Shifting practice in pediatric prescription opioid use in the emergency department for fractures.

OBJECTIVES: Judicious opioid use is important for balancing patient comfort and safety. Although opioid use is well studied in adult populations, pediatric opioid prescription practices are less understood and there are very few guidelines regarding its usage. The purpose of this study was to investigate pediatric opioid prescription trends by emergency medicine physicians over the last ten years, including assessing proxies for the adequacy of pain control and risk of any opioid-related adverse events including overdose. METHODS: A retrospective analysis was performed of all patients age 0 to 18 who presented to an urban county hospital emergency department (ED) between 2007 and 2017 for acute fracture care. Data collected included age, opioids given in the ED, opioid prescriptions from the ED, adverse events, and secondary opioid prescriptions. Opioid prescription quantities were assessed in morphine equivalents (Meqs). RESULTS: Out of 4713 patients diagnosed with acute fracture, opioid prescriptions from the ED were given to 1772 patients (37.6%), with a mean quantity of 107.0 Meqs (SD = 69.1). Over the ten-year period studied, prescription rates declined from 54.8% in 2007 to 13.6% in 2017. Although 201 (4.3%) fracture patients had a second fracture-related ED visit, only 27 visits (0.57%) were for inadequate pain control, with no significant differences in year-to-year analysis. During the ten-year study period, there were zero opioid overdoses reported among pediatric fracture patients. CONCLUSIONS: A major shift has occurred in the last ten years, as emergency medicine physicians now favor non-opioid pain management regimens over opioids for the majority of pediatric fracture patients. There was no increase in the rate of inadequate pain control requiring a return to the ED, even as opioid prescription rates declined during the study period.

Take -home naloxone rescue kits following heroin overdose in the emergency department to prevent opioid overdose related repeat emergency department visits, hospitalization and death- a pilot study.

BACKGROUND: Opioid overdoses are at an epidemic in the United States causing the deaths of thousands each year. Project DAWN (Deaths Avoided with Naloxone) is an opioid overdose education and naloxone distribution program in Ohio that distributes naloxone rescue kits at clinics and in the emergency departments of a single hospital system. METHODS: We performed a retrospective analytic cohort study comparing heroin overdose survivors who presented to the emergency department and were subsequently discharged. We compared those who received a naloxone rescue kit at discharge with those who did not. Our composite outcome was repeat opioid overdose related emergency department visit(s), hospitalization and death at 0-3 months and at 3-6 months following emergency department overdose. Heroin overdose encounters were identified by ICD- 9 or 10 codes and data was abstracted from the electronic medical record for emergency department patients who presented for heroin overdose and were discharged over a 31- month period between 2013 and 2016. Patients were excluded for previous naloxone access, incarceration, suicidal ideation, admission to the hospital or death from acute overdose on initial emergency department presentation. Data was analyzed with the Chi- square statistical test. RESULTS: We identified 291emergency department heroin overdose encounters by ICD-9 or 10 codes and were analyzed. A total of 71% of heroin overdose survivors received a naloxone rescue kit at emergency department discharge. Between the patients who did not receive a naloxone rescue kit at discharge, no overdose deaths occurred and 10.8% reached the composite outcome. Of the patients who received a naloxone rescue kit, 14.4% reached the composite endpoint and 7 opioid overdose deaths occurred in this cohort. No difference in mortality at 3 or 6 months was detected, p = 0.15 and 0.36 respectively. No difference in the composite outcome was detected at 3 or 6 months either, p = 0.9 and 0.99 respectively. CONCLUSIONS: Of our emergency department patients receiving a naloxone rescue kit we did not find a benefit in the reduction of repeat emergency department visits hospitalizations, or deaths following a non-fatal heroin overdose.

The use of an emergency department dysphagia screen is associated with decreased pneumonia in acute strokes.

