Impact of Preexisting Depression and Anxiety on Hospital Readmission and Long-Term Survival After Cardiac Arrest.

BACKGROUND: While sudden cardiac arrest (CA) survivors are at risk for developing psychiatric disorders, little is known about the impact of preexisting mental health conditions on long-term survival or postacute healthcare utilization. We examined the prevalence of preexisting psychiatric conditions in CA patients who survived hospital discharge, characterized incidence and reason for inpatient psychiatry consultation during these patients' acute hospitalizations, and determined the association of pre-CA depression and anxiety with hospital readmission rates and long-term survival. We hypothesized that prior depression or anxiety would be associated with higher hospital readmission rates and lower long-term survival. METHODS: We conducted a retrospective cohort study including patients resuscitated from in- and out-of-hospital CA who survived both admission and discharge from a single hospital between January 1, 2010, and December 31, 2017. We identified patients from our prospective registry, then performed a structured chart review to abstract past psychiatric history, prescription medications for psychiatric conditions, and identify inpatient psychiatric consultations. We used administrative data to identify readmissions within 1 year and vital status through December 31, 2020. We used multivariable Cox regressions controlling for patient demographics, medical comorbidities, discharge Cerebral Performance Category and disposition, depression, and anxiety history to predict long-term survival and hospital readmission. RESULTS: We included 684 subjects. Past depression or anxiety was noted in 24% (n = 162) and 19% (n = 129) of subjects. A minority of subjects (n = 139, 20%) received a psychiatry consultation during the index hospitalization. Overall, 262 (39%) subjects had at least 1 readmission within 1 year. Past depression was associated with an increased hazard of hospital readmission (hazard ratio 1.50, 95% CI 1.11-2.04), while past anxiety was not associated with readmission. Neither depression nor anxiety were independently associated with long-term survival. CONCLUSIONS: Depression is an independent risk factor for hospital readmission in CA survivors.

Home oxygen therapy from the emergency department for COVID-19 an observational study.

STUDY OBJECTIVE: During the COVID-19 pandemic, prescribing supplemental oxygen was a common reason for hospitalization of patients. We evaluated outcomes of COVID-19 patients discharged from the Emergency Department (ED) with home oxygen as part of a program to decrease hospital admissions. METHODS: We retrospectively observed COVID-19 patients with an ED visit resulting in direct discharge or observation from April 2020 to January 2022 at 14 hospitals in a single healthcare system. The cohort included those discharged with new oxygen supplementation, a pulse oximeter, and return instructions. Our primary outcome was subsequent hospitalization or death outside the hospital within 30 days of ED or observation discharge. RESULTS: Among 28,960 patients visiting the ED for COVID-19, providers admitted 11,508 (39.7%) to the hospital, placed 907 (3.1%) in observation status, and discharged 16,545 (57.1%) to home. A total of 614 COVID-19 patients (535 discharge to home and 97 observation unit) went home on new oxygen therapy. We observed the primary outcome in 151 (24.6%, CI 21.3-28.1%) patients. There were 148 (24.1%) patients subsequently hospitalized and 3 (0.5%) patients who died outside the hospital. The subsequent hospitalized mortality rate was 29.7% with 44 of the 148 patients admitted to the hospital dying. Mortality all cause at 30 days in the entire cohort was 7.7%. CONCLUSIONS: Most patients discharged to home with new oxygen for COVID-19 safely avoid later hospitalization and few patients die within 30 days. This suggests the feasibility of the approach and offers support for ongoing research and implementation efforts.

Emergeny Medicine Resident Trauma Intubation Success and Prior Intubation Experience.

BACKGROUND: Emergency medicine residents are often involved in the management of trauma airways. There are few data on the correlation between prior intubation experience and first-pass trauma intubation success for emergency medicine residents. OBJECTIVES: We attempted to elucidate a relationship between prior resident intubation experience and first-pass success for trauma patient intubation. METHODS: We combined two data sets to assess for correlation between prior intubation experience for postgraduate year 2 and 3 residents and first-pass success for trauma patient intubation. Prior intubation experience was gathered from resident procedure logs and trauma intubation data were collected as part of a quality-monitoring program. A univariable logistic regression analysis for all available variables was performed, with first-pass intubation success as the outcome of interest. RESULTS: We included 295 consecutive trauma patients intubated at a Level I trauma center where we could link the resident prior intubation experience (total intubations) with intubation attempt quality data. First-pass success for all emergency medicine residents was 82.3% (233/283). Overall successful intubation rate for emergency medicine residents was 90.4% (256/283). The combination of airway management by both the resident and emergency medicine attending provided an overall success rate of 97.3% (287/295). There was no statistically significant association between first-pass success and prior resident intubation experience or any of the other measured variables. CONCLUSION: We did not demonstrate any significant correlation between first-pass intubation success and number of prior intubations performed by the emergency medicine resident.

