Risk Stratification of Older Adults Who Present to the Emergency Department With Syncope: The FAINT Score.

STUDY OBJECTIVE: Older adults with syncope are commonly treated in the emergency department (ED). We seek to derive a novel risk-stratification tool to predict 30-day serious cardiac outcomes. METHODS: We performed a prospective, observational study of older adults (≥60 years) with unexplained syncope or near syncope who presented to 11 EDs in the United States. Patients with a serious diagnosis identified in the ED were excluded. We collected clinical and laboratory data on all patients. Our primary outcome was 30-day all-cause mortality or serious cardiac outcome. RESULTS: We enrolled 3,177 older adults with unexplained syncope or near syncope between April 2013 and September 2016. Mean age was 73 years (SD 9.0 years). The incidence of the primary outcome was 5.7% (95% confidence interval [CI] 4.9% to 6.5%). Using Bayesian logistic regression, we derived the FAINT score: history of heart failure, history of cardiac arrhythmia, initial abnormal ECG result, elevated pro B-type natriuretic peptide, and elevated high-sensitivity troponin T. A FAINT score of 0 versus greater than or equal to 1 had sensitivity of 96.7% (95% CI 92.9% to 98.8%) and specificity 22.2% (95% CI 20.7% to 23.8%), respectively. The FAINT score tended to be more accurate than unstructured physician judgment: area under the curve 0.704 (95% CI 0.669 to 0.739) versus 0.630 (95% CI 0.589 to 0.670). CONCLUSION: Among older adults with syncope or near syncope of potential cardiac cause, a FAINT score of zero had a reasonably high sensitivity for excluding death and serious cardiac outcomes at 30 days. If externally validated, this tool could improve resource use for this common condition.

The Accuracy of Interqual Criteria in Determining the Observation versus Inpatient Status in Older Adults with Syncope.

BACKGROUND: McKesson's InterQual criteria are widely used in hospitals to determine if patients should be classified as observation or inpatient status, but the accuracy of the criteria is unknown. OBJECTIVE: We sought to determine whether InterQual criteria accurately predicted length of stay (LOS) in older patients with syncope. METHODS: We conducted a secondary analysis of a cohort study of adults ≥60 years of age who had syncope. We calculated InterQual criteria and classified the patient as observation or inpatient status. Outcomes were whether LOS were less than or greater than 2 midnights. RESULTS: We analyzed 2361 patients; 1227 (52.0%) patients were male and 1945 (82.8%) were white, with a mean age of 73.2 ± 9.0 years. The median LOS was 32.6 h (interquartile range 24.2-71.8). The sensitivity of InterQual criteria for LOS was 60.8% (95% confidence interval 57.9-63.6%) and the specificity was 47.8% (95% confidence interval 45.0-50.5%). CONCLUSIONS: In older adults with syncope, those who met InterQual criteria for inpatient status had longer LOS compared with those who did not; however, the accuracy of the criteria to predict length of stay over 2 days is poor, with a sensitivity of 60% and a specificity of 48%. Future research should identify criteria to improve LOS prediction.

Clinical Benefit of Hospitalization for Older Adults With Unexplained Syncope: A Propensity-Matched Analysis.

STUDY OBJECTIVE: Many adults with syncope are hospitalized solely for observation and testing. We seek to determine whether hospitalization versus outpatient management for older adults with unexplained syncope is associated with a reduction in postdisposition serious adverse events at 30 days. METHODS: We performed a propensity score analysis using data from a prospective, observational study of older adults with unexplained syncope or near syncope who presented to 11 emergency departments (EDs) in the United States. We enrolled adults (≥60 years) who presented with syncope or near syncope. We excluded patients with a serious diagnosis identified in the ED. Clinical and laboratory data were collected on all patients. The primary outcome was rate of post-ED serious adverse events at 30 days. RESULTS: We enrolled 2,492 older adults with syncope and no serious ED diagnosis from April 2013 to September 2016. Mean age was 73 years (SD 8.9 years), and 51% were women. The incidence of serious adverse events within 30 days after the index visit was 7.4% for hospitalized patients and 3.19% for discharged patients, representing an unadjusted difference of 4.2% (95% confidence interval 2.38% to 6.02%). After propensity score matching on risk of hospitalization, there was no statistically significant difference in serious adverse events at 30 days between the hospitalized group (4.89%) and the discharged group (2.82%) (risk difference 2.07%; 95% confidence interval -0.24% to 4.38%). CONCLUSION: In our propensity-matched sample of older adults with unexplained syncope, for those with clinical characteristics similar to that of the discharged cohort, hospitalization was not associated with improvement in 30-day serious adverse event rates.

