The Effect of Access to Electronic Health Records on Throughput Efficiency and Imaging Utilization in the Emergency Department.

STUDY OBJECTIVE: To evaluate whether the availability of Electronic Health Records (EHRs) reduces throughput time and utilization of advanced imaging for patients in an academic ED. DATA SOURCES: All patients arriving at an academic Emergency Department (ED) via ambulance between June 1, 2011, and June 4, 2012, were included in the study. This accounted for 9,970 unique ambulance patient visits. STUDY DESIGN: Retrospective noninterventional analysis of patients in an academic ED. The primary independent variable was whether the patient had a prior EHR at the study hospital. Main outcomes were throughput time, number of advanced diagnostic imaging studies (CT, MRI, ultrasound), and the associated cost of these imaging studies. A set of controls, including age, gender, ICD9 codes, acuity measures, and NYU ED algorithm case severity classifications, was used in an ordinary least-squares (OLS) regression framework to estimate the association between EHR availability and the outcome measures. PRINCIPAL FINDINGS: A patient with a prior EHR experienced a mean reduction in CT scans of 13.9 percent ([4.9, 23.0]). There was no material change in throughput time for patients with a prior EHR and no difference in utilization of other imaging studies across patients with a prior EHR and those without. Cost savings associated with prior EHRs are $22.52 per patient visit. CONCLUSION: EHR availability for ED patients is associated with a reduction in CT scans and cost savings but had no impact on throughput time or order frequency of other imaging studies.

EDTITRATE (Emergency Department Telemedicine Initiative to Rapidly Accommodate in Times of Emergency).

Objective Emergency Department (ED) patient volumes are unpredictable, which can result in service delays and patients leaving without care. We initiated a programme of emergency physician (EP) telepresence in the ED with the objectives of assessing feasibility, safety, patient and provider acceptance, and throughput time. Methods This was a prospective convenience study. Patients presenting to the ED during operation of the study who were planned for placement in the waiting room were considered for enrolment. A faculty EP conducted patient evaluations via telepresence with confirmatory evaluation by the onsite faculty EP prior to disposition. Patient care was either taken to completion by the telemedicine EP or initiated and handed off to the onsite team. Measures included patient demographics, triage class (ESI 1-5), throughput time and a single question satisfaction survey (rating 1-5, 5 most favourable) completed by patients, registered nurses and EPs. Patients were called within 3 days and the electronic health record reviewed at 7 days looking for unscheduled visits and adverse events. Results In total, 130 patients were enrolled. Mean triage class was 3.9 with a median throughput of 150 minutes (IQR = 116.5, 206). Non-telemedicine patients during the same time period with similar triage classes had a median throughput of 287 minutes (IQR = 199, 408). Mean satisfaction scores were: patient 4.91, nurse 4.75, onsite EP 4.47 and telemedicine EP 4.79. There was one potential misdiagnosis and no adverse events. Conclusion Patient evaluation by EP via telepresence is feasible, safe, readily accepted by patients and providers and associated with reduced throughput time.

The impact of patient telephone call after discharge on likelihood to recommend in an academic emergency department.