BACKGROUND: Dysphagia is a common problem for patients after an acute stroke which can lead to hospital acquired pneumonia (HAP) increasing morbidity and mortality. The Joint Commission has directed that stroke certified hospitals perform a dysphagia screen at the time of initial presentation. We sought to evaluate if our ED dysphagia screen was correlated with lower rates of pneumonia in acute stroke patients. METHODS: We conducted a pre-post trial evaluating rates of pneumonia in patients with ischemic and hemorrhagic stroke both before and after the use of our ED dysphagia screen. We defined HAP as a new infiltrate treated with antibiotics. Rates of HAP were compared using the χ2 test. Any patients transferred out of our health system were excluded. RESULTS: We evaluated 419 and 469 preintervention hemorrhagic strokes and 1022 and 462 post screen ischemic strokes respectively. In the hemorrhagic groups rates of dysphagia were similar but rates of HAP decreased from 19% to 15% (P < 0.001) in the pre- post groups respectively. In the ischemic stroke groups rates of HAP decreased from 13.8% to 8% in the pre-post groups respectively, (P = 0.007). Rates of intubation were similar in the hemorrhagic groups and were higher in the post screen ischemic stroke cohort. CONCLUSION: The use of our ED dysphagia screen was associated with a significant reduction in the rates of HAP in both ischemic and hemorrhagic stroke patients. Given the high rates of dysphagia and significant comorbidity and complications for these stroke patients, the use of a screen is warranted.

The Advanced Reperfusion Era: Implications for Emergency Systems of Ischemic Stroke Care.

Large vessel ischemic stroke is a leading cause of morbidity and mortality throughout the world. Recent advances in endovascular stroke treatment are changing the treatment paradigm for these patients. This concepts article summarizes the time-dependent nature of stroke care and evaluates the recent advancements in endovascular treatment. These advancements have significant implications for out-of-hospital, hospital, and regional systems of stroke care. Emergency medicine clinicians have a central role in implementing these systems that will ensure timely treatment of patients and selection of those who may benefit from endovascular care.

Drill down analysis of door-to-needle time of acute ischemic stroke patients treated with intravenous tissue plasminogen activator.

OBJECTIVE: Target stroke guidelines recommend a door-to-needle time of ≤60 minutes for acute ischemic stroke (AIS) patients treated with intravenous (IV) tissue-type plasminogen activator (tPA). We sought to analyze all diagnostic steps involved in the acute evaluation and treatment of AIS with IV tPA and to look for causes of delay in door to needle time (DNT). METHODS: A review of AIS patients treated in the emergency department with IV tPA. Times comparing intervals from door to head computed tomography (CT), CT result, electrocardiogram (ECG), chest radiograph, and IV tPA treatment. Non-modifiable delays in treatment were recorded. Data are presented in minutes (min) as medians with interquartile range and logistic regression was used as appropriate. RESULTS: A total of 79 AIS patients, with 22 (28%) receiving IV tPA ≤60 minutes were analyzed. Patients were more likely to get treated with IV tPA in ≤60 minutes if symptom onset was >90 minutes (OR 3.52; 1.03-12.1; P < .05) or if the ECG was done after the head CT (OR 3.67; 1.29-10.5; P < .02). Unavoidable delays related to trauma, intubation, or delayed familial consent occurred in 13 (16%) patients. CONCLUSIONS: An ECG performed before the head CT is completed increased CT time by 6 minutes and a chest radiograph obtained before the head CT increased CT time by 13 minutes. DNT ≤60 minutes for AIS patients are affected by the order of diagnostic studies. In a minority of patients the DNT is affected by non-modifiable issues.

Central versus local adjudication of myocardial infarction in a cardiac biomarker trial.

