Emergency Medicine Leadership in Industry-sponsored Clinical Trials

OBJECTIVE: To identify and characterize emergency medicine (EM) researchers who, since 1990, have served on a steering committee (SC) or as overall principal investigator (PI) of an industry-sponsored, multicenter clinical trial involving a pharmaceutical or device. METHODS: North American EM research directors (RDs) and other prominent EM investigators (for those hospitals without a RD) were identified from eight sources, including the Society for Academic Emergency Medicine RD Interest Group and the Multicenter Airway Research Collaboration (MARC) database. The identified investigators were sent a screening survey requesting information regarding industry-sponsored clinical research at their site. The individual EM investigators identified by this screening survey were then interviewed by telephone (validation survey) to further explore their leadership experience in industry-sponsored clinical trials. RESULTS: Of 153 identified RDs and prominent EM researchers, 138 responded to the screening survey (90% response rate). Eighty-five EM investigators reportedly had served on a SC or as overall PI for an industry-sponsored clinical trial. Of these 85 North American EM investigators, 77 were available for a structured telephone interview (91% response rate). Although 41 (53%) of the investigators confirmed their leadership role, 36 (47%) had not served in either role. Among the 41 confirmed investigators, 19 (25%) had served as a SC member, 10 (13%) had served as overall PI, and 12 (16%) had experience in both roles. Individual responses provided suggestions for pursuing such leadership positions. CONCLUSIONS: These data suggest the opportunity to expand EM leadership in industry-sponsored clinical trials and demonstrate the need for validation of reports obtained by a departmental research contact. The suggestions from EM researchers who have attained these leadership roles may provide strategies for investigators interested in pursuing these positions.     

Time to antibiotics for septic shock: evaluating a proposed performance measure

Purposes

International guidelines recommend antibiotics within 1 hour of septic shock recognition; however, a recently proposed performance measure is focused on measuring antibiotic administration within 3 hours of emergency department (ED) arrival. Our objective was to describe the time course of septic shock and subsequent implications for performance measurement.

Basic procedures

Cross-sectional study of consecutive ED patients ultimately diagnosed with septic shock. All patients were evaluated at an urban, academic ED in 2006 to 2008. Primary outcomes included time to definition of septic shock and performance on 2 measures: antibiotics within 3 hours of ED arrival vs antibiotics within 1 hour of septic shock definition.

Main findings

Of 267 patients with septic shock, the median time to definition was 88 minutes (interquartile range, 37-156), and 217 patients (81.9%) met the definition within 3 hours of arrival. Of 221 (83.4%) of patients who received antibiotics within 3 hours of arrival, 38 (17.2%) did not receive antibiotics within 1 hour of definition. Of 207 patients who received antibiotics within 1 hour of definition, 11.6% (n = 24) did not receive antibiotics within 3 hours of arrival. The arrival measure did not accurately classify performance in 23.4% of patients.

Principal conclusions

Nearly 1 of 5 patients cannot be captured for performance measurement within 3 hours of ED arrival due to the variable progression of septic shock. Use of this measure would misclassify performance in 23% of patients. Measuring antibiotic administration based on the clinical course of septic shock rather than from ED arrival would be more appropriate.     

Implementation of an Emergency Department–based Transient Ischemic Attack Clinical Pathway: A Pilot Study in Knowledge Translation

Objectives To assess the feasibility of implementing an emergency department (ED)—based transient ischemic attack (TIA) clinical pathway that uses computer-based clinical support, and to evaluate measures of quality, safety, and efficiency.
Methods This was a prospective cohort study of adult patients presenting to a community ED with symptoms consistent with acute TIA. Adherence to the clinical pathway served as a test of feasibility. Compliance with guideline recommendations for antithrombotic therapy and vascular imaging were used as process measures of quality. The 90-day risk of recurrent TIA, stroke, or death provided estimates of safety. Efficiency was assessed by measuring the rate of uneventful hospitalization, defined as a hospital admission that did not result in any major medical event or vascular intervention such as endarterectomy or stent placement.
Results Of the 75 subjects enrolled, physician adherence to the clinical pathway was 85.3%, and 35 patients (46.7%) were discharged home from the ED. Antithrombotic agents were prescribed to 68 (90.7%), and vascular imaging was performed in 70 (93.3%). The 90-day risk of recurrent TIA was seven out of 75 (9.3%; 95% confidence interval [CI] = 4.6% to 18.0%), one patient experienced stroke (1.3%; 95% CI = 0.2% to 7.2%), and three patients died (4.0%; 95% CI = 1.4% to 11.1%). Uneventful hospitalization occurred in 38 of 40 patients (95.0%).
Conclusions Implementation of a clinical pathway for the evaluation and management of TIA using computer-based clinical support is feasible in a community ED setting. This pilot study in knowledge translation provides a design framework for further studies to assess the safety and efficiency of a structured ED-based TIA clinical pathway.     

