Cardiology consultation reduces provocative testing rates in an ED observation unit.

BACKGROUND: In evaluating patients with chest pain, emergency department observation units (EDOUs) may use a staffing model in which emergency physicians determine patient testing (EP model) or a model similar to a chest pain unit (CPU) in which cardiologists determine provocative testing (CPU model). METHODS: We performed a prospective study with 30-day telephone follow-up for all chest pain patients placed in our EDOU. Halfway through the study period, our EDOU transitioned from an EP model to a CPU model. We compared provocative testing rates and outcomes between the 2 models. RESULTS: Over the 34-month study period, our EDOU evaluated 1190 patients for chest pain. Patients placed in the EDOU during the 17-month CPU model were more likely to be moderate risk (Thrombolysis in Myocardial Infarction score 3-5) than those during the 17-month EP model: 24.9% vs 18.8%, P = .011. Despite this difference, rates of provocative testing (stress testing or coronary computed tomography) were lower during the CPU model: 47.1% vs 56.5%, P = .001. This reduction was particularly evident among low-risk patients (Thrombolysis in Myocardial Infarction score 0-2): 49.8% vs 58.1%, P = .011. Rates of myocardial infarction, percutaneous coronary intervention, or coronary artery bypass graft were similar between the 2 groups (2.8% vs 3.2%, P = .140). We noted no significant events or missed diagnoses in either group during the 30-day follow-up. CONCLUSION: An EDOU model that used mandatory cardiology consultation resulted in decreased provocative testing, particularly among low-risk chest pain patients. Future research should explore the cost-effectiveness of this model.

Emergency Medicine resident anesthesia training in a private vs. academic setting.

BACKGROUND: Airway management is an essential part of any Emergency Medicine (EM) training program. Academic centers typically provide training to many learners at various training levels in a number of medical specialties during anesthesiology rotations. This potentially creates competition for intubation procedures that may negatively impact individual experiences. OBJECTIVES: We hypothesized that residents would report higher numbers of intubations and improved educational value in a private practice, rather than an academic, anesthesiology rotation. METHODS: EM residents' anesthesiology training was evaluated pre and post a change in training setting from an academic institution to a private practice institution. Outcome measures included the number of self-reported intubations, resident ratings of the rotation, and the number of positive comments. Residents' evaluation was measured with: a 14-item evaluation; subjective comments, which two blinded reviewers rated as positive, negative, or neutral; and transcripts from structured interviews to identify themes related to training settings. RESULTS: The number of intubations increased significantly in the private practice setting (4.6 intubations/day vs. 1.5 intubations/day, p < 0.001). Resident evaluations improved significantly with the private practice experience (mean scores of 3.83 vs. 2.23, p-values <0.05). Residents' impressions were also significantly higher for the private practice setting with respect to increased educational value, greater use of adjunct airway devices, and directed teaching. CONCLUSIONS: Number of intubations performed and residents' rating of the educational value were more favorable for a private practice anesthesiology rotation. Alternative settings may provide benefit for training in areas that have competition among trainees.

Prospective evaluation of the use of the thrombolysis in myocardial infarction score as a risk stratification tool for chest pain patients admitted to an ED observation unit.

BACKGROUND: The Thrombolysis in Myocardial Infarction (TIMI) score has shown use in predicting 30-day and 1-year outcomes in emergency department (ED) patients with potential acute coronary syndrome. Few studies have evaluated the TIMI score in risk stratifying patients selected for the ED observation Unit (EDOU). Risk stratification of patients in this group could identify those at risk for significant cardiac events. Our goal was to evaluate TIMI use for risk stratification in this population and compare outcomes among differing scores. METHODS: A prospective observational study with 30-day telephone follow-up for a 12 month period. Baseline data, outcomes related to EDOU stay, admission, and 30-day outcomes were recorded. TIMI scores were calculated for each patient placed in EDOU. TIMI score was not utilized in the decision to place patients in observation. RESULTS: N = 552. Composite outcomes recorded were myocardial infarction, revascularization, or death either during the EDOU stay, inpatient admission, or the 30-day follow-up. Eighteen composite outcomes were recorded: stent (12 patients), coronary artery bypass graft (3 patients), myocardial infarction and stent (2 patients), and myocardial infarction, and coronary artery bypass graft (1 patient). Distribution by TIMI score was: 0 (102 patients), 1 (196), 2 (142), 3 (72), 4 (27), and 5 (5). Risk of composite outcome increased by score: 0 (1%), 1 (2.6%), 2 (2.1%), 3 (6.9%), 4 (11.1%), and 5 (20%). Those with an intermediate risk score (3-5) were also more likely to require admission (15.4% vs 9.8%, P = .048). CONCLUSION: The TIMI risk score may serve as an effective risk stratification tool among chest pain patients selected for EDOU placement. Patients with intermediate-risk by TIMI may be considered for inpatient admission and/or more aggressive evaluation and therapy.

