External Validation of a Tool to Identify Low-Risk Patients With Isolated Subdural Hematoma and Preserved Consciousness.

STUDY OBJECTIVE: The SafeSDH Tool was derived to identify patients with isolated (no other type of intracranial hemorrhage) subdural hematoma who are at very low risk of neurologic deterioration, neurosurgical intervention, or death. Patients are low risk by the tool if they have none of the following: use of anticoagulant or nonaspirin antiplatelet agent, Glasgow Coma Score (GCS) <14, more than 1 discrete hematoma, hematoma thickness >5 mm, or midline shift. We attempted to externally validate the SafeSDH Tool. METHODS: We performed a retrospective chart review of patients aged ≥16 with a GCS ≥13 and isolated subdural hematoma who presented to 1 of 6 academic and community hospitals from 2005 to 2018. The primary outcome, a composite of neurologic deterioration (seizure, altered mental status, or symptoms requiring repeat imaging), neurosurgical intervention, discharge on hospice, and death, was abstracted from discharge summaries. Hematoma thickness, number of hematomas, and midline shift were abstracted from head imaging reports. Anticoagulant use, antiplatelet use, and GCS were gathered from the admission record. RESULTS: The validation data set included 753 patients with isolated subdural hematoma. Mortality during the index admission was 2.1%; 26% of patients underwent neurosurgical intervention. For the composite outcome, sensitivity was 99% (95% confidence interval [CI] 97 to 100), and specificity was 31% (95% CI 27 to 35). The tool identified 162 (21.5%) patients as low risk. Negative likelihood ratio was 0.03 (95% CI 0.01 to 0.11). CONCLUSION: The SafeSDH Tool identified patients with isolated subdural hematoma who are at low risk for poor outcomes with high sensitivity. With prospective validation, these low-risk patients could be safe for management in less intensive settings.

Diagnostic management of acute pulmonary embolism: a prediction model based on a patient data meta-analysis.

AIMS: Risk stratification is used for decisions regarding need for imaging in patients with clinically suspected acute pulmonary embolism (PE). The aim was to develop a clinical prediction model that provides an individualized, accurate probability estimate for the presence of acute PE in patients with suspected disease based on readily available clinical items and D-dimer concentrations. METHODS AND RESULTS: An individual patient data meta-analysis was performed based on sixteen cross-sectional or prospective studies with data from 28 305 adult patients with clinically suspected PE from various clinical settings, including primary care, emergency care, hospitalized and nursing home patients. A multilevel logistic regression model was built and validated including ten a priori defined objective candidate predictors to predict objectively confirmed PE at baseline or venous thromboembolism (VTE) during follow-up of 30 to 90 days. Multiple imputation was used for missing data. Backward elimination was performed with a P-value <0.10. Discrimination (c-statistic with 95% confidence intervals [CI] and prediction intervals [PI]) and calibration (outcome:expected [O:E] ratio and calibration plot) were evaluated based on internal-external cross-validation. The accuracy of the model was subsequently compared with algorithms based on the Wells score and D-dimer testing. The final model included age (in years), sex, previous VTE, recent surgery or immobilization, haemoptysis, cancer, clinical signs of deep vein thrombosis, inpatient status, D-dimer (in µg/L), and an interaction term between age and D-dimer. The pooled c-statistic was 0.87 (95% CI, 0.85-0.89; 95% PI, 0.77-0.93) and overall calibration was very good (pooled O:E ratio, 0.99; 95% CI, 0.87-1.14; 95% PI, 0.55-1.79). The model slightly overestimated VTE probability in the lower range of estimated probabilities. Discrimination of the current model in the validation data sets was better than that of the Wells score combined with a D-dimer threshold based on age (c-statistic 0.73; 95% CI, 0.70-0.75) or structured clinical pretest probability (c-statistic 0.79; 95% CI, 0.76-0.81). CONCLUSION: The present model provides an absolute, individualized probability of PE presence in a broad population of patients with suspected PE, with very good discrimination and calibration. Its clinical utility needs to be evaluated in a prospective management or impact study. REGISTRATION: PROSPERO ID 89366.

Primary Infection Site as a Predictor of Sepsis Development in Emergency Department Patients.