Comparison of 30-Day Serious Adverse Clinical Events for Elderly Patients Presenting to the Emergency Department With Near-Syncope Versus Syncope.

STUDY OBJECTIVE: Controversy remains in regard to the risk of adverse events for patients presenting with syncope compared with near-syncope. The purpose of our study is to describe the difference in outcomes between these groups in a large multicenter cohort of older emergency department (ED) patients. METHODS: From April 28, 2013, to September 21, 2016, we conducted a prospective, observational study across 11 EDs in adults (≥60 years) with syncope or near-syncope. A standardized data extraction tool was used to collect information during their index visit and at 30-day follow-up. Our primary outcome was the incidence of 30-day death or serious clinical events. Data were analyzed with descriptive statistics and multivariate logistic regression analysis adjusting for relevant demographic or historical variables. RESULTS: A total of 3,581 patients (mean age 72.8 years; 51.6% men) were enrolled in the study. There were 1,380 patients (39%) presenting with near-syncope and 2,201 (61%) presenting with syncope. Baseline characteristics revealed a greater incidence of congestive heart failure, coronary artery disease, previous arrhythmia, nonwhite race, and presenting dyspnea in the near-syncope compared with syncope cohort. There were no differences in the primary outcome between the groups (near-syncope 18.7% versus syncope 18.2%). A multivariate logistic regression analysis identified no difference in 30-day serious outcomes for patients with near-syncope (odds ratio 0.94; 95% confidence interval 0.78 to 1.14) compared with syncope. CONCLUSION: Near-syncope confers risk to patients similar to that of syncope for the composite outcome of 30-day death or serious clinical event.

QTc prolongation as a marker of 30-day serious outcomes in older patients with syncope presenting to the Emergency Department.

BACKGROUND: Syncope is a common chief complaint in the ED, and the electrocardiogram (ECG) is a routine diagnostic tool in the evaluation of syncope. We assessed whether increasingly prolonged QTc intervals are associated with composite 30-day serious outcomes in older adults presenting to the ED with syncope. METHODS: This is a secondary analysis of a prospective, observational study at 11 EDs in adults 60 years or older who presented with syncope or near syncope. We excluded patients presenting without an ECG, measurement of QTc, non-sinus rhythm, bundle branch block or those without 30-day follow-up. We categorized QTc cutoffs into values of <451; 451-470; 471-500, and >500 ms. We determined the rate of composite 30-day serious outcomes including ED serious outcomes and 30-day arrhythmias not identified in ED. RESULTS: The study cohort included 2609 patients. There were 1678 patients (64.3%) that had QTc intervals <451 ms; 544 (20.8%) were 451-470 ms; 302 (11.6%) were 471-500 ms, and 85 (3.3%) had intervals >500 ms. Composite 30-day serious outcomes was associated with increasingly prolonged QTc intervals (13.0%, 15.3%, 18.2%, 22.4%, p = 0.01), but this association did not persist in multivariate analysis. CONCLUSIONS: In a cohort of older patients presenting with syncope, increased QTc interval was a marker of but was not independently predictive of composite 30-day serious outcomes.

Recurrent syncope is not an independent risk predictor for future syncopal events or adverse outcomes.