BACKGROUND: Patient satisfaction is a common parameter tracked by health care systems, and likely influences patient provider choice and may impact insurer payment. Achieving high satisfaction in an academic emergency department (ED) can be a daunting task due to variable volumes, acuity, and overcrowding. OBJECTIVE: The objective of this study was to assess the impact of a postdischarge telephone call by a staff member after discharge from the ED on patient satisfaction. METHODS: This was a prospective cohort study conducted in the two University of California San Diego Health System EDs. Press Ganey patient satisfaction surveys are mailed to a random sample of 50% of all discharged patients. In August 2010 a program of MD and RN telephone call back 1 to 5 days after the ED visit was initiated. In conjunction with this program, a custom question was added to the standard survey, "Called back after discharge, Yes/No?" All surveys returned between September 22, 2010 and December 7, 2010 were reviewed, and those that chose to self-identify were selected to allow for ED chart review. The key outcome variable "likelihood to recommend score" was dichotomized into the highest category, 5 (very good) and remaining levels, 1-4 (very poor, poor, fair, good). ED records were abstracted for data on waiting time (WT), length of stay (LOS), and triage class (TC). These variables were selected because they have been shown to impact patient satisfaction in prior studies. Likelihood to recommend ratings for those reporting "Yes" to call back were compared to those reporting "No" to call back. Summary statistics were generated for patient characteristics in the "Yes" and "No" groups. Ninety-five percent confidence intervals (CIs) for all counts and proportions were calculated with the "exact" method. A logistic regression model was constructed assessing odds ratio (OR) for likelihood-to-recommend score 5 while controlling for the variables of WT, LOS, and TC. RESULTS: In the study period, about 5000 surveys were mailed, 507 were returned, and 368 self-identified. Of those that self-identified, 136 patients answered "Yes" to the callback question and 232 answered "No." The mean age for those indicating "Yes" was 55.8 years (CI 52.9-58.7), and for those indicating "No," 50.7 years (CI 47.9-53.5). Gender and triage code were similar between the two groups. Among those answering "Yes," 89.0% (CI 82.5-93.7) provided a "5" rating for "likelihood to recommend," compared to 55.6% (CI 49.0-62.1) who replied "No" for call back. The logistic regression model generated an OR of 6.35 (CI 3.4-11.7) for providing a level 5 rating for "likelihood to recommend" for patients reporting "Yes" for call back after controlling for WT, LOS, and TC. CONCLUSION: In the study institution, patients that are called back are much more likely to have a favorable impression of the visit as assessed by likelihood to recommend regardless of WT, LOS, or TC. These data support "call back" as an effective strategy to improve ED patient satisfaction.

The impact of post-discharge patient call back on patient satisfaction in two academic emergency departments.

BACKGROUND: Patients' satisfaction is a common parameter tracked by health care systems and Emergency Departments (EDs). OBJECTIVES: To determine whether telephone calls by health care providers to patients after discharge from the ED was associated with improved patient satisfaction. METHODS: Retrospective analysis of Press Ganey (PG; Press Ganey Associates, South Bend, IN) surveys from two EDs operated by the University of California San Diego Health System. Responses to the YES/NO question, "After discharge, did you receive a phone call from an ED staff member?" was compared to the responses to the question "likelihood of recommending this ED to others" (LR). This variable could be ranked with a score of 1 (very poor) to 5 (very good). Responses were dichotomized into two groups, 1-4 and 5. Chi-squared was performed to assess LR between those answering YES vs. NO to the call back question. Differences in proportion, 95% confidence interval (CI), and p-value are reported. Rankings for percentage of 5s across all EDs in the PG database were compared based upon YES/NO responses. RESULTS: In the 12-month study period, about 30,000 surveys were mailed and 2250 (7.5%) were returned. Three hundred forty-seven (15.4%) checked off YES for the call back question. Percentage of 5s for LR for NO call back was 51.1% and for YES call back was 70.6% (difference = 19.5; 95% CI 14.0-24.6; p < 0.001).These values correlated with an ED ranking of 14(th) and 85(th) percentile, respectively. CONCLUSION: This retrospective study demonstrated a strong association between post-visit patient call back and LR. Further prospective study with control for co-variables is warranted.

Impact of patient and family communication in a pediatric emergency department on likelihood to recommend.

OBJECTIVE: Identify the specific patient experience variables that most strongly predict satisfaction as measured by the likelihood to recommend rating. METHODS: We performed a retrospective analysis of a patient satisfaction survey distributed to patients during their visit to an academic children's hospital emergency department (ED) during a 3-month period. Any incomplete or incorrectly completed surveys were excluded. The associations between staff communication variables and "likelihood to recommend" were assessed while controlling for daily ED flow data. RESULTS: A total of 3135 surveys were completed with 825 (26%) excluded for incomplete or incorrect entry. After controlling for daily census, median daily wait time and median daily length of stay, the communication question that asks if the nurse or physician kept them informed while in the examination room had the strongest association (odds ratio, 12.2; 95% confidence interval, 9.3-16.1; P < 0.001), with the response of "always" likely to recommend this ED. CONCLUSIONS: This study demonstrates that keeping patients and their families informed has a more positive effect on patient satisfaction than any other variable studied even in the setting of increased census and wait times.

