Catching Those Who Fall Through the Cracks: Integrating a Follow-Up Process for Emergency Department Patients with Incidental Radiologic Findings.

STUDY OBJECTIVE: Abnormal findings unrelated to the indication for testing are identified on emergency department (ED) imaging studies. We report the design and implementation of an electronic health record-based interdisciplinary referral system and our experience from the first 13 months of ensuring that patients with incidental radiology findings were connected with the appropriate outpatient surveillance. METHODS: Our informatics team standardized the contemporaneous reporting of critical radiology alerts using our ED trackboard and created a companion follow-up request form for the treating ED clinicians to complete. The forms were routed to nurse case managers, who arranged follow-ups based on the findings and clinical significance. The primary outcome was the proportion of ED patient visits with identified incidental findings that had documented communication of the incidental findings and surveillance plans. RESULTS: Over the first 13 months after implementation, 932 ED patient visits had critical radiology alert referrals, for a total of 982 incidental findings. The primary outcome (confirmed post-ED communication and documented follow-up plan) was attained in 888 (95.3%, 95% confidence interval [CI] 93.9% to 96.6%) ED patient visits with confirmed post-ED communication and documented follow-up plans. The team was unable to contact or confirm follow-up with 44 (4.7%, 95% CI 3.4 to 6.1) patients by telephone or through the health care system's electronic communication tools. CONCLUSION: We report the implementation of a standardized notification and referral system for ED patients with incidental radiology findings. The development of a reliable notification and follow-up system is an important patient safety intervention given the opportunity to potentially identify undiagnosed malignancies.

A celebration with unforeseen consequences: Celebratory gunfire causing injury.

A 41-year-old otherwise healthy women presented to the emergency department via emergency services after collapsing after feeling a "slap" on her head while celebrating a national holiday. Physical exam and computed tomography scan showed the presence of a retained ballistic fragment in her high parietal scalp, making her the victim of injury by celebratory gunfire, an illegal, but not uncommon, practice. She was admitted for concussive symptoms, her bullet was removed without incident and after a period of observation she was discharged in stable condition to home.

A model for rapid emergency department expansion for the COVID-19 pandemic.

COVID-19 has caused global dramatic change in medical practices including the introduction of temporary screening and assessment areas outside the footprint of the main hospital structures. Following the initial surge of patients with novel coronavirus (2019-nCoV) in the United States, our medical center rapidly designed and constructed an alternative assessment and treatment site in a converted parking garage deck for emergency department patients with suspected or confirmed 2019-nCoV. During the first month after opening, 651 patients were treated in this alternative assessment area including 54 patients who tested positive for 2019-nCoV. This accounted for 55% of the 98 patients with confirmed novel coronavirus (2019-nCoV) who were treated in our ED. This report provides a blueprint for the necessary steps, materials, labor needs and barriers, both anticipated and unanticipated, to rapidly construct an alternative ED treatment site during a pandemic.

Comparison of Etomidate and Ketamine for Induction During Rapid Sequence Intubation of Adult Trauma Patients.

STUDY OBJECTIVE: Induction doses of etomidate during rapid sequence intubation cause transient adrenal dysfunction, but its clinical significance on trauma patients is uncertain. Ketamine has emerged as an alternative for rapid sequence intubation induction. Among adult trauma patients intubated in the emergency department, we compare clinical outcomes among those induced with etomidate and ketamine. METHODS: The study entailed a retrospective evaluation of a 4-year (January 2011 to December 2014) period spanning an institutional protocol switch from etomidate to ketamine as the standard induction agent for adult trauma patients undergoing rapid sequence intubation in the emergency department of an academic Level I trauma center. The primary outcome was hospital mortality evaluated with multivariable logistic regression, adjusted for age, vital signs, and injury severity and mechanism. Secondary outcomes included ICU-free days and ventilator-free days evaluated with multivariable ordered logistic regression using the same covariates. RESULTS: The analysis included 968 patients, including 526 with etomidate and 442 with ketamine. Hospital mortality was 20.4% among patients induced with ketamine compared with 17.3% among those induced with etomidate (adjusted odds ratio [OR] 1.41; 95% confidence interval [CI] 0.92 to 2.16). Patients induced with ketamine had ICU-free days (adjusted OR 0.80; 95% CI 0.63 to 1.00) and ventilator-free days (adjusted OR 0.96; 95% CI 0.76 to 1.20) similar to those of patients induced with etomidate. CONCLUSION: In this analysis spanning an institutional protocol switch from etomidate to ketamine as the standard rapid sequence intubation induction agent for adult trauma patients, patient-centered outcomes were similar for patients who received etomidate and ketamine.

