergency department (ED) vary widely without clear evidence to guide the identification of high-risk patients requiring inpatient management. We sought to determine (1) variation in hospital admission and (2) modifiable factors associated with hospitalization of AFF patients within a U.S. integrated health system. METHODS: This multicenter prospective observational study of health plan members with symptomatic AFF was conducted using convenience sampling in 7 urban community EDs from 05/2011 to 08/2012. Prospective data collection included presenting symptoms, characteristics of atrial dysrhythmia, ED physician impression of hemodynamic instability, comorbid diagnoses, ED management, and ED discharge rhythm. All centers had full-time on-call cardiology consultation available. Additional variables were extracted from the electronic health record. We identified factors associated with hospitalization and included predictors in a multivariate Poisson Generalized Estimating Equations regression model to estimate adjusted relative risks while accounting for clustering by physician. RESULTS: Among 1,942 eligible AFF patients, 1,074 (55.3%) were discharged home and 868 (44.7%) were hospitalized. Hospitalization rates ranged from 37.4% to 60.4% across medical centers. After adjustment, modifiable factors associated with increased hospital admission from the ED included non-sinus rhythm at ED discharge, no attempted cardioversion, and heart rate reduction. DISCUSSION: Within an integrated health system, we found significant variation in AFF hospitalization rates and identified several modifiable factors associated with hospital admission. Standardizing treatment goals that specifically address best practices for ED rate reduction and rhythm control may reduce hospitalizations.

Graded Coronary Risk Stratification for Emergency Department Patients With Chest Pain: A Controlled Cohort Study.

Background Resource utilization among emergency department (ED) patients with possible coronary chest pain is highly variable. Methods and Results Controlled cohort study amongst 21 EDs of an integrated healthcare system examining the implementation of a graded coronary risk stratification algorithm (RISTRA-ACS [risk stratification for acute coronary syndrome]). Thirteen EDs had access to RISTRA-ACS within the electronic health record (RISTRA sites) beginning in month 24 of a 48-month study period (January 2016 to December 2019); the remaining 8 EDs served as contemporaneous controls. Study participants had a chief complaint of chest pain and serum troponin measurement in the ED. The primary outcome was index visit resource utilization (observation unit or hospital admission, or 7-day objective cardiac testing). Secondary outcomes were 30-day objective cardiac testing, 60-day major adverse cardiac events (MACE), and 60-day MACE-CR (MACE excluding coronary revascularization). Difference-in-differences analyses controlled for secular trends with stratification by estimated risk and adjustment for risk factors, ED physician and facility. A total of 154 914 encounters were included. Relative to control sites, 30-day objective cardiac testing decreased at RISTRA sites among patients with low (≤2%) estimated 60-day MACE risk (-2.5%, 95% CI -3.7 to -1.2%, P<0.001) and increased among patients with non-low (>2%) estimated risk (+2.8%, 95% CI +0.6 to +4.9%, P=0.014), without significant overall change (-1.0%, 95% CI -2.1 to 0.1%, P=0.079). There were no statistically significant differences in index visit resource utilization, 60-day MACE or 60-day MACE-CR. Conclusions Implementation of RISTRA-ACS was associated with better allocation of 30-day objective cardiac testing and no change in index visit resource utilization or 60-day MACE. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03286179.

Clinical characteristics of COVID-19 patients evaluated in the emergency department: A retrospective cohort study of 801 cases.