Almost 20% of patients with syncope will experience another event. It is unknown whether recurrent syncope is a marker for a higher or lower risk etiology of syncope. The goal of this study is to determine whether older adults with recurrent syncope have a higher likelihood of 30-day serious clinical events than patients experiencing their first episode. METHODS: This study is a pre-specified secondary analysis of a multicenter prospective, observational study conducted at 11 emergency departments in the US. Adults 60 years or older who presented with syncope or near syncope were enrolled. The primary outcome was occurrence of 30-day serious outcome. The secondary outcome was 30-day serious cardiac arrhythmia. In multivariate analysis, we assessed whether prior syncope was an independent predictor of 30-day serious events. RESULTS: The study cohort included 3580 patients: 1281 (35.8%) had prior syncope and 2299 (64.2%) were presenting with first episode of syncope. 498 (13.9%) patients had 1 prior episode while 771 (21.5%) had >1 prior episode. Those with recurrent syncope were more likely to have congestive heart failure, coronary artery disease, previous diagnosis of arrhythmia, and an abnormal ECG. Overall, 657 (18.4%) of the cohort had a serious outcome by 30 days after index ED visit. In multivariate analysis, we found no significant difference in risk of events (adjusted odds ratio 1.09; 95% confidence interval 0.90-1.31; p = 0.387). CONCLUSION: In older adults with syncope, a prior history of syncope within the year does not increase the risk for serious 30-day events.

Orthostatic vital signs do not predict 30 day serious outcomes in older emergency department patients with syncope: A multicenter observational study.

BACKGROUND: Syncope is a common chief complaint among older adults in the Emergency Department (ED), and orthostatic vital signs are often a part of their evaluation. We assessed whether abnormal orthostatic vital signs in the ED are associated with composite 30-day serious outcomes in older adults presenting with syncope. METHODS: We performed a secondary analysis of a prospective, observational study at 11 EDs in adults ≥ 60 years who presented with syncope or near syncope. We excluded patients lost to follow up. We used the standard definition of abnormal orthostatic vital signs or subjective symptoms of lightheadedness upon standing to define orthostasis. We determined the rate of composite 30-day serious outcomes, including those during the index ED visit, such as cardiac arrhythmias, myocardial infarction, cardiac intervention, new diagnosis of structural heart disease, stroke, pulmonary embolism, aortic dissection, subarachnoid hemorrhage, cardiopulmonary resuscitation, hemorrhage/anemia requiring transfusion, with major traumatic injury from fall, recurrent syncope, and death) between the groups with normal and abnormal orthostatic vital signs. RESULTS: The study cohort included 1974 patients, of whom 51.2% were male and 725 patients (37.7%) had abnormal orthostatic vital signs. Comparing those with abnormal to those with normal orthostatic vital signs, we did not find a difference in composite 30-serious outcomes (111/725 (15.3%) vs 184/1249 (14.7%); unadjusted odds ratio, 1.05 [95%CI, 0.81-1.35], p = 0.73). After adjustment for gender, coronary artery disease, congestive heart failure (CHF), history of arrhythmia, dyspnea, hypotension, any abnormal ECG, physician risk assessment, medication classes and disposition, there was no association with composite 30-serious outcomes (adjusted odds ratio, 0.82 [95%CI, 0.62-1.09], p = 0.18). CONCLUSIONS: In a cohort of older adult patients presenting with syncope who were able to have orthostatic vital signs evaluated, abnormal orthostatic vital signs did not independently predict composite 30-day serious outcomes.

ECG Predictors of Cardiac Arrhythmias in Older Adults With Syncope.