Who leaves the emergency department without being seen? A public hospital experience in Georgetown, Guyana.

BACKGROUND: Left without being seen (LWBS) proportions are commonly used as quality control indicators, but little data is available on LWBS proportions in the developing world. This study sought to determine the proportion and characteristics of patients who LWBS from the emergency department (ED) of the main public hospital in Georgetown, Guyana. METHODS: This is a retrospective cross-sectional analysis of an ED quality assurance database. Registration personnel collected demographic information on patients presenting to the ED over a 2-week period in July 2010. Both univariate and multivariate analysis were conducted to determine patient characteristics associated with LWBS. RESULTS: The LWBS proportion was 5.7%. In univariate analysis, patients 18 or older (OR 1.48, 95%CI 1.03-2.12), presenting during the 4PM-12AM shift (OR 2.15, 95%CI 1.53-3.01), with non-urgent triage classification (OR 1.88, 95%CI 1.76-4.66), with non-traumatic chief complaints (OR 1.70, 95%CI 1.14-2.55), or who were not transferred (OR 2.13, 95%CI 1.00-4.55) had significantly higher odds of LWBS. On multivariate analysis, only patients 18 or older (OR 1.54, 95%CI 1.02-2.33), presenting during the 4PM-12AM shift (OR 2.29, 95%CI 1.54-3.40), and with non-traumatic chief complaints (OR 2.39, 95%CI 1.43-4.02) were found to be significantly associated with LWBS. Sex, residence in the capital city, time to triage, transfer status, use of EMS, and triage classification were not statistically associated with LWBS. CONCLUSIONS: LWBS proportions are used as quality control indicators and this study determined the LWBS proportion at a public hospital in a developing country and some of the patient characteristics associated with LWBS. This can be helpful to develop strategies to decrease LWBS proportions and to assess progress over time.

Assessment of the Framingham risk factors among ED patients with newly diagnosed atrial fibrillation.

STUDY OBJECTIVE: Atrial fibrillation (AF) is often first diagnosed in the emergency department (ED) and accounts for nearly 1% of all emergency department (ED) visits. Our objective was to assess the Framingham Heart Study risk score for AF development in ED patients with newly diagnosed AF. METHODS: We systematically reviewed the electronic medical records of ED patients with newly diagnosed AF between August 2005 and July 2008. We measured the frequency of the Framingham Heart Study predictors and calculated each patient's risk score. RESULTS: During the 3-year study period, 914 patients had 1228 ED visits. New AF was diagnosed in 296 (32%) patients. Among these patients, 107 (36%) were female, 127 (43%) had prior ED visits since 2003, 189 (64%) were taking hypertension medications and 170 (57.4%) had previous electrocardiograms with measurable PR intervals. The median PR interval was 166 ms (151 to 180) and 60% of available PR intervals were 160 ms or greater. The median (interquartile range) age, body mass index, and systolic blood pressure were 66 years (53-77), 27 (23-31), and 134 mm Hg (118-151), respectively. Median risk score was 7 (3-9) indicating high predicted risk. Heart failure and cardiac murmurs were previously diagnosed in 45 (15%) and 32 (11%) of these patients, respectively. CONCLUSIONS: The Framingham risk factors for AF are commonly encountered among ED patients with newly diagnosed AF. The ED might provide an opportunity to identify patients at high risk for AF and refer them for primary prevention interventions.