Predicting falls within 3 months of emergency department discharge among community-dwelling older adults using self-report tools versus a brief functional assessment.

BACKGROUND: Identifying older adults with risk for falls prior to discharge home from the Emergency Department (ED) could help direct fall prevention interventions, yet ED-based tools to assist risk stratification are under-developed. The aim of this study was to assess the performance of self-report and functional assessments to predict falls in the 3 months post-ED discharge for older adults. METHODS: A prospective cohort of community-dwelling adults age 60 years and older were recruited from one urban ED (N = 134). Participants completed: a single item screen for mobility (SIS-M), the 12-item Stay Independent Questionnaire (SIQ-12), and the Timed Up and Go test (TUG). Falls were defined through self-report of any fall at 1- and 3-months and medical record review for fall-related injury 3-months post-discharge. We developed a hybrid-convolutional recurrent neural network (HCRNN) model of gait and balance characteristics using truncal 3-axis accelerometry collected during the TUG. Internal validation was conducted using bootstrap resampling with 1000 iterations for SIS-M, FRQ, and GUG and leave-one-out for the HCRNN. We compared performance of M-SIS, FRQ, TUG time, and HCRNN by calculating the area under the receiver operating characteristic area under the curves (AUCs). RESULTS: 14 (10.4%) of participants met our primary outcome of a fall or fall-related injury within 3-months. The SIS-M had an AUC of 0.42 [95% confidence interval (CI) 0.19-0.65]. The SIQ-12 score had an AUC of 0.64 [95% confidence interval (CI) 0.49-0.80]. The TUG had an AUC of 0.48 (95% CI 0.29-0.68). The HCRNN model using generated accelerometer features collected during the TUG had an AUC of 0.99 (95% CI 0.98-1.00). CONCLUSION: We found that self-report and functional assessments lack sufficient accuracy to be used in isolation in the ED. A neural network model using accelerometer features could be a promising modality but research is needed to externally validate these findings.

Phenotyping Cardiac Arrest: Bench and Bedside Characterization of Brain and Heart Injury Based on Etiology.

OBJECTIVES: Cardiac arrest etiology may be an important source of between-patient heterogeneity, but the impact of etiology on organ injury is unknown. We tested the hypothesis that asphyxial cardiac arrest results in greater neurologic injury than cardiac etiology cardiac arrest (ventricular fibrillation cardiac arrest), whereas ventricular fibrillation cardiac arrest results in greater cardiovascular dysfunction after return of spontaneous circulation. DESIGN: Prospective observational human and randomized animal study. SETTING: University laboratory and ICUs. PATIENTS: Five-hundred forty-three cardiac arrest patients admitted to ICU. SUBJECTS: Seventy-five male Sprague-Dawley rats. INTERVENTIONS: We examined neurologic and cardiovascular injury in Isoflurane-anesthetized rat cardiac arrest models matched by ischemic time. Hemodynamic and neurologic outcomes were assessed after 5 minutes no flow asphyxial cardiac arrest or ventricular fibrillation cardiac arrest. Comparison was made to injury patterns observed after human asphyxial cardiac arrest or ventricular fibrillation cardiac arrest. MEASUREMENTS AND MAIN RESULTS: In rats, cardiac output (20 ± 10 vs 45 ± 9 mL/min) and pH were lower and lactate higher (9.5 ± 1.0 vs 6.4 ± 1.3 mmol/L) after return of spontaneous circulation from ventricular fibrillation cardiac arrest versus asphyxial cardiac arrest (all p < 0.01). Asphyxial cardiac arrest resulted in greater early neurologic deficits, 7-day neuronal loss, and reduced freezing time (memory) after conditioned fear (all p < 0.05). Brain antioxidant reserves were more depleted following asphyxial cardiac arrest. In adjusted analyses, human ventricular fibrillation cardiac arrest was associated with greater cardiovascular injury based on peak troponin (7.8 ng/mL [0.8-57 ng/mL] vs 0.3 ng/mL [0.0-1.5 ng/mL]) and ejection fraction by echocardiography (20% vs 55%; all p < 0.0001), whereas asphyxial cardiac arrest was associated with worse early neurologic injury and poor functional outcome at hospital discharge (n = 46 [18%] vs 102 [44%]; p < 0.0001). Most ventricular fibrillation cardiac arrest deaths (54%) were the result of cardiovascular instability, whereas most asphyxial cardiac arrest deaths (75%) resulted from neurologic injury (p < 0.0001). CONCLUSIONS: In transcending rat and human studies, we find a consistent phenotype of heart and brain injury after cardiac arrest based on etiology: ventricular fibrillation cardiac arrest produces worse cardiovascular dysfunction, whereas asphyxial cardiac arrest produces worsened neurologic injury associated with greater oxidative stress.

