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3.
Acad Emerg Med ; 2019 Nov 15.
Artigo em Inglês | MEDLINE | ID: mdl-31733003

RESUMO

OBJECTIVE: More than 2 million patients present to a US emergency department (ED) annually and leave without being seen (LWBS) due to delays in initiating care. We evaluated whether tele-intake at the time of presentation would reduce LWBS rates and ED throughput measures. METHODS: We conducted a before and after study at an urban community hospital. The intervention was use of a tele-intake physician to triage patients from 11am - 6pm, 7 days per week. Tele-intake providers performed a triage history and physical examination, documented findings and initiated orders in the medical record. We assessed the impact of this program using the domains of the National Quality Forum (NQF) framework evaluating access, provider experience, and effectiveness of care. The main outcome was 24-hour LWBS rate. Secondary outcomes were overall door to provider and door to disposition times, left without treatment complete (LWTC), left against medical advice (AMA), left without treatment (LWOT) and physician experience. We compared the 6-month tele-intake period to the same period from the prior year (October 1- April 1, 2017 versus 2016). Additionally, we conducted a survey of our physicians to assess their experience with the program. RESULTS: Total ED volume was similar in the before and after periods (19,892 vs 19,646 patients). The 24-hour LWBS rate was reduced from 2.30% (95% CI 2.0-2.5%) to 1.69%; (1.51-1.87%); p<0.001. Overall door to provider time decreased (median 19 [IQR,9-38] v 16.2 [7.8-34.3] minutes; p<0.001); but ED length of stay for all patients (defined as door in to door out time for all patients) minimally increased (184 minutes [IQR, 100-292] v 184.3 [IQR, 104.4-300]; p<0.001). There was an increase in door to discharge times (146 [IQR, 83-231] v 148 [IQR, 88.2-233.6]; p<0.001) and door to admit times (330 [IQR,253-432] v 357.6 [260.3-514.5]; p<0.001). We saw an increase in LWTC [0.59% (95% CI 0.49-0.70 v 1.1% (CI 0.9-1.2); p<0.001], but no change in AMA [1.4% (95% CI 1.2 - 1.6) v 1.6% (95% CI 1.4-1.78), p=0.21] or LWOT [4.3% (95% CI 4.1-4.6) v 4.4% (95% CI 4.1-4.7), p=0.7. Tele-intake providers thought tele-intake added value (12/15, 80%) and allowed them to effectively address medical problems (14/15, 95%), but only (10/15, 67%) thought it was as good as in-person triage. Of the receiving physicians, most agreed with statements that tele-intake did not interfere with care (19/22, 86%), helped complement care (19/21, 90%) and gave the patient a better experience (19/22, 86%). CONCLUSION: Remote tele-intake provided in an urban community hospital ED reduced LWBS and time to provider but increased left without treatment complete rates and had no impact on LWOT.

4.
Mol Psychiatry ; 2019 Nov 19.
Artigo em Inglês | MEDLINE | ID: mdl-31745239

RESUMO

Adverse posttraumatic neuropsychiatric sequelae (APNS) are common among civilian trauma survivors and military veterans. These APNS, as traditionally classified, include posttraumatic stress, postconcussion syndrome, depression, and regional or widespread pain. Traditional classifications have come to hamper scientific progress because they artificially fragment APNS into siloed, syndromic diagnoses unmoored to discrete components of brain functioning and studied in isolation. These limitations in classification and ontology slow the discovery of pathophysiologic mechanisms, biobehavioral markers, risk prediction tools, and preventive/treatment interventions. Progress in overcoming these limitations has been challenging because such progress would require studies that both evaluate a broad spectrum of posttraumatic sequelae (to overcome fragmentation) and also perform in-depth biobehavioral evaluation (to index sequelae to domains of brain function). This article summarizes the methods of the Advancing Understanding of RecOvery afteR traumA (AURORA) Study. AURORA conducts a large-scale (n = 5000 target sample) in-depth assessment of APNS development using a state-of-the-art battery of self-report, neurocognitive, physiologic, digital phenotyping, psychophysical, neuroimaging, and genomic assessments, beginning in the early aftermath of trauma and continuing for 1 year. The goals of AURORA are to achieve improved phenotypes, prediction tools, and understanding of molecular mechanisms to inform the future development and testing of preventive and treatment interventions.