Intranasal sufentanil for the treatment of acute pain in a winter resort clinic.

INTRODUCTION: Painful extremity injuries are common patient complaints in resort clinics, urgent care clinics, and emergency departments. We hypothesized that intranasal (IN) sufentanil could provide rapid, noninvasive, effective pain relief to patients presenting with acute extremity injuries. METHODS: This was an unblinded, nonrandomized, observational study that enrolled a convenience sample of patients presenting to a university-affiliated ski clinic with acute moderate to severe pain associated with a traumatic injury between the months of January and March 2011. Patients were excluded if they reported an allergy to sufentanil or had hypoxia, significant head injury, or hypotension. Nurses administered IN sufentanil using an IN atomizer device. The nurse recorded patient-reported pain scores (0-10 scale) on arrival and at 10, 20, and 30 minutes after administration of sufentanil. RESULTS: During the study period, 40 patients were enrolled; 75% were men. The average age was 32 years (range, 16-60 years). The average dose of sufentanil was 37.7 µg. Five patients (12.5%) were given additional IN analgesia. Average pain on arrival was 9 (on a 10-point scale), and the mean reduction in pain scores was 4.7 (95% confidence interval [CI], 3.67-5.57) at 10 minutes, 5.79 (95% CI, 4.81-6.77) at 20 minutes, and 5.74 (95% CI, 4.72-6.76) at 30 minutes. CONCLUSION: In this limited observational trial, IN sufentanil provided rapid, safe, and noninvasive pain relief to patients presenting with acute traumatic extremity injuries. Given the ease of administration, this may serve as a viable option for use in other settings, such as urgent care clinics and emergency departments.

Prospective evaluation of the treatment of intermediate-risk chest pain patients in an emergency department observation unit.

BACKGROUND: Emergency department observation units (EDOUs) serve an important role in the evaluation and risk stratification of low-risk chest pain patients. OBJECTIVES: Our goal was to evaluate our EDOU protocol for intermediate-risk chest pain patients and compare outcomes and inpatient admission rates for low-risk and intermediate-risk patients. METHODS: Prospective observational study with 30-day telephone follow-up for all chest pain patients admitted to our EDOU from June 1, 2009 to May 31, 2010. Our protocol for intermediate-risk chest pain patients includes patients with a self-reported history of coronary artery disease and negative initial cardiac testing in the emergency department. The EDOU protocol involves telemetry, serial cardiac biomarker testing, and mandatory cardiology consultation. RESULTS: A total of 552 chest pain patients were evaluated, including 100 (18.1%) intermediate-risk and 452 (81.9%) low-risk patients. Intermediate-risk chest pain patients were significantly more likely to have a myocardial infarction or undergo revascularization (stent or coronary artery bypass graft) (8.0% vs. 2.2%, P = 0.008). Intermediate-risk patients had a higher inpatient admission rate (16.0% vs. 8.8%, P = 0.032). There were no significant unanticipated adverse events at 30-day follow-up in either group. CONCLUSIONS: In conclusion, intermediate-risk chest pain patients in an EDOU had higher rates of significant cardiac events and inpatient admission. Intermediate-risk patients may be appropriate for EDOU placement, given the acceptable inpatient admission rate and the lack of significant adverse events in the 30-day follow-up period. However, given the higher rate of significant cardiac events, the results of our study emphasize the need for increased vigilance and close cardiology consultation in the intermediate-risk group.

Prospective evaluation of an ED observation unit protocol for trauma activation patients.

BACKGROUND: The University of Utah emergency department (ED) observation unit (EDOU) cares for over 2500 patients each year, with a significant portion of these patients being trauma activation patients. We evaluated the safety and efficacy of our EDOU trauma protocol and described patient characteristics and outcomes of trauma patients managed in an EDOU. METHODS: We performed a prospective observational study of all trauma patients admitted to the EDOU over a 1-year period. Patient disposition, interventions, and adverse events during observation were recorded. Thirty-day follow-up was performed by telephone and chart review to evaluate for missed injuries, repeat hospitalizations, or repeat traumatic events. RESULTS: A total of 259 trauma patients were admitted to the EDOU during the study period and were contacted at least 30 days after discharge. There were no deaths, intubations, or other adverse events. At 30-day follow-up, there was 1 missed injury, which did not result in an adverse outcome. Ten patients were reevaluated in the ED or required hospitalization for events occurring after their initial EDOU stay but related to their initial trauma evaluation. The inpatient admission rate from the EDOU was 10.4%, and 3.1% of patients reported another traumatic event during the 30-day follow-up period. CONCLUSIONS: There were no adverse outcomes in trauma patients admitted to the EDOU, and our inpatient admission rate was within the generally accepted admission rate for patients in observation status. The EDOU appears to be a safe alternative to inpatient admission for the evaluation of minimally injured trauma activation patients.