Adjunct Ketamine Use in the Management of Severe Ethanol Withdrawal.

OBJECTIVES: Ketamine offers a plausible mechanism with favorable kinetics in treatment of severe ethanol withdrawal. The purpose of this study is to determine if a treatment guideline using an adjunctive ketamine infusion improves outcomes in patients suffering from severe ethanol withdrawal. DESIGN: Retrospective observational cohort study. SETTING: Academic tertiary care hospital. PATIENTS: Patients admitted to the ICU and diagnosed with delirium tremens by Diagnostic and Statistical Manual of Mental Disorders V criteria. INTERVENTIONS: Pre and post guideline, all patients were treated in a symptom-triggered fashion with benzodiazepines and/or phenobarbital. Postguideline, standard symptom-triggered dosing continued as preguideline, plus, the patient was initiated on an IV ketamine infusion at 0.15-0.3 mg/kg/hr continuously until delirium resolved. Based upon withdrawal severity and degree of agitation, a ketamine bolus (0.3 mg/kg) was provided prior to continuous infusion in some patients. MEASUREMENTS AND MAIN RESULTS: A total of 63 patients were included (29 preguideline; 34 postguideline). Patients treated with ketamine were less likely to be intubated (odds ratio, 0.14; p < 0.01; 95% CI, 0.04-0.49) and had a decreased ICU stay by 2.83 days (95% CI, -5.58 to -0.089; p = 0.043). For ICU days outcome, correlation coefficients were significant for alcohol level and total benzodiazepine dosing. For hospital days outcome, correlation coefficients were significant for patient age, aspartate aminotransferase, and alanine aminotransferase level. Regression revealed the use of ketamine was associated with a nonsignificant decrease in hospital stay by 3.66 days (95% CI, -8.40 to 1.08; p = 0.13). CONCLUSIONS: Mechanistically, adjunctive therapy with ketamine may attenuate the demonstrated neuroexcitatory contribution of N-methyl-D-aspartate receptor stimulation in severe ethanol withdrawal, reduce the need for excessive gamma-aminobutyric acid agonist mediated-sedation, and limit associated morbidity. A ketamine infusion in patients with delirium tremens was associated with reduced gamma-aminobutyric acid agonist requirements, shorter ICU length of stay, lower likelihood of intubation, and a trend toward a shorter hospitalization.

Factors associated with advanced cardiac care in prehospital chest pain patients.

INTRODUCTION: Many patients transported by emergency medical services (EMS) may require advanced cardiac care but do not have ST-segment elevation (STEMI) on the initial prehospital EKG. We sought to identify factors associated with the need for advanced cardiac care in undifferentiated EMS patients reporting chest pain in the absence of STEMI on EKG. METHODS: We performed a retrospective analysis of all adult patients, reporting atraumatic chest pain from a single EMS agency, presenting to a single, urban hospital over a 10-year period. Patients with STEMI on prehospital electrocardiogram were excluded. Patient demographics, chest pain characteristics and prehospital factors were abstracted for all patients. We identified those patients that required advanced cardiac care and performed regression analysis to determine associated factors. RESULTS: A total of 956 charts were analyzed. Of this total, 193 patients (20.2%) met the primary composite outcome. Of the outcome group, 185 patients (95.9%) had coronary artery disease documented on cardiac catheterization, 22 patients (11.4%) underwent CABG, and seven patients (3.6%) died in the hospital. Most significant variables (multivariable IRR) included age (1.02), male gender (1.65), history of MI (1.47), PCI (1.66), hyperlipidemia (1.40), diaphoresis (1.51), home aspirin (1.53), and improvement with EMS treatment (1.60). CONCLUSION: We have identified several factors that could be considered when risk stratifying prehospital patients reporting chest pain. While potentially predictive, the factors are broad and support the need for other objective factors that could augment prediction of patients who may benefit from early advanced cardiac care.

A Novel Artificial Intelligence System for Endotracheal Intubation.