ED crowding and the use of nontraditional beds.

BACKGROUND AND OBJECTIVES: In an effort to compensate for crowding, many emergency departments (EDs) evaluate and treat patients in nontraditional settings such as gurneys in hallways and conference rooms. The impact of this practice on ED evaluation time is unknown. RESEARCH DESIGN AND SUBJECTS: A historical cohort of adult ED visits to an academic hospital between August 1, 2009 and August 1, 2010, was used to evaluate the relationship between ED bed assignment (traditional, hallway, or conference room bed) and mean ED evaluation time, defined as the time spent in an ED bed before admission or discharge. Chief complaints were categorized into the 5 most frequent categories: abdominal/genitourinary, joint/muscle, general (fever, malaise), head/neck, and other. Multiple linear regression and marginal prediction were used to calculate the mean ED evaluation times for each bed type, overall, and by chief complaint category. RESULTS: During the study period, 15 073 patient visits met the inclusion criteria. After adjustment for patient and ED factors, assignments to hallway and conference room beds were associated with increases in a mean ED evaluation time of 13.3 minutes (95% confidence interval, 13.2-13.3) and 10.9 minutes (95% confidence interval, 10.8-10.9), respectively, compared with the traditional bed ED evaluation time. This varied by chief complaint category. CONCLUSIONS: Use of nontraditional beds is associated with increases in mean ED evaluation time; however, these increases are small and may be further minimized by restricting the use of nontraditional beds to patients with specific chief complaints. Nontraditional beds may have a role in improving ED throughput during times of crowding.

Predictors of ambulance transport in patients with ST-elevation myocardial infarction.

INTRODUCTION: Despite intense public awareness campaigns, many patients with ST-elevation myocardial infarction (STEMI) do not utilize Emergency Medical Services (EMS) transportation to the Emergency Department (ED). Predictors for mode of transport by EMS versus private vehicle in patients with an acute STEMI were investigated. Hypothesis It was hypothesized that patient characteristics, specifically older age, male sex, and a history of a prior cardiac intervention, would be associated with a higher likelihood of EMS utilization. METHODS: A retrospective, observational cohort study was performed for all STEMI patients treated from April 1, 2007 through June 30, 2010 at an urban, academic ED with 24-hour cardiac catheterization available. Multivariable analyses with predetermined predictors (age, sex, prior cardiac intervention, weekend/evening arrival) were performed to investigate associations with mode of transport. Door-to-balloon (D2B) times were calculated. RESULTS: Of the 209 STEMI patients, 11 were excluded, leaving 198 for analysis. Median age was 60 years (IQR: 53-70), 138 (70%) arrived by private vehicle, and 60 (30%) by EMS. The primary analysis did not identify significant predictors for EMS, but a post-hoc model found that private insurance (OR 0.18; 95% CI, 0.07-0.45) was associated with fewer EMS transports. Although not statistically significant due to the great variability in time of arrival for STEMI patients transported by private vehicle, EMS transports had shorter D2B times. During business hours and weekend/evenings, EMS had D2B times of 50 (IQR: 42-61) and 58 minutes (IQR: 47-63), respectively, while private vehicle transports had median D2B times of 62 (IQR: 50-74) and 78 minutes (IQR: 66-106). Conclusion No associations between mode of transport and patient age, sex, weekend/evening presentation and history of a prior cardiac intervention were identified. Privately insured patients were less likely to use EMS when experiencing a STEMI. More effective ways are needed to educate the public on the importance of EMS activation when one is concerned for acute coronary syndrome.

A clinical prediction model to estimate risk for 30-day adverse events in emergency department patients with symptomatic atrial fibrillation.

