Clinical predictors of endotracheal intubation in patients presenting to the emergency department with angioedema.

OBJECTIVES: The objective of this study is to identify predictors of airway compromise among patients presenting to the emergency department with angioedema in order to develop and validate a risk score to augment clinician gestalt regarding need for intubation. METHODS: Retrospective chart review of emergency department patients with a diagnosis of angioedema. After data extraction they were randomly divided into a training and test set. The training set was used to identify factors associated with intubation and to develop a model and risk score to predict intubation. The model and risk score were then applied to the test set. RESULTS: A total of 594 patients were included. Past medical history of hypertension, presence of shortness of breath, drooling, and anterior tongue or pharyngeal swelling were independent predictors included in our final model and risk score. The Area Under the Curve for the Receiver Operator Characteristic curve was 87.55% (83.42%-91.69%) for the training set and 86.1% (77.62%-94.60%) for the test set. CONCLUSIONS: A simple scoring algorithm may aid in predicting angioedema patients at high and low risk for intubation. External validation of this score is necessary before wide-spread adoption of this decision aid.

Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Acute Headache

This clinical policy from the American College of Emergency Physicians addressed key issues in the evaluation and management of adult patients presenting to the emergency department with acute headache. 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 presenting with acute headache, are there risk-stratification strategies that reliably identify the need for emergent neuroimaging? (2) In the adult emergency department patient treated for acute primary headache, are nonopioids preferred to opioid medications? (3) In the adult emergency department patient presenting with acute headache, does a normal noncontrast head computed tomography scan performed within 6 hours of headache onset preclude the need for further diagnostic workup for subarachnoid hemorrhage? (4) In the adult emergency department patient who is still considered to be at risk for subarachnoid hemorrhage after a negative noncontrast head computed tomography, is computed tomography angiography of the head as effective as lumbar puncture to safely rule out subarachnoid hemorrhage? Evidence was graded and recommendations were made based on the strength of the available data.

Correction: Correction to 'Clinical Policy: Procedural Sedation and Analgesia in the Emergency Department' [Annals of Emergency Medicine 63 (2014) 247-258.e18].

Due to a miscommunication during the process of transferring this manuscript from our editorial team to Production, the Members of the American College of Emergency Physicians Clinical Policies Committee (Oversight Committee) were not properly indexed in PubMed. This has now been corrected online. This has now been corrected online. The publisher would like to apologize for any inconvenience caused.

Naloxone Triggering the RRT: A Human Antidote?

OBJECTIVES: At our institution, we observed an increase in opioid-related adverse events after instituting a new pain treatment protocol. To prevent this, we programmed the Omnicell drug dispensing system to page the RRT whenever naloxone was withdrawn on the general wards. METHODS: Retrospective review of a prospectively collected database with a before and after design. RESULTS: When comparing the two 12-month periods, there was a decrease in monthly opioid-related cardiac arrests from 0.75 to 0.25 per month (difference = 0.5; 95% CI, 0.04-0.96, P = 0.03) and a nearly significant decrease in code deaths from 0.25 to 0 per month (difference = -0.25; 95% CI, -0.02-0.52, P = 0.07) without a significant decrease in pain satisfaction scores (difference = -2.3; 95% CI, -4.4 to 9.0, P = 0.48) over the study period. There were also decreased RRT interventions from 7.3 to 5.6 per month (difference = -1.7; 95% CI, -0.31 to -3.03, P = 0.02) and decreased inpatient transfers from 2.9 to 1.8 transfers per month (difference = -1.2; 95% CI, -0.38 to -1.96, P = 0.005). When adjusting for inpatient admissions and inpatient days, there was a decrease in opioid-related cardiac arrests from 2.9 to 0.1 per 10,000 admissions (difference = -2.0; 95% CI, -0.2 to -3.8, P = 0.03) and a decrease in cardiac arrests from 0.5 to 0.2 per 10,000 patients (difference = -0.34; 95% CI, -.02 to -0.65, P = 0.04). CONCLUSION: Naloxone-triggered activation of the RRT resulted in reduced opioid-related inpatient cardiac arrests without adversely affecting pain satisfaction scores.

End-tidal carbon dioxide and occult injury in trauma patients: ETCO2 does not rule out severe injury.