Severe iron deficiency anemia and lice infestation.

BACKGROUND: Lice infestation is a commonly encountered disorder in emergency medicine. The louse survives from a blood meal from its host; hence, iron deficiency anemia is a theoretic possibility. A limited number of reports of severe iron deficiency anemia have appeared in the veterinary literature, but a thorough review of the medical literature did not reveal a single instance in human beings. OBJECTIVE: We report a small case series of patients with heavy louse infestation and profound iron deficiency anemia. CASE REPORT: The index case along with two other cases discovered from an exhaustive search of 4 years of the institution's Emergency Department records all had heavy infestation with head and body lice. Laboratory evaluation revealed serum hemoglobin levels under 6 gm/dL, low serum ferritin levels, and microcytic red blood cell indices. All patients were admitted to the hospital, received transfusions, and had evaluation of their anemia. No patient had evidence of gastrointestinal blood loss or alternative explanation for their anemia. CONCLUSIONS: Although cause and effect cannot be established from this case series, to the best of our knowledge, this is the first published evidence of a provocative association of louse infestation and severe iron deficiency anemia in humans.

Comparison of three aspirin formulations in human volunteers.

INTRODUCTION: The treatment of acute coronary syndrome (ACS) includes the administration of aspirin. Current guidelines recommend chewing aspirin tablets to increase absorption. While this is intuitive, there are scant data supporting this recommendation. The purpose of this study is to assess which of 3 different aspirin formulations is most rapidly absorbed after ingestion. METHODS: A prospective, open-label, 3-way crossover volunteer study at a tertiary university medical center with human subjects 18 years or older. Fasted subjects were randomly assigned to receive aspirin 1,950 mg as (1) solid aspirin tablets swallowed whole, (2) solid aspirin tablet chewed then swallowed, or (3) a chewable aspirin formulation chewed and swallowed. Serum salicylate measurements were obtained over a period of 180 minutes. Pharmacokinetic parameters were determined. RESULTS: Thirteen males and 1 female completed all 3 arms of study. Peak serum salicylate concentrations were seen at 180 minutes in all groups. Mean peaks were 10.4, 11.3, and 12.2 mg/dL in groups 1, 2, and 3, respectively. Mean area under the time concentration was 1,153, 1,401, and 1,743 mg-min/dL in groups 1, 2, and 3, respectively. No measurable salicylate concentrations were seen in 6 subjects in group 1 at 60 minutes as compared to 1 subject in group 2. All subjects in group 3 had measurable levels at 45 minutes. There were no adverse effects in any of the subjects during the study period. CONCLUSION: Our data demonstrate that the chewable aspirin formulation achieved the most rapid rate of absorption. In addition, the chewable formulation absorption was more complete than the other formulations at 180 minutes. These data suggest that in the treatment of ACS, a chewable aspirin formulation may be preferable to solid tablet aspirin, either chewed or swallowed.

Nanofiltered C1 inhibitor concentrate for treatment of hereditary angioedema.