STUDY OBJECTIVE: Atrial fibrillation affects more than 2 million people in the United States and accounts for nearly 1% of emergency department (ED) visits. Physicians have little information to guide risk stratification of patients with symptomatic atrial fibrillation and admit more than 65%. Our aim is to assess whether data available in the ED management of symptomatic atrial fibrillation can estimate a patient's risk of experiencing a 30-day adverse event. METHODS: We systematically reviewed the electronic medical records of all ED patients presenting with symptomatic atrial fibrillation between August 2005 and July 2008. Predefined adverse outcomes included 30-day ED return visit, unscheduled hospitalization, cardiovascular complication, or death. We performed multivariable logistic regression to identify predictors of 30-day adverse events. The model was validated with 300 bootstrap replications. RESULTS: During the 3-year study period, 914 patients accounted for 1,228 ED visits. Eighty patients were excluded for non-atrial-fibrillation-related complaints and 2 patients had no follow-up recorded. Of 832 eligible patients, 216 (25.9%) experienced at least 1 of the 30-day adverse events. Increasing age (odds ratio [OR] 1.20 per decade; 95% confidence interval [CI] 1.06 to 1.36 per decade), complaint of dyspnea (OR 1.57; 95% CI 1.12 to 2.20), smokers (OR 2.35; 95% CI 1.47 to 3.76), inadequate ventricular rate control (OR 1.58; 95% CI 1.13 to 2.21), and patients receiving ß-blockers (OR 1.44; 95% CI 1.02 to 2.04) were independently associated with higher risk for adverse events. C-index was 0.67. CONCLUSION: In ED patients with symptomatic atrial fibrillation, increased age, inadequate ED ventricular rate control, dyspnea, smoking, and ß-blocker treatment were associated with an increased risk of a 30-day adverse event.

Placing physician orders at triage: the effect on length of stay.

STUDY OBJECTIVE: Emergency department (ED) crowding is a significant problem nationwide, and numerous strategies have been explored to decrease length of stay. Placing a physician in the triage area to rapidly disposition low-acuity patients and begin evaluations on more complex patients is one strategy that can be used to lessen the effect of ED crowding. The goal of this study is to assess the effect of order placement by a triage physician on length of stay for patients ultimately treated in a bed within the ED. METHODS: We conducted a pre-experimental study with retrospective data to evaluate patients with and without triage physician orders at a single academic institution. A matched comparison was performed by pairing patients with the same orders and similar propensity scores. Propensity scores were calculated with demographic and triage data, chief complaint, and ED capacity on the patient's arrival. RESULTS: During the 23-month study period, a total of 66,909 patients were sent to the waiting room after triage but still eventually spent time in an ED bed. A quarter of these patients (23%) had physician orders placed at triage. After a matched comparison, patients with triage orders had a 37-minute (95% confidence interval 34 to 40 minutes) median decrease in time spent in an ED bed, with an 11-minute (95% confidence interval 7 to 15 minutes) overall median increase in time until disposition. CONCLUSION: Our study suggests that early orders placed by a triage physician have an effect on ED operations by reducing the amount of time patients spend occupying an ED bed.

Factors Influencing Time-Dependent Quality Indicators for Patients With Suspected Acute Coronary Syndrome.

OBJECTIVES: Rapid risk stratification and timely treatment are critical to favorable outcomes for patients with acute coronary syndrome (ACS). Our objective was to identify patient and system factors that influence time-dependent quality indicators (QIs) for patients with unstable angina/non-ST elevation myocardial infarction (NSTEMI) in the emergency department (ED). METHODS: A retrospective, cohort study was conducted during a 42-month period of all patients 24 years or older suspected of having ACS as defined by receiving an electrocardiogram and at least 1 cardiac biomarker test. Cox regression was used to model the effects of patient characteristics, ancillary service use, staffing provisions, equipment availability, and ED and hospital crowding on ACS QIs. RESULTS: Emergency department adherence rates to national standards for electrocardiogram readout time and biomarker turnaround time were 42% and 37%, respectively. Cox regression models revealed that chief complaints without chest pain and the timing of stress testing and medication administration were associated with the most significant delays. CONCLUSIONS: Patient and system factors both significantly influenced QI times in this cohort with unstable angina/NSTEMI. These results illustrate both the complexity of diagnosing patients with NSTEMI and the competing effects of clinical and system factors on patient flow through the ED.