STUDY OBJECTIVE: Cardiac arrhythmia is a life-threatening condition in older adults who present to the emergency department (ED) with syncope. Previous work suggests the initial ED ECG can predict arrhythmia risk; however, specific ECG predictors have been variably specified. Our objective is to identify specific ECG abnormalities predictive of 30-day serious cardiac arrhythmias in older adults presenting to the ED with syncope. METHODS: We conducted a prospective, observational study at 11 EDs in adults aged 60 years or older who presented with syncope or near syncope. We excluded patients with a serious cardiac arrhythmia diagnosed during the ED evaluation from the primary analysis. The outcome was occurrence of 30-day serous cardiac arrhythmia. The exposure variables were predefined ECG abnormalities. Independent predictors were identified through multivariate logistic regression. The sensitivities and specificities of any predefined ECG abnormality and any ECG abnormality identified on adjusted analysis to predict 30-day serious cardiac arrhythmia were also calculated. RESULTS: After exclusion of 197 patients (5.5%; 95% confidence interval [CI] 4.7% to 6.2%) with serious cardiac arrhythmias in the ED, the study cohort included 3,416 patients. Of these, 104 patients (3.0%; 95% CI 2.5% to 3.7%) had a serious cardiac arrhythmia within 30 days from the index ED visit (median time to diagnosis 2 days [interquartile range 1 to 5 days]). The presence of nonsinus rhythm, multiple premature ventricular conductions, short PR interval, first-degree atrioventricular block, complete left bundle branch block, and Q wave/T wave/ST-segment abnormalities consistent with acute or chronic ischemia on the initial ED ECG increased the risk for a 30-day serious cardiac arrhythmia. This combination of ECG abnormalities had a similar sensitivity in predicting 30-day serious cardiac arrhythmia compared with any ECG abnormality (76.9% [95% CI 67.6% to 84.6%] versus 77.9% [95% CI 68.7% to 85.4%]) and was more specific (55.1% [95% CI 53.4% to 56.8%] versus 46.6% [95% CI 44.9% to 48.3%]). CONCLUSION: In older ED adults with syncope, approximately 3% receive a diagnosis of a serious cardiac arrhythmia not recognized on initial ED evaluation. The presence of specific abnormalities on the initial ED ECG increased the risk for 30-day serious cardiac arrhythmias.

Emergency department use and barriers to wellness: a survey of emergency department frequent users.

BACKGROUND: There is no common understanding of how needs of emergency department (ED) frequent users differ from other patients. This study sought to examine how to best serve this population. Examinations of why ED frequent users present to the ED, what barriers to care exist, and what service offerings may help these patients achieve an optimal level of health were conducted. METHODS: We performed a prospective study of frequent ED users in an adult only, level 1 trauma center with approximately 90,000 visits per year. Frequent ED users were defined as those who make four or more ED visits in a 12 month period. Participants were administered a piloted structured interview by a trained researcher querying demographics, ED usage, perceived barriers to care, and potential aids to maintaining health. RESULTS: Of 1,523 screened patients, 297 were identified as frequent ED users. One hundred frequent ED users were enrolled. The mean age was 48 years (95% CI 45-51). The majority of subjects were female (64%, 64/100, 95% CI 55-73%), white (61%, 60/98, 95% CI 52-71%) and insured by Medicaid (55%, 47/86, 95% CI 44-65%) or Medicare (23%, 20/86, 95% CI 14-32%). Subjects had a median of 6 ED visits, and 2 inpatient admissions in the past 12 months at this hospital. Most frequent ED users (61%, 59/96, 95% CI 52-71%) stated the primary reason for their visit was that they felt that their health problem could only be treated in an ED. Transportation presented as a major barrier to few patients (7%, 7/95, 95% CI 3-14%). Subjects stated that "after-hours options, besides the ED for minor health issues" (63%, 60/95, 95% CI 53-73%) and having "a nurse to work with you one-on-one to help manage health care needs" (53%, 50/95, 95% CI 43-63%) would be most helpful in achieving optimal health. CONCLUSION: This study characterized ED frequent users and identified several opportunities to better serve this population. By understanding barriers to care from the patient perspective, health systems can potentially address unmet needs that prevent wellness in this population.

Validation of cell-cycle arrest biomarkers for acute kidney injury using clinical adjudication.

