Trends in Initial Anticoagulation Among US Patients Hospitalized With Acute Pulmonary Embolism 2011-2020.

STUDY OBJECTIVE: Guidelines recommend low-molecular-weight heparin (LMWH) and direct oral anticoagulants (DOACs) rather than unfractionated heparin (UFH) for treatment of acute pulmonary embolism (PE) given their efficacy and reduced risk of bleeding. Using data from a large consortium of US hospitals, we examined trends in initial anticoagulation among hospitalized patients diagnosed with acute PE. METHODS: We conducted a retrospective study of inpatient and observation cases between January 1, 2011, and December 31, 2020, among individuals aged more than or equal to 18 years treated at acute care hospitals contributing data to the Premier Healthcare Database. Included cases received a diagnosis of acute PE, underwent imaging for PE, and received anticoagulation at the time of admission. The primary outcome was the initial anticoagulant selected for treatment. RESULTS: Among 299,016 cases at 1,045 hospitals, similar proportions received initial treatment with UFH (47.4%) and LMWH (47.9%). Between 2011 and 2020, the proportion of patients initially treated with UFH increased from 41.9% to 56.3%. Over this period, use of LMWH as the initial anticoagulant was reduced from 58.1% in 2011 to 37.3% in 2020. The proportion of cases admitted to the ICU, treated with mechanical ventilation or vasopressors, and inpatient mortality were stable. Factors most strongly associated with receipt of UFH were admission to the ICU (odds ratio [OR] 6.90; 95% confidence interval [CI] 6.31 to 7.54) or step-down unit (OR 2.30; 95% CI 2.16 to 2.45), receipt of thrombolysis (OR 4.25; 95% CI 3.09 to 5.84) or vasopressors (OR 1.83; 95% CI 1.32 to 2.54), and chronic renal disease (OR 1.67; 95% CI 1.54 to 1.81). CONCLUSIONS: Despite recommendations that LMWH and DOACs be considered first-line for most patients with acute PE, use of UFH is common and increasing. Further research is needed to elucidate factors associated with persistent use of UFH and opportunities for deimplementation of low-value care.

Validity of Computer-interpreted "Normal" and "Otherwise Normal" ECG in Emergency Department Triage Patients.

Introduction: Chest pain is the second most common chief complaint for patients undergoing evaluation in emergency departments (ED) in the United States. The American Heart Association recommends immediate physician interpretation of all electrocardiograms (ECG) performed for adults with chest pain within 10 minutes to evaluate for the finding of ST-elevation myocardial infarction (STEMI). The ECG machines provide computerized interpretation of each ECG, potentially obviating the need for immediate physician analysis; however, the reliability of computer-interpreted findings of "normal" or "otherwise normal" ECG to rule out STEMI requiring immediate intervention in the ED is unknown. Methods: We performed a prospective cohort analysis of 2,275 ECGs performed in triage in the adult ED of a single academic medical center, comparing the computerized interpretations of "normal" and "otherwise normal" ECGs to those of attending cardiologists. ECGs were obtained with a GE MAC 5500 machine and interpreted using Marquette 12SL. Results: In our study population, a triage ECG with a computerized interpretation of "normal" or "otherwise normal" ECG had a negative predictive value of 100% for STEMI (one-sided, lower 97.5% confidence interval 99.6%). None of the studied patients with these ECG interpretations had a final diagnosis of STEMI, acute coronary syndrome, or other diagnosis requiring emergent cardiac catheterization. Conclusion: In our study population, ECG machine interpretations of "normal" or "otherwise normal" ECG excluded findings of STEMI. The ECGs with these computerized interpretations could safely wait for physician interpretation until the time of patient evaluation without delaying an acute STEMI diagnosis.

Barriers and Facilitators to Harm Reduction for Opioid Use Disorder: A Qualitative Study of People With Lived Experience.

STUDY OBJECTIVE: Although an increasing number of emergency departments (ED) offer opioid agonist treatment, naloxone, and other harm reduction measures, little is known about patient perspectives on harm reduction practices delivered in the ED. The objective of this study was to identify patient-focused barriers and facilitators to harm reduction strategies in the ED. METHODS: We conducted semistructured interviews with a convenience sample of individuals in Massachusetts diagnosed with opioid use disorder. We developed an interview guide, and interviews were recorded, transcribed, and analyzed in an iterative process using reflexive thematic analysis. After initial interviews and coding, we triangulated the results among a focus group of 4 individuals with lived experience. RESULTS: We interviewed 25 participants with opioid use disorder, 6 recruited from 1 ED and 19 recruited from opioid agonist treatment clinics. Key themes included accessibility of harm reduction supplies, lack of self-care resulting from withdrawal and hopelessness, the impact of stigma on the likelihood of using harm reduction practices, habit and knowledge, as well as the need for user-centered harm reduction interventions. CONCLUSION: In this study, people with lived experience discussed the characteristics and need for user-centered harm reduction strategies in the ED that centered on reducing stigma, treatment of withdrawal, and availability of harm reduction materials.

A Novel Algorithm for Improving the Prehospital Diagnostic Accuracy of ST-Segment Elevation Myocardial Infarction.