BACKGROUND: Sepsis is a life-threatening condition but predicting its development and progression remains a challenge. OBJECTIVE: This study aimed to assess the impact of infection site on sepsis development among emergency department (ED) patients. METHODS: Data were collected from a single-center ED between January 2016 and December 2019. Patient encounters with documented infections, as defined by the Systematized Nomenclature of Medicine-Clinical Terms for upper respiratory tract (URI), lower respiratory tract (LRI), urinary tract (UTI), or skin or soft-tissue infections were included. Primary outcome was the development of sepsis or septic shock, as defined by Sepsis-1/2 criteria. Secondary outcomes included hospital disposition and length of stay, blood and urine culture positivity, antibiotic administration, vasopressor use, in-hospital mortality, and 30-day mortality. Analysis of variance and various different logistic regression approaches were used for analysis with URI used as the reference variable. RESULTS: LRI was most associated with sepsis (relative risk ratio [RRR] 5.63; 95% CI 5.07-6.24) and septic shock (RRR 21.2; 95% CI 17.99-24.98) development, as well as hospital admission rates (odds ratio [OR] 8.23; 95% CI 7.41-9.14), intensive care unit admission (OR 4.27; 95% CI 3.84-4.74), in-hospital mortality (OR 6.93; 95% CI 5.60-8.57), and 30-day mortality (OR 7.34; 95% CI 5.86-9.19). UTIs were also associated with sepsis and septic shock development, but to a lesser degree than LRI. CONCLUSIONS: Primary infection sites including LRI and UTI were significantly associated with sepsis development, hospitalization, length of stay, and mortality among patients presenting with infections in the ED.

Pandemic phase-related racial and ethnic disparities in COVID-19 positivity and outcomes among patients presenting to emergency departments during the first two pandemic waves in the USA.

BACKGROUND: In many countries including the USA, the UK and Canada, the impact of COVID-19 on people of colour has been disproportionately high but examination of disparities in patients presenting to ED has been limited. We assessed racial and ethnic differences in COVID-19 positivity and outcomes in patients presenting to EDs in the USA, and the effect of the phase of the pandemic on these outcomes. METHODS: This is a retrospective cohort study of adult patients tested for COVID-19 during, or 14 days prior to, the index ED visit in 2020. Data were obtained from the National Registry of Suspected COVID-19 in Emergency Care network which has data from 155 EDs across 27 US states. Hierarchical models were used to account for clustering by hospital. The outcomes included COVID-19 diagnosis, hospitalisation at index visit, subsequent hospitalisation within 30 days and 30-day mortality. We further stratified the analysis by time period (early phase: March-June 2020; late phase: July-September 2020). RESULTS: Of the 26 111 adult patients, 38% were non-Hispanic White (NHW), 29% Black, 20% Hispanic/Latino, 3% Asian and 10% all others; half were female. The median age was 56 years (IQR 40-69), and 53% were diagnosed with COVID-19; of those, 59% were hospitalised at index visit. Of those discharged from ED, 47% had a subsequent hospitalisation in 30 days. Hispanic/Latino patients had twice (adjusted OR (aOR) 2.3; 95% CI 1.8 to 3.0) the odds of COVID-19 diagnosis than NHW patients, after adjusting for age, sex and comorbidities. Black, Asian and other minority groups also had higher odds of being diagnosed (compared with NHW patients). On stratification, this association was observed in both phases for Hispanic/Latino patients. Hispanic/Latino patients had lower odds of hospitalisation at index visit, but when stratified, this effect was only observed in early phase. Subsequent hospitalisation was more likely in Asian patients (aOR 3.1; 95% CI 1.1 to 8.7) in comparison with NHW patients. Subsequent ED visit was more likely in Blacks and Hispanic/Latino patients in late phase. CONCLUSION: We found significant differences in ED outcomes that are not explained by comorbidity burden. The gap decreased but persisted during the later phase in 2020.

Stroke Screening Process for Spanish-Speaking Patients.

