National cost savings, operational and safety benefits from use of magnetocardiography in the assessment of emergency department chest pain patients.

Study objectives: Patients frequently present to the emergency department (ED) with chest pain requiring further risk stratification. Traditional cardiac diagnostics such as stress testing may expose patients to ionizing radiation, may not be readily available, may take significant time for testing and interpretation, and adds cost to the workup. Magnetocardiography (MCG) is an alternative approach to assess candidates more quickly and efficiently than routine downstream testing. Design: We created and ran 1000 trials of a Monte Carlo simulation. Using this simulation, we modeled the national annual impact by averting further cardiac diagnostics. Setting: All EDs in the United States. Participants: All ED adult patients with chest pain. Interventions: Simulated use of MCG to reduce avoidable downstream cardiac diagnostics. Main outcome measures: Our primary outcome was to estimate the impact of an MCG-first strategy on the annual national cost savings among eligible patients in the ED. Our secondary outcomes were the estimated reduction in short-stay hospitalizations, cancer cases, and cancer deaths due to radiation exposure. Results: An MCG-first strategy was estimated to save a mean (±SD) of $574 million (±$175 million) by avoiding 555,000 (±93,000) downstream cardiac diagnostic tests. This resulted in a national annual cumulative decrease of 500,000 (±84,000) hospitalizations, 7,600,000 (±1,500,000) bed hours, 409 (±110) new cancer diagnoses, and 210 (±56) new cancer deaths due to radiation exposure from avoidable cardiac diagnostics. Conclusions: If adopted widely and used consistently, an MCG-first strategy among eligible patients could yield substantial benefits by averting avoidable cardiac diagnostic testing.

Disaster healthcare disparities solutions: Part 2-Response.

The purpose of this study was to explore the potential solutions for disaster healthcare disparities. This paper is the second of a three-part series that was written by the Disaster Healthcare Disparities Workgroup of the American College of Emergency Physicians Disaster Preparedness and Response Committee. The committee conducted a literature review and chose articles most representative and demonstrative of solutions to disaster healthcare disparities found in a past workgroup product. Many solutions for disaster healthcare disparities during disaster response were found. Some of these solutions have been successfully implemented and some are hypothetical. Solutions for disaster healthcare disparities seen during response are achievable but there is still much work to do. A variety of the proposed solutions can be advocated for by nondisaster specialists leading to better care for all our patients.

Disaster healthcare disparities solutions: Part 3-Recovery and mitigation.

The purpose of this study was to explore the potential solutions for disaster healthcare disparities. This paper is the third of a three-part series that was written by the Disaster Healthcare Disparities Workgroup of the American College of Emergency Physicians Disaster Preparedness and Response Committee. The committee conducted a literature review and chose articles most representative and demonstrative of solutions to disaster healthcare disparities found in a past workgroup product. Many solutions for disaster healthcare disparities seen during recovery and mitigation were found. Some of these solutions have been successfully implemented and some remain theoretical. Solutions for disaster healthcare disparities seen during recovery and mitigation are achievable but there is still much work to do. Many of these solutions can be advocated for by nondisaster specialists.

Disaster healthcare disparities solutions: Part 1-Preparation.

The purpose of this study was to explore the potential solutions for disaster healthcare disparities. This paper is the first of a three-part series that was written by the Disaster Healthcare Disparities Workgroup of the American College of Emergency Physicians Disaster Preparedness and Response Committee. The committee workgroup conducted a literature review and chose articles most representative and demonstrative of solutions to disaster healthcare disparities found in a past workgroup product exploring disaster healthcare disparities seen in disaster. Many solutions for disaster healthcare disparities during preparation were found. Some of these solutions have been successfully implemented, while others are still theoretical. Solutions for disaster healthcare disparities seen in disaster preparation are achievable, but there is still much work to do. There are a variety of solutions that can be easily advocated for by disaster and nondisaster specialists, leading to better care for our patients.

Accelerated magnetocardiography in the evaluation of patients with suspected cardiac ischemia: The MAGNETO trial.