BACKGROUND: Hereditary angioedema due to C1 inhibitor deficiency is characterized by recurrent acute attacks of swelling that can be painful and sometimes life-threatening. METHODS: We conducted two randomized trials to evaluate nanofiltered C1 inhibitor concentrate in the management of hereditary angioedema. The first study compared nanofiltered C1 inhibitor concentrate with placebo for treatment of an acute attack of angioedema. A total of 68 subjects (35 in the C1 inhibitor group and 33 in the placebo group) were given one or two intravenous injections of the study drug (1000 units each). The primary end point was the time to the onset of unequivocal relief. The second study was a crossover trial involving 22 subjects with hereditary angioedema that compared prophylactic twice-weekly injections of nanofiltered C1 inhibitor concentrate (1000 units) with placebo during two 12-week periods. The primary end point was the number of attacks of angioedema per period, with each subject acting as his or her own control. RESULTS: In the first study, the median time to the onset of unequivocal relief from an attack was 2 hours in the subjects treated with C1 inhibitor concentrate but longer than 4 hours in those given placebo (P=0.02). In the second study, the number of attacks per 12-week period was 6.26 with C1 inhibitor concentrate given as prophylaxis, as compared with 12.73 with placebo (P<0.001); the subjects who received the C1 inhibitor concentrate also had significant reductions in both the severity and the duration of attacks, in the need for open-label rescue therapy, and in the total number of days with swelling. CONCLUSIONS: In subjects with hereditary angioedema, nanofiltered C1 inhibitor concentrate shortened the duration of acute attacks. When used for prophylaxis, nanofiltered C1 inhibitor concentrate reduced the frequency of acute attacks. (Funded by Lev Pharmaceuticals; ClinicalTrials.gov numbers, NCT00289211, NCT01005888, NCT00438815, and NCT00462709.)

Impact of an express admit unit on emergency department length of stay.

BACKGROUND: Express admit units (EAUs) have been proposed as a way to expedite patient flow through the Emergency Department (ED). OBJECTIVES: We sought to determine the effect of opening a five-bed EAU unit for temporary placement of admitted patients on our ED length of stay (LOS) and waiting room times (WT). METHOD: This was a before-and-after interventional study of the 3-month period immediately before (pre-EAU) and after opening (post-EAU) of the EAU. We compared ED LOS and WT for patients admitted and discharged from the ED for both time periods, controlling for daily census and patient acuity. RESULTS: During the post-EAU period, 386 patients (26.2% of total admits) were admitted through the EAU. Overall LOS decreased from 8:21 (interquartile range [IQR] 6:02-11:20) to 7:41 (IQR 5:22-10:16) for all admitted patients (p < 0.001), and from 3:41 (IQR 2:05-5:58) to 3:35 (IQR 2:00-5:55) for the discharged patients (p = 0.025). After controlling for census and acuity, the LOS decreased an average of 10% (95% confidence interval [CI] 6%-14%; p < 0.001) for admitted patients and 4% (95% CI 2%-7%; p = 0.001) for discharged patients. These changes represented a decreased LOS of about 50 and 9 min, respectively. There were no significant differences in WT (0:44; IQR 0:09-2:07 vs. 0:50; IQR 0:11-2:20 for admitted patients and 0:41; IQR 0:09-1:50 vs. 0:41; IQR 0:10-1:47 for discharged patients). However, after controlling for census and acuity, WT decreased 9% (95% CI 1%-16%; p = 0.022) for discharged patients, which represented a decrease of about 4 min. CONCLUSIONS: With an EAU, there was a modest improvement in ED LOS despite an overall increase in daily ED volume.

Rapid Emergency Department Heart Failure Outpatients Trial (REDHOT II): a randomized controlled trial of the effect of serial B-type natriuretic peptide testing on patient management.