INTRODUCTION: The Balance Eyes Face Arms Speech Time stroke screening tool may have limitations for Spanish-speaking individuals. The purpose of this study is to identify potential screen failure events during evaluation for intervenable acute ischemic stroke events among Spanish-speaking patients. METHODS: This is a retrospective, observational, single-center study at an urban academic center during 2020. Patients with a positive stroke screen were stratified by Spanish or non-Spanish. We measured last known well, sensitivity, specificity, negative predictive value, and positive predictive value of the emergency department provider's decision to escalate to complete stroke evaluation with acute ischemic stroke as the outcome of interest. RESULTS: Among 796 patients (mean age of 52 years, 56% female, 37% Spanish speaking), 30% of patients with positive stroke screen were converted to complete stroke evaluation. For provider escalation to complete stroke evaluation for the outcome of acute ischemic stroke events, prevalence was 13%, sensitivity 81%, positive predictive value 22%, and negative predictive value 97% for the overall sample. Spanish-speaking patients were less likely to progress from screening to complete stroke evaluation (25.8% vs 32.8%; 95% for difference CI, 0.57-13.5). Importantly, there was no difference in rate of acute ischemic stroke between Spanish- and non-Spanish-speaking patients. DISCUSSION: Over 1 year, with 796 patients triggered at triage by Balance Eyes Face Arms Speech Time for positive stroke screens, only 13% resulted in an acute ischemic stroke. Spanish-speaking patients were less likely to progress from screening to complete stroke evaluation, but the rate of acute ischemic stroke was not different by language.

Safety and Efficiency of Diagnostic Strategies for Ruling Out Pulmonary Embolism in Clinically Relevant Patient Subgroups : A Systematic Review and Individual-Patient Data Meta-analysis.

BACKGROUND: How diagnostic strategies for suspected pulmonary embolism (PE) perform in relevant patient subgroups defined by sex, age, cancer, and previous venous thromboembolism (VTE) is unknown. PURPOSE: To evaluate the safety and efficiency of the Wells and revised Geneva scores combined with fixed and adapted D-dimer thresholds, as well as the YEARS algorithm, for ruling out acute PE in these subgroups. DATA SOURCES: MEDLINE from 1 January 1995 until 1 January 2021. STUDY SELECTION: 16 studies assessing at least 1 diagnostic strategy. DATA EXTRACTION: Individual-patient data from 20 553 patients. DATA SYNTHESIS: Safety was defined as the diagnostic failure rate (the predicted 3-month VTE incidence after exclusion of PE without imaging at baseline). Efficiency was defined as the proportion of individuals classified by the strategy as "PE considered excluded" without imaging tests. Across all strategies, efficiency was highest in patients younger than 40 years (47% to 68%) and lowest in patients aged 80 years or older (6.0% to 23%) or patients with cancer (9.6% to 26%). However, efficiency improved considerably in these subgroups when pretest probability-dependent D-dimer thresholds were applied. Predicted failure rates were highest for strategies with adapted D-dimer thresholds, with failure rates varying between 2% and 4% in the predefined patient subgroups. LIMITATIONS: Between-study differences in scoring predictor items and D-dimer assays, as well as the presence of differential verification bias, in particular for classifying fatal events and subsegmental PE cases, all of which may have led to an overestimation of the predicted failure rates of adapted D-dimer thresholds. CONCLUSION: Overall, all strategies showed acceptable safety, with pretest probability-dependent D-dimer thresholds having not only the highest efficiency but also the highest predicted failure rate. From an efficiency perspective, this individual-patient data meta-analysis supports application of adapted D-dimer thresholds. PRIMARY FUNDING SOURCE: Dutch Research Council. (PROSPERO: CRD42018089366).

Ruling out pulmonary embolism across different healthcare settings: A systematic review and individual patient data meta-analysis.