INTRODUCTION: Early detection of ST-segment elevation myocardial infarction (STEMI) on the prehospital electrocardiogram (ECG) improves patient outcomes. Current software algorithms optimize sensitivity but have a high false-positive rate. The authors propose an algorithm to improve the specificity of STEMI diagnosis in the prehospital setting. METHODS: A dataset of prehospital ECGs with verified outcomes was used to validate an algorithm to identify true and false-positive software interpretations of STEMI. Four criteria implicated in prior research to differentiate STEMI true positives were applied: heart rate <130, QRS <100, verification of ST-segment elevation, and absence of artifact. The test characteristics were calculated and regression analysis was used to examine the association between the number of criteria included and test characteristics. RESULTS: There were 44,611 cases available. Of these, 1,193 were identified as STEMI by the software interpretation. Applying all four criteria had the highest positive likelihood ratio of 353 (95% CI, 201-595) and specificity of 99.96% (95% CI, 99.93-99.98), but the lowest sensitivity (14%; 95% CI, 11-17) and worst negative likelihood ratio (0.86; 95% CI, 0.84-0.89). There was a strong correlation between increased positive likelihood ratio (r2 = 0.90) and specificity (r2 = 0.85) with increasing number of criteria. CONCLUSIONS: Prehospital ECGs with a high probability of true STEMI can be accurately identified using these four criteria: heart rate <130, QRS <100, verification of ST-segment elevation, and absence of artifact. Applying these criteria to prehospital ECGs with software interpretations of STEMI could decrease false-positive field activations, while also reducing the need to rely on transmission for physician over-read. This can have significant clinical and quality implications for Emergency Medical Services (EMS) systems.

Addressing the rising trend of high-risk pulmonary embolism mortality: Clinical and research priorities.

BACKGROUND: Deaths from high-risk pulmonary embolism (PE) appear to have increased in the US over the last decade. Modifiable risks contributing to this worrisome trend present opportunities for physicians, researchers, and healthcare policymakers to improve care. METHODS: We sought to contextualize contemporary, high-risk PE epidemiology and examine clinical trials, quality improvement opportunities, and healthcare policy initiatives directed at reducing mortality. RESULTS: We observed significant and modifiable excess mortality due to high-risk PE. We identified several opportunities to improve care including: (1) rapid translation of forthcoming data on reperfusion strategies into clinical practice; (2) improved risk stratification tools; (3) quality improvement initiatives to address presumptive anticoagulation practice gaps; and (3) adoption of health policy initiatives to establish pulmonary embolism response teams and address the social determinants of health. CONCLUSION: Addressing knowledge and practice gaps in intermediate and high-risk PE management must be prioritized and informed by forthcoming high-quality data. Implementation efforts are needed to improve acute PE management and resolve treatment disparities.

Barriers and Facilitators to the Outpatient Management of Low-risk Pulmonary Embolism From the Emergency Department.

STUDY OBJECTIVE: Although recommended by professional society guidelines, outpatient management of low-risk pulmonary embolism (PE) from emergency departments (EDs) in the US remains uncommon. The objective of this study was to identify barriers and facilitators to the outpatient management of PE from the ED using implementation science methodology. METHODS: We conducted semistructured interviews with a purposeful sample of emergency physicians using maximum variation sampling, aiming to recruit physicians with diverse practice patterns regarding the management of low-risk PE. We developed an interview guide using the implementation science frameworks-the Consolidated Framework for Implementation Research and the Theoretical Domains Framework. Interviews were recorded, transcribed, and analyzed in an iterative process. RESULTS: We interviewed 26 emergency physicians from 11 hospital systems, and the participants were diverse with regard to years in practice, practice setting, and engagement with outpatient management of PE. Although outer setting determinants, such as medicolegal climate, follow-up, and insurance status were universal, our participants revealed that the importance of these determinants were moderated by individual-level and inner setting determinants. Prominent themes included belief in consequences, belief in capabilities, and institutional support and culture. Inertia of clinical practice and complexity of the process were important subthemes. CONCLUSION: In this qualitative study, clinicians reported common barriers and facilitators that initially focused on outer setting and external barriers but centered on clinician beliefs, fear, and local culture. Efforts to increase outpatient treatment of select patients with acute PE should be informed by these barriers and facilitators, which are aligned with the deimplementation theory.

Use of high-sensitivity cardiac troponin in the emergency department: A policy resource and education paper (PREP) from the American College of Emergency Physicians.

This Policy Resource and Education Paper (PREP) from the American College of Emergency Physicians (ACEP) discusses the use of high-sensitivity cardiac troponin (hs-cTn) in the emergency department setting. This brief review discusses types of hs-cTn assays as well as the interpretation of hs-cTn in the setting of various clinical factors such as renal dysfunction, sex, and the important distinction between myocardial injury versus myocardial infarction. In addition, the PREP provides one possible example of an algorithm for the use of a hs-cTn assay in patients in whom the treating clinician is concerned about potential acute coronary syndrome.

The role of emergency physicians in the fight against health misinformation: Implications for resident training.