Prevalence of incidental findings in trauma patients detected by computed tomography imaging.

STUDY OBJECTIVE: The primary intention of spiral computed tomography (SCT) in trauma patients is to identify significant injuries. However, unanticipated information is often discovered. We hypothesize that SCT often identifies clinically significant incidental findings in trauma patients. METHODS: This was a retrospective protocol chart review of consecutive adult trauma patients seen at a level I trauma center. A complete SCT was defined as computed tomography imaging of the head, cervical spine, chest, abdomen, and pelvis, thoracic, and lumbar spine. Incidental findings were classified into 2 categories: type 1, which requires urgent evaluation, and type 2, which requires informing the patient but does not mandate urgent follow-up. RESULTS: We reviewed 3246 patient charts and 3092 met inclusion criteria. Type 1 findings were reported in 990 (32.0%; 95% confidence interval [CI], 30.4%-33.7%) patients. Type 2 findings were found in 1274 (41.2%; 95% CI, 39.5%-42.9%) patients. Female sex (odds ratio, 1.38; 95% CI, 1.16-1.65) and older age (odds ratio, 2.61; 95% CI, 2.33-2.93) were independently associated with a higher prevalence of type 1 findings. There were 631 incidental findings concerning for neoplasm, which included 196 pulmonary nodules, 99 liver, 36 renal, 23 brain, and 11 breast masses. CONCLUSIONS: A significant number of trauma patients evaluated with SCT are diagnosed with potentially serious incidental findings. For long-term care and medicolegal concerns, physicians need to inform patients of these incidental findings and the need for further evaluation.

Charge Reductions Associated With Shorter Time to Recovery in Septic Shock.

BACKGROUND: Septic shock therapies that shorten the time to physiologic and clinical recovery may result in financial savings. However, the financial implications of improving these nonmortal outcomes are not well characterized. Therefore, we quantified hospital charges associated with four outcomes: ICU length of stay, duration of invasive mechanical ventilation, duration of vasopressor use, and new renal replacement therapy. METHODS: This was an observational study using administrative data from a large academic hospital in the United States. The analysis included adults treated with vasopressors for septic shock in a medical ICU. Linear regression modeling with ordinary least square was used to estimate the incremental hospital charges associated with 1 day of ICU length of stay, 1 day of mechanical ventilation, 1 day of vasopressor use, and new renal replacement therapy. RESULTS: The study population included 587 adults with septic shock, including 180 (30.7%) who died in the hospital. The median charge for a septic shock hospitalization was $98,583 (interquartile range [IQR], $61,177-$136,672). Decreases in ICU length of stay, mechanical ventilation duration, and vasopressor duration of 1 day were associated with charge reductions of $15,670 (IQR, $15,023-$16,317), $15,284 (IQR, $13,566-$17,002), and $17,947 (IQR, $16,344-$19,549), respectively. Avoidance of new renal replacement therapy was associated with a charge reduction of $36,051 (IQR, $22,353-$49,750). CONCLUSIONS: Septic shock therapies that reduce the duration of organ support and ICU care have the potential to lead to substantial financial savings.

Implementation of an Opioid Detoxification Management Pathway Reduces Emergency Department Length of Stay.