OBJECTIVES: The impact of regulatory requirements, which require central adjudication for the diagnosis of acute myocardial infarction (AMI) in cardiac biomarker studies, is unclear. We determined the impact of local (at the site of subject enrollment) versus central adjudication of AMI on final diagnosis. METHODS: This is a retrospective analysis of data from the Myeloperoxidase in the Diagnosis of Acute Coronary Syndromes Study, an 18-center prospective study of patients with suspected acute coronary syndromes, with enrollment from December 19, 2006, to September 20, 2007. Local adjudication of AMI was performed by a single site investigator at each center following the protocol-specified definition and according to the year 2000 definition of AMI, which based cardiac troponin (cTn) elevation on local cut points for each of the 13 different assays. After completion of the Myeloperoxidase in the Diagnosis of Acute Coronary Syndromes Study primary analysis and to evaluate a new troponin assay, a Food and Drug Administration-mandated central adjudication was performed by 3 investigators at different institutions. This adjudication used the 2007 Universal Definition of AMI, which differs by use of the manufacturer's 99th percentile cTn cut point. We describe the outcome of this process and compare it with the local adjudication. Central adjudicators were not blinded to local adjudications. For central adjudication, discrepant diagnoses were resolved by consensus. Local versus central cTn cut points differed for 6 assays. Both definitions required a rise and/or fall of cTn. Discrepant cases were reviewed by the lead author. Difficult cases were defined as having a difference between local and central adjudication, an elevated cTn with a temporal rise and fall, and a negative or absent risk stratification test. Statistics were by χ(2), κ, and logistic regression. RESULTS: Of 1,107 patients enrolled, 11 had indeterminate central adjudication, leaving 1,096 for analysis. In spite of high agreement across central versus local adjudicators, κ = 0.79 (95% CI [0.73, 0.85]), AMI was diagnosed more often by central adjudication, 134 (12.2%) versus 104 (9.5%), with 44 local diagnoses (4%) changed from non-AMI to AMI (n = 37) or AMI to non-AMI (n = 7) (P < .001). These 44 represented 34% (95% CI 26%-42%) of 141 cases in which either central or local adjudication was AMI. Of diagnoses changed to AMI, 3 reasons contributed approximately one-third each: the local use of a non-99th percentile cTn cutoff (32%), the possibility of human error (34%), and difficult cases (34%). CONCLUSION: Despite an acceptable κ, over a third of patients with a diagnosis of AMI were not assigned that diagnosis by both sets of adjudicators. This supports the importance of 1 standard method for diagnosis of AMI.

Variables associated with discordance between emergency physician and neurologist diagnoses of transient ischemic attacks in the emergency department.

STUDY OBJECTIVE: Transient ischemic attack is a common clinical diagnosis in emergency department (ED) patients with acute neurologic complaints. Accurate diagnosis of transient ischemic attack is essential to help guide evaluation and avoid treatment delays. We seek to determine the prevalence of discordant diagnosis for patients receiving an ED diagnosis of transient ischemic attack compared with neurologist final diagnosis. Secondary goals are to evaluate the influence of atypical transient ischemic attack symptoms, the ABCD2 score, and emergency physician experience on discordant diagnoses. METHODS: We performed a retrospective cohort study evaluating all ED patients receiving a diagnosis of transient ischemic attack during a 4-year period. The emergency physician diagnosis was compared with that of the neurologist. The neurologist's final diagnosis was considered the criterion standard diagnosis. Subject demographic and clinical information was collected with a structured instrument. The following atypical symptoms present at the ED evaluation were evaluated with logistic regression: headache, tingling, involuntary movement, seeing flashing lights or wavy lines, dizziness, confusion, incontinence, and ABCD2 score of 4 or greater. Bivariate analysis was used to evaluate the influence of emergency physician experience (≤6 years versus >6 years) on discordant diagnosis. Odds ratios (ORs) and proportions are reported with 95% confidence intervals (CIs), interquartile range was used where appropriate. RESULTS: We evaluated 436 subjects, of whom 7 were excluded, allowing 429 subjects for evaluation. Of these individuals, 156 (36%; 95% CI 32% to 41%) received a discordant diagnosis. The median emergency physician time in clinical practice was 6 years (interquartile range 2 to 12 years). Features associated with a discordant transient ischemic attack diagnosis included headache (OR 2.52; 95% CI 1.59 to 3.99), involuntary movement (OR 3.19; 95% CI 1.35 to 7.54), and dizziness (OR 1.92; 95% CI 1.22 to 3.02). Incontinence, confusion, and seeing wavy lines or flashing lights were not significantly associated with a discordant diagnosis. Patients with tingling and a high ABCD2 score had an increased odds of concordant transient ischemic attack diagnosis (OR 0.54, 95% CI 0.32 to 0.92; OR 0.53, 95% CI 0.35 to 0.82, respectively). CONCLUSION: Discordant diagnoses between emergency physicians and neurologists were observed in 36% of patients. The presence of headache, involuntary movement, and dizziness predicted discordant diagnoses, whereas the presence of tingling and an increased ABCD2 score predicted concordant transient ischemic attack diagnosis.