Background: Diagnosing ischemia in emergency department (ED) patients with suspected acute coronary syndrome (sACS) is challenging with equivocal disposition of intermediate risk patients. Objective: Compare sensitivity and specificity of magnetocardiography (MCG) versus standard of care (SOC) stress testing in diagnosing myocardial ischemia. Methods: Multicenter, prospective, observational cohort study. ED patients with sACS and HEART score ≥ 3 underwent 90 s noninvasive MCG to detect myocardial ischemia. Results were blinded to the patient's clinicians. MCGs were read independently by 3 physicians blinded to clinical data. Myocardial ischemia was ≥70 % epicardial coronary artery stenosis, revascularization within 30 days, or 30-day major adverse cardiac events (MACE). Time to first test (TTT) and patient satisfaction for MCG and SOC were compared. Results: Of enrolled patients (N = 390) (mean age 59 ± 12 years, 45 % female), 99 (25 %) underwent a non-invasive stress test: 42 (14 %) diagnosed with ischemia. MCG sensitivity was 66.7 % (50.5-80.4 %, 95 % CI) and specificity 57.1 % (50.0-63.3 %, 95 % CI) for detecting coronary ischemia. Noninvasive stress testing (stress echo, nuclear stress, and exercise stress) had the same sensitivity 66.7 % (95 % CI 29.9 % to 92.5 %) and a specificity of 89.9 % (95 % CI 81.7-95.3 %). Mean TTT was shorter for MCG, 3.18 h (SD 1.91) vs. SOC stress testing 22.71 (SD 15.23), p < 0.0001. Mean patient experience was MCG 4.7 versus 3.0 SOC stress testing (p < 0.0001). Conclusion: MCG provides similar sensitivity and lower specificity as non-invasive stress testing in ED sACS patients. Time to test is shorter for MCG with higher patient satisfaction scores.

Disparities in disaster healthcare: A review of past disasters.

OBJECTIVE: To review the literature on the effects seen after disaster on those with poor social determinants of health (SDOH) and individual social needs. DESIGN: The Disaster Preparedness and Response Committee of the American College of Emergency Physicians (ACEP) formed a work group to study healthcare disparities seen in disaster. This group was composed of six physicians on the committee, all of whom have extensive background in disaster medicine and the chair of the committee. A systematic literature review regarding past disasters and all the healthcare disparities seen was undertaken with the goal of organizing this information in one broad concise document looking at multiple disasters over history. The group reviewed multiple documents regarding SDOH and individual social needs for a complete understanding of these factors. Then, a topic list of healthcare disparities resulting from these factors was composed. This list was then filled out with subtopics falling under the header topics. Each member of the workgroup took one of these topics of healthcare disparity seen in disasters and completed a literature search. The databases reviewed include PubMed Central, Google Scholar, and Medline. The terms queried were disaster, healthcare disparities, disaster healthcare disparities, healthcare disparities associated with disasters, SDOH and disaster, special populations and disaster effects, and vulnerable populations and disaster effects. Each author chose articles they felt were most representative and demonstrative of the healthcare disparities seen in past disasters. These social determinant factors and individual social needs were then cross referenced in relation to past disasters for both their causes and the effect they had on various populations after disaster. This was presented to the ACEP board as a committee report. RESULTS: All the SDOH and individual social needs showed significant negative effects for the populations when combined with a disaster event. These SDOH cut across age, race, and gender affecting a wide swath of people. Previous disaster planning either did not plan or under planned for these marginalized populations during disaster events. CONCLUSIONS: Disparities in healthcare are a pervasive problem that effects many different groups. Disasters magnify and more fully expose these healthcare disparities. We have explored the healthcare disparities with past disasters. These disparities, although common, can be mitigated. The recognition of these poor determinants of health can lead to better and more comprehensive disaster planning for future disasters. Subsequent research is needed to explore these healthcare disparities exacerbated by disasters and to find methods for their mitigation.

Interventions to improve the psychological well-being of healthcare workers in disasters, pandemics, and mass casualty events.

OBJECTIVES: This information paper will describe the current research and recommendations for improving healthcare worker's (HCW) mental health. Individual and organizational goals will be outlined with items broken up into the time frames of predisaster, during a disaster, and post-disaster. METHODS: A team of subject matter experts reviewed the current literature utilizing a search of PubMed, Google Scholar, relevant article reference lists, and subject matter interviews. RESULTS: Thirty-six distinct recommendations were identified and distributed into the time frames of predisaster, during a disaster, and post-disaster. Twenty-one of these are pertaining to organizational goals and factors. Fifteen recommendations are identified for individual HCWs. CONCLUSIONS: Additional institutional and government policies supporting the protection of HCW's mental health are required to reduce the stigma and fear, preventing frontline workers from seeking help with the psychological effects of disasters, mass casualty incidents, and pandemics. Further research dealing with ways to ameliorate the negative effects of the stress related to the duties and responsibilities of HCWs, which are exacerbated by disasters, is needed.