OBJECTIVE: To determine if early measurement of end-tidal carbon dioxide (ETCO2) in nonintubated patients triaged to a level 1 trauma center has utility in ruling out severe injury. METHODS: We performed a prospective cohort study of adult patients triaged to our urban, academic, level 1 trauma center. Included patients had ETCO2 measured within 30 minutes of arrival. Chart review was performed on enrolled patients to identify severe injury defined by: admission to an intensive care unit, need for an invasive procedure, blood product transfusion, acute blood loss anemia, and acute clinically significant finding on computed tomographic scan. RESULTS: Of 170 patients enrolled, 115 met the outcome of no severe injury. Mean ETCO2 for patients without and with severe injury was 33.1 mm Hg (SD, 5.8) and 30.3 mm Hg (SD, 6.7), respectively. This difference reached statistical significance (P=.05), but did not demonstrate added clinical utility when combined with Glasgow Coma Scale, systolic blood pressure, and age in predicting the primary outcome (area under curve, 0.70 with ETCO2 vs area under curve, 0.68 without ETCO2, P=.5). Patients with ETCO2 ≤30 mm Hg were found to be older, more likely to require intensive care unit admission or emergency operative intervention, develop acute blood loss anemia, and have an acute finding on computed tomography than patients with a higher ETCO2. CONCLUSION: End-tidal carbon dioxide cannot be used to rule out severe injury in patients meeting criteria for trauma center care. The ETCO2 ≤30 mm Hg may be associated with increased risk of traumatic severe injury.

SimWars.

BACKGROUND: Simulation use for training residents has become an expectation in emergency medicine in order to improve the educational dimensions of cognitive knowledge, critical thinking, psychomotor skills, and clinical performance. DISCUSSION: This article is a descriptive piece highlighting a novel group education format-"SimWars." The keys to a successful SimWars competition, including descriptions of necessary personnel and tips on effective case development, as well as lessons learned from its development and implementation, are described. After reading this article, educators will have the background necessary to implement their own simulation-enhanced training sessions. CONCLUSIONS: SimWars gives educators an opportunity to watch the decision-making process of the learners as they manage simulated complex scenarios in a cooperative competitive environment.

Impact of an abbreviated cardiac enzyme protocol to aid rapid discharge of patients with cocaine-associated chest pain in the clinical decision unit.

INTRODUCTION: In 2007 there were 64,000 visits to the emergency department (ED) for possible myocardial infarction (MI) related to cocaine use. Prior studies have demonstrated that low- to intermediate-risk patients with cocaine-associated chest pain can be safely discharged after 9-12 hours of observation. The goal of this study was to determine the safety of an 8-hour protocol for ruling out MI in patients who presented with cocaine-associated chest pain. METHODS: We conducted a retrospective review of patients treated with an 8-hour cocaine chest pain protocol between May 1, 2011 and November 30, 2012 who were sent to the clinical decision unit (CDU) for observation. The protocol included serial cardiac biomarker testing with Troponin-T, CK-MB (including delta CK-MB), and total CK at 0, 2, 4, and 8 hours after presentation with cardiac monitoring for the observation period. Patients were followed up for adverse cardiac events or death within 30 days of discharge. RESULTS: There were 111 admissions to the CDU for cocaine chest pain during the study period. One patient had a delta CK-MB of 1.6 ng/ml, but had negative Troponin-T at all time points. No patient had a positive Troponin-T or CK-MB at 0, 2, 4 or 8 hours, and there were no MIs or deaths within 30 days of discharge. Most patients were discharged home (103) and there were 8 inpatient admissions from the CDU. Of the admitted patients, 2 had additional stress tests that were negative, 1 had additional cardiac biomarkers that were negative, and all 8 patients were discharged home. The estimated risk of missing MI using our protocol is, with 99% confidence, less than 5.1% and with 95% confidence, less than 3.6% (99% CI, 0-5.1%; 95% CI, 0-3.6%). CONCLUSION: Application of an abbreviated cardiac enzyme protocol resulted in the safe and rapid discharge of patients presenting to the ED with cocaine-associated chest pain.

Clinical policy: procedural sedation and analgesia in the emergency department.