BACKGROUND: B-type natriuretic peptide is useful to diagnose heart failure. We determined whether the use of serial B-type natriuretic peptide measurements to guide treatment improves the outcome in patients with acute heart failure. METHODS AND RESULTS: We conducted a randomized controlled trial of patients with acute heart failure in 10 academic and community emergency departments. The experimental group received serial B-type natriuretic peptide testing (at 3, 6, 9, and 12 hours then daily). The control group received usual care. Our outcomes were hospital length of stay, 30-day readmission rate, and all-cause mortality. There were 219 controls and 228 experimental patients. Mean age was 64 years, 49% were women, 58% were blacks, and 34% were whites. Groups were similar in baseline characteristics. Comparing the serial testing with the control group, there was no difference in length of stay (6.5 days [95% CI, 5.2 to 7.9] versus 6.5 days [95% CI, 5.6 to 7.3]; difference, 0.1 [95% CI, -1.7 to 1.5]), in-hospital mortality (2.2% [95% CI, 0.9 to 5.0] versus controls, 3.2% [95% CI, 1.6 to 6.5]; difference, 1.0% [95% CI, -2.3 to 4.5]), 30-day mortality (3.7% [95% CI, 1.8 to 7.5] versus 5.5% [95% CI, 3.0 to 9.8]; difference, 1.8% [95% CI, -2.8 to 6.5]), or hospital revisit rate (20.2% [95% CI, 15.0 to 26.6] versus 23.7% [95% CI, 18.0 to 30.6]; difference, 3.5% [95% CI, -5.1 to 12.1]). CONCLUSIONS: In this study of 447 patients hospitalized for suspected heart failure, we were unable to demonstrate a benefit of serial testing with B-type natriuretic peptide in terms of hospital length of stay, mortality, or readmission rate.

Impact of an internet-based emergency department appointment system to access primary care at safety net community clinics.

STUDY OBJECTIVE: We evaluate the effect of an Internet-based, electronic referral system (termed IMPACT-ED for Improving Medical home and Primary care Access to the Community clinics Through the ED) on access and follow-up at primary care community clinics for safety net emergency department (ED) patients. METHODS: We conducted a nonblinded interventional trial at an urban, safety net, hospital ED with a census of 39,000 annually. IMPACT-ED identified patients who had no source of regular care and lived in a 15-ZIP-code low-income area served by 3 community clinics. Emergency physicians received an automated notification through the electronic medical record to access an imbedded software program for scheduling follow-up clinic appointments. Patients who would benefit from a follow-up clinic visit within 2 weeks as determined by the emergency physician received a computer-generated appointment time and clinic map with bus routes as part of their discharge instructions, and the clinics received an electronic notification of the appointment. We compared frequency of follow-up for a 6-month period before implementation when patients received written instructions to call the clinic on their own (pre-IMPACT) and 6 months after implementation (post-IMPACT). Statistical analysis was conducted with chi(2) testing, and corresponding 95% confidence intervals are presented. RESULTS: There were 326 patients who received an appointment (post-IMPACT), of whom 81 followed up at the clinic as directed (24.8%), compared with 399 patients who received a referral (pre-IMPACT), of whom 4 followed up as directed (1.0%), for an absolute improvement of 23.8% (95% confidence interval 19.1% to 28.6%). CONCLUSION: Although most patients still failed to follow up at the community clinics as directed, the use of an Internet-based scheduling program linking a safety net ED with local community clinics significantly improved the frequency of follow-up for patients without primary care.

Characteristics of spacer device use by patients with asthma and COPD.

OBJECTIVE: Spacer devices (SD) in conjunction with metered dose inhalers (MDI) have been shown to be as effective as saline nebulizers for the delivery of beta-agonists. A preliminary study suggests that SDs are not consistently used. The purpose of this study was to investigate patterns of SD ownership and use to identify potential targets for future educational efforts to increase ownership and use of SD. METHODS: Cross-sectional convenience sample survey of patients presenting to an academic Emergency Department (ED) with a history of asthma/COPD (chronic obstructive pulmonary disease). Informed consent was obtained. Survey data included demographics, association with a primary care physician (PCP), SD ownership, patterns of use, opinions of efficacy about SD and disease severity assessed by duration of asthma/COPD, prior ED visits, hospitalizations, and history of prior intubation. Patterns of use are described and univariate and multivariate analyses were used to identify factors associated with SD ownership. RESULTS: Of the 313 patients, 55.9% were female, the mean age was 46.0 years (standard deviation 14.7), 54.3% were white, and 143 patients (45.7%) reported owning a SD. A total of 36.4% reported a prior hospitalization for their condition and 24% reported a history of being intubated. Less than half of patients presenting with asthma or COPD exacerbation that reported owning a SD used it the day of presentation to the ED. Logistic regression identified having a PCP and a history of prior hospitalization for asthma/COPD as factors independently associated with SD ownership (odds ratio [OR] 1.7, 95% confidence interval [CI] 1.1-2.7 and OR 2.2, CI 1.3-3.5, respectively). CONCLUSION: A majority of patients with asthma/COPD do not own a SD. These data suggest that there is significant opportunity for educational efforts directed at a broad range of asthma/COPD patients in hopes of increasing ownership and use of SD.