Male Victims of Domestic Violence and Their History of Perpetrating Violence

Abstract. Objective: To determine whether male victims of domestic violence have similar rates of violence perpetration compared with men evaluated in the ED with other causes of injury. Methods: Case-control retrospective ED record review with linkage to police department records. Cases were identified by ICD code N-code 995.81 (adult maltreatment syndrome) over a 4-year period (January 1, 1991, to December 31, 1994) at one urban trauma center. Medical records were reviewed to confirm that the assailant was an intimate female partner. Controls were identified by E-codes 880–888 (unintentional falls) and matched by age, race, and date of visit. All names were linked to police department record information regarding arrests for domestic violence perpetration, nonaggravated assaults, aggravated assaults, firearms violations, and driving under the influence of alcohol (DUI). This information was reported without patient identifiers. Comparisons between cases and controls were made with x² analysis. Results: Forty-five cases and 45 controls were identified. The cases were injured by unarmed fights, E960 (31%); cuttings, E966 (33%); blunt objects, E968.2 (31%); and bites, E968.8 (5%). Median age (interquartile range) for cases was 32 (25.75, 38.25) years and for controls was 31 (25, 36.5) years. Median follow-up (interquartile range) of police records after ED visit was 45 (37, 50) months for cases and 45 (36.75, 51) months for controls. Fifty-one percent of the cases had arrests for domestic violence perpetration vs 22.2% of the controls (p = 0.009). Forty-four percent of the cases had been arrested for nonaggravated assaults vs 20.0% of the controls (p = 0.024). There was no statistical difference between the cases and controls in arrests for aggravated assaults (13.3% vs 4.4%), firearm violations (22.2% vs 17.8%), or DUIs (35.6% vs 20%). Conclusion: Men who present to the ED with injuries inflicted by their female partners have a high rate of domestic violence perpetration. This information calls into question whether many male “victims” of domestic violence are injured in self-defense by the female “victim.” Also, injury by a female partner may be a useful indicator to identify batterers, so they can be referred by appropriate resources.     

Brighton sleep survey: a study of sleep in 20-45-year olds

A total of 2714 people, aged 20-45 years from the Brighton area who completed a questionnaire were interviewed on their sleep patterns and complaints, medication, behavioural aids, and consumption of caffeine and alcohol. Analysis showed that 24% had delayed sleep onset, 23% awakened frequently, 19% awakened early, 21% were dissatisfied with sleep, and 8% took medication to aid sleep. Of those on night shifts, 29% awakened frequently and 25% awakened early. There were 648 responses describing behavioural sleeping aids. The moderate consumption of caffeine and alcohol had no significant effect on sleep. The main differences between this survey and other published data relate to the comparison of sleep reports from men with those from women, the sleep of nightshift and dayshift workers and the effects of caffeine and alcohol. These differences may arise from sampling characteristics and the form of the questionnaire.     

Development and Implementation of a Model to Improve Identification of Patients Infected with HIV Using Diagnostic Rapid Testing in the Emergency Department