6.
Clin Exp Emerg Med ; 6(2): 106-112, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31261481

RESUMO

OBJECTIVE: Cardiogenic syncope can present as a seizure. The distinction between seizure disorder and cardiogenic syncope can only be made if one considers the diagnosis. Our main objective was to identify whether patients presenting with a chief complaint (reason for visit) as seizure or syncope received an electrocardiogram in the emergency department across all age groups. METHODS: We conducted a secondary analysis of data collected in the 2010 to 2014 National Hospital Ambulatory Medical Care Survey comparing patients presenting with a chief complaint of syncope versus seizure to determine likelihood of getting an evaluation for possible life threatening cardiovascular disease. The primary endpoint was receiving an electrocardiogram in the emergency department; secondary endpoint was receiving cardiac biomarkers. RESULTS: There was a total of 144,094 patient encounters. Of these visits, 1,553 had syncope and 1,470 had seizure (60.3% vs. 44.2% female, 19.9% vs. 29.0% non-white). After adjusting for age, sex, mode of arrival and insurance, patients with syncope were more likely to receive an electrocardiogram compared to patients with seizure (odds ratio, 10.86; 95% confidence interval [CI], 8.52 to 13.84). This was true across all age groups (0 to 18 years, 56% vs. 7.5%; 18 to 44 years, 60% vs. 27%; 45 to 64 years, 82% vs. 41%; ≥65 years, 85% vs. 68%; P<0.01 for all). Car- diac biomarkers were also obtained more frequently in adult patients with syncope patients (18 to 44 years, 17.5% vs. 10.5%; 45 to 64 years, 33.8% vs. 21.4%; ≥65 years, 47.1% vs. 32.3%; P<0.01 for all). CONCLUSION: Patients evaluated in the emergency department for syncope received an electrocar- diogram and cardiac biomarkers more frequently than those that had seizure.

7.
Curr Hypertens Rep ; 21(8): 58, 2019 Jun 12.
Artigo em Inglês | MEDLINE | ID: mdl-31190099

RESUMO

PURPOSE OF REVIEW: The goals of this paper were to examine recent literature on the social determinants of health as they relate to hypertension and cardiovascular disease, and discuss relevance to the practice of emergency medicine. RECENT FINDINGS: Social determinants of health, defined by the World Health Organization as "the conditions in which people are born, grow, live, work, and age" ( https://www.who.int/social_determinants/thecommission/en/ ) play a complex role in the development of hypertension and cardiovascular disease and the persistence of racial disparities in related health outcomes. Deciphering the independent association between minority status and social determinants in the United States is challenging. As a result, much of the recent interventional work has targeted populations by race or ethnicity in order to address these disparities. There is opportunity to expand the work on social determinants of health and hypertension. This includes exploring innovative approaches to identifying at-need individuals and breaking down traditional siloes to develop multidimensional interventions. New funding and payment mechanisms will allow for providers and health systems to identify and target modifiable social determinants of health at the level of the individual patient to improve outcomes.