BACKGROUND: The challenging clinical dilemma of detecting pulmonary embolism (PE) in suspected patients is encountered in a variety of healthcare settings. We hypothesized that the optimal diagnostic approach to detect these patients in terms of safety and efficiency depends on underlying PE prevalence, case mix, and physician experience, overall reflected by the type of setting where patients are initially assessed. The objective of this study was to assess the capability of ruling out PE by available diagnostic strategies across all possible settings. METHODS AND FINDINGS: We performed a literature search (MEDLINE) followed by an individual patient data (IPD) meta-analysis (MA; 23 studies), including patients from self-referral emergency care (n = 12,612), primary healthcare clinics (n = 3,174), referred secondary care (n = 17,052), and hospitalized or nursing home patients (n = 2,410). Multilevel logistic regression was performed to evaluate diagnostic performance of the Wells and revised Geneva rules, both using fixed and adapted D-dimer thresholds to age or pretest probability (PTP), for the YEARS algorithm and for the Pulmonary Embolism Rule-out Criteria (PERC). All strategies were tested separately in each healthcare setting. Following studies done in this field, the primary diagnostic metrices estimated from the models were the "failure rate" of each strategy-i.e., the proportion of missed PE among patients categorized as "PE excluded" and "efficiency"-defined as the proportion of patients categorized as "PE excluded" among all patients. In self-referral emergency care, the PERC algorithm excludes PE in 21% of suspected patients at a failure rate of 1.12% (95% confidence interval [CI] 0.74 to 1.70), whereas this increases to 6.01% (4.09 to 8.75) in referred patients to secondary care at an efficiency of 10%. In patients from primary healthcare and those referred to secondary care, strategies adjusting D-dimer to PTP are the most efficient (range: 43% to 62%) at a failure rate ranging between 0.25% and 3.06%, with higher failure rates observed in patients referred to secondary care. For this latter setting, strategies adjusting D-dimer to age are associated with a lower failure rate ranging between 0.65% and 0.81%, yet are also less efficient (range: 33% and 35%). For all strategies, failure rates are highest in hospitalized or nursing home patients, ranging between 1.68% and 5.13%, at an efficiency ranging between 15% and 30%. The main limitation of the primary analyses was that the diagnostic performance of each strategy was compared in different sets of studies since the availability of items used in each diagnostic strategy differed across included studies; however, sensitivity analyses suggested that the findings were robust. CONCLUSIONS: The capability of safely and efficiently ruling out PE of available diagnostic strategies differs for different healthcare settings. The findings of this IPD MA help in determining the optimum diagnostic strategies for ruling out PE per healthcare setting, balancing the trade-off between failure rate and efficiency of each strategy.

The 2013 to 2019 Emergency Medicine Workforce: Clinician Entry and Attrition Across the US Geography.

STUDY OBJECTIVE: We sought to identify longitudinal trends in workforce entry and attrition among rural and urban emergency physicians, nonemergency physicians, and advanced practice providers. METHODS: We performed a repeated cross-sectional analysis, from 2013 to 2019, of emergency clinicians who received reimbursement for at least 50 Evaluation and Management services [99281-99285] from Medicare part B within any study year. We calculated the emergency workforce's entry and attrition rates annually. Entry was defined as clinicians newly entering or re-entering the workforce, and attrition was defined as clinicians leaving permanently or temporarily. We stratified the analyses by rural designation and assessed the proportions and state-level changes in clinician density. RESULTS: In total, 82,499 unique clinicians performed at least 50 Evaluation and Management services within any of the 7 study years examined, including 47,000 emergency physicians, 9,029 nonemergency physicians, and 26,470 advanced practice providers. Emergency physicians made up a decreasing proportion of the workforce (68.1% in 2013; 65.5% in 2019), and advanced practice providers made up an increasing proportion of the workforce (20.9% in 2013; 26.1% in 2019). Annually, 5.9% to 6.8% (2,186 to 2,407) of emergency physicians newly entered and 0.8% to 1.4% (264 to 515) re-entered the workforce, whereas 3.8% to 4.9% (1,241 to 1,793) permanently left and 0.8% to 1.6% (276 to 521) temporarily left. Additionally, the total proportion of clinicians practicing in rural designations decreased, and advanced practice providers separately made up a substantially increasing proportion of the rural workforce (23.0% in 2013; 32.7% in 2019). Substantial state-level variation existed in the supply and demand of emergency clinician densities per 100,000 population. CONCLUSION: The annual rate of emergency physician attrition was collectively more than 5%, well above the 3% assumed in a recently publicized projection, suggesting a potential overestimation of the anticipated future clinician surplus. Notably, the attrition of emergency physicians has disproportionately affected vulnerable rural areas. This work can inform emergency medicine workforce decisions regarding residency training, advanced practice provider utilization, and clinician employment.

SARS-CoV-2 Positivity in Ambulatory Symptomatic Patients Is Not Associated With Increased Venous or Arterial Thrombotic Events in the Subsequent 30 Days.