Intranasal Ketorolac for Acute Pain in Adult Emergency Department Patients.

Pain is a common complaint in the emergency department. An alternative to opioids is desirable. Oral medications are not feasible with gastrointestinal disorders or NPO. Intravenous medications require skill and time. Intravenous/intramuscular medications are painful with potential needlestick injury. Intranasal medications have rapid onset, easy administration, do not need skilled providers, and no risk of needlestick injury. A total of 28 adults with acute pain (numeric rating scale ≥ 4) received intranasal ketorolac. Numeric rating scale decreased in all: 32% complete pain relief, median (interquartile range) decrease -5 (-6.8 to -4) (p < .001). Pain relief onset was median [interquartile range] 5 (2.3, 15.0) min. Vital signs remained normal. There were no nasal mucosal changes, no complications. Minor side effects, mostly nasal burning, in 43%, resolved within 5 min. Patients and nurses were satisfied with intranasal ketorolac, and would use it again. Intranasal ketorolac had a rapid onset, was effective, safe, well tolerated with minor side effects that resolved quickly.

Nursing home evacuations due to disasters in the United States over 22.5 years from 1995 to 2017.

A large and growing segment of the United States population resides in nursing homes. Many nursing home residents have multiple comorbidities, are unable to perform activities of daily living, and need assistance for their daily functioning. They are some of the most fragile and vulnerable members of the population. Disasters are increasing in frequency and severity. This makes it likely that disasters will strike nursing homes and affect their residents. The purpose of this study was to evaluate the characteristics of disasters in the United States that resulted in nursing home evacuations. There were 51 reported nursing home evacuations due to a disaster over 22.5 years between 1995 and 2017. Natural disasters were responsible for the majority of evacuations (58.8 percent) followed by man-made unintentional disasters (37.3 percent) and man-made intentional (arson) (3.9 percent). The single most common reason for evacuation was hurricanes (23.5 percent, N = 12) and internal fires (23.5 percent, N = 12). Water-related disasters accounted for nearly three-fourths of the natural disasters (hurricanes 40 percent, N = 12; floods, 33.3 percent, N = 10; total 73.3 percent, N = 22), then snow/ice storms (13.3 percent, N = 4). Of man-made disasters, over two-thirds (66.7 percent) were due to internal fires (internal fires, n = 12, 57.1 percent and arson n = 2, 9.5 percent; total N = 14, 66.7 percent). The highest number of evacuations occurred in Texas, Louisiana, Missouri, New York, and Pennsylvania. This knowledge should enable nursing home administrators, disaster planners, public health officials, and others to improve preparedness for disasters that lead to nursing home evacuations.

Fifteen Years' Experience With Safe and Effective Procedural Sedation in Infants and Children in a General Emergency Department.

OBJECTIVE: To evaluate procedural sedation (PS) in infants/children, performed by emergency physicians in a general (nonpediatric) emergency department (ED). METHODS: Procedural sedation prospectively recorded on a standardized form over 15 years. Demographics, sedatives, and analgesia associations with adverse events were explored with logistic regressions. RESULTS: Of 3274 consecutive PS, 1177 were pediatric: 2 months to 21 years, mean age (±SD) 8.7 ± 5.2 years, 63% boys, 717 White, 435 Black, 25 other. Eight hundred and seventy were American Society of Anesthesiology (ASA) 1, 256 ASA 2, 39 ASA 3, 11 ASA 4, 1 ASA 5. Procedural sedation indications are as follows: fracture reduction (n = 649), dislocation reduction (n = 114), suturing/wound care (n = 244), lumbar puncture (n = 49), incision and drainage (n = 37), foreign body removal (n = 28), other (n = 56). Sedatives were ketamine (n = 762), propofol ( = 354), benzodiazepines (n = 157), etomidate (n = 39), barbiturates (n = 39). There were 47.4% that received an intravenous opioid. Success rate was 100%. Side effects included nausea/vomiting, itching/rash, emergence reaction, myoclonus, paradoxical reaction, cough, hiccups. Complications were oxygen desaturation less than 90%, bradypnea respiratory rate less than 8, apnea, tachypnea, hypotension, hypertension, bradycardia, tachycardia. Normal range of vital signs was age-dependent. Seventy-four PS (6.3%) resulted in a side effect and 8 PS (3.2%) a complication. No one died, required hospital admission, intubation, or any invasive procedure. CONCLUSIONS: Adverse events in infants/children undergoing PS in a general ED are low and comparable to a pediatric ED at a children's hospital. Pediatric PS can be done safely and effectively in a general ED by nonpediatric EM physicians for a wide array of procedures.