RATIONALE: We recently reported two novel biomarkers for acute kidney injury (AKI), tissue inhibitor of metalloproteinases (TIMP)-2 and insulin-like growth factor binding protein 7 (IGFBP7), both related to G1 cell cycle arrest. OBJECTIVES: We now validate a clinical test for urinary [TIMP-2]·[IGFBP7] at a high-sensitivity cutoff greater than 0.3 for AKI risk stratification in a diverse population of critically ill patients. METHODS: We conducted a prospective multicenter study of 420 critically ill patients. The primary analysis was the ability of urinary [TIMP-2]·[IGFBP7] to predict moderate to severe AKI within 12 hours. AKI was adjudicated by a committee of three independent expert nephrologists who were masked to the results of the test. MEASUREMENTS AND MAIN RESULTS: Urinary TIMP-2 and IGFBP7 were measured using a clinical immunoassay platform. The primary endpoint was reached in 17% of patients. For a single urinary [TIMP-2]·[IGFBP7] test, sensitivity at the prespecified high-sensitivity cutoff of 0.3 (ng/ml)(2)/1,000 was 92% (95% confidence interval [CI], 85-98%) with a negative likelihood ratio of 0.18 (95% CI, 0.06-0.33). Critically ill patients with urinary [TIMP-2]·[IGFBP7] greater than 0.3 had seven times the risk for AKI (95% CI, 4-22) compared with critically ill patients with a test result below 0.3. In a multivariate model including clinical information, urinary [TIMP-2]·[IGFBP7] remained statistically significant and a strong predictor of AKI (area under the curve, 0.70, 95% CI, 0.63-0.76 for clinical variables alone, vs. area under the curve, 0.86, 95% CI, 0.80-0.90 for clinical variables plus [TIMP-2]·[IGFBP7]). CONCLUSIONS: Urinary [TIMP-2]·[IGFBP7] greater than 0.3 (ng/ml)(2)/1,000 identifies patients at risk for imminent AKI. Clinical trial registered with www.clinicaltrials.gov (NCT 01573962).

Hallway Patients Reduce Overall Emergency Department Satisfaction.

BACKGROUND: Patient satisfaction impacts emergency medicine in multiple ways, including patient-physician rapport, patient compliance with medical recommendations, and individual physician and hospital reimbursement issues. OBJECTIVE: The objective of this study was to assess the differences, if any, in satisfaction scores among patients treated in regular treatment rooms vs. those treated in hallway treatment areas. METHODS: A cross-sectional survey study of conveniently sampled participants from both regular treatment rooms and hallway treatment areas in an urban, adult community teaching emergency department (ED) was performed confidentially, measuring overall satisfaction, as well as satisfaction with regard to treatment location only, medical care only, and their willingness to return to or recommend the ED in the future based on their experience. Each of these four outcomes was measured on a 100-mm visual analog scale. RESULTS: Overall satisfaction scores were 8 mm lower for those patients treated in hallway treatment areas, and there was a 20-mm difference with regard to location only. After controlling for apparent baseline differences between the groups, a 7.6-mm difference for overall satisfaction remained. CONCLUSIONS: Despite differences between patients placed in regular treatment rooms vs. hallway treatment areas, overall satisfaction levels are lower for those patients treated in hallway treatment areas. This difference is likely attributable primarily to their hallway location, and stakeholders should therefore take appropriate steps to address such discrepancies.

Weakness and fatigue in older ED patients in the United States.

BACKGROUND: The objectives of this study are to estimate the prevalence of weakness and fatigue visits in older emergency department (ED) patients, to compare demographics and resource use in these patients with those without these complaints, and to determine their ED diagnoses and disposition. METHODS: We performed a cross-sectional cohort analysis of ED visits in patients aged older than 65 years from the 2003 to 2007 National Hospital Ambulatory Medical Care Surveys. Weakness and fatigue visits had a reason for visit code of generalized weakness (1020.0) or tiredness and exhaustion (1015.0); the comparison cohort lacked these codes. Descriptive data are presented as totals, means, and proportions with 95% confidence intervals (CIs). Comparisons between cohorts used χ(2) for proportions and the adjusted Wald test for means. RESULTS: There were an estimated 575 million ED visits, those aged 65 years and older made 14.7% (95% CI, 14.2-15.3) of visits. Overall, 6.0% (95% CI, 5.6-6.4) of these visits had weakness and fatigue; this was the fifth most common primary reason for visit. Weakness and fatigue visits increased with age. Weakness and fatigue visits had longer ED lengths of stay (300 vs 249 minutes, P < .001), more diagnostic tests (7.7 vs 5.0, P < .001), procedures (5.7 vs 4.7, P < .001), and hospital admissions (55% vs 35%, P < .001). The most common primary diagnoses for the weakness and fatigue cohort were "other malaise and fatigue," pneumonia, and urinary tract infection. CONCLUSION: Weakness and fatigue are common in older ED patients. These patients undergo more tests and procedures, and most are admitted.