8.
Am J Emerg Med ; 2019 Mar 25.
Artigo em Inglês | MEDLINE | ID: mdl-30928476

RESUMO

BACKGROUND: Syncope is a common chief complaint among older adults in the Emergency Department (ED), and orthostatic vital signs are often a part of their evaluation. We assessed whether abnormal orthostatic vital signs in the ED are associated with composite 30-day serious outcomes in older adults presenting with syncope. METHODS: We performed a secondary analysis of a prospective, observational study at 11 EDs in adults ≥ 60 years who presented with syncope or near syncope. We excluded patients lost to follow up. We used the standard definition of abnormal orthostatic vital signs or subjective symptoms of lightheadedness upon standing to define orthostasis. We determined the rate of composite 30-day serious outcomes, including those during the index ED visit, such as cardiac arrhythmias, myocardial infarction, cardiac intervention, new diagnosis of structural heart disease, stroke, pulmonary embolism, aortic dissection, subarachnoid hemorrhage, cardiopulmonary resuscitation, hemorrhage/anemia requiring transfusion, with major traumatic injury from fall, recurrent syncope, and death) between the groups with normal and abnormal orthostatic vital signs. RESULTS: The study cohort included 1974 patients, of whom 51.2% were male and 725 patients (37.7%) had abnormal orthostatic vital signs. Comparing those with abnormal to those with normal orthostatic vital signs, we did not find a difference in composite 30-serious outcomes (111/725 (15.3%) vs 184/1249 (14.7%); unadjusted odds ratio, 1.05 [95%CI, 0.81-1.35], p = 0.73). After adjustment for gender, coronary artery disease, congestive heart failure (CHF), history of arrhythmia, dyspnea, hypotension, any abnormal ECG, physician risk assessment, medication classes and disposition, there was no association with composite 30-serious outcomes (adjusted odds ratio, 0.82 [95%CI, 0.62-1.09], p = 0.18). CONCLUSIONS: In a cohort of older adult patients presenting with syncope who were able to have orthostatic vital signs evaluated, abnormal orthostatic vital signs did not independently predict composite 30-day serious outcomes.

9.
Curr Heart Fail Rep ; 16(1): 12-20, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30828762

RESUMO

PURPOSE OF REVIEW: Acute heart failure accounts for over one million hospital discharges annually. Current guidelines suggest treatments for AHF should begin "without delay" but this time interval has not been clearly defined. RECENT FINDINGS: Data suggest that certain treatments such as earlier treatment with diuretics and vasodilators may improve patient symptom relief, morbidity, and mortality. Secondary analyses of clinical trials of novel treatments under development have not shown similar results. The data are equivocal regarding the impact of early treatment in AHF on in-hospital and long-term morbidity and mortality. Improved clinical trial designs will help answer when and if "early" treatment should begin and whether it impacts short- and long-term outcomes in AHF.

10.
Acad Emerg Med ; 26(3): 303-316, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30667132

RESUMO

OBJECTIVES: Organizations to promote career networking and mentorship among women are recommended as a best practice to support the recruitment and retention of women physicians; however, the impact of such organizations is unknown. Our primary objective is to describe the impact of a national woman-focused organization for academic emergency physicians on retention and advancement. METHODS: We conducted semistructured interviews of past and present organization leaders, as well as members at varying stages in their careers. Physicians with experience in qualitative methods conducted interviews and coded all transcripts using inductive content analysis techniques. Themes were reviewed and discussed to ensure consensus. RESULTS: We performed 17 interviews lasting 20 to 30 minutes each, resulting in 476 total minutes of transcript. Participants represented varying stages of career experience, ranging from 2 to 35 years since residency completion (median = 9.5 years). Median years of participation in the woman-focused organization was 10 years. Over half (53%) of participants were past presidents of the organization. The dominant themes encompassed facilitating academic advancement through scholarly productivity, leadership experiences, awards, and promotions; mentorship and sponsorship; peer support and collaborations; reduced professional isolation; and initiatives to address systemic gender inequities and challenges, including strategies to navigate bias, promote pay equity, and advocate for family-friendly workplace policies. DISCUSSION: Active participation in a woman-focused professional organization enhances members' career retention and advancement by creating opportunities and relationships that facilitate leadership, enabling scholarly work to advance equity and inclusion, and cultivating a sense of belonging. While challenges and barriers persist, the myriad benefits of a women-focused professional organization reported by members and leaders represent important steps toward greater equity for women and other underrepresented groups in academic medicine.