Prevention of posterior wall puncture with a self-made needle block.

Vascular access is one of the most commonly performed invasive procedures in medicine. Ultrasound-guided vascular access has been shown to improve patient safety, decrease associated complications and increase first attempt success rates, however, the risk for a posterior venous wall puncture (PVWP) still exists. To reduce this complication, needle guides have been used, though, current methods have limited accessibility and generalizability. Thus, the aim of this article is to describe how a self-made needle block constructed with materials present in a central line kit can reduce the incidence of PVWP and its associated complications in novice POCUS users.

Ultrasound-guided peripheral intravenous access in chronic kidney disease patients.

OBJECTIVE: Ultrasound-guided peripheral intravenous (USPIV) catheters are being placed in emergency department (ED) patients with increasing frequency. USPIV catheters have been shown to improve the success rates of cannulation. It is unknown what the long-term effect of USPIV placement will be on fistula creation in chronic kidney disease (CKD) patients considering these ultrasound-guided peripheral lines often target the same deeper vessels used for fistulas. This study aimed to survey whether emergency medicine programs place restrictions on USPIV placement in patients with CKD stages 3-5. METHODS: This was a survey study encompassing all 110 emergency ultrasound fellowship directors in the United States at the time the survey was conducted. Data was collected on an anonymous and voluntary basis. The primary outcome was the number of programs with restrictions on USPIV placement in patients with CKD stage 3 or greater. RESULTS: Of the 56 programs that responded, 21% reported having policies limiting which patients were appropriate for USPIV. Despite this, only one program reported placing restrictions on USPIV in CKD stage 3 or greater (p < 0.0001). CONCLUSIONS: Emergency departments do not have or follow restrictions placed on USPIV placement in patients with CKD stage 3 or greater. The use of these veins in the ED may result in thrombosis as well as inflammation and permanent scarring which could negatively impact the ability to utilize those vessels for fistula creation. Future studies are needed to further characterize the impact of USPIV on fistula creation.

Troponin is unrelated to outcomes in heart failure patients discharged from the emergency department.

Background: Prior data has demonstrated increased mortality in hospitalized patients with acute heart failure (AHF) and troponin elevation. No data has specifically examined the prognostic significance of troponin elevation in patients with AHF discharged after emergency department (ED) management. Objective: Evaluate the relationship between troponin elevation and outcomes in patients with AHF who are treated and released from the ED. Methods: This was a secondary analysis of the Get with the Guidelines to Reduce Disparities in AHF Patients Discharged from the ED (GUIDED-HF) trial, a randomized, controlled trial of ED patients with AHF who were discharged. Patients with elevated conventional troponin not due to acute coronary syndrome (ACS) were included. Our primary outcome was a composite endpoint: time to 30-day cardiovascular death and/or heart failure-related events. Results: Of the 491 subjects included in the GUIDED-HF trial, 418 had troponin measured during the ED evaluation and 66 (16%) had troponin values above the 99th percentile. Median age was 63 years (interquartile range, 54-70), 62% (n = 261) were male, 63% (n = 265) were Black, and 16% (n = 67) experienced our primary outcome. There were no differences in our primary outcome between those with and without troponin elevation (12/66, 18.1% vs 55/352, 15.6%; P = 0.60). This effect was maintained regardless of assignment to usual care or the intervention arm. In multivariable regression analysis, there was no association between our primary outcome and elevated troponin (hazard ratio, 1.00; 95% confidence interval,  0.49-2.01, P = 0.994). Conclusion: If confirmed in a larger cohort, these findings may facilitate safe ED discharge for a group of patients with AHF without ACS when an elevated troponin is the primary reason for admission.