BACKGROUND: Coronavirus disease 2019 (COVID-19), the disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has extracted devastating tolls. Despite its pervasiveness, robust information on disease characteristics in the emergency department (ED) and how that information predicts clinical course remain limited. METHODS: We conducted a retrospective cohort study of the first ED visit from SARS-CoV-2-positive patients in our health system, from February 21, 2020 to April 5, 2020. We reviewed each patient's ED visit(s) and included the first visit with symptoms consistent with COVID-19. We collected demographic, clinical, and treatment variables from electronic health records and structured manual chart review. We used multivariable logistic regression to examine the association between patient characteristics and 2 primary outcomes: a critical outcome and hospitalization from index visit. Our critical outcome was defined as death or advanced respiratory support (high flow nasal cannula or greater) within 21 days. RESULTS: Of the first 1030 encounters, 801 met our inclusion criteria: 15% were over age 75 years, 47% were female, and 24% were non-Hispanic white. We found 161 (20%) had a critical outcome and 393 (49%) were hospitalized. Independent predictors of a critical outcome included a history of hypertension, abnormal chest x-ray, elevated neutrophil to lymphocyte ratio, elevated blood urea nitrogen (BUN), measured fever, and abnormal respiratory vital signs (respiratory rate, oxygen saturation). Independent predictors of hospitalization included abnormal pulmonary auscultation, elevated BUN, measured fever, and abnormal respiratory vital signs. CONCLUSIONS: In this large, diverse study of ED patients with COVID-19, we have identified numerous clinical characteristics that have independent associations with critical illness and hospitalization.

Prospective Validation and Comparative Analysis of Coronary Risk Stratification Strategies Among Emergency Department Patients With Chest Pain.

Background Coronary risk stratification is recommended for emergency department patients with chest pain. Many protocols are designed as "rule-out" binary classification strategies, while others use graded-risk stratification. The comparative performance of competing approaches at varying levels of risk tolerance has not been widely reported. Methods and Results This is a prospective cohort study of adult patients with chest pain presenting between January 2018 and December 2019 to 13 medical center emergency departments within an integrated healthcare delivery system. Using an electronic clinical decision support interface, we externally validated and assessed the net benefit (at varying risk thresholds) of several coronary risk scores (History, ECG, Age, Risk Factors, and Troponin [HEART] score, HEART pathway, Emergency Department Assessment of Chest Pain Score Accelerated Diagnostic Protocol), troponin-only strategies (fourth-generation assay), unstructured physician gestalt, and a novel risk algorithm (RISTRA-ACS). The primary outcome was 60-day major adverse cardiac event defined as myocardial infarction, cardiac arrest, cardiogenic shock, coronary revascularization, or all-cause mortality. There were 13 192 patient encounters included with a 60-day major adverse cardiac event incidence of 3.7%. RISTRA-ACS and HEART pathway had the lowest negative likelihood ratios (0.06, 95% CI, 0.03-0.10 and 0.07, 95% CI, 0.04-0.11, respectively) and the greatest net benefit across a range of low-risk thresholds. RISTRA-ACS demonstrated the highest discrimination for 60-day major adverse cardiac event (area under the receiver operating characteristic curve 0.92, 95% CI, 0.91-0.94, P<0.0001). Conclusions RISTRA-ACS and HEART pathway were the optimal rule-out approaches, while RISTRA-ACS was the best-performing graded-risk approach. RISTRA-ACS offers promise as a versatile single approach to emergency department coronary risk stratification. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03286179.

Effect of Clinical Decision Support on Diagnostic Imaging for Pediatric Appendicitis: A Cluster Randomized Trial.