OBJECTIVES: With the rise of opioid use in the United States, the increasing demand for treatment for opioid use disorders presents both a challenge and an opportunity to develop new care pathways for emergency department (ED) patients seeking opioid detoxification. We set out to improve the care of patients presenting to our ED seeking opioid detoxification by implementing a standardized management pathway and to measure the effects of this intervention. METHODS: We conducted a before-after study of the effects of an opioid detoxification management pathway on ED length of stay (EDLOS), use of resources (social worker consultation, laboratory tests obtained), and return visits to the same ED within 30 days of discharge. All data were collected retrospectively by review of the electronic health record. RESULTS: Ultimately, 107 patients presented to the ED that met criteria, 52 in the intervention period and 55 in the preintervention period. Median EDLOS in the intervention period was 152 (interquartile range [IQR] = 93-237) minutes compared to 312 (IQR = 187-468) minutes in the preintervention period (p < 0.001). Patients in the intervention period less frequently had a social work consultation (32.7% vs. 83.6%, p < 0.001) or had laboratory tests obtained (32.7% vs 74.5%, p < 0.001) and more frequently were prescribed a medication for withdrawal symptoms (57.7% vs. 29.1%, p = 0.003). CONCLUSIONS: Implementation of an opioid detoxification management pathway reduced EDLOS, reduced utilization of resources, and increased the proportion of patients prescribed medications for symptom relief.

Measuring Emergency Department Acuity.

BACKGROUND: Emergency department (ED) acuity is the general level of patient illness, urgency for clinical intervention, and intensity of resource use in an ED environment. The relative strength of commonly used measures of ED acuity is not well understood. METHODS: We performed a retrospective cross-sectional analysis of ED-level data to evaluate the relative strength of association between commonly used proxy measures with a full spectrum measure of ED acuity. Common measures included the percentage of patients with Emergency Severity Index (ESI) scores of 1 or 2, case mix index (CMI), academic status, annual ED volume, inpatient admission rate, percentage of Medicare patients, and patients seen per attending-hour. Our reference standard for acuity is the proportion of high-acuity charts (PHAC) coded and billed according to the Centers for Medicare and Medicaid Service's Ambulatory Payment Classification (APC) system. High-acuity charts included those APC 4 or 5 or critical care. PHAC was represented as a fractional response variable. We examined the strength of associations between common acuity measures and PHAC using Spearman's rank correlation coefficients (rs ) and regression models including a quasi-binomial generalized linear model and linear regression. RESULTS: In our univariate analysis, the percentage of patients ESI 1 or 2, CMI, academic status, and annual ED volume had statistically significant associations with PHAC. None explained more than 16% of PHAC variation. For regression models including all common acuity measures, academic status was the only variable significantly associated with PHAC. CONCLUSION: Emergency Severity Index had the strongest association with PHAC followed by CMI and annual ED volume. Academic status captures variability outside of that explained by ESI, CMI, annual ED volume, percentage of Medicare patients, or patients per attending per hour. All measures combined only explained only 42.6% of PHAC variation.

Effect of a Handover Tool on Efficiency of Care and Mortality for Interhospital Transfers.

BACKGROUND: Interhospital transfer is frequent, and transferred patients experience delays in the provision of care and higher mortality rates when compared to patients directly admitted. The interhospital handover is a key opportunity to improve care but has not been evaluated. OBJECTIVE: To determine the effect of a universal handover tool on timeliness of care, length of stay (LOS), and mortality among interhospital transfer patients. DESIGN, SETTING, AND PATIENTS: Retrospective cohort of patients transferred to an academic medical center between July 1, 2009 and December 31, 2010 with interrupted time-series design. INTERVENTION: One-page handover tool containing information critical for immediate patient care instituted hospital-wide on July 1, 2010. The handover tool was completed by the transferring physician and available for review before patient arrival. MEASUREMENTS: Time-to-admission order entry, LOS after transfer, in-hospital mortality. RESULTS: There was no significant change in the time-to-admission order entry after implementation (47 minutes vs. 45 minutes, adjusted P = 0.94). There was a nonstatistically significant reduction in LOS after implementation (6.5 days vs. 5.8 days, adjusted P = 0.06). In-hospital mortality for transfer patients declined significantly in the postintervention period from 12.0% to 8.9% (adjusted odds ratio, 0.68; 95% confidence interval, 0.47 - 0.99, P = 0.04). There was no change in mortality for the concurrent control group. CONCLUSION: Implementation of a standardized handover tool for interhospital transfer was feasible and may be associated with significant reductions in length of stay and mortality. Widespread adoption of similar tools may improve outcomes in this high-risk population. Journal of Hospital Medicine 2017;12:23-28.