11.
Am J Emerg Med ; 37(5): 869-872, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30361153

RESUMO

Almost 20% of patients with syncope will experience another event. It is unknown whether recurrent syncope is a marker for a higher or lower risk etiology of syncope. The goal of this study is to determine whether older adults with recurrent syncope have a higher likelihood of 30-day serious clinical events than patients experiencing their first episode. METHODS: This study is a pre-specified secondary analysis of a multicenter prospective, observational study conducted at 11 emergency departments in the US. Adults 60 years or older who presented with syncope or near syncope were enrolled. The primary outcome was occurrence of 30-day serious outcome. The secondary outcome was 30-day serious cardiac arrhythmia. In multivariate analysis, we assessed whether prior syncope was an independent predictor of 30-day serious events. RESULTS: The study cohort included 3580 patients: 1281 (35.8%) had prior syncope and 2299 (64.2%) were presenting with first episode of syncope. 498 (13.9%) patients had 1 prior episode while 771 (21.5%) had >1 prior episode. Those with recurrent syncope were more likely to have congestive heart failure, coronary artery disease, previous diagnosis of arrhythmia, and an abnormal ECG. Overall, 657 (18.4%) of the cohort had a serious outcome by 30 days after index ED visit. In multivariate analysis, we found no significant difference in risk of events (adjusted odds ratio 1.09; 95% confidence interval 0.90-1.31; p = 0.387). CONCLUSION: In older adults with syncope, a prior history of syncope within the year does not increase the risk for serious 30-day events.

12.
Am J Emerg Med ; 37(4): 685-689, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30017687

RESUMO

BACKGROUND: Syncope is a common chief complaint in the ED, and the electrocardiogram (ECG) is a routine diagnostic tool in the evaluation of syncope. We assessed whether increasingly prolonged QTc intervals are associated with composite 30-day serious outcomes in older adults presenting to the ED with syncope. METHODS: This is a secondary analysis of a prospective, observational study at 11 EDs in adults 60 years or older who presented with syncope or near syncope. We excluded patients presenting without an ECG, measurement of QTc, non-sinus rhythm, bundle branch block or those without 30-day follow-up. We categorized QTc cutoffs into values of <451; 451-470; 471-500, and >500 ms. We determined the rate of composite 30-day serious outcomes including ED serious outcomes and 30-day arrhythmias not identified in ED. RESULTS: The study cohort included 2609 patients. There were 1678 patients (64.3%) that had QTc intervals <451 ms; 544 (20.8%) were 451-470 ms; 302 (11.6%) were 471-500 ms, and 85 (3.3%) had intervals >500 ms. Composite 30-day serious outcomes was associated with increasingly prolonged QTc intervals (13.0%, 15.3%, 18.2%, 22.4%, p = 0.01), but this association did not persist in multivariate analysis. CONCLUSIONS: In a cohort of older patients presenting with syncope, increased QTc interval was a marker of but was not independently predictive of composite 30-day serious outcomes.

13.
Telemed J E Health ; 25(7): 599-603, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30070966

RESUMO

Background: Value enhancing telehealth (TH) lacks a robust body of formal clinically focused quality assessment studies. Innovations such as telehealth must always demonstrate that it preserves or hopefully advances quality. Introduction: We sought to determine whether adherence to the evidence-based Choosing Wisely (CW) recommendations (antibiotic stewardship) for acute sinusitis differs for encounters through direct-to-consumer (DTC) telemedicine verses "in-person" care in an emergency department (ED) or an urgent care (UC) center. Materials and Methods: Study design was a retrospective review. Patients with a symptom complex consistent with acute sinusitis treated through DTC were matched with ED and UC patients, based upon time of visit. Charts were reviewed to determine patient characteristics, chief complaint, final diagnosis, presence or absence of criteria within the CW guidelines, and whether or not antibiotics were prescribed. The main outcome was adherence to the CW campaign recommendations. Results: A total of 570 visits were studied: 190 DTC, 190 ED, and 190 UC visits. The predominant chief complaints were upper respiratory infection (36%), sore throat (25%), and sinusitis (18%). Overall, there was a 67% (95% CI 62.3-71.7) adherence rate with the CW guidelines for sinusitis: DTC visits (71%), ED visits (68%), and UC visits (61%). There was a nonsignificant difference (p = 0.29) in adherence to CW guidelines based upon type of visit (DTC, UC, and ED). Discussion: The challenge is to demonstrate whether or not DTC TH compromises quality. Conclusion: In this study, DTC visits were associated with at least as good an adherence to the CW campaign recommendations as emergency medicine (EM) and UC in-person visits.