Utility of COVID-19 antigen testing in the emergency department.

BACKGROUND: The BinaxNOW coronavirus disease 2019 (COVID-19) Ag Card test (Abbott Diagnostics Scarborough, Inc.) is a lateral flow immunochromatographic point-of-care test for the qualitative detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) nucleocapsid protein antigen. It provides results from nasal swabs in 15 minutes. Our purpose was to determine its sensitivity and specificity for a COVID-19 diagnosis. METHODS: Eligible patients had symptoms of COVID-19 or suspected exposure. After consent, 2 nasal swabs were collected; 1 was tested using the Abbott RealTime SARS-CoV-2 (ie, the gold standard polymerase chain reaction test) and the second run on the BinaxNOW point of care platform by emergency department staff. RESULTS: From July 20 to October 28, 2020, 767 patients were enrolled, of which 735 had evaluable samples. Their mean (SD) age was 46.8 (16.6) years, and 422 (57.4%) were women. A total of 623 (84.8%) patients had COVID-19 symptoms, most commonly shortness of breath (n = 404; 55.0%), cough (n = 314; 42.7%), and fever (n = 253; 34.4%). Although 460 (62.6%) had symptoms ≤7 days, the mean (SD) time since symptom onset was 8.1 (14.0) days. Positive tests occurred in 173 (23.5%) and 141 (19.2%) with the gold standard versus BinaxNOW test, respectively. Those with symptoms >2 weeks had a positive test rate roughly half of those with earlier presentations. In patients with symptoms ≤7 days, the sensitivity, specificity, and negative and positive predictive values for the BinaxNOW test were 84.6%, 98.5%, 94.9%, and 95.2%, respectively. CONCLUSIONS: The BinaxNOW point-of-care test has good sensitivity and excellent specificity for the detection of COVID-19. We recommend using the BinasNOW for patients with symptoms up to 2 weeks.

CLUE: a randomized comparative effectiveness trial of IV nicardipine versus labetalol use in the emergency department.

INTRODUCTION: Our purpose was to compare the safety and efficacy of food and drug administration (FDA) recommended dosing of IV nicardipine versus IV labetalol for the management of acute hypertension. METHODS: Multicenter randomized clinical trial. Eligible patients had 2 systolic blood pressure (SBP) measures ≥180 mmHg and no contraindications to nicardipine or labetalol. Before randomization, the physician specified a target SBP ± 20 mmHg (the target range: TR). The primary endpoint was the percent of subjects meeting TR during the initial 30 minutes of treatment. RESULTS: Of 226 randomized patients, 110 received nicardipine and 116 labetalol. End organ damage preceded treatment in 143 (63.3%); 71 nicardipine and 72 labetalol patients. Median initial SBP was 212.5 (IQR 197, 230) and 212 mmHg (IQR 200,225) for nicardipine and labetalol patients (P = 0.68), respectively. Within 30 minutes, nicardipine patients more often reached TR than labetalol (91.7 vs. 82.5%, P = 0.039). Of 6 BP measures (taken every 5 minutes) during the study period, nicardipine patients had higher rates of five and six instances within TR than labetalol (47.3% vs. 32.8%, P = 0.026). Rescue medication need did not differ between nicardipine and labetalol (15.5 vs. 22.4%, P = 0.183). Labetalol patients had slower heart rates at all time points (P < 0.01). Multivariable modeling showed nicardipine patients were more likely in TR than labetalol patients at 30 minutes (OR 2.73, P = 0.028; C stat for model = 0.72) CONCLUSIONS: Patients treated with nicardipine are more likely to reach the physician-specified SBP target range within 30 minutes than those treated with labetalol.