Use of antitussive medications in acute cough in young children.

Acute cough, a common complaint in young children, is often the result of a viral upper respiratory infection. Cough and cold remedies generate billions of dollars in annual sales in the United States, despite a lack of evidence of their efficacy and multiple warnings by the US Food and Drug Administration. The current article begins with the best available evidence for common over-the-counter (OTC) and prescription antitussive remedies in children. The article concludes with a discussion of the pros and cons for the use of antitussives in children with cough. In general, OTC antitussive medications should not be routinely used in children under 2 years of age. In certain cases, antitussives with minimal adverse profile and some evidence of benefit may be recommended after informed counseling.

ACR Appropriateness Criteria® Infective Endocarditis.

Infective endocarditis can involve a normal, abnormal, or prosthetic cardiac valve. The diagnosis is typically made clinically with persistently positive blood cultures, characteristic signs and symptoms, and echocardiographic evidence of valvular vegetations or valvular complications such as abscess, dehiscence, or new regurgitation. Imaging plays an important role in the initial diagnosis of infective endocarditis, identifying complications, prognostication, and informing the next steps in therapy. This document outlines the initial imaging appropriateness of a patient with suspected infective endocarditis and for additional imaging in a patient with known or suspected infective endocarditis. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR appropriateness criteria infective endocarditis

Infective endocarditis can involve a normal, abnormal, or prosthetic cardiac valve. The diagnosis is typically made clinically with persistently positive blood cultures, characteristic signs and symptoms, and echocardiographic evidence of valvular vegetations or valvular complications such as abscess, dehiscence, or new regurgitation. Imaging plays an important role in the initial diagnosis of infective endocarditis, identifying complications, prognostication, and informing the next steps in therapy. This document outlines the initial imaging appropriateness of a patient with suspected infective endocarditis and for additional imaging in a patient with known or suspected infective endocarditis. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Community-Acquired Pneumonia.

This clinical policy from the American College of Emergency Physicians is a revision of the 2009 "Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Community-Acquired Pneumonia." A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions: (1) In the adult emergency department patient diagnosed with community-acquired pneumonia, what clinical decision aids can inform the determination of patient disposition? (2) In the adult emergency department patient with community-acquired pneumonia, what biomarkers can be used to direct initial antimicrobial therapy? (3) In the adult emergency department patient diagnosed with community-acquired pneumonia, does a single dose of parenteral antibiotics in the emergency department followed by oral treatment versus oral treatment alone improve outcomes? Evidence was graded and recommendations were made based on the strength of the available data.

Topical Refrigerant Spray for IVs: Patient/Provider Responses - Prospective, Double-blind, Randomized Study.

Painful procedures are common. Patients prefer analgesia for painful procedures. Studies indicate that use of a topical refrigerant spray (TRS) prior to needlestick procedures decreases needlestick pain. TRS is easy to apply, inexpensive, has fast onset, and avoids needlestick pain and anxiety, and needlestick injury risk. Patient and health care provider (HCP) acceptance of any technique is essential before it is adopted. This study evaluated the decrease in pain with TRS and the patient and HCP satisfaction and acceptance of TRS for peripheral intravenous (PIV) placement. Adults (N = 300) randomized to placebo or TRS and HCPs (N = 300) placing PIVs answered questionnaires. Patients had significantly less pain than with prior PIVs, and were satisfied with and would use TRS in the future (P < 0.001). HCP felt that patients had significantly (P < 0.001) less pain with TRS than the placebo, and were satisfied with the TRS, and would use TRS in the future.Registered at Clinicaltrials.gov NCT01670487.