Saline versus balanced crystalloids for intravenous fluid therapy in the emergency department: study protocol for a cluster-randomized, multiple-crossover trial.

BACKGROUND: Prior studies in critically ill patients suggest the supra-physiologic chloride concentration of 0.9% ("normal") saline may be associated with higher risk of renal failure and death compared to physiologically balanced crystalloids. However, the comparative effects of 0.9% saline and balanced fluids are largely unexamined among patients outside the intensive care unit, who represent the vast majority of patients treated with intravenous fluids. METHODS/DESIGN: This study, entitled Saline Against Lactated Ringer's or Plasma-Lyte in the Emergency Department (SALT-ED), is a pragmatic, cluster, multiple-crossover trial at a single institution evaluating clinical outcomes of adults treated with 0.9% saline versus balanced crystalloids for intravenous fluid resuscitation in the emergency department. All adults treated in the study emergency department receiving at least 500 mL of isotonic crystalloid solution during usual clinical care and subsequently hospitalized outside the intensive care unit are included. Treatment allocation of 0.9% saline versus balanced crystalloids is assigned by calendar month, with study patients treated during the same month assigned to the same fluid type. The first month (January 2016) was randomly assigned to balanced crystalloids, with each subsequent month alternating between 0.9% saline and balanced crystalloids. For balanced crystalloid treatment, clinicians can choose either Lactated Ringer's or Plasma-Lyte A©. The study period is set at 16 months, which will result in an anticipated estimated sample size of 15,000 patients. The primary outcome is hospital-free days to day 28, defined as the number of days alive and out of the hospital from the index emergency department visit until 28 days later. Major secondary outcomes include proportion of patients who develop acute kidney injury by creatinine measurements; major adverse kidney events by hospital discharge or day 30 (MAKE30), which is a composite outcome of death, new renal replacement therapy, and persistent creatinine elevation >200% of baseline; and in-hospital mortality. DISCUSSION: This ongoing pragmatic trial will provide the most comprehensive evaluation to date of clinical outcomes associated with 0.9% saline compared to physiologically balanced fluids in patients outside the intensive care unit. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02614040 . Registered on 18 November 2015.

The AFFORD clinical decision aid to identify emergency department patients with atrial fibrillation at low risk for 30-day adverse events.

There is wide variation in the management of patients with atrial fibrillation (AF) in the emergency department (ED). We aimed to derive and internally validate the first prospective, ED-based clinical decision aid to identify patients with AF at low risk for 30-day adverse events. We performed a prospective cohort study at a university-affiliated tertiary-care ED. Patients were enrolled from June 9, 2010, to February 28, 2013, and followed for 30 days. We enrolled a convenience sample of patients in ED presenting with symptomatic AF. Candidate predictors were based on ED data available in the first 2 hours. The decision aid was derived using model approximation (preconditioning) followed by strong bootstrap internal validation. We used an ordinal outcome hierarchy defined as the incidence of the most severe adverse event within 30 days of the ED evaluation. Of 497 patients enrolled, stroke and AF-related death occurred in 13 (3%) and 4 (<1%) patients, respectively. The decision aid included the following: age, triage vitals (systolic blood pressure, temperature, respiratory rate, oxygen saturation, supplemental oxygen requirement), medical history (heart failure, home sotalol use, previous percutaneous coronary intervention, electrical cardioversion, cardiac ablation, frequency of AF symptoms), and ED data (2 hours heart rate, chest radiograph results, hemoglobin, creatinine, and brain natriuretic peptide). The decision aid's c-statistic in predicting any 30-day adverse event was 0.7 (95% confidence interval 0.65, 0.76). In conclusion, in patients with AF in the ED, Atrial Fibrillation and Flutter Outcome Risk Determination provides the first evidence-based decision aid for identifying patients who are at low risk for 30-day adverse events and candidates for safe discharge.