This clinical policy from the American College of Emergency Physicians is the revision of a 2005 clinical policy evaluating critical questions related to procedural sedation in the emergency department.1 A writing subcommittee reviewed the literature to derive evidence-based recommendations to help clinicians answer the following critical questions: (1) In patients undergoing procedural sedation and analgesia in the emergency department,does preprocedural fasting demonstrate a reduction in the risk of emesis or aspiration? (2) In patients undergoing procedural sedation and analgesia in the emergency department, does the routine use of capnography reduce the incidence of adverse respiratory events? (3) In patients undergoing procedural sedation and analgesia in the emergency department, what is the minimum number of personnel necessary to manage complications? (4) Inpatients undergoing procedural sedation and analgesia in the emergency department, can ketamine, propofol, etomidate, dexmedetomidine, alfentanil and remifentanil be safely administered? A literature search was performed, the evidence was graded, and recommendations were given based on the strength of the available data in the medical literature.

Proactive rounding by the rapid response team reduces inpatient cardiac arrests.

OBJECTIVE: Rapid response teams (RRTs) are frequently employed to respond to deteriorating inpatients. Proactive rounding (PR) consists of the RRT nurse rounding through the inpatient wards identifying high risk patients and intervening preemptively. At our institution, PR began in July of 2007. Our objective was to determine the effect of PR by the RRT at our institution on non-ICU cardiac arrests, code deaths, RRT interventions, and transfers to a higher level of care. Also, to report ICU transfer survival and survival to discharge rates after the start of PR. DESIGN: Retrospective review of a prospectively collected database. SETTING: A tertiary, academic, level 1 trauma center with 696 beds and a rapid response system. PATIENTS: 1253 Non-ICU cardiac arrests from 2005 through June of 2012. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The total study period included 223,267 inpatient admissions (70,129 pre-PR and 153,138 post-PR) and 1,250,814 patient days (391,088 pre-PR and 859,726 post-PR). The quarterly code rate before PR was 66 and the code rate after the institution of PR was 30 (difference=36.8, 95% CI 25.6-48.0, p<.001). Quarterly code deaths decreased from 29 to 7 (difference=21.95, 95% CI 16.3-27.6, p<.001). This decrease in floor codes and code deaths was still present after adjusting for inpatient admission and inpatient days. Average quarterly RRT interventions increased from 141 in the pre-PR period to 690 in the post-PR period (difference=549, 95% CI 360-738, p<.001). Average quarterly transfers to HLC went up from 38 pre-PR to 164 post-PR (difference=126, 95% CI 79-172, p<.001). CONCLUSIONS: The institution of proactive rounding at a tertiary care, academic, level 1 trauma center results in reduced floor codes and code deaths as well as increased RRT interventions and transfers to a higher level of care.

Simulation center accreditation and programmatic benchmarks: a review for emergency medicine.

Simulation-based education has grown significantly over the past 10 years. As a result, more professional organizations are developing or implementing accreditation processes to help define minimum standards and best practices in simulation-based training. However, the benefits and potential pitfalls of sponsoring and implementing such programs have yet to be fully evaluated across specialties. The board of directors of the Society for Academic Emergency Medicine (SAEM) requested an evaluation of the potential to create an emergency medicine (EM)-based Simulation Consultation and Accreditation Service. In response to this request, the Simulation Accreditation and Consultation Work Group, a subgroup of the Committee on Technology in Medical Education (now Simulation Academy), was created. The work group was charged with: 1) reviewing current benchmarks and standards set by existing simulation accreditation programs; 2) analyzing current EM simulation program structures, including leadership, administrative, and financial components; and 3) proposing a potential model for EM-based simulation accreditation. This article outlines currently existing and proposed accreditation models and identifies components that support best practices. It then goes on to describe three general programmatic models to better understand how simulation training can be operationalized in EM. Finally, the work group uses this collective information to propose how an accreditation process, in concert with the SAEM Simulation Consultation Service, can enhance and advance EM simulation training.

Successful implementation of a family and patient activated rapid response team in an adult level 1 trauma center.

BACKGROUND: When cardiac arrests occur in hospitalized patients, delays in treatment are associated with lower survival and poorer outcomes. Patients often show a physiological deterioration hours before cardiac or pulmonary arrest. As a result, many hospitals have implemented a rapid response team (RRT) as part of their involvement in the 100,000 Lives Campaign sponsored by the Institute for Healthcare Improvement. METHOD: In conjunction with the University Health System Consortium (UHC) Patient- and Family-Centered Care Implementation Collaborative, Shands Jacksonville Medical Center (SJMC) launched a pilot RRT program in October 2006 followed by campus-wide implementation in July 2007. The program was enhanced to allow patient and family activation of the RRT in October 2007. RESULTS: A review of the first 2 years of data indicates that the SJMC RRT received 25 patient or family activated calls. Forty-eight percent of the calls were initiated by a family member and 52% by the actual patient. Reasons for the calls have varied but the most frequent reason identified by the patient or family member was "something just doesn't feel right" with the patient. Other leading reasons for calls were similar to criteria that are used by staff-initiated calls, such as shortness of breath and pain issues. CONCLUSION: This is one of the first initiations of a family activated component of the RRT in an adult hospital that has led to improvements in outcomes such as reduction in mortality rates and non-ICU codes, without an overload of false positive calls.