BACKGROUND: COVID-19 has been associated with increased risk of thromboembolism in critically ill patients. OBJECTIVE: We sought to examine the association of SARS-CoV-2 test positivity and subsequent acute vascular thrombosis, including venous thromboembolism (VTE) or arterial thrombosis (AT), in a large nationwide registry of emergency department (ED) patients tested with a nucleic acid test for suspected SARS-CoV-2. METHODS: The RECOVER (Registry of Potential COVID-19 in Emergency Care) registry includes 155 EDs across the United States. We performed a retrospective cohort study to produce odds ratios (ORs) for COVID-19-positive vs. COVID-19-negative status as a predictor of 30-day VTE or AT, adjusting for age, sex, active cancer, intubation, hospital length of stay, and intensive care unit (ICU) care. RESULTS: Comparing 14,056 COVID-19-positive patients with 12,995 COVID-19-negative patients, the overall 30-day prevalence of VTE events was 1.4% vs. 1.3%, respectively (p = 0.44, χ2). Multivariable analysis identified that testing positive for SARS-CoV-2 status was negatively associated with both VTE (OR 0.76; 95% confidence interval [CI] 0.61-0.94) and AT (OR 0.51; 95% CI 0.32-0.80), whereas intubation, ICU care, and age 50 years or older were positively associated with both VTE and AT. CONCLUSIONS: In contrast to other reports, results from this large, hetereogenous national sample of ED patients tested for SARS-CoV-2, showed no association between vascular thrombosis and COVID-19 test positivity.

The Emergency Medicine Physician Workforce: Projections for 2030.

STUDY OBJECTIVE: The goals of this study were to determine the current and projected supply in 2030 of contributors to emergency care, including emergency residency-trained and board-certified physicians, other physicians, nurse practitioners, and physician assistants. In addition, this study was designed to determine the current and projected demand for residency-trained, board-certified emergency physicians. METHODS: To forecast future workforce supply and demand, sources of existing data were used, assumptions based on past and potential future trends were determined, and a sensitivity analysis was conducted to determine how the final forecast would be subject to variance in the baseline inputs and assumptions. Methods included: (1) estimates of the baseline workforce supply of physicians, nurse practitioners, and physician assistants; (2) estimates of future changes in the raw numbers of persons entering and leaving that workforce; (3) estimates of the productivity of the workforce; and (4) estimates of the demand for emergency care services. The methodology assumes supply equals demand in the base year and estimates the change between the base year and 2030; it then compares supply and demand in 2030 under different scenarios. RESULTS: The task force consensus was that the most likely future scenario is described by: 2% annual graduate medical education growth, 3% annual emergency physician attrition, 20% encounters seen by a nurse practitioner or physician assistant, and 11% increase in emergency department visits relative to 2018. This scenario would result in a surplus of 7,845 emergency physicians in 2030. CONCLUSION: The specialty of emergency medicine is facing the likely oversupply of emergency physicians in 2030. The factors leading to this include the increasing supply of and changing demand for emergency physicians. An organized, collective approach to a balanced workforce by the specialty of emergency medicine is imperative.

Patient-Reported Opioid Pill Consumption After an ED Visit: How Many Pills Are People Using?

OBJECTIVES: Recent guidelines advise limiting opioid prescriptions for acute pain to a three-day supply; however, scant literature quantifies opioid use patterns after an emergency department (ED) visit. We sought to describe opioid consumption patterns after an ED visit for acute pain. DESIGN: Descriptive study with data derived from a larger interventional study promoting safe opioid use after ED discharge. SETTING: Urban academic emergency department (>88,000 annual visits). SUBJECTS: Patients were eligible if age >17 years, not chronically using opioids, and newly prescribed hydrocodone-acetaminophen and were included in the analysis if they returned the completed 10-day medication diary. METHODS: Patient demographics and opioid consumption are reported. Opioid use is described in daily number of pills and daily morphine milligram equivalents (MME) both for the sample overall and by diagnosis. RESULTS: Two hundred sixty patients returned completed medication diaries (45 [17%] back pain, 52 [20%] renal colic, 54 [21%] fracture/dislocation, 40 [15%] musculoskeletal injury [nonfracture], and 69 [27%] "other"). The mean age (SD) was 45 (15) years, and 59% of the sample was female. A median of 12 pills were prescribed. Patients with renal colic used the least opioids (total pills: median [interquartile range {IQR}] = 3 [1-7]; total MME: median [IQR] = 20 [10-50]); patients with back pain used the most (total pills: median [IQR] = 12 [7-16]; total MME: median [IQR] = 65 [47.5-100]); 92.5% of patients had leftover pills. CONCLUSIONS: In this sample, pill consumption varied by illness category; however, overall, patients were consuming low quantities of pills, and the majority had unused pills 10 days after their ED visit.

Who Is Keeping Their Unused Opioids and Why?