14.
Cureus ; 10(4): e2433, 2018 Apr 05.
Artigo em Inglês | MEDLINE | ID: mdl-29876155

RESUMO

Introduction Given the rapid expansion of telehealth (TH), there is an emerging need for trained professionals who can effectively deliver TH services. As there is no formal TH training program for residents, the Department of Emergency Medicine (DEM) at Thomas Jefferson University (TJU) developed a pilot training program for senior post-graduate-year three (PGY-3) residents that exposed them to TH practices. The objective of the study was to determine the feasibility of developing a resident-led, post-Emergency-Department (ED) visit TH follow-up program as an educational opportunity to 1) address patient satisfaction; and 2) expose senior residents to TH delivery. Methods During a one-month block in their third-year of training, EM residents were exposed to and educated on TH delivery and utility through on-the-job, just-in-time training. Residents spent four hours per week evaluating patients previously seen in the ED within the last 5-7 days in the form of TH follow-up visits. ED patients were screened to identify which patient chief complaints and presentations were appropriate for a follow-up visit, given a specific day and time for their TH encounter, facilitated by a resident, and supervised by a faculty member trained in TH. Demographic patient and visit data were collected. Residents then completed a brief survey at the end of the rotation to capture their educational experiences and recommendations for subsequent training improvement. Results Over 12 months, 197 TH follow-up visits were performed by 12 residents. One hundred twenty-six patients (64%) were female. Top chief complaints included extremity pain (11.2%); abdominal pain (8.1%); upper respiratory infections (8.1%); lacerations (7.6%), and motor vehicle accidents (7.6%). The average number of days between the ED visit and the TH follow-up call was 5.1 days (IQR 3-6). 44.7% of patients were compliant with their discharge instructions and medications. On a Likert scale low (1) to high (10)], average patient helpfulness rating was 8.2 (IQR 7.8-10) and the average patient likelihood to recommend a TH follow-up visit was 8.5 (IQR 8-10). Ten residents completed the follow-up survey on the educational experience of the rotation (response rate 83%), of which seven described there is value to have a TH rotation in the curriculum. Thematic analysis of open-ended responses yielded constructive feedback for programmatic improvement. Conclusion The authors propose a feasible TH training opportunity integrated into EM residency training to assist them with meeting a rapidly-growing demand for TH and prepare them for diverse job opportunities.

15.
Emergencias (Sant Vicenç dels Horts) ; 30(3): 194-200, jun. 2018. ilus, tab
Artigo em Espanhol | IBECS | ID: ibc-172962

RESUMO

La muerte súbita e inesperada en jóvenes es un evento raro pero devastador. Aunque su incidencia es baja, se registran de 1,3 a 8,5 casos de muerte súbita cardiaca (MSC) por cada 100.000 jóvenes y se asocia frecuentemente con una autopsia negativa. Muchas de las causas de la MSC con autopsia negativa se heredan de forma autosómica dominante. Algunas causas de MSC con autopsia positiva en pacientes jóvenes incluyen la miocardiopatía hipertrófica (MCH) y la displasia arritmogénica de ventriculo derecho. Las causas de autopsia negativa incluyen causas arritmogénicas heredadas, como el síndrome de QT largo, el síndrome de Brugada, la taquicardia ventricular polimórfica catecolaminérgica, el syndrome de Wolff-Parkinson-White (WPW) y la fibrilación ventricular idiopática. La pregunta importante para los profesionales de urgencias es: ¿cómo podemos predecir y prevenir la MSC en los jóvenes antes de la autopsia?