Objectives Infection with the human immunodeficiency virus (HIV) continues to expand in nontraditional risk groups, and the prevalence of undiagnosed infection remains relatively high in the patient populations of urban emergency departments (EDs). Unfortunately, HIV testing in this setting remains uncommon. The objectives of this study were 1) to develop a physician‐based diagnostic rapid HIV testing model, 2) to implement this model in a high‐volume urban ED, and 3) to prospectively characterize the patients who were targeted by physicians for testing and determine the proportions who completed rapid HIV counseling, testing, and referral; tested positive for HIV infection; and were successfully linked into medical and preventative care. Methods An interdisciplinary group of investigators developed a model for performing physician‐based diagnostic rapid HIV testing in the ED. This model was then evaluated using a prospective cohort study design. Emergency physicians identified patients at risk for undiagnosed HIV infection using clinical judgment and consensus guidelines. Testing was performed by the hospital's central laboratory, and clinical social workers performed pretest and posttest counseling and provided appropriate medical and preventative care referrals, as defined by the model. Results Over the 30‐month study period, 105,856 patients were evaluated in the ED. Of these, 681 (0.64%; 95% confidence interval [CI] = 0.60% to 0.69%) were identified by physicians and completed rapid HIV counseling, testing, and referral. Of the 681 patients, 15 (2.2%; 95% CI = 1.2% to 3.6%) patients tested positive for HIV infection and 12 (80%; 95% CI = 52% to 96%) were successfully linked into care. Conclusions A physician‐based diagnostic HIV testing model was developed, successfully implemented, and sustained in a high‐volume, urban ED setting. While the use of this model successfully identified patients with undiagnosed HIV infection in the ED, the overall level of testing remained low. Innovative testing programs, such as nontargeted screening, more specific targeted screening, or alternative hybrid methods, are needed to more effectively identify undiagnosed HIV infection in the ED patient population.     

Provider Adherence to a Clinical Practice Guideline for Acute Asthma in a Pediatric Emergency Department

Critics of the use of clinical practice guidelines (CPGs) in an emergency department (ED) setting believe that they are too cumbersome and time-consuming, but to the best of the authors' knowledge, potential barriers to CPG adherence in the ED have not been prospectively evaluated. OBJECTIVES: To measure provider adherence to an ED CPG based on National Asthma Education and Prevention Program (NAEPP) recommendations, and to determine factors associated with provider nonadherence. METHODS: Prospective, cohort study of children aged 1-18 years with the diagnosis of an acute exacerbation of asthma who were seen in a pediatric ED and requiring admission, as well as a random selection of children discharged to home following pediatric ED care. The following adherence parameters were assessed: at least three nebulized albuterol treatments in the first hour; early steroid administration (after the first nebulizer treatment); clinical assessments using pulse oximetry and peak expiratory flow (PEF) (for children >6 years old); and use of a clinical score to assess acute illness severity (Asthma Severity Score). Nonadherence was defined as any deviation of the above parameters. RESULTS: Between July 1, 1998, and June 30, 1999, 369 patients were studied. Of these, 38% (139) were discharged to home, 38% (140) were admitted to the observation unit, and 24% (90) were admitted to the inpatient unit. Illness severities at initial presentation to the ED were: 24% (86) had mild exacerbations, 59% (212) had moderate exacerbations, and 17% (62) had severe exacerbations. Sixty-eight percent (95% CI = 63% to 73%) of the patients were managed with complete adherence to the CPG. Of the 32% with some form of nonadherence, most (63%) were children older than 6 years; in this group 64% (48/75) were nonadherent due to lack of PEF assessment. When PEF assessment was disregarded, an 83% (95% CI = 79% to 87%) adherence to the CPG was achieved. Other nonadherence factors included: lack of at least three nebulized albuterol treatments provided timely within the first hour (5%); delay in steroid administration (6%); lack of pulse oximeter use (0.5%); and failure to record clinical score to assess severity (1.1%). Patient age, illness severity (acute and chronic), first episode of wheezing, and high ED volume periods (evenings and weekends) did not worsen adherence. CONCLUSIONS: Clinical practice guidelines can be used successfully in the pediatric ED and provide a more efficient management and treatment approach to acute exacerbations of childhood asthma. With a systematic and concise CPG, barriers to adherence in a pediatric ED appear to be minimal, with the exception of using PEF in the routine ED assessment.     

Evaluation of the Emergency Severity Index (version 3) Triage Algorithm in Pediatric Patients