Characteristics of the first two years of applicants to a new emergency medicine residency program.

BACKGROUND: To the best of our knowledge, no study has compared the effect of using the Electronic Residency Application Service (ERAS) on applicant pool characteristics for a new emergency medicine (EM) residency program. OBJECTIVE: We sought to compare applicants in an EM residency program's first year, in which the ERAS is not typically used, to applicants in year 2 (using ERAS). METHODS: We reviewed the applications to the new University of Utah EM residency program for the entering classes of 2005 (year 1) and 2006 (year 2). RESULTS: In total, 130 and 458 prospective residents applied during year 1 and year 2, respectively. Applicants using and not using ERAS were similar in average Step 1 score (211.8 vs. 212.4, respectively; p = 0.791), previously failed Step 1 or Step 2 attempt (12.1% vs. 11.0%, respectively; p = 0.729), previous failure to match in a residency program (8.6% vs. 4.6%, respectively; p = 0.083), previous residency training (18.8% vs. 14.9%, respectively; p = 0.288), and the percent who had completed an EM clerkship (95.3% vs. 93.0%, respectively; p = 0.342). Applicants not using ERAS were more likely to have been remediated in medical school (13.2% vs. 4.2%; p < 0.001) and to have a Standardized Letter of Recommendation (SLOR) (87% vs. 78%; p = 0.024). Applicants using ERAS were more likely to have a SLOR match estimate of "very competitive" (38.2% vs. 54.1%; p = 0.004). Applicants were similar in having attended a "top tier" medical school (44.5% vs. 41.3%, p = 0.508). CONCLUSION: Despite significantly fewer applicants, those applying without the use of ERAS to a new EM residency program were generally comparable to the applicant pool that did permit the use of ERAS. The larger number of applicants the second year likely reflects the use of ERAS.

Low-risk young adult patients with chest pain may not benefit from routine cardiac stress testing: a Bayesian analysis.

INTRODUCTION: Low-risk emergency department (ED) chest pain patients with a nondiagnostic electrocardiogram (ECG) and negative cardiac biomarkers are commonly evaluated with cardiac stress testing to detect undiagnosed coronary artery disease. Provocative testing incurs certain costs and may require additional time investment either in the ED or in an observation setting. Recent research has questioned the utility of provocative testing in young adults with negative cardiac biomarkers and nondiagnostic ECG. We sought to evaluate the utility of cardiac stress testing in our population of young adult patients with chest pain. METHODS: We performed a retrospective chart review of all chest pain patients aged 40 years and younger who were admitted to our ED observation unit over the 14-month period between April 2006 and May 2007. We included all patients who were admitted to the observation unit for serial biomarkers and provocative testing and had normal or nondiagnostic ECG, no history of coronary disease, and an initial negative troponin. We recorded baseline characteristics and stress test results of these patients and reviewed the patient charts for the 30-day period following discharge to identify repeat hospital visits and adverse events. We used Bayesian analysis to estimate the rate of true-positive stress testing in this population, using the only prior study of unit patients showing as high as 2 of 220 patients testing positive as a prior estimate. RESULTS: A total of 36 patients met inclusion criteria; average age was 34.6 years old (range: 22-40 years) and 61% were male. Patient risk factors included hypertension (19%), diabetes (6%), family history (42%), and smoking (44%). All patients had negative serial cardiac biomarkers and a negative treadmill stress echocardiogram. Thirty-day follow-up demonstrated no adverse cardiac events. We performed Bayesian analysis through the addition of the 36 patients to the 220 patients represented by prior data. The posterior probability distribution changed slightly in location and scale gave a median estimated rate of positive stress testing in this population of 1.04% (95% credible interval, 0.24%-2.78%). CONCLUSIONS: The population of chest pain patients younger than 40 years with no history of coronary disease, a nondiagnostic ECG, and negative serial biomarkers may not benefit from provocative testing. Our findings complement those reported previously on the limited utility of cardiac stress testing in this population.

Evaluating applicants to a new emergency medicine residency program: subjective assessment of applicant characteristics.