Emergency physicians on the frontlines of the COVID-19 pandemic are first-hand witnesses to the direct impact of health misinformation and disinformation on individual patients, communities, and public health at large. Therefore, emergency physicians naturally have a crucial role to play to steward factual information and combat health misinformation. Unfortunately, most physicians lack the communications and social media training needed to address health misinformation with patients and online, highlighting an obvious gap in emergency medicine training. We convened an expert panel of academic emergency physicians who have taught and conducted research about health misinformation at the Society for Academic Emergency Medicine (SAEM) Annual Meeting in New Orleans, LA, on May 13, 2022. The panelists represented geographically diverse institutions including Baystate Medical Center/Tufts University, Boston Medical Center, Northwestern University, Rush Medical College, and Stanford University. In this article, we describe the scope and impact of health misinformation, introduce methods for addressing misinformation in the clinical environment and online, acknowledge the challenges of tackling misinformation from our physician colleagues, demonstrate strategies for debunking and prebunking, and highlight implications for education and training in emergency medicine. Finally, we discuss several actionable interventions that define the role of the emergency physician in the management of health misinformation.

Treatment of pediatric behavioral health patients with intravenous and intramuscular chemical restraints: Results from a nationwide sample of emergency departments.

BACKGROUND: Behavioral health crises in pediatric emergency department (ED) patients are increasingly common. Chemical restraints can be utilized for patients who present imminent danger to self or others. We sought to describe the use of intravenous (IV)/intramuscular (IM) chemical restraints for pediatric behavioral health ED patients across a nationwide sample of hospitals and describe factors associated with restraint use. METHODS: This was a retrospective study of patients ages 8-17 treated at 822 EDs contributing data to the Premier Healthcare Database between January 1, 2018, and December 31, 2020, with a behavioral health discharge diagnosis. The primary outcome was the use of IV/IM chemical restraint medication. We developed a hierarchical model to examine patient and hospital-level factors associated with treatment with IV/IM chemical restraint medications. RESULTS: Of 630,384 cases, 4.8% received IV/IM chemical restraint. Patient factors associated with higher odds of chemical restraint were older age (ages 13-17 years [adjusted odds ratio {AOR} 1.53, 95% confidence interval {CI} 1.48-1.58]), anxiety disorders (AOR 1.69, 95% CI 1.64-1.74), disruptive disorders (AOR 1.61, 95% CI 1.53-1.69), suicide/self-injury (AOR 1.3, 95% CI 1.26-1.34), substance use (AOR 1.24, 95% CI 1.20-1.28), and bipolar disorder (AOR 1.23, 95% CI 1.17-1.30). Participants with complex comorbidities were more likely to receive chemical restraint (AOR 1.32, 95% CI 1.26-1.39). After patient and hospital factors were adjusted for, the median OR indicating the influence of the individual hospital on the odds of chemical restraint was 1.43 (95% CI 1.40-1.47). CONCLUSIONS: We found that age and certain behavioral health diagnoses were associated with receipt of IV/IM chemical restraint during pediatric behavioral health ED visits. Additionally, whether a patient was treated with chemical restraints was strongly influenced by the hospital to which they presented for treatment.

Bilateral Emboli and Highest Heart Rate Predict Hospitalization of Emergency Department Patients With Acute, Low-Risk Pulmonary Embolism.

STUDY OBJECTIVE: Some patients with acute pulmonary embolism (PE) will suffer adverse clinical outcomes despite being low risk by clinical decision rules. Emergency physician decisionmaking processes regarding which low-risk patients require hospitalization are unclear. Higher heart rate (HR) or embolic burden may increase short-term mortality risk, and we hypothesized that these variables would be associated with an increased likelihood of hospitalization for patients designated as low risk by the PE Severity Index. METHODS: This was a retrospective cohort study of 461 adult emergency department (ED) patients with a PE Severity Index score of fewer than 86 points. Primary exposures were the highest observed ED HR, most proximal embolus location (proximal vs distal), and embolism laterality (bilateral vs unilateral PE). The primary outcome was hospitalization. RESULTS: Of 461 patients meeting inclusion criteria, most (57.5%) were hospitalized, 2 patients (0.4%) died within 30 days, and 142 (30.8%) patients were at elevated risk by other criteria (Hestia criteria or biochemical/radiographic right ventricular dysfunction). Variablesassociated with an increased likelihood of admission were highest observed ED HR of ≥110 beats/minute (vs HR <90 beats/min) (adjusted odds ratio [aOR] 3.11; 95% confidence interval [CI] 1.07 to 9.57), highest ED HR 90 to 109 (aOR 2.03; 95% CI 1.18-3.50) and bilateral PE (aOR 1.92; 95% CI 1.13 to 3.27). Proximal embolus location was not associated with the likelihood of hospitalization (aOR 1.19; 95% CI 0.71 to 2.00). CONCLUSIONS: Most patients were hospitalized, often with recognizable high-risk characteristics not accounted for by the PE Severity Index. Highest ED HR of ≥90 beats/min and bilateral PE were associated with a physician's decision for hospitalization.