Auscultation of Bowel Sounds and Ultrasound of Peristalsis Are Neither Compartmentalized Nor Correlated.

Objective  Auscultation of bowel sounds has been taught as a component of the physical examination since the beginning of the 20th century. However, there has been little research or consensus on the significance of listening in different quadrants. Some textbooks indicate that bowel sounds are the result of peristalsis in that region, while others state that bowel sounds can be generalized over the entire abdominal wall. With ultrasonography, peristalsis can be visualized in a dynamic and non-invasive manner. The purpose of this study was to determine the relationship between auscultation of bowel sounds and visualization of peristalsis with ultrasound, to understand whether or not bowel sounds and peristalsis are compartmentalized. Methods  Study participants quietly lay supine, while one investigator positioned an ultrasound probe on the abdomen visualizing the small intestine, and a second investigator placed an EKO Digital Stethoscope (Eko Devices, Inc., Oakland, CA) directly adjacent to the probe auscultate for bowel sounds. During a two-minute interval, a third investigator noted every time a bowel sound was heard (A+), peristalsis was seen (U+), or a combined event (C+) occurred, recording the total number of events. Measurements were recorded from four quadrants (right upper quadrant {RUQ}, left upper quadrant {LUQ}, right lower quadrant {RLQ}, left lower quadrant {LLQ}) and the periumbilical region (PUR). Fisher Exact test was used to determine whether there were significant differences between the number of bowel sounds heard but not seen (A+) and those seen but not heard (U+) with sounds that were both seen and heard (C+). Significance was determined with p < 0.05. Results  A total of 16 participants were included, with a combined 973 discrete bowel events, both auscultated and visualized. No quadrant showed a significant correlation between an isolated sound (A+) or peristalsis (U+) and a combined event (C+), indicating there were many events where an auscultated sound failed to correlate with observed peristalsis, and vice versa. The average p-value was 0.544, with a range of 0.052-1.00. Conclusion  This study showed that there is no significant correlation between auscultated bowel sounds and peristalsis within a given region. This study calls into question whether auscultation of all four quadrants provides more meaningful information than auscultation of one central point of the abdomen.

Innovations with tele-ultrasound in education sonography: the use of tele-ultrasound to train novice scanners.

OBJECTIVES: Point-of-care ultrasound (POCUS) has become increasingly integrated into medical education given the growing role of evaluative and procedural techniques in practice today. Tele-ultrasound is a new and promising venture that aims to expand medical knowledge and education to previously unreached or underserved areas. This study aimed to determine the non-inferiority of teaching ultrasound remotely using tele-ultrasound via the Philips Lumify (Philips Medical Systems, Bothell, WA) system, which utilizes video conferencing technology and real-time imaging that can be viewed by the operator and educator simultaneously. METHODS: Three commonly used ultrasound exams were taught and evaluated in 56 ultrasound-naive medical participants: Focused Assessment with Sonography in Trauma (FAST), Lower Extremity Deep Venous Thrombosis (LEDVT) screening, and ultrasound-guided vascular access. The participants were randomized into either in-person traditional learning or tele-ultrasound learning with the Philips Lumify (Philips Medical Systems, Bothell, WA) units. The primary outcome of interest was the ability to perform certain tasks for each exam RESULTS: Competency on each exam was tested across all exams and no inferiority was found between in-person and remote learning (p < 0.05). CONCLUSIONS: Our findings support the use of tele-ultrasound in beginner ultrasound education.

Improvement in Kansas City Cardiomyopathy Questionnaire Scores After a Self-Care Intervention in Patients With Acute Heart Failure Discharged From the Emergency Department.