Prehospital electrocardiographic computer identification of ST-segment elevation myocardial infarction.

BACKGROUND: Identifying ST-segment elevation myocardial infarctions (STEMIs) in the field can decrease door-to-balloon times. Paramedics may use a computer algorithm to help them interpret prehospital electrocariograms (ECGs). It is unknown how accurately the computer can identify STEMIs. OBJECTIVES: To Determine the sensitivity and specificity of prehospital ECGs in identifying patients with STEMI. METHODS: Retrospective cross-sectional study of 200 prehospital ECGs acquired using Lifepak 12 monitors and transmitted by one of more than 20 emergency medical services (EMS) agencies to the emergency department (ED) of a Summa Akron City Hospital, a level 1 trauma center between January 1, 2007, and February 18, 2010. The ED sees more than 73,000 adult patients and treats 120 STEMIs annually. The laboratory performs 3,400 catheterizations annually. The first 100 patients with a diagnosis of STEMI and cardiac catheterization laboratory activation from the ED were analyzed. For comparison, a control group of 100 other ECGs from patients without a STEMI were randomly selected from our Medtronic database using a random-number generator. For patients with STEMI, an accurate computer interpretation was "acute MI suspected." Other interpretations were counted as misses. Specificity and sensitivity were calculated with confidence intervals (CIs). The sample size was determined a priori for a 95% CI of ±10%. RESULTS: Zero control patients were incorrectly labeled "acute MI suspected." The specificity was 100% (100/100; 95% CI 0.96-1.0), whereas the sensitivity was 58% (58/100; 95% CI 0.48-0.67). This would have resulted in 42 missed cardiac catheterization laboratory activations, but zero inappropriate activations. The most common incorrect interpretation of STEMI ECGs by the computer was "data quality prohibits interpretation," followed by "abnormal ECG unconfirmed." CONCLUSIONS: Prehospital computer interpretation is not sensitive for STEMI identification and should not be used as a single method for prehospital activation of the cardiac catheterizing laboratory. Because of its high specificity, it may serve as an adjunct to interpretation.

Paramedic ability to recognize ST-segment elevation myocardial infarction on prehospital electrocardiograms.

BACKGROUND: Identifying ST-segment elevation myocardial infarctions (STEMIs) by paramedics can decrease door-to-balloon times. While many paramedics are trained to obtain and interpret electrocardiograms (ECGs), it is unknown how accurately they can identify STEMIs. OBJECTIVE: This study evaluated paramedics' accuracy in recognizing STEMI on ECGs when faced with potential STEMI mimics. METHODS: This was a descriptive cohort study using a survey administered to paramedics. The survey contained questions about training, experience, and confidence, along with 10 ECGs: three demonstrating STEMIs (inferior, anterior, and lateral), two with normal results, and five STEMI mimics (left ventricular hypertrophy [LVH], ventricular pacing, left and right bundle branch blocks [LBBB, RBBB], and supraventricular tachycardia [SVT]). We calculated the overall sensitivity and specificity and the proportion correct with 95% confidence intervals (CIs). RESULTS: We obtained 472 surveys from 30 municipal emergency medical services (EMS) agencies in five counties with 15 medical directors from seven hospitals. The majority (69%) reported ECG training within the preceding year, 31% within six months; and 74% were confident in recognizing STEMIs. The overall sensitivity and specificity for STEMI detection were 75% and 53% (95% CI 73%-77%, 51%-55%), respectively. Ninety-six percent (453/472, 95% CI 94%-98%) correctly identified the inferior myocardial infarction (MI), but only 78% (368/472, 94% CI 74%-82%) identified the anterior MI and 51% (241/472, 46%-56%) the lateral MI. Thirty-seven percent (173/472, 95% CI 32%-41%) of the paramedics correctly recognized LVH, 39% (184/472, 95% CI 35%-44%) LBBB, and 53% (249/472, 95% CI 48%-57%) ventricular pacing as not a STEMI. Thirty-nine percent (185/472, 95% CI 35%-44%) correctly identified all three STEMIs; however, only 3% of the paramedics were correct in all interpretations. The two normal ECGs were recognized as not a STEMI by 97% (459/472, 95% CI 95%-99%) and 100% (472/472, 95% CI 99%-100%). There was no correlation between training, experience, or confidence and accuracy in recognizing STEMIs. CONCLUSIONS: Despite training and a high level of confidence, the paramedics in our study were only able to identify an inferior STEMI and two normal ECGs. Given the paramedics' low sensitivity and specificity, we cannot rely solely on their ECG interpretation to activate the cardiac catheterization laboratory. Future research should involve the evaluation of training programs that include assessment, initial training, testing, feedback, and repeat training.