Sudden unexpected death in the young, though rare, is devastating for both the family and the community. Although only 1.3 to 8.5 cases of sudden cardiac death (SCD) occur per 100 000 young people, autopsy is often inconclusive. Many causes of SCD are related to autosomal dominant inherited risk, however; therefore, answers are important for survivors. Causes of autopsy-positive SCD in young patients include hypertrophic cardiomyopathy and arrhythmogenic right ventricular dysplasia. Autopsy-negative SCD has been related to inherited arrhythmogenic causes such as long QT syndrome, Brugada syndrome, catecholaminergic polymorphic ventricular tachycardia, WolffParkinson-White syndrome, and idiopathic ventricular fibrillation. The important question for the emergency physician is how SCD can be predicted and prevented in the young so that there is no need for an autopsy


Assuntos
Humanos , Morte Súbita Cardíaca/prevenção & controle , Síndrome de Brugada/complicações , Síndrome do QT Longo/complicações , Taquicardia Ventricular/complicações , Biomarcadores/análise , Autopsia/estatística & dados numéricos , Síndrome de Wolff-Parkinson-White/complicações , Cardiomiopatia Hipertrófica/complicações
16.
Emergencias ; 30(3): 194-200, 2018 06.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-29687676

RESUMO

OBJECTIVES: Sudden unexpected death in the young, though rare, is devastating for both the family and the community. Although only 1.3 to 8.5 cases of sudden cardiac death (SCD) occur per 100 000 young people, autopsy is often inconclusive. Many causes of SCD are related to autosomal dominant inherited risk, however; therefore, answers are important for survivors. Causes of autopsy-positive SCD in young patients include hypertrophic cardiomyopathy and arrhythmogenic right ventricular dysplasia. Autopsy-negative SCD has been related to inherited arrhythmogenic causes such as long QT syndrome, Brugada syndrome, catecholaminergic polymorphic ventricular tachycardia, Wolff- Parkinson-White syndrome, and idiopathic ventricular fibrillation. The important question for the emergency physician is how SCD can be predicted and prevented in the young so that there is no need for an autopsy.


Assuntos
Causas de Morte , Morte Súbita Cardíaca/prevenção & controle , Adolescente , Adulto , Autopsia , Criança , Morte Súbita Cardíaca/etiologia , Eletrocardiografia , Serviços Médicos de Emergência , Doenças Genéticas Inatas/diagnóstico , Doenças Genéticas Inatas/mortalidade , Humanos , Pessoa de Meia-Idade , Fatores de Risco , Adulto Jovem
17.
Thromb Res ; 166: 63-70, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29656169

RESUMO

INTRODUCTION: We sought to determine the test characteristics of an automated INNOVANCE D-dimer assay for the exclusion of pulmonary embolism (PE) and deep venous thrombosis (DVT) in emergency department (ED) patients using standard and age-adjusted cut-offs. METHODS: Cross-sectional, international, multicenter study of consecutive patients with suspected DVT or PE in 24 centers (18 USA, 6 Europe). Evaluated patients had low or intermediate Wells PE or DVT scores. For the standard cut-off, a D-dimer result <500 ng/ml was negative. For the age adjusted cut-off, we used the formula: Age (years) ∗ 10. The diagnostic standard was imaging demonstrating PE or DVT within 3 months. We calculated test characteristics using standard methods. We also explored modifications of the age adjustment multiplier. RESULTS: We included 3837 patients and excluded 251. The mean age of patients evaluated for PE (n = 1834) was 48 ±â€¯16 years, with 676 (37%) male, and 1081 (59%) white. The mean age of evaluated for DVT (n = 1752) was 53 ±â€¯16 years, with 710 (41%) male, and 1172 (67%) white. D-dimer test characteristics for PE were: sensitivity 98.0%, specificity 55.4%, negative predictive value (NPV) 99.8%, positive predictive value (PPV) 11.4%, and for DVT were: sensitivity 92.0%, specificity 44.8%, NPV 98.8%, PPV 10.3%. Age adjustment increased specificity (59.6% [PE], 51.1% [DVT]), but increasing the age-adjustment multiplier decreased sensitivity without increasing specificity. CONCLUSIONS: INNOVANCE D-dimer is highly sensitive and can exclude PE and DVT in ED patients with low- and intermediate- pre-test probability. Age-adjustment increases specificity, without increasing false negatives.