BACKGROUND: We conducted a secondary analysis of changes in the Kansas City Cardiomyopathy Questionnaire (KCCQ)-12 over 30 days in a randomized trial of self-care coaching versus structured usual care in patients with acute heart failure who were discharged from the emergency department. METHODS: Patients in 15 emergency departments completed the KCCQ-12 at emergency department discharge and at 30 days. We compared change in KCCQ-12 scores between the intervention and usual care arms, adjusted for enrollment KCCQ-12 and demographic characteristics. We used linear regression to describe changes in KCCQ-12 summary scores and logistic regression to characterize clinically meaningful KCCQ-12 subdomain changes at 30 days. RESULTS: There were 350 patients with both enrollment and 30-day KCCQ summary scores available; 166 allocated to usual care and 184 to the intervention arm. Median age was 64 years (interquartile range, 55-70), 37% were female participants, 63% were Black, median KCCQ-12 summary score at enrollment was 47 (interquartile range, 33-64). Self-care coaching resulted in significantly greater improvement in health status compared with structured usual care (5.4-point greater improvement, 95% CI, 1.12-9.68; P=0.01). Improvements in health status in the intervention arm were driven by improvements within the symptom frequency (adjusted odds ratio, 1.62 [95% CI, 1.01-2.59]) and quality of life (adjusted odds ratio, 2.39 [95% CI, 1.46-3.90]) subdomains. CONCLUSIONS: In this secondary analysis, patients with acute heart failure who received a tailored, self-care intervention after emergency department discharge had clinically significant improvements in health status at 30 days compared with structured usual care largely due to improvements within the symptom frequency and quality of life subdomains of the KCCQ-12. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02519283.

The effect of an observation unit on the rate of ED admission and discharge for pyelonephritis.

OBJECTIVES: We sought to determine if the opening of an adult emergency department (ED) observation unit (OU) would impact the rate of hospital admission and ED discharges for pyelonephritis. METHODS: A retrospective cohort study was performed with all adult patients from October 2003 through December 2006 in the ED meeting inclusion criteria for pyelonephritis. Clinical, demographic, and laboratory data were recorded. Primary outcomes were rates of admission, ED discharge, and return ED visits before and after the opening of our OU. We compared admission, discharge, and readmission rates using the chi(2) test. RESULTS: Nine hundred thirty charts were reviewed with 633 included for analysis. Urine cultures were performed on 420 subjects with 71% being positive. The percentage of patients admitted to a hospital inpatient unit from the ED decreased from 36% to 26% (relative risk [RR], 0.73; P = .01) after opening the OU. The percentage of patients discharged home from the ED decreased from 65% to 51% (RR, 0.76; P < .001). Among OU patients, 29% were admitted to the hospital for further inpatient care. Emergency department recidivism was unchanged by opening the OU (RR, 0.86; P = .68). CONCLUSIONS: The creation of an OU appears to influence admission decisions of ED physicians. We found that the creation of an OU significantly reduced hospital admissions for pyelonephritis but also significantly reduced ED discharges to home for pyelonephritis at our institution.

Myocardial Infarction Can Be Safely Excluded by High-sensitivity Troponin I Testing 3 Hours After Emergency Department Presentation.