Characteristics of prehospital ST-segment elevation myocardial infarctions.

INTRODUCTION: Despite attention directed at treatment times of ST-segment elevation myocardial infarctions (STEMIs), little is known about the types of STEMIs presenting to the emergency department (ED). OBJECTIVE: The purpose of this study was to determine the relative frequencies and characteristics of emergency medical services (EMS) STEMIs compared with those in patients who present to the ED by walk-in. This information may be applied in EMS training, system planning, and public education. METHODS: This was a query of a prospectively gathered database of all STEMIs in patients presenting to Summa Akron City Hospital ED in 2009 and 2010. We collected demographic information, chief complaint, mode and time of arrival, and STEMI pattern (anterior, lateral, inferior, or posterior). We excluded transfers and in-hospital STEMIs. We calculated means, percentages, significance, and 95% confidence intervals (CIs) ± 10%. RESULTS: We analyzed data from 308 patients. Most patients (241/308, 78%, CI 73%-83%) arrived by EMS, were male (203/308, 66%, CI 60%-71%), and were white (286/308, 93%, CI 89%-96%). Patients arriving by EMS were older (average 63 years, range 35-95) than walk-in patients (average 57 years, range 24-92). Two percent (5/241, 2%, CI 1%-5%) of EMS STEMI patients were under 40 years of age, compared with 10% (7/67, 10%, CI 4%-20%) of walk-in patients (p = 0.0017). The most common chief complaint was chest pain (278/308, 90%, CI 86%-93%). Inferior STEMIs were most common (167/308, 54%, CI 49%-60%), followed by anterior (127/308, 41%, CI 48%-60%), lateral (8/308, 3%, CI 1%-5%), and posterior (6/308, 2%, CI 1%-4%). A day-of-the-week analysis showed that no specific day was most common for STEMI presentation. Forty percent (122/308, 40%, CI 34%-45%) of patients presented during open catheterization laboratory hours (Monday through Friday, 0730-1700 hours). There was no significant statistical difference between EMS and walk-in patients with regard to STEMI pattern or patient demographics. CONCLUSIONS: In this study, 95% (294/308) of all STEMIs were inferior or anterior infarctions, and these types of presentations should be stressed in EMS education. Most STEMI patients at this institution arrived by ambulance and during off-hours. Younger patients were more likely to walk in. We need further study, but we may have identified a target population for future interventions. Key words: emergency medical services; allied health personnel; electrocardiography; myocardial infarction; heart catheterization; STEMI.

Predictors of epinephrine autoinjector needle length inadequacy.

BACKGROUND: Self-administered epinephrine is the primary out-of-hospital treatment of anaphylaxis. Intramuscular injection of epinephrine results in higher peak plasma concentration than subcutaneous injection. With the prevalence of obesity, autoinjectors may not have an adequate needle length for intramuscular injection. OBJECTIVES: To measure muscle depth and evaluate predictors of autoinjector needle length inadequacy. METHODS: We performed a prospective cross-sectional study of a convenience sample of low acuity emergency department patients aged 18 to 55 years. We recorded demographic data, measured thigh circumference, and calculated body mass index (BMI). Using ultrasound, we took depth-to-muscle measurements of the vastus lateralus in a standing position, with and without gentle pressure to simulate muscle compression that occurs with correct autoinjector use. We conducted univariate analyses using χ(2) and t tests with P ≤ .05 and 95% confidence intervals. We considered the patient a potential "failure" risk if his/her muscle depth exceeded 15.9 mm (longest available epinephrine autoinjectors needle). RESULTS: We enrolled 120 subjects with a mean BMI of 29.2 kg/m(2). Thirty-one percent (31%) of our sample were found to be failure risks (36/116; confidence interval, 22.6%-39.5%). Women were 6.4 times more likely than men to be a failure risk (54.4% vs 5% for men failure rate; P < .001). Failures were more likely to be shorter, have a higher BMI, and have larger thigh circumference (P < .001). We did not find any statistical difference in muscle depth for race, age, or weight. CONCLUSION: The current epinephrine autoinjector needle length is inadequate for intramuscular injection, especially among women.