OBJECTIVE: Adequate visualization of the glottic opening is a key factor to successful endotracheal intubation (ETI); however, few objective tools exist to help guide providers' ETI attempts toward the glottic opening in real-time. Machine learning/artificial intelligence has helped to automate the detection of other visual structures but its utility with ETI is unknown. We sought to test the accuracy of various computer algorithms in identifying the glottic opening, creating a tool that could aid successful intubation. METHODS: We collected a convenience sample of providers who each performed ETI 10 times on a mannequin using a video laryngoscope (C-MAC, Karl Storz Corp, Tuttlingen, Germany). We recorded each attempt and reviewed one-second time intervals for the presence or absence of the glottic opening. Four different machine learning/artificial intelligence algorithms analyzed each attempt and time point: k-nearest neighbor (KNN), support vector machine (SVM), decision trees, and neural networks (NN). We used half of the videos to train the algorithms and the second half to test the accuracy, sensitivity, and specificity of each algorithm. RESULTS: We enrolled seven providers, three Emergency Medicine attendings, and four paramedic students. From the 70 total recorded laryngoscopic video attempts, we created 2,465 time intervals. The algorithms had the following sensitivity and specificity for detecting the glottic opening: KNN (70%, 90%), SVM (70%, 90%), decision trees (68%, 80%), and NN (72%, 78%). CONCLUSIONS: Initial efforts at computer algorithms using artificial intelligence are able to identify the glottic opening with over 80% accuracy. With further refinements, video laryngoscopy has the potential to provide real-time, direction feedback to the provider to help guide successful ETI.

Duration of resuscitation efforts and functional outcome after out-of-hospital cardiac arrest: when should we change to novel therapies?

BACKGROUND: Functionally favorable survival remains low after out-of-hospital cardiac arrest. When initial interventions fail to achieve the return of spontaneous circulation, they are repeated with little incremental benefit. Patients without rapid return of spontaneous circulation do not typically survive with good functional outcome. Novel approaches to out-of-hospital cardiac arrest have yielded functionally favorable survival in patients for whom traditional measures had failed, but the optimal transition point from traditional measures to novel therapies is ill defined. Our objective was to estimate the dynamic probability of survival and functional recovery as a function of resuscitation effort duration to identify this transition point. METHODS AND RESULTS: Retrospective cohort study of a cardiac arrest database at a single site. We included 1014 adult (≥18 years) patients experiencing nontraumatic out-of-hospital cardiac arrest between 2005 and 2011, defined as receiving cardiopulmonary resuscitation or defibrillation from a professional provider. We stratified by functional outcome at hospital discharge (modified Rankin scale). Survival to hospital discharge was 11%, but only 6% had a modified Rankin scale of 0 to 3. Within 16.1 minutes of cardiopulmonary resuscitation, 89.7% (95% confidence interval, 80.3%-95.8%) of patients with good functional outcome had achieved return of spontaneous circulation, and the probability of good functional recovery fell to 1%. Adjusting for prehospital and inpatient covariates, cardiopulmonary resuscitation duration (minutes) is independently associated with favorable functional status at hospital discharge (odds ratio, 0.84; 95% confidence interval, 0.72-0.98; P=0.02). CONCLUSIONS: The probability of survival to hospital discharge with a modified Rankin scale of 0 to 3 declines rapidly with each minute of cardiopulmonary resuscitation. Novel strategies should be tested early after cardiac arrest rather than after the complete failure of traditional measures.

Prevalence and interventional outcomes of patients with resolution of ST-segment elevation between prehospital and in-hospital ECG.

OBJECTIVE: To determine the prevalence and significance of ST-segment elevation resolution between prehospital and first hospital ECG. METHODS: We examined consecutive prehospital ECGs transmitted to a single medical command center in southwestern Pennsylvania between January 1, 2009 and December 31, 2011. We included ECG cases with ST-segment elevation myocardial infarction (STEMI) and excluded cases with incomplete prehospital and/or hospital data. Our primary outcome was ST-segment resolution (STR), defined by cases no longer meeting STEMI criteria on the first in-hospital ECG. Primary variables of interest included prehospital vital signs and treatment, cardiac catheterization findings, and time intervals for diagnostics and treatment. Analysis included t-tests for continuous variables and chi-squared analysis for categorical variables. RESULTS: We reviewed 24,197 prehospital ECGs and identified 293 cases of prehospital STEMI. Complete hospital and prehospital records were available for 83 cases (28%). Analyzed cohort was an average 62 years old and the majority were male (67%), with a primary complaint of chest pain (93%). STR occurred in 18 cases (22%, CI 14-32%). There were no differences between STR and non-STR cases in prehospital vital signs or treatments. 95% of patients underwent cardiac catheterization with a mean door-to-needle time of 57 minutes (interquartile range 43-71). Comparing STR and non-STR cases, significant lesions (≥50%) were found in 94 and 97% of patients (p = 0.6), and subtotal or total lesions (≥95%) were found in 63 and 85% (p = 0.1), respectively. CONCLUSIONS: We found that ST-segment resolution occurred prior to catheterization in 1 of 5 patients with prehospital STEMI, emphasizing the necessity of prehospital ECG in risk stratification of patients with suspected coronary disease. Coronary lesions and intervention rates did not differ between STR and non-STR, suggesting that catheterization is warranted even when STEMI criteria are no longer met in-hospital.