Objectives: As demand for emergency services outpaces available allocated resources, emergency department (ED) triage systems face increasing scrutiny. Longer waits for care make the use of reliable, valid triage systems imperative to patient safety. Little is known about the reliability and validity of triage systems in children. The purpose of this study was to evaluate the reliability and validity of the Emergency Severity Index version 3 (ESIv.3) triage algorithm in a pediatric population. Methods: This two‐phase investigation used both retrospective chart review and prospective, observational designs. Interrater reliability was evaluated using ED triage scenarios, a prospective cohort of ED patients presenting to triage, and retrospective triage assignments using the original triage note. ED triage nurses, nurse investigators, and physician investigators performed retrospective blinded triages using only the original triage note to assess reproducibility. In the second phase, validity was assessed using a retrospective analysis of observed resource use, ED length of stay, and hospitalization compared with resource utilization estimated at triage by the ESI. Results: In the reliability phase, weighted κ for ED nurse triage of standard scenarios ranged from 0.84 to 1.00, representing excellent agreement. Twenty ED pediatric patients were triaged simultaneously by an ED triage nurse and the nurse investigator. Weighted κ was 0.82 (95% confidence interval = 0.66 to 0.98), also representing strong agreement between raters. When used for retrospective chart review, the weighted κ statistics ranged from 0.42 to 0.84, representing poor to good agreement among the different categories of reviewers. During the validity phase, 510 patients were included in the final data analysis. Hospitalization, ED length of stay, and resource utilization were strongly associated with ESIv.3 category. Conclusions: The ESI triage algorithm demonstrated reliability and validity between triage assignment and resource use in this group of ED pediatric patients.     

Failure to Validate a Predictive Model for Refusal of Care to Emergency-department Patients

Objective: To determine whether previously developed triage criteria for refusal of care to patients presenting to an emergency department (ED) with nonurgent problems could be validated for an independent patient population.
Methods: A convenience sample of 534 adults presenting to a municipal hospital ED between July 1, 1992, and October 15, 1992, who met preestablished criteria for refusal of care were entered into a prospective, observational, cohort study. The single target outcome variable was hospitalization. In order to optimize the criteria's performance, both the triage nurse and the physician caring for the patient had to agree that all criteria for "refusal of care" were specifically met. No patient was refused care, nor was a patient's management or disposition interfered with in any way by the investigators. All patients were followed until hospital admission or release from the ED.
Results: Six (1.1%) of 534 patients (95% CI 0.4–2.4) who met the criteria for refusal of care were hospitalized. This represents a greater than 50-fold difference in incidence of hospitalization when compared with that found by other investigators, who reported that only 0.02% (95% CI 0.0004–0.04) of those patients who were refused care subsequently required hospitalization (p < 10–7).
Conclusion: The authors were unable to validate a previously developed predictive model for refusal of care to patients presenting to an ED. Refusal of care to selected ED patients based on current guidelines is not a viable solution to overcrowding. Alternative strategies must be sought.     

Mental Status Screening of Emergency Department Patients: Normative Study of the Quick Confusion Scale

OBJECTIVE: In order to increase the utility of the Quick Confusion Scale (QCS), a six-item, 15-point instrument used in screening for impaired mental status in an emergency department (ED) setting, clinical norms were established for an ED patient population. METHODS: The QCS was administered to ED patients of a university-based hospital during a nine-week period. All subjects scoring less than 15 on the QCS were also administered the Mini-Mental State Examination (MMSE); 731 patients provided QCS scores for use in this study and 295 provided MMSE scores in addition to their QCS scores. RESULTS: The internal consistency of the QCS was found to be within acceptable limits given that the briefness of the scale forced restriction in the variability coefficient. QCS scores were converted to a standardized metric (percentile ranks), population parameters were consulted, and two cutoff scores were established: one that suggests the likelihood of a cognitive impairment, signaling a need for further evaluation (QCS score of 11); and one that indicates an almost certain cognitive impairment (QCS score of 7). Percentile rank comparisons between subjects' scores on the MMSE and on the QCS provided additional validity for the cutoff scores. CONCLUSIONS: The QCS, in its focus on providing a quickly obtained, easily calculated, and readily interpreted score, presents a viable alternative to currently existing practices for assessing mental status in ED patients.     

Informed Consent for Research: Current Practices in Academic Emergency Medicine

Background:  The emergency department (ED) environment presents unique barriers to the process of obtaining informed consent for research.
Objectives:  The objective was to identify commonalities and differences in informed consent practices for research employed in academic EDs.
Methods:  Between July 1, 2006, and June 30, 2007, an online survey was sent to the research directors of 142 academic emergency medicine (EM) residency training programs identified through the Accreditation Council for Graduate Medical Education (ACGME).
Results:  Seventy-one (50%) responded. The average number of simultaneous clinical ED-based research projects reported was 7.3 (95% confidence interval [CI] = 5.53 to 9.07). Almost half (49.3%) of respondents reported that EM residents are responsible for obtaining consent. Twenty-nine (41.4%) participating institutions do not require documentation of an individual resident