The impact of arm position on the measurement of orthostatic blood pressure.

Blood pressure is a standard vital sign in patients evaluated in an Emergency Department. The American Heart Association has recommended a preferred position of the arm and cuff when measuring blood pressure. There is no formal recommendation for arm position when measuring orthostatic blood pressure. The objective of this study was to assess the impact of different arm positions on the measurement of postural changes in blood pressure. This was a prospective, unblinded, convenience study involving Emergency Department patients with complaints unrelated to cardiovascular instability. Repeated blood pressure measurements were obtained using an automatic non-invasive device with each subject in a supine and standing position and with the arm parallel and perpendicular to the torso. Orthostatic hypotension was defined as a difference of >or= 20 mm Hg systolic or >or= 10 mm Hg diastolic when subtracting standing from supine measurements. There were four comparisons made: group W, arm perpendicular supine and standing; group X, arm parallel supine and standing; group Y, arm parallel supine and perpendicular standing; and group Z, arm perpendicular supine and parallel standing. There were 100 patients enrolled, 55 men, mean age 44 years. Four blood pressure measurements were obtained on each patient. The percentage of patients meeting orthostatic hypotension criteria in each group was: W systolic 6% (95% CI 1%, 11%), diastolic 4% (95% CI 0%, 8%), X systolic 8% (95% CI 3%, 13%), diastolic 9% (95% CI 3%, 13%), Y systolic 19% (95% CI 11%, 27%), diastolic 30% (95% CI 21%, 39%), Z systolic 2% (95% CI 0%, 5%), diastolic 2% (95% CI 0%, 5%). Comparison of Group Y vs. X, Z, and W was statistically significant (p < 0.0001). Arm position has a significant impact on determination of postural changes in blood pressure. The combination of the arm parallel when supine and perpendicular when standing may significantly overestimate the orthostatic change. Arm position should be held constant in supine and standing positions when assessing for orthostatic change in blood pressure.

Impact of abdominal helical computed tomography on the rate of negative appendicitis.

Helical abdominal computed tomography (HCT) is a common test in the evaluation of patients with presumed appendicitis. Studies have demonstrated HCT to have high sensitivity, specificity, and positive and negative predictive value. Despite this, there has not been consistent demonstration that HCT has had beneficial effect on patient outcome. The objective of this study was to assess the impact of HCT on patient outcome as measured by the rate of negative appendicitis and perforated appendicitis. Patients were identified from a pathology department database that included all patients taken to the operating room with a pre-operative diagnosis of appendicitis. Pathologic specimen analysis was used to determine the presence of appendicitis and perforation. Two periods were studied: Period A, a 4-year interval before the arrival of HCT; and Period B, a 3-year period several years after the incorporation of HCT into the evaluation of suspected appendicitis. Primary outcome measures were the rates of negative appendicitis and perforated appendicitis. During Period A, 316 patients were identified; 12% had conventional computed tomography, none had HCT. The negative appendicitis rate was 15.5%; the perforated appendicitis rate was 11.6%. During Period B, 477 patients were identified; 81.5% had HCT. The negative appendicitis rate was 7.9%; the perforated appendicitis rate was 14.4%. The difference in negative appendicitis rates was 7.6% (3.0%, 12.4%), and in perforated appendicitis it was -2.8% (95% CI -8.0%, 2.1%). At the study institution, there was a 48% decrease in the rate of negative appendicitis encountered in association with the common use of HCT.