Importance: Appendicitis is the most common pediatric surgical emergency. Efforts to improve efficiency and quality of care have increased reliance on computed tomography (CT) and ultrasonography (US) in children with suspected appendicitis. Objective: To evaluate the effectiveness of an electronic health record-linked clinical decision support intervention, AppyCDS, on diagnostic imaging, health care costs, and safety outcomes for patients with suspected appendicitis. Design, Setting, and Participants: In this parallel, cluster randomized trial, 17 community-based general emergency departments (EDs) in California, Minnesota, and Wisconsin were randomized to the AppyCDS intervention group or usual care (UC) group. Patients were aged 5 to 20 years, presenting for an ED visit with right-sided or diffuse abdominal pain lasting 5 days or less. We excluded pregnant patients, those with a prior appendectomy, those with selected comorbidities, and those with traumatic injuries. The trial was conducted from October 2016 to July 2019. Interventions: AppyCDS prompted data entry at the point of care to estimate appendicitis risk using the pediatric appendicitis risk calculator (pARC). Based on pARC estimates, AppyCDS recommended next steps in care. Main Outcomes and Measures: Primary outcomes were CT, US, or any imaging (CT or US) during the index ED visit. Safety outcomes were perforations, negative appendectomies, and missed appendicitis. Costs were a secondary outcome. Ratio of ratios (RORs) for primary and safety outcomes and differences by group in cost were used to evaluate effectiveness of the clinical decision support tool. Results: We enrolled 3161 patients at intervention EDs and 2779 patients at UC EDs. The mean age of patients was 11.9 (4.6) years and 2614 (44.0%) were boys or young men. RORs for CT (0.94; 95% CI, 0.75-1.19), US (0.98; 95% CI, 0.84-1.14), and any imaging (0.96; 95% CI, 0.86-1.07) did not differ by study group. In an exploratory analysis conducted in 1 health system, AppyCDS was associated with a reduction in any imaging (ROR, 0.82; 95% CI, 0.73- 0.93) for patients with pARC score of 15% or less and a reduction in CT (ROR, 0.58; 95% CI, 0.45-0.74) for patients with a pARC score of 16% to 50%. Perforations, negative appendectomies, and cases of missed appendicitis by study phase did not differ significantly by study group. Costs did not differ overall by study group. Conclusions and Relevance: In this study, AppyCDS was not associated with overall reductions in diagnostic imaging; exploratory analysis revealed more appropriate use of imaging in patients with a low pARC score. Trial Registration: ClinicalTrials.gov Identifier: NCT02633735.

Computed Tomography Use in Children With Minor Head Trauma Presenting to 21 Community Emergency Departments Within an Integrated Health-Care System.

INTRODUCTION: Decreasing unnecessary cranial computed tomography (CT) use in pediatric head trauma patients remains important for emergency departments (EDs) across the US. Our study evaluated CT use in children with minor blunt head trauma in 21 community EDs within an integrated health-care system. METHODS: We studied all children younger than 18 years old presenting to 21 community EDs between 2016 through 2018 with acute minor blunt head trauma, defined by an algorithm of ED chief complaints and diagnoses. We excluded patients with traumatic brain injuries diagnosed in the prior year, a CT within 24 hours prior to the ED visit, or an ED Glasgow Coma Scale score of less than 14. RESULTS: Among 39,792 pediatric minor head trauma ED visits, the aggregate CT use proportion across all EDs was 12.9% [95% confidence interval (CI), 12.6-13.3%; facility-level range, 5.4-21.6%]. The 7 facilities that had previously received a clinical decision support system intervention implementing the Pediatric Emergency Care Applied Research Network rules during 2013 through 2014 had an aggregate mean CT ordering rate of 11.2% (95% CI, 10.7-11.7%; facility-level range, 5.4-14.3%) compared to 14.1% (95% CI, 13.6-14.5%; facility-level range, 7.3-21.6%) for the nonintervention facilities. CONCLUSION: CT use for children with minor blunt head trauma in the community EDs of an integrated health-care system was low and stable across facilities from 2016 through 2018. This may be indicative of the safe stewardship of resources in the system, including the absence of financial or medicolegal incentives to scan very low-risk patients as well the availability of resources for close patient follow-up.

Automated Retrospective Calculation of the EDACS and HEART Scores in a Multicenter Prospective Cohort of Emergency Department Chest Pain Patients.