Program director longevity in emergency medicine residencies: A 40-year analysis.

Objective: We sought to assess trends in emergency medicine residency program director (PD) length of service over the past 40 years and evaluate relationships between duration of service and important factors such as PD start year, geographic region, and year of program initial accreditation. Methods: We retrospectively analyzed program data from the American Medical Association Graduate Medical Education Directory and Emergency Medicine Residents' Association Match database. We calculated descriptive statistics and used linear regression to assess the impact of PD start year, region, and year of program initial accreditation on PD duration of service. Results: We gathered data on 783 unique PDs between 1983 and 2023. The overall mean ± SD PD duration of service was 6.19 ± 4.72 years (range 1-29 years). The mean duration of service by decade of start date was 6.49 years in the 1980s, 7.39 years in the 1990s, 5.92 years in the 2000s, 4.08 years in the 2010s, and 2 years in the 2020s. Both PD start year (p = 0.002) and program initial accreditation year (p = 0.001) significantly predicted duration of PD service. Region did not significantly predict duration of PD service (p = 0.225). Conclusions: Duration of service as a PD is decreasing in recent decades. Both PD start year and year of initial program accreditation significantly predict duration of service as PD. Future research must be done to better understand this phenomenon and uncover strategies to promote PD longevity.

Metabolic Manipulation and Therapeutic Hypothermia.

Hypothermia has multiple physiological effects, including decreasing metabolic rate and oxygen consumption (VO2). There are few human data about the magnitude of change in VO2 with decreases in core temperature. We aimed to quantify to magnitude of reduction in resting VO2 as we reduced core temperature in lightly sedated healthy individuals. After informed consent and physical screening, we cooled participants by rapidly infusing 20 mL/kg of cold (4°C) saline intravenously and placing surface cooling pads on the torso. We attempted to suppress shivering using a 1 mcg/kg intravenous bolus of dexmedetomidine followed by titrated infusion at 1.0 to 1.5 µg/(kg·h). We measured resting metabolic rate VO2 through indirect calorimetry at baseline (37°C) and at 36°C, 35°C, 34°C, and 33°C. Nine participants had mean age 30 (standard deviation 10) years and 7 (78%) were male. Baseline VO2 was 3.36 mL/(kg·min) (interquartile range 2.98-3.76) mL/(kg·min). VO2 was associated with core temperature and declined with each degree decrease in core temperature, unless shivering occurred. Over the entire range from 37°C to 33°C, median VO2 declined 0.7 mL/(kg·min) (20.8%) in the absence of shivering. The largest average decrease in VO2 per degree Celsius was by 0.46 mL/(kg·min) (13.7%) and occurred between 37°C and 36°C in the absence of shivering. After a participant developed shivering, core body temperature did not decrease further, and VO2 increased. In lightly sedated humans, metabolic rate decreases around 5.2% for each 1°C decrease in core temperature from 37°C to 33°C. Because the largest decrease in metabolic rate occurs between 37°C and 36°C, subclinical shivering or other homeostatic reflexes may be present at lower temperatures.

Real-Time Electronic Patient Portal Use Among Emergency Department Patients.