OBJECTIVE: To better understand patients' reasoning for keeping unused opioid pills. METHODS: As part of a larger study, patients were asked their plans for their unused opioids. Responses were categorized as "dispose," "keep," and "don't know." Baseline characteristics were compared between the "keep" and "dispose" groups. Verbatim responses categorized as "keep" were analyzed qualitatively using a team-based inductive approach with constant comparison across cases. RESULTS: One hundred patients planned to dispose of their pills; 117 planned to keep them. There were no differences in demographics between the groups. Among patients who planned to keep their pills, the mean age was 43 years and 47% were male. Analysis revealed four categories of patient responses: 1) plans to keep their pills "just in case," with reference to a medical condition (e.g., kidney stone); 2) plans to keep pills "just in case" without reference to any medical condition; 3) plans to dispose in delayed fashion (e.g., after pill expiration) or unsure of how to dispose; and 4) no identified plans, yet intended to keep pills. In this sample, there were no differences in characteristics of those reporting planning to keep vs dispose of pills; however, there were diverse reasons for keeping opioids. CONCLUSIONS: This manuscript describes a sample of patients who kept their unused opioids and presents qualitative data detailing their personal reasoning for keeping the unused pills. Awareness of the range of motivations underpinning this behavior may inform the development of tailored education and risk communication messages to improve opioid disposal.

Does Overall Cervical Spine Pathology Relate to the Clinical Heterogeneity of Chronic Whiplash?

BACKGROUND AND PURPOSE: There remains limited evidence for the clinical importance of most imaging findings in whiplash. However, it is possible the type and number of findings on Computed Tomography (CT) may contribute to prognostic recovery models. The purpose is to interpret cervical spine pathologies in the context of known factors influencing recovery. MATERIALS AND METHODS: This is a secondary analysis from a database of 97 acutely injured participants enrolled in a prospective inception cohort study. Thirty-eight participants underwent standard of care cervical spine CT in the emergency medicine department. All 38 participants were assessed at <1-week, 2-weeks, and 3-months post-injury and classified using percentage scores on the Neck Disability Index (recovered/mild (NDI of 0-28%) or moderate/severe (NDI ≥ 30%)). Between-group comparison of categorical variables (gender (male/female), presence of at least one CT finding (yes/no), and presence of ≥3 pathologies on CT (yes/no)) was conducted using 2-tailed Fisher's exact test. RESULTS: Participants from both groups demonstrated at least one observable pathology. The group with persistent moderate/severe symptoms presented with significantly more pathology at baseline than those who later reported recovery or milder symptoms at 3-months post injury (p = 0.02). CONCLUSIONS: This preliminary study, which needs replication in a larger cohort, provides foundation that the number of degenerative pathologies seen on initial post MVC CT may be associated with the subsequent clinical course of whiplash.

Perceptions and expectations of health-related quality of life among geriatric patients seeking emergency care: a qualitative study.

BACKGROUND: Health-related quality of life (HRQoL), encompassing social, emotional, and physical wellbeing is an important clinical outcome of medical care, especially among geriatric patients. It is unclear which domains of HRQoL are most important to geriatric patients and which domains they hope to address when using the Emergency Department (ED). The objective of this study was to understand which aspects of HRQoL are most valued by geriatric patients in the ED and what expectations patients have for addressing or improving HRQoL during an ED visit. METHODS: This was a qualitative focus group study of geriatric ED patients from an urban, academic ED in the United States with > 16,500 annual geriatric visits. Patients were eligible if they were age > =65 years and discharged from the ED within 45 days of recruitment. Semi-structured pilot interviews and focus groups were conducted several weeks after the ED visit. Participants shared their ED experiences and to discuss their perceptions of the subsequent impact on their quality of life, focusing on the domains of physical, mental, and social health. Latent content and constant comparative methods were used to code focus group transcripts and analyze for emergent themes. RESULTS: Three individuals participated in pilot interviews and 31 participated in six focus groups. Twelve codes across five main themes relating to HRQoL were identified. Patients recalled: (1) A strong desire to regain physical function, and (2) anxiety elicited by the emotional experience of seeking care in the emergency department, due to uncertainty in diagnosis, treatment, and prognosis. In addition, patients noted both (3) interpersonal impacts of health on quality of life, primarily mediated primarily by social interaction, and (4) an individual experience of health and quality of life mediated primarily by mental health. Finally, (5) patients questioned if the ED was the right place to attempt to address HRQoL. CONCLUSIONS: Patients expressed anxiety around the time of their ED visit related to uncertainty, they desired functional recovery, and identified both interpersonal effects of health on quality of life mediated by social health, and an individual experience of health and quality of life mediated by mental health.

