Serial use of existing clinical decisions aids can reduce computed tomography pulmonary angiography for pulmonary embolism.

Pulmonary embolism (PE) remains a diagnostic challenge in emergency medicine. Clinical decision aids (CDAs) like the Pulmonary Embolism Rule-Out Criteria (PERC) are sensitive but poorly specific; serial CDA use may improve specificity. The goal of this before-and-after study was to determine if serial use of existing CDAs in a novel diagnostic algorithm safely decreases the use of CT pulmonary angiograms (CTPA). This was a retrospective before-and-after study conducted at an urban ED with 105,000 annual visits. Our algorithm uses PERC, Wells' score, and D-dimer in series, before moving to CTPA. The algorithm was introduced in January, 2017. Use of CDAs and D-dimer in the 24 months pre- and 12 months post-intervention were obtained by chart review. The algorithm's effect on CTPA ordering was assessed by comparing volume 5 years pre- and 3 years post-intervention, adjusted for ED volume. Mean CTPAs per 1000 adult ED visits was 11.1 in the 5 pre-intervention years and 9.9 in the 3 post-intervention years (p < 0.0001). Use of PERC, Wells' score and D-dimer increased from 1.1%, 1.1%, and 28% to 8.8% (p = 0.0002) 8.1% (p = 0.0005), and 35% (p = 0.0066), respectively. Pre-intervention, there were six potentially missed PEs compared to three in the post-intervention period. Introduction of our serial CDA diagnostic algorithm was associated with increased use of CDAs and D-dimer and reduced CTPA rate without an apparent increase in the number of missed PEs. Prospective validation is needed to confirm these results.

Do low-dose corticosteroids improve mortality or shock reversal in patients with septic shock? A systematic review and position statement prepared for the American Academy of Emergency Medicine.

BACKGROUND: The management of septic shock has undergone a significant evolution in the past decade. A number of trials have been published to evaluate the efficacy of low-dose corticosteroid administration in patients with septic shock. METHODS: The Sepsis Sub-committee of the American Academy of Emergency Medicine Clinical Practice Committee performed an extensive search of the contemporary literature and identified seven relevant trials. RESULTS: Six of the seven trials reported a mortality outcome of patients in septic shock. Analysis of the data revealed that the relative risk (RR) of 28-day all-cause mortality in septic shock patients who received low-dose corticosteroids was 0.92 (95% confidence interval [CI] 0.79-1.07). All seven trials reported data concerning shock reversal or the withdrawal of vasopressors. Pooled results revealed that the RR of shock reversal is 1.17 (95% CI 1.07-1.28), which suggests that there may be significant improvement in shock reversal after corticosteroid administration. It is important to understand that two of the seven studies reviewed were disproportionately represented and accounted for 799 of 1005 patients (80%) considered for this recommendation. CONCLUSIONS: The evidence suggests that low-dose corticosteroids may reverse shock faster; however, mortality is not improved for the overall population.

Quantifying off-hour emergency physician coverage of in-hospital codes: a survey of community emergency departments.

BACKGROUND: Community emergency physicians (EPs) are often required to respond to unstable patients outside of their department during off-hours. OBJECTIVE: The primary objective of this study was to describe the critical care responsibility of community EPs outside of their departments. METHODS: A one-page survey was mailed to emergency department (ED) directors of 10 states and Washington, DC. RESULTS: Three hundred forty of 1169 surveys were returned. The median (interquartile range [IQR]) number of hospital and intensive care unit (ICU) beds was 145 (IQR 60-242) and 11 (IQR 6-20), respectively. Median ED annual volume and ICU admission percentage was reported to be 25K (IQR 14-40) and 5% (IQR 2-10), respectively. Seventy-six percent of reporting institutions require EPs to leave their department and respond to medical codes on the floors after hours. In 57% of institutions, the EP was the only physician required to respond. In addition, 48% of EPs must respond to unstable patients in the ICUs after hours. Hospitals in which EPs were required to respond to medical codes and unstable ICU patients were more likely to have fewer hospital beds (137 vs. 275; p<0.001), fewer ICU beds (12 vs. 27; p<0.001), and have a smaller ED annual volume (24 K vs. 39 K; p<0.001). CONCLUSIONS: Many community EPs are responsible for covering critically ill patients outside of their ED. Further investigation is required to determine the impact on patient care.