Assuntos
Produtos de Degradação da Fibrina e do Fibrinogênio/metabolismo , Tromboembolia Venosa/diagnóstico , Fatores Etários , Bioensaio , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Tromboembolia Venosa/patologia
19.
Cardiol Clin ; 36(1): 1-12, 2018 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-29173670

RESUMO

Chest pain is a common complaint in the emergency department, and it is the job of clinicians to rule out life-threatening diagnoses such as acute coronary syndrome. The history, physical examination, cardiac risk factors, electrocardiogram findings, and clinician judgment are often not enough to distinguish between causes of chest pain syndromes and to reliably rule out acute myocardial ischemia. New cardiac troponin assays, especially in conjunction with clinical decision algorithms, help clinicians rapidly exclude acute myocardial infarction. For further risk stratification, stress testing or coronary computed tomography angiography can be used in the emergency department.


Assuntos
Síndrome Coronariana Aguda/diagnóstico , Dor no Peito/diagnóstico , Angiografia por Tomografia Computadorizada/métodos , Angiografia Coronária/métodos , Medição de Risco/métodos , Síndrome Coronariana Aguda/epidemiologia , Dor no Peito/epidemiologia , Diagnóstico Diferencial , Serviço Hospitalar de Emergência , Saúde Global , Humanos , Incidência , Fatores de Risco
20.
Ann Emerg Med ; 71(4): 497-505.e4, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-28844764

RESUMO

STUDY OBJECTIVE: Emergency department (ED) crowding and patient boarding are associated with increased mortality and decreased patient satisfaction. This study uses a positive deviance methodology to identify strategies among high-performing, low-performing, and high-performance improving hospitals to reduce ED crowding. METHODS: In this mixed-methods comparative case study, we purposively selected and recruited hospitals that were within the top and bottom 5% of Centers for Medicare & Medicaid Services case-mix-adjusted ED length of stay and boarding times for admitted patients for 2012. We also recruited hospitals that showed the highest performance improvement in metrics between 2012 and 2013. Interviews were conducted with 60 key leaders (physicians, nurses, quality improvement specialists, and administrators). RESULTS: We engaged 4 high-performing, 4 low-performing, and 4 high-performing improving hospitals, matched on hospital characteristics including geographic designation (urban versus rural), region, hospital occupancy, and ED volume. Across all hospitals, ED crowding was recognized as a hospitalwide issue. The strategies for addressing ED crowding varied widely. No specific interventions were associated with performance in length-of-stay metrics. The presence of 4 organizational domains was associated with hospital performance: executive leadership involvement, hospitalwide coordinated strategies, data-driven management, and performance accountability. CONCLUSION: There are organizational characteristics associated with ED decreased length of stay. Specific interventions targeted to reduce ED crowding were more likely to be successfully executed at hospitals with these characteristics. These organizational domains represent identifiable and actionable changes that other hospitals may incorporate to build awareness of ED crowding.


Assuntos
Aglomeração , Serviço Hospitalar de Emergência/normas , Admissão do Paciente/estatística & dados numéricos , Melhoria de Qualidade , Listas de Espera , Adulto , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Satisfação do Paciente , Fatores de Tempo , Estados Unidos
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