A comparison of analgesic prescribing among ED back and neck pain visits receiving physical therapy versus usual care.

OBJECTIVE: Physical therapy (PT) is commonly cited as a non-opioid pain strategy, and previous studies indicate PT reduces opioid utilization in outpatients with back pain. No study has yet examined whether PT is associated with lower analgesic prescribing in the ED setting. METHODS: This was a retrospective cohort study of discharged ED visits with a primary ICD-10 diagnosis relating to back or neck pain from 10/1/15 to 2/21/17 at an urban academic ED. Visits receiving a PT evaluation were matched with same-date visits receiving usual care. We compared the primary outcomes of opioid and benzodiazepine prescribing between the two cohorts using chi-squared test and multivariable logistic regression. RESULTS: 74 ED visits received PT during the study period; these visits were matched with 390 same-date visits receiving usual care. Opioid prescribing among ED-PT visits was not significantly higher compared to usual care visits on both unadjusted analysis (50% vs 42%, p = 0.19) and adjusted analysis (adjOR 1.05, 95% CI 0.48-2.28). However, benzodiazepine prescribing among ED-PT visits was significantly higher than usual care visits on both unadjusted (45% vs 23%, p < 0.001) and adjusted analysis (adjOR 3.65, 95% CI 1.50-8.83). CONCLUSIONS: In this single center study, ED back and neck pain visits receiving PT were no less likely to receive an opioid prescription and were more likely to receive a benzodiazepine than visits receiving usual care. Although prior studies demonstrate that PT may reduce opioid utilization in the subsequent year, these results indicate that analgesic prescribing is not reduced at the initial ED encounter.

National Practice Patterns of Obtaining Informed Consent for Stroke Thrombolysis.

BACKGROUND AND PURPOSE: No standard approach to obtaining informed consent for stroke thrombolysis with tPA (tissue-type plasminogen activator) currently exists. We aimed to assess current nationwide practice patterns of obtaining informed consent for tPA. METHODS: An online survey was developed and distributed by e-mail to clinicians involved in acute stroke care. Multivariable logistic regression analyses were performed to determine independent factors contributing to always obtaining informed consent for tPA. RESULTS: Among 268 respondents, 36.7% reported always obtaining informed consent and 51.8% reported the informed consent process caused treatment delays. Being an emergency medicine physician (odds ratio, 5.8; 95% confidence interval, 2.9-11.5) and practicing at a nonacademic medical center (odds ratio, 2.1; 95% confidence interval, 1.0-4.3) were independently associated with always requiring informed consent. The most commonly cited cause of delay was waiting for a patient's family to reach consensus about treatment. CONCLUSIONS: Most clinicians always or often require informed consent for stroke thrombolysis. Future research should focus on standardizing content and delivery of tPA information to reduce delays.

Community-Acquired Pneumonia Requiring Hospitalization among U.S. Adults.

BACKGROUND: Community-acquired pneumonia is a leading infectious cause of hospitalization and death among U.S. adults. Incidence estimates of pneumonia confirmed radiographically and with the use of current laboratory diagnostic tests are needed. METHODS: We conducted active population-based surveillance for community-acquired pneumonia requiring hospitalization among adults 18 years of age or older in five hospitals in Chicago and Nashville. Patients with recent hospitalization or severe immunosuppression were excluded. Blood, urine, and respiratory specimens were systematically collected for culture, serologic testing, antigen detection, and molecular diagnostic testing. Study radiologists independently reviewed chest radiographs. We calculated population-based incidence rates of community-acquired pneumonia requiring hospitalization according to age and pathogen. RESULTS: From January 2010 through June 2012, we enrolled 2488 of 3634 eligible adults (68%). Among 2320 adults with radiographic evidence of pneumonia (93%), the median age of the patients was 57 years (interquartile range, 46 to 71); 498 patients (21%) required intensive care, and 52 (2%) died. Among 2259 patients who had radiographic evidence of pneumonia and specimens available for both bacterial and viral testing, a pathogen was detected in 853 (38%): one or more viruses in 530 (23%), bacteria in 247 (11%), bacterial and viral pathogens in 59 (3%), and a fungal or mycobacterial pathogen in 17 (1%). The most common pathogens were human rhinovirus (in 9% of patients), influenza virus (in 6%), and Streptococcus pneumoniae (in 5%). The annual incidence of pneumonia was 24.8 cases (95% confidence interval, 23.5 to 26.1) per 10,000 adults, with the highest rates among adults 65 to 79 years of age (63.0 cases per 10,000 adults) and those 80 years of age or older (164.3 cases per 10,000 adults). For each pathogen, the incidence increased with age. CONCLUSIONS: The incidence of community-acquired pneumonia requiring hospitalization was highest among the oldest adults. Despite current diagnostic tests, no pathogen was detected in the majority of patients. Respiratory viruses were detected more frequently than bacteria. (Funded by the Influenza Division of the National Center for Immunizations and Respiratory Diseases.).