Importance: Patients with inequitable access to patient portals frequently present to emergency departments (EDs) for care. Little is known about portal use patterns among ED patients. Objectives: To describe real-time patient portal usage trends among ED patients and compare demographic and clinical characteristics between portal users and nonusers. Design, Setting, and Participants: In this cross-sectional study of 12 teaching and 24 academic-affiliated EDs from 8 health systems in California, Connecticut, Massachusetts, Ohio, Tennessee, Texas, and Washington, patient portal access and usage data were evaluated for all ED patients 18 years or older between April 5, 2021, and April 4, 2022. Exposure: Use of the patient portal during ED visit. Main Outcomes and Measures: The primary outcomes were the weekly proportions of ED patients who logged into the portal, viewed test results, and viewed clinical notes in real time. Pooled random-effects models were used to evaluate temporal trends and demographic and clinical characteristics associated with real-time portal use. Results: The study included 1 280 924 unique patient encounters (53.5% female; 0.6% American Indian or Alaska Native, 3.7% Asian, 18.0% Black, 10.7% Hispanic, 0.4% Native Hawaiian or Pacific Islander, 66.5% White, 10.0% other race, and 4.0% with missing race or ethnicity; 91.2% English-speaking patients; mean [SD] age, 51.9 [19.2] years). During the study, 17.4% of patients logged into the portal while in the ED, whereas 14.1% viewed test results and 2.5% viewed clinical notes. The odds of accessing the portal (odds ratio [OR], 1.36; 95% CI, 1.19-1.56), viewing test results (OR, 1.63; 95% CI, 1.30-2.04), and viewing clinical notes (OR, 1.60; 95% CI, 1.19-2.15) were higher at the end of the study vs the beginning. Patients with active portal accounts at ED arrival had a higher odds of logging into the portal (OR, 17.73; 95% CI, 9.37-33.56), viewing test results (OR, 18.50; 95% CI, 9.62-35.57), and viewing clinical notes (OR, 18.40; 95% CI, 10.31-32.86). Patients who were male, Black, or without commercial insurance had lower odds of logging into the portal, viewing results, and viewing clinical notes. Conclusions and Relevance: These findings suggest that real-time patient portal use during ED encounters has increased over time, but disparities exist in portal access that mirror trends in portal usage more generally. Given emergency medicine's role in caring for medically underserved patients, there are opportunities for EDs to enroll and train patients in using patient portals to promote engagement during and after their visits.

Multivariate analysis of successful intravenous line placement in the prehospital setting.

BACKGROUND: Intravenous (IV) line placement is an important prehospital advanced life support skill, but IV success rates are variable among providers. Little is known about what factors are associated with successful IV placement, limiting the ability to develop benchmarks for skill maintenance, such as requiring a specific number of IV placements per year. OBJECTIVE: We aimed to identify whether first-pass IV success was associated with the number of attempted or successful previous IV attempts. We hypothesized that IV success is associated with the number of successful IV placements in the preceding year. METHODS: We retrospectively studied 800 consecutive charts with an IV attempt from 11 suburban and rural emergency medical services (EMS) agencies over a one-month period. Cases involving pediatric patients (age <18 years) and those with incomplete data were excluded. Success of the first IV attempt was identified. Potential predictor variables were collected and analyzed by univariate logistic regression, including patient age, systolic blood pressure, history of IV drug abuse or renal disease, traumatic event, catheter size, and location of IV attempt, as well as the individual provider's numbers of total and successful IV attempts in the preceding year. Variables significantly associated with IV success at the p < 0.10 level were included in a multivariate regression model using a p-value of 0.05. RESULTS: Of 602 cases meeting the study criteria, 469 (77.9%) had a successful first-pass IV placement. Significantly associated with IV success in the univariate regression were patient age (p = 0.054), trauma (p = 0.074), IV catheter size (p < 0.001), IV location (p = 0.056), and the number of previous successful IV attempts (p = 0.039), whereas the number of total previous IV attempts was not significantly associated (p = 0.871). In the multivariate logistic regression model, only IV catheter size had a significant association (p < 0.001), with a larger-bore IV catheter size associated with higher success. CONCLUSION: In this retrospective study, larger IV catheter size, but not the prehospital providers' previous year's experience, was associated with successful IV placement in adult patients. These data fail to support requirements for a minimum number of yearly IV placements by full-time paramedics to improve success rates.

Diagnostic accuracy of a rapid checklist to identify delirium in older patients transported by EMS.

BACKGROUND: The presence of delirium in elderly patients is common and has been identified as an independent marker for increased mortality and hospital-acquired complications, yet it is poorly recognized by health care providers. Early recognition of delirium in the prehospital setting has the potential to improve outcomes, but is not feasible without valid assessment tools. OBJECTIVE: To determine whether use of a rapid delirium checklist by prehospital providers is a valid way to identify cases of delirium compared with a criterion standard and whether the checklist is better at identifying delirium than the Glasgow Coma Score (GCS). METHODS: We conducted a prospective study at two academic, tertiary-care emergency departments (EDs) where a convenience sample of matched dyads of emergency medical services providers and elderly patients (age ≥65 years) were enrolled. Prehospital providers reported limited demographics and work history about themselves. They also reported vital signs and GCS for each patient and completed the checklist asking about presence of the four features of delirium. The patient then underwent a cognitive assessment using the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) by a trained investigator, which was used as the criterion standard. Criterion validity and concurrent validity of the delirium checklist and abnormal GCS were evaluated using sensitivity and specificity. RESULTS: Two hundred fifty-nine matched dyads were studied. Delirium occurred in 24 (9%) of the elderly patients sampled. Prehospital providers' recognition of any delirium symptom resulted in a sensitivity of 0.63 (95% confidence interval [CI] 0.43-0.79) and a specificity of 0.74 (95% CI 0.73-0.84). Prehospital report of a GCS <15 has a sensitivity of 0.67 (95% CI 0.47-0.82) and a specificity of 0.85 (95% CI 0.80-0.89). CONCLUSIONS: A rapid delirium checklist can identify 63% of patients with delirium, but performed no better than the GCS. Future research should determine whether a rapid test of cognition improves early identification of elderly patients with delirium.