The impact of a pneumatic tube and computerized physician order management on laboratory turnaround time.

STUDY OBJECTIVE: We assess the effect of sequential modifications in laboratory processing, including pneumatic tube transport and fully computerized order management, on laboratory turnaround time in the emergency department (ED). METHODS: This was an observational analysis of a comprehensive computerized database derived from ED, laboratory, and hospital information systems. The setting was an academic urban ED with annual census of 38,000. Participants and interventions included all patients who had laboratory testing (serum sodium level, troponin level, or CBC count) during three 1-month study periods: before pneumatic tube and computerized order management (prepneumatic tube), after pneumatic tube but before computerized order management (postpneumatic tube), and after both pneumatic tube and computerized order management (postpneumatic tube/computerized order management). The primary outcome measure was median laboratory turnaround time, reported with interquartile ranges. Additional measures included ED census and number of laboratory tests ordered during each study period. RESULTS: The monthly ED census was 3,021, 3,428, and 3,066 for the prepneumatic tube, postpneumatic tube, and postpneumatic tube/computerized order management periods. There was a significant decrease in turnaround time with each period and each test over time. For serum sodium testing, the median laboratory turnaround time decreased from 55.9 to 46.7 to 37.2 minutes for prepneumatic tube, postpneumatic tube, and postpneumatic tube/computerized order management periods. For CBC-count testing, median times decreased from 55.6 to 42.2 to 36.3 minutes, respectively. For troponin I testing, median times decreased from 52.8 to 41.8 to 30.6 minutes, respectively. CONCLUSION: Changes in laboratory specimen management, including the use of a pneumatic tube and computerized order management, resulted in a progressive decrease in laboratory turnaround time in the study ED.

B-type natriuretic peptide (BNP) levels and ethnic disparities in perceived severity of heart failure: results from the Rapid Emergency Department Heart Failure Outpatient Trial (REDHOT) multicenter study of BNP levels and emergency department decision making in patients presenting with shortness of breath.

BACKGROUND: Previous studies have shown that in patients presenting to the emergency department (ED) with heart failure, there is a disconnect between the perceived severity of congestive heart failure (CHF) by physicians and the severity as determined by B-type natriuretic peptide (BNP) levels. Whether ethnicity plays a role in this discrepancy is unknown. METHODS AND RESULTS: The Rapid Emergency Department Heart Failure Outpatient Trial (REDHOT) was a 10-center trial of 464 patients seen in the ED with acute dyspnea and BNP level higher than 100 pg/mL on arrival. Physicians were blinded to BNP levels. Patients were followed for 90 days after discharge. A total of 151 patients identified themselves as white (32.5%) and 294 as black (63.4%). Of these, 90% were hospitalized. African Americans were more likely to be perceived as New York Heart Association class I or II than whites (P = .01). Blacks who were discharged from the ED had higher median BNP levels than whites who were discharged (1293 vs. 533, P = .004). The median BNP of blacks who were discharged was actually higher than the median BNP of blacks who were admitted (1293 vs. 769, P = .04); the same did not hold true for whites. BNP was predictive of 90-day outcome in both blacks and whites; however, perceived severity of CHF, race, and ED disposition did not contribute to the prediction of events. CONCLUSION: In patients presenting to the ED with heart failure, the disconnect between perceived severity of CHF and severity as determined by BNP levels is most pronounced in African Americans.

Gray zone BNP levels in heart failure patients in the emergency department: results from the Rapid Emergency Department Heart Failure Outpatient Trial (REDHOT) multicenter study.