Pulmonary embolism critical care update: prognosis, treatment, and research gaps.

PURPOSE OF REVIEW: We provide a timely update on treatment care issues facing clinicians and patients with acute pulmonary embolism accompanied by either right ventricular strain (sub-massive pulmonary embolism) or shock (massive pulmonary embolism). RECENT FINDINGS: Care and research changes over the last several years have resulted in four important trends: more consensus and accuracy in the way acute pulmonary embolism severity is described and communicated among acute care clinicians and researchers, increased availability and use of risk prediction scoring systems, increased use of advanced invasive therapy in the setting of severe right ventricular dysfunction, and emergence of multidisciplinary pulmonary embolism response teams to guide standard care decision-making. SUMMARY: Pulmonary embolism with shock should be treated with either systemic or catheter-based thrombolytic therapy in the absence of contraindications. Patients with sub-massive pulmonary embolism accompanied by right heart dysfunction who are treated with thrombolytic therapy likely will experience more rapid improvement in RV function and are less likely to progress to hemodynamic decompensation. This comes, however, with an increased risk of major bleeding. Our recommendation is to consider catheter-based or systemic fibrinolytic therapy in sub-massive pulmonary embolism cases where patients demonstrate high-risk features such as: severe RV strain on echo or CT, and importantly worsening over time trends in pulse, SBP, and oxygenation despite anticoagulation. Understanding the impact of advanced therapy beyond standard anticoagulation on patient-centered outcomes, such as functional status and quality of life represent a research knowledge gap.

Procalcitonin as a Marker of Etiology in Adults Hospitalized With Community-Acquired Pneumonia.

BACKGROUND: Recent trials suggest procalcitonin-based guidelines can reduce antibiotic use for respiratory infections. However, the accuracy of procalcitonin to discriminate between viral and bacterial pneumonia requires further dissection. METHODS: We evaluated the association between serum procalcitonin concentration at hospital admission with pathogens detected in a multicenter prospective surveillance study of adults hospitalized with community-acquired pneumonia. Systematic pathogen testing included cultures, serology, urine antigen tests, and molecular detection. Accuracy of procalcitonin to discriminate between viral and bacterial pathogens was calculated. RESULTS: Among 1735 patients, pathogens were identified in 645 (37%), including 169 (10%) with typical bacteria, 67 (4%) with atypical bacteria, and 409 (24%) with viruses only. Median procalcitonin concentration was lower with viral pathogens (0.09 ng/mL; interquartile range [IQR], <0.05-0.54 ng/mL) than atypical bacteria (0.20 ng/mL; IQR, <0.05-0.87 ng/mL; P = .05), and typical bacteria (2.5 ng/mL; IQR, 0.29-12.2 ng/mL; P < .01). Procalcitonin discriminated bacterial pathogens, including typical and atypical bacteria, from viral pathogens with an area under the receiver operating characteristic (ROC) curve of 0.73 (95% confidence interval [CI], .69-.77). A procalcitonin threshold of 0.1 ng/mL resulted in 80.9% (95% CI, 75.3%-85.7%) sensitivity and 51.6% (95% CI, 46.6%-56.5%) specificity for identification of any bacterial pathogen. Procalcitonin discriminated between typical bacteria and the combined group of viruses and atypical bacteria with an area under the ROC curve of 0.79 (95% CI, .75-.82). CONCLUSIONS: No procalcitonin threshold perfectly discriminated between viral and bacterial pathogens, but higher procalcitonin strongly correlated with increased probability of bacterial pathogens, particularly typical bacteria.