OBJECTIVES: Coronary risk scores are commonly applied to emergency department patients with undifferentiated chest pain. Two prominent risk score-based protocols are the Emergency Department Assessment of Chest pain Score Accelerated Diagnostic Protocol (EDACS-ADP) and the History, ECG, Age, Risk factors, and Troponin (HEART) pathway. Since prospective documentation of these risk determinations can be challenging to obtain, quality improvement projects could benefit from automated retrospective risk score classification methodologies. METHODS: EDACS-ADP and HEART pathway data elements were prospectively collected using a Web-based electronic clinical decision support (eCDS) tool over a 24-month period (2018-2019) among patients presenting with chest pain to 13 EDs within an integrated health system. Data elements were also extracted and processed electronically (retrospectively) from the electronic health record (EHR) for the same patients. The primary outcome was agreement between the prospective/eCDS and retrospective/EHR data sets on dichotomous risk protocol classification, as assessed by kappa statistics (ĸ). RESULTS: There were 12,110 eligible eCDS uses during the study period, of which 66 and 47% were low-risk encounters by EDACS-ADP and HEART pathway, respectively. Agreement on low-risk status was acceptable for EDACS-ADP (ĸ = 0.73, 95% confidence interval [CI] = 0.72 to 0.75) and HEART pathway (ĸ = 0.69, 95% CI = 0.68 to 0.70) and for the continuous scores (interclass correlation coefficients = 0.87 and 0.84 for EDACS and HEART, respectively). CONCLUSIONS: Automated retrospective determination of low risk status by either the EDACS-ADP or the HEART pathway provides acceptable agreement compared to prospective score calculations, providing a feasible risk adjustment option for use in large data set analyses.

Diagnostic Performance of Emergency Physician Gestalt for Predicting Acute Appendicitis in Patients Age 5 to 20 Years.

OBJECTIVES: Pediatric appendicitis remains a challenging diagnosis in the emergency department (ED). Available risk prediction algorithms may contribute to excessive ED imaging studies. Incorporation of physician gestalt assessment could help refine predictive tools and improve diagnostic imaging decisions. METHODS: This study was a subanalysis of a parent study that prospectively enrolled patients ages 5 to 20.9 years with a chief complaint of abdominal pain presenting to 11 community EDs within an integrated delivery system between October 1, 2016, and September 30, 2018. Prior to diagnostic imaging, attending emergency physicians enrolled patients with ≤5 days of right-sided or diffuse abdominal pain using a Web-based application embedded in the electronic health record. Predicted risk (gestalt) of acute appendicitis was prospectively entered using a sliding scale from 1% to 100%. As a planned secondary analysis, we assessed the performance of gestalt via c-statistics of receiver operating characteristic (ROC) curves; tested associations between gestalt performance and patient, physician, and facility characteristics; and examined clinical characteristics affecting gestalt estimates. RESULTS: Of 3,426 patients, 334 (9.8%) had confirmed appendicitis. Physician gestalt had excellent ROC curve characteristics (c-statistic = 0.83, 95% confidence interval = 0.81 to 0.85), performing particularly well in the low-risk strata (appendicitis rate = 1.1% in gestalt 1%-10% range, negative predictive value of 98.9% for appendicitis diagnosis). Physicians with ≥5 years since medical school graduation demonstrated improved gestalt performance over those with less experience (p = 0.007). All clinical characteristics tested, except pain <24 hours, were significantly associated with physician gestalt value (p < 0.05). CONCLUSION: Physician gestalt for acute appendicitis diagnosis performed well, especially in low-risk patients and when employed by experienced physicians.

Text message alerts to emergency physicians identifying potential study candidates increase clinical trial enrollment.

Prospective enrollment of research subjects in the fast-paced emergency department (ED) is challenging. We sought to develop a software application to increase real-time clinical trial enrollment during an ED visit. The Prospective Intelligence System for Clinical Emergency Services (PISCES) scans the electronic health record during ED encounters for preselected clinical characteristics of potentially eligible study participants and notifies the treating physician via mobile phone text alerts. PISCES alerts began 3 months into a cluster randomized trial of an electronic health record-based risk stratification tool for pediatric abdominal pain in 11 Northern California EDs. We compared aggregate enrollment before (2577 eligible patients, October 2016 to December 2016) and after (12 049 eligible patients, January 2017 to January 2018) PISCES implementation. Enrollment increased from 10.8% to 21.1% following PISCES implementations (P < .001). PISCES significantly increased study enrollment and can serve as a valuable tool to assist prospective research enrollment in the ED.