OBJECTIVES: The study purpose was to examine "gray zone" B-type natriuretic peptide (BNP) levels (100-500 pg/mL) in terms of associated clinical factors, perceived severity, and outcomes in patients with established congestive heart failure (CHF). BACKGROUND: Although gray zone BNP levels may have diagnostic ambiguity, the implications of these levels in patients with an established diagnosis of CHF have not been examined. METHODS: REDHOT was a national prospective study in which 464 patients seen in the emergency department with dyspnea had BNP levels drawn. Entrance criteria included a BNP > 100 pg/mL; however, physicians were blinded to the actual BNP level. Patients were followed up for 90 days. RESULTS: Thirty-three percent had gray zone BNP levels. There was no difference in perceived New York Heart Association class (P = .32) or admission rates (P = .76) between the gray zone and non-gray zone groups; 62% of patients with a gray zone BNP were identified as class III or IV CHF. Despite this perceived severity, the 90-day event rate was lower in the gray zone group (19.2% vs 32.9%, respectively, P = .002). Although patients in the gray zone had more symptoms of concomitant pulmonary disease, multivariate analysis could not demonstrate any variable that worsened the prognosis of patients with a gray zone BNP level. CONCLUSIONS: In patients with established CHF, those with gray zone BNP levels have a better prognosis than those with non-gray zone levels despite being perceived by physicians as having New York Heart Association class III or IV CHF.

Impact of helical computed tomography on the rate of negative appendicitis.

OBJECTIVE: To assess the impact of helical computed tomography (HCT) on the rate of negative appendicitis (NA). METHODS: A before-and-after comparison study comparing data from a prospective consecutive case series to data from a retrospective chart review. The prospective series included all patients presenting to the ED during a 19-month period, during which patients with suspected appendicitis were managed in accordance with a guideline that stipulated HCT in selected cases. The retrospective group included patients taken to the operating room (OR) with a preoperative diagnosis of appendicitis over a 4-year time frame before the use of HCT. The primary outcome variable was the rate of NA. RESULTS: During the HCT era, 104 of 310 patients, 71 (68%; 95% confidence interval [CI], 59-76) men and 33 (32%; 95% CI, 24-41) women, were taken to the OR with a diagnosis of appendicitis. Fourteen (13.5%; 95% CI, 8-21) were NA. During the pre-HCT period, 445 patients, 280 (62.9%; 95% CI, 58-67) men and 165 (37.1%; 95% CI, 33-42) women were taken to the OR with the preoperative diagnosis of appendicitis, and 66 (14.8%; 95% CI, 12-19) were NA. CONCLUSION: At the study institution, the selective use of HCT did not result in a significant decline in the rate of NA.

Impact of rapid entry and accelerated care at triage on reducing emergency department patient wait times, lengths of stay, and rate of left without being seen.

STUDY OBJECTIVE: Patients who leave before being seen by a physician represent a significant problem for many emergency departments (EDs). We sought to determine the effect of a new ED rapid entry and accelerated care at triage (REACT) process on the frequency of patients who leave before being seen. METHODS: We conducted a before-after intervention design to study the effect of REACT for ambulatory patients presenting to our urban academic center ED with a census of approximately 37,000. This process redesign included patient identification tracking, integrated computer interfaces to eliminate up-front registration tasks, immediate placement of patients in open ED beds, and physician-directed ancillary testing and care at triage when no ED beds were available. Outcome measures included the average monthly rate of patients who left before being seen during the 6 months before (pre-REACT) and 6 to 12 months after (post-REACT) its initiation. Other measures included average of mean monthly rates of wait times, ED length of stay, ED census, and admissions. RESULTS: There was a significant decrease in leave before being seen frequency from the pre-REACT to post-REACT periods (3.2% absolute decrease [95% confidence interval (CI) 1.9% to 4.6%]), despite an overall increase in ED census. Average mean monthly patient wait times decreased by 24 minutes [95% CI 10 to 38 minutes] after the initiation of REACT, as did overall ED length of stay by 31 minutes [95% CI 6 to 57 minutes]. CONCLUSION: The initiation of a rapid entry and accelerated care process significantly decreased patient leave before being seen rates, average wait times and length of stay, despite an overall increase in patient census.