Emergency physician recognition of delirium.

OBJECTIVE: To compare the recognition of delirium by emergency physicians based on observations made during routine clinical care with concurrent ratings made by a trained researcher after formal cognitive assessment and to examine each of the four individual features of delirium separately to determine the variation in identification across features. METHODS: In a prospective study, a convenience sample of 259 patients, aged ≥65 years, who presented to two urban, teaching hospital emergency departments (EDs) in Western Pennsylvania between 21 June and 29 August 2011, underwent paired delirium ratings by an emergency physician and a trained researcher. Emergency physicians were asked to use their clinical judgment to decide whether the patient had any of the following delirium features: (1) acute change in mental status, (2) inattention, (3) disorganised thinking and (4) altered level of consciousness. Questions were prompted with examples of delirium features from the Confusion Assessment Method. Concurrently, a trained researcher interviewed surrogates to determine feature 1, conducted a cognitive test for delirium (Confusion Assessment Method for the intensive care unit) to determine delirium features 2 and 3 and used the Richmond Agitation and Sedation Scale to determine feature 4. RESULTS: In the 2-month study period, trained researchers identified delirium in 24/259 (9%; 95% CI 0.06 to 0.13) older patients admitted to the ED. However, attending emergency physicians recognised delirium in only 8 of the 24 and misidentified delirium in a further seven patients. Emergency physicians were particularly poor at recognising altered level of consciousness but were better at recognising acute change in mental status and inattention. CONCLUSIONS: When emergency physicians use routine clinical observations, they may miss diagnosing up to two-thirds of patients with delirium. Recognition of delirium can be enhanced with standardised cognitive testing.

The development of a novel natural language processing tool to identify pediatric chest radiograph reports with pneumonia.

Objective: Chest radiographs are frequently used to diagnose community-acquired pneumonia (CAP) for children in the acute care setting. Natural language processing (NLP)-based tools may be incorporated into the electronic health record and combined with other clinical data to develop meaningful clinical decision support tools for this common pediatric infection. We sought to develop and internally validate NLP algorithms to identify pediatric chest radiograph (CXR) reports with pneumonia. Materials and methods: We performed a retrospective study of encounters for patients from six pediatric hospitals over a 3-year period. We utilized six NLP techniques: word embedding, support vector machines, extreme gradient boosting (XGBoost), light gradient boosting machines Naïve Bayes and logistic regression. We evaluated their performance of each model from a validation sample of 1,350 chest radiographs developed as a stratified random sample of 35% admitted and 65% discharged patients when both using expert consensus and diagnosis codes. Results: Of 172,662 encounters in the derivation sample, 15.6% had a discharge diagnosis of pneumonia in a primary or secondary position. The median patient age in the derivation sample was 3.7 years (interquartile range, 1.4-9.5 years). In the validation sample, 185/1350 (13.8%) and 205/1350 (15.3%) were classified as pneumonia by content experts and by diagnosis codes, respectively. Compared to content experts, Naïve Bayes had the highest sensitivity (93.5%) and XGBoost had the highest F1 score (72.4). Compared to a diagnosis code of pneumonia, the highest sensitivity was again with the Naïve Bayes (80.1%), and the highest F1 score was with the support vector machine (53.0%). Conclusion: NLP algorithms can accurately identify pediatric pneumonia from radiography reports. Following external validation and implementation into the electronic health record, these algorithms can facilitate clinical decision support and inform large database research.

Diagnostic yield of computed tomography after non-traumatic out-of-hospital cardiac arrest.