BACKGROUND: Because of the Accreditation Council for Graduate Medical Education (ACGME) and the Residency Review Committee (RRC) approval timelines, new residency programs cannot use Electronic Residency Application Service (ERAS) during their first year of applicants. AIM: We sought to identify differences between program directors' subjective ratings of applicants from an emergency medicine (EM) residency program's first year (in which ERAS was not used) to their ratings of applicants the following year in which ERAS was used. METHOD: The University of Utah Emergency Medicine Residency Program received approval from the ACGME in 2004. Applicants for the entering class of 2005 (year 1) did not use ERAS, submitting a separate application, while those applying for the following year (year 2) used ERAS. Residency program directors rated applicants using subjective components of their applications, assigning scores on scales from 0-10 or 0-5 (10 or 5 = highest score) for select components of the application. We retrospectively reviewed and compared these ratings between the 2 years of applicants. RESULTS: A total of 130 and 458 prospective residents applied during year 1 and year 2, respectively. Applicants were similar in average scores for research (1.65 vs. 1.81, scale 0-5, p = 0.329) and volunteer work (5.31 vs. 5.56, scale 0-10, p = 0.357). Year 1 applicants received higher scores for their personal statement (3.21 vs. 2.22, scale 0-5, p < 0.001), letters of recommendation (7.0 vs. 5.94, scale 0-10, p < 0.001), dean's letter (3.5 vs. 2.7, scale 1-5, p < 0.001), and in their potential contribution to class characteristics (4.64 vs. 3.34, scale 0-10, p < 0.001). CONCLUSION: While the number of applicants increased, the use of ERAS in a new residency program did not improve the overall subjective ratings of residency applicants. Year 1 applicants received higher scores for the written components of their applications and in their potential contributions to class characteristics.

Utility of the emergency department observation unit in ensuring stress testing in low-risk chest pain patients.

BACKGROUND: Recent research has noted low rates of compliance among ED chest pain patients referred for outpatient stress testing. The practice at our institution, a 39,000 visits per year emergency department (ED), is to place chest pain patients considered low risk for acute coronary syndrome in an observation unit for serial biomarker testing and provocative cardiac testing. Our objective was to determine the rates of positive stress tests among this group and to extrapolate from this the potential missed positive stress tests if these patients were referred instead for outpatient stress testing. METHODS: This was a retrospective chart review of all chest pain patients admitted to the ED observation unit between April 2006 and June 2007. Baseline information, including a history of coronary disease, was recorded. Patients underwent a treadmill stress test, nuclear stress test, or coronary CT scan at the discretion of the attending emergency physician and/or the consulting cardiologist. Rates of positive stress test or coronary CT and patient disposition (admission to an inpatient unit versus discharge for outpatient follow-up) were noted. RESULTS: A total of 353 patients underwent stress testing or coronary CT during the study period: 257 (72.8%) patients had an exercise treadmill echocardiogram, 61 (17.3%) patients underwent nuclear stress testing, and 35 (9.9%) patients had a coronary CT. Seventy patients (19.8%) had a history of coronary disease but had been considered appropriate for observation by the attending emergency physician. Thirty-nine stress tests were positive (11%) and 11 were indeterminate (3.1%). Among patients with no history of coronary disease, 20 stress tests were positive (7.1%), and 10 were indeterminate (3.5%). Of all patients with a positive stress test, 19 (48.7%) underwent cardiac catheterization and 1 (2.6%) had coronary artery bypass graft. Twenty-one of 39 patients with a positive stress test (54%) were ultimately admitted to an inpatient unit per the recommendation of the consulting cardiologist. Assuming a best-case scenario in which 70% of patients referred for outpatient stress testing actually have the testing done (based on a recent report of outpatient compliance), physicians would miss approximately 3.3% of patients with a positive stress test if these patients were discharged directly from the ED. CONCLUSION: Among chest pain patients admitted to an ED observation unit, the rate of positive stress tests was 11%. Approximately 3.3% of patients with positive stress tests may have been missed if these patients were instead referred for outpatient testing.

Etomidate for procedural sedation in the emergency department.

STUDY OBJECTIVE: To review our experience with etomidate in nonintubated patients in the emergency department. DESIGN: A 2-year retrospective chart review of consecutive patients receiving etomidate for sedation. SETTING: Emergency department of a university-based teaching hospital. PATIENTS: Forty-eight patients who underwent painful procedures in the emergency department. MEASUREMENTS AND MAIN RESULTS: Demographics, dosing information, recovery times, and adverse events were abstracted using a standardized data collection form. Forty-eight nonintubated patients were sedated with etomidate. Mean age was 34 years (range 6-80 yrs); 38 were men and 10 women; two were children. The mean initial dose of etomidate was 13 mg. Adverse events occurred in 11 (21%) patients. None sustained any substantial morbidity as indicated by need for intubation, prolonged emergency department stay, or hospital admission. CONCLUSION: Although controversial, etomidate holds promise as a potent sedative agent for patients undergoing painful procedures in the emergency department. A large prospective evaluation is needed to document the performance and complications of this agent.