Frailty assessment in the emergency department.

BACKGROUND: Frailty (defined as weakness, slowness, weight loss, exhaustion, and physical inactivity) is characterized by increased vulnerability to stressors. Frail older patients are at increased risk of Emergency Department (ED) visits, hospitalization, disability, and death. OBJECTIVES: Our aims were to determine the prevalence of frailty (and assess the feasibility of measuring frailty) in older ED patients. We also assessed the correlation of self-reported speed and weakness to measured values and the association between frailty and function. METHODS: We performed a study of discharged ED patients aged ≥ 65 years. We used Fried's frailty definition and a validated activities-of-daily-living (ADL) scale. We measured self-reported and objective weakness and slowness. Data were reported as means and proportions with 95% confidence interval (CI); associations were measured using 95% CI for the differences. Ninety patients provided a 95% CI of ± 10%. RESULTS: The mean age of the 90 patients was 76 ± 6.4 SD years; 51% were male. Mean assessment time was 7.4 min (95% CI 6.9-7.9). Twenty percent of patients were frail (18/90, 95% CI 12-30%). Self-report was 18% sensitive and 90% specific for objective weakness; self-report was 42% sensitive and 86% specific for objective slowness. Frail and weak patients were more likely dependent in one or more ADLs (26% difference, 95% CI 1-51% and 20% difference, 95% CI 1-41%, respectively). CONCLUSIONS: Frailty is common in discharged older ED patients. Self-reported weakness and slowness are poor predictors of their objective counterparts. Frailty was associated with ADL dependence. These two domains may be reliable markers for elderly ED patients at high risk for adverse outcomes.

Performance of a Standardized Clinical Assay for Urinary C-C Motif Chemokine Ligand 14 (CCL14) for Persistent Severe Acute Kidney Injury.

Background: Clinical use of biomarkers requires the development of standardized assays and establishment of cutoffs. Urinary C-C motif chemokine ligand 14 (CCL14) has been validated to predict persistent severe AKI in critically ill patients with established AKI. We now report on the performance of standardized cutoffs using a clinical assay. Methods: A second aim of the multicenter RUBY Study was to establish two cutoffs for the prediction of persistent severe AKI (defined as KDIGO stage 3 AKI for at least 72 consecutive hours). Patients who received renal replacement therapy (RRT) or died before achieving 72 hours in stage 3 AKI were also considered to have reached the end point. Results: A cutoff value for urinary CCL14 of 1.3 ng/ml was determined to achieve high sensitivity (91%; 95% CI, 84% to 96%), and 13 ng/ml achieved high specificity (93%; 95% CI, 89% to 96%). The cutoff of 1.3 ng/ml identifies the majority (91%) of patients who developed persistent severe AKI with a negative predictive value of 92%. The cutoff at 13 ng/ml had a positive predictive value of 72% (with a negative predictive value of 75%). In multivariable adjusted analyses, a CCL14 concentration between 1.3 and 13 ng/ml had an adjusted odds ratio (aOR) of 3.82 (95% CI, 1.73 to 9.12; P=0.001) for the development of persistent severe AKI compared with those with a CCL14 ≤1.3 ng/ml, whereas a CCL14 >13 ng/ml had an aOR of 10.4 (95% CI, 3.89 to 29.9; P<0.001). Conclusions: Using a clinical assay, these standardized cutoffs (1.3 and 13 ng/ml) allow for the identification of patients at high risk for the development of persistent severe AKI. These results have immediate utility in helping to guide AKI patient care and may facilitate future clinical trials.Clinical Trial registry name and registration number: Identification and Validation of Biomarkers of Acute Kidney Injury Recovery, NCT01868724.