AIM: Determine the frequency with which computed tomography (CT) after out-of-hospital cardiac arrest (OHCA) identifies clinically important findings. METHODS: We included non-traumatic OHCA patients treated at a single center from February 2019 to February 2021. Clinical practice was to obtain CT head in comatose patients. Additionally, CT of the cervical spine, chest, abdomen, and pelvis were obtained if clinically indicated. We identified CT imaging obtained within 24 hours of emergency department (ED) arrival and summarized radiology findings. We used descriptive statistics to summarize population characteristics and imaging results, report their frequencies and, post hoc, compared time from ED arrival to catheterization between patients who did and did not undergo CT. RESULTS: We included 597 subjects, of which 491 (82.2%) had a CT obtained. Time to CT was 4.1 hours [2.8-5.7]. Most (n = 480, 80.4%) underwent CT head, of which 36 (7.5%) had intracranial hemorrhage and 161 (33.5%) had cerebral edema. Fewer subjects (230, 38.5%) underwent a cervical spine CT, and 4 (1.7%) had acute vertebral fractures. Most subjects (410, 68.7%) underwent a chest CT, and abdomen and pelvis CT (363, 60.8%). Chest CT abnormalities included rib or sternal fractures (227, 55.4%), pneumothorax (27, 6.6%), aspiration or pneumonia (309, 75.4%), mediastinal hematoma (18, 4.4%) and pulmonary embolism (6, 3.7%). Significant abdomen and pelvis findings were bowel ischemia (24, 6.6%) and solid organ laceration (7, 1.9%). Most subjects that had CT imaging deferred were awake and had shorter time to catheterization. CONCLUSIONS: CT identifies clinically important pathology after OHCA.

Duration of cardiopulmonary resuscitation and phenotype of post-cardiac arrest brain injury.

BACKGROUND: Patients resuscitated from cardiac arrest have variable severity of primary hypoxic ischemic brain injury (HIBI). Signatures of primary HIBI on brain imaging and electroencephalography (EEG) include diffuse cerebral edema and burst suppression with identical bursts (BSIB). We hypothesize distinct phenotypes of primary HIBI are associated with increasing cardiopulmonary resuscitation (CPR) duration. METHODS: We identified from our prospective registry of both in-and out-of-hospital CA patients treated between January 2010 to January 2020 for this cohort study. We abstracted CPR duration, neurological examination, initial brain computed tomography gray to white ratio (GWR), and initial EEG pattern. We considered four phenotypes on presentation: awake; comatose with neither BSIB nor cerebral edema (non-malignant coma); BSIB; and cerebral edema (GWR ≤ 1.20). BSIB and cerebral edema were considered as non-mutually exclusive outcomes. We generated predicted probabilities of brain injury phenotype using localized regression. RESULTS: We included 2,440 patients, of whom 545 (23%) were awake, 1,065 (44%) had non-malignant coma, 548 (23%) had BSIB and 438 (18%) had cerebral edema. Only 92 (4%) had both BSIB and edema. Median CPR duration was 16 [IQR 8-28] minutes. Median CPR duration increased in a stepwise manner across groups: awake 6 [3-13] minutes; non-malignant coma 15 [8-25] minutes; BSIB 21 [13-31] minutes; cerebral edema 32 [22-46] minutes. Predicted probability of phenotype changes over time. CONCLUSIONS: Brain injury phenotype is related to CPR duration, which is a surrogate for severity of HIBI. The sequence of most likely primary HIBI phenotype with progressively longer CPR duration is awake, coma without BSIB or edema, BSIB, and finally cerebral edema.

Potential utility of near-infrared spectroscopy in out-of-hospital cardiac arrest: an illustrative case series.

OBJECTIVE: We evaluated the measurement of tissue oxygen content (StO(2)) by continuous near-infrared spectroscopy (NIRS) during and following cardiopulmonary resuscitation (CPR) and compared the changes in StO(2) and end-tidal carbon dioxide (ETCO(2)) as a measure of return of spontaneous circulation (ROSC) or rearrest. METHODS: This was a case series of five patients who experienced out-of hospital cardiac arrest. Patients included those who had already experienced ROSC, who were being transported to the hospital, or who were likely to have a reasonable amount of time remaining in the resuscitation efforts. Patients were continuously monitored from the scene using continuous ETCO(2) monitoring and a NIRS StO(2) monitor until they reached the hospital. The ETCO(2) and StO(2) values were continuously recorded and analyzed for comparison of the time points when patients were clinically identified to have ROSC or rearrest. RESULTS: Four of five patients had StO(2) and EtCO(2) recorded during an episode of CPR and all were monitored during the postarrest period. Three patients experienced rearrest en route to the hospital. Downward trends were noted in StO(2) prior to each rearrest, and rapid increases were noted after ROSC. The StO(2) data showed less variance than the ETCO(2) data in the periarrest period. CONCLUSIONS: This preliminary study in humans demonstrates that StO(2) dynamically changes during periods of hemodynamic instability in postarrest patients. These data suggest that a decline in StO(2) level may correlate with rearrest and may be useful as a tool to predict rearrest in post-cardiac arrest patients. A rapid increase in StO(2) was also seen upon ROSC and may be a better method of identifying ROSC during CPR than pauses for pulse checks or ETCO(2) monitoring.