Range-wide genetic differentiation among North American great gray owls (Strix nebulosa) reveals a distinct lineage restricted to the Sierra Nevada, California.

Investigations of regional genetic differentiation are essential for describing phylogeographic patterns and informing management efforts for species of conservation concern. In this context, we investigated genetic diversity and evolutionary relationships among great gray owl (Strix nebulosa) populations in western North America, which includes an allopatric range in the southern Sierra Nevada in California. Based on a total dataset consisting of 30 nuclear microsatellite DNA loci and 1938-base pairs of mitochondrial DNA, we found that Pacific Northwest sampling groups were recovered by frequency and Bayesian analyses of microsatellite data and each population sampled, except for western Canada, showed evidence of recent population bottlenecks and low effective sizes. Bayesian and maximum likelihood phylogenetic analyses of sequence data indicated that the allopatric Sierra Nevada population is also a distinct lineage with respect to the larger species range in North America; we suggest a subspecies designation for this lineage should be considered (Strix nebulosa yosemitensis). Our study underscores the importance of phylogeographic studies for identifying lineages of conservation concern, as well as the important role of Pleistocene glaciation events in driving genetic differentiation of avian fauna.

Clinical policy: Critical issues in the evaluation and management of adult patients presenting to the emergency department with acute headache.

This clinical policy from the American College of Emergency Physicians is an update of a 2002 clinical policy on the evaluation and management of adult patients presenting to the emergency department (ED) with acute, nontraumatic headache. A writing subcommittee reviewed the literature to derive evidence-based recommendations to help clinicians answer the following 5 critical questions: (1) Does a response to therapy predict the etiology of an acute headache? (2) Which patients with headache require neuroimaging in the ED? (3) Does lumbar puncture need to be routinely performed on ED patients being worked up for nontraumatic subarachnoid hemorrhage whose noncontrast brain computed tomography (CT) scans are interpreted as normal? (4) In which adult patients with a complaint of headache can a lumbar puncture be safely performed without a neuroimaging study? (5) Is there a need for further emergent diagnostic imaging in the patient with sudden-onset, severe headache who has negative findings in both CT and lumbar puncture? Evidence was graded and recommendations were given based on the strength of the available data in the medical literature.

Defining team performance for simulation-based training: methodology, metrics, and opportunities for emergency medicine.

Across health care, teamwork is a critical element for effective patient care. Yet, numerous well-intentioned training programs may fail to achieve the desired outcomes in team performance. Hope for the improvement of teamwork in health care is provided by the success of the aviation and military communities in utilizing simulation-based training (SBT) for training and evaluating teams. This consensus paper 1) proposes a scientifically based methodology for SBT design and evaluation, 2) reviews existing team performance metrics in health care along with recommendations, and 3) focuses on leadership as a target for SBT because it has a high likelihood to improve many team processes and ultimately performance. It is hoped that this discussion will assist those in emergency medicine (EM) and the larger health care field in the design and delivery of SBT for training and evaluating teamwork.

Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with acute headache.

This clinical policy from the American College of Emergency Physicians is an update of a 2002 clinical policy on the evaluation and management of adult patients presenting to the emergency department (ED) with acute, nontraumatic headache. A writing subcommittee reviewed the literature to derive evidence-based recommendations to help clinicians answer the following 5 critical questions: (1) Does a response to therapy predict the etiology of an acute headache? (2) Which patients with headache require neuroimaging in the ED? (3) Does lumbar puncture need to be routinely performed on ED patients being worked up for nontraumatic subarachnoid hemorrhage whose noncontrast brain computed tomography (CT) scans are interpreted as normal? (4) In which adult patients with a complaint of headache can a lumbar puncture be safely performed without a neuroimaging study? (5) Is there a need for further emergent diagnostic imaging in the patient with sudden-onset, severe headache who has negative findings in both CT and lumbar puncture? Evidence was graded and recommendations were given based on the strength of the available data in the medical literature.