BACKGROUND: The accuracy and speed by which acute myocardial infarction (AMI) is excluded are an important determinant of emergency department (ED) length of stay and resource utilization. While high-sensitivity troponin I (hsTnI) >99th percentile (upper reference level [URL]) represents a "rule-in" cutpoint, our purpose was to evaluate the ability of the Beckman Coulter hsTnI assay, using various level-of-quantification (LoQ) cutpoints, to rule out AMI within 3 hours of ED presentation in suspected acute coronary syndrome (ACS) patients. METHODS: This multicenter evaluation enrolled adults with >5 minutes of ACS symptoms and an electrocardiogram obtained per standard care. Exclusions were ST-segment elevation or chronic hemodialysis. After informed consent was obtained, blood samples were collected in heparin at ED admission (baseline), ≥1 to 3, ≥3 to 6, and ≥6 to 9 hours postadmission. Samples were processed and stored at -20°C within 1 hour and were tested at three independent clinical laboratories on an immunoassay system (DxI 800, Beckman Coulter). Analytic cutpoints were the URL of 17.9 ng/L and two LoQ cutpoints, defined as the 10 and 20% coefficient of variation (5.6 and 2.3 ng/L, respectively). A criterion standard MI diagnosis was adjudicated by an independent endpoint committee, blinded to hsTnI, and using the universal definition of MI. RESULTS: Of 1,049 patients meeting the entry criteria, and with baseline and 1- to 3-hour hsTnI results, 117 (11.2%) had an adjudicated final diagnosis of AMI. AMI patients were typically older, with more cardiovascular risk factors. Median (IQR) presentation time was 4 (1.6-16.0) hours after symptom onset, although AMI patients presented ~0.5 hour earlier than non-AMI. Enrollment and first blood draw occurred at a mean of ~1 hour after arrival. To evaluate the assay's rule-out performance, patients with any hsTnI > URL were considered high risk and were excluded. The remaining population (n = 829) was divided into four LoQ relative categories: both hsTnI < LoQ (Lo-Lo cohort); first hsTnI < LoQ and 2nd > LoQ (Lo-Hi cohort); first > LoQ and second < LoQ (Hi-Lo cohort); or both > LoQ (Hi-Hi cohort). In patients with any hsTnI result <20% CV LoQ (Groups 1-3), n = 231 (23.9% ruled out), AMI negative predictive value (NPV) was 100% (95% confidence interval [CI] = 98.9% to 100%). In patients with any hsTnI below the 10% LoQ, n = 611 (58% rule out), AMI NPV was 100% (95% CI = 99.5% to 100%). Of the Hi-Hi cohort (i.e., no hsTnI below the 10% LoQ, but both < URL), there were four AMI patients, NPV was 98.2% (95% CI = 95.4% to 99.3%), and sensitivity was 96.6. CONCLUSIONS: Patients presenting >3 hours after the onset of suspected ACS symptoms, with at least two Beckman Coulter Access hsTnI < URL and at least one of which is below either the 10 or the 20% LoQ, had a 100% NPV for AMI. Two hsTnI values 1 to 3 hours apart with both < URL, but also >LoQ had inadequate sensitivity and NPV.

Can the ABCD2 risk score predict positive diagnostic testing for emergency department patients admitted for transient ischemic attack?

BACKGROUND AND PURPOSE: We sought to determine if the ABCD2 score, typically used for risk stratification, could predict having a positive diagnostic test in patients evaluated acutely for transient ischemic attack. METHODS: We performed a retrospective cohort study for patients admitted from our emergency department with a new diagnosis of transient ischemic attack confirmed by a neurologist. ABCD2 scores were calculated and patients with a score of > or = 4 were placed in the high-risk cohort. Tests evaluated included electrocardiogram, CT, MRI, MR angiography, carotid ultrasonography, and echocardiography. Specific test findings considered to signify positive diagnostic tests were created a priori. RESULTS: We identified 256 patients with transient ischemic attack for inclusion; 167 (61%) were female, the median age was 60 years (interquartile range, 50 to 72), and 162 (63%) patients had an ABCD2 score of > or = 4. Rates of completion of diagnostic testing were electrocardiogram, 270 (100%); CT, 224 (88%); MRI, 89 (35%); MR angiography, 68 (27%); carotid ultrasonography, 125 (49%); and echocardiography, 135 (53%). Univariate analysis found a significant association only with elevated ABCD2 score and carotid duplex testing (P<0.05). CONCLUSION: An elevated ABCD2 score may help predict patients with severe carotid occlusive disease but does not predict positive outcome in other commonly ordered tests for patients being evaluated for transient ischemic attack. An elevated ABCD2 score cannot be recommended as a tool to guide diagnostic testing in patients presenting acutely with transient ischemic attack.

Observation unit management of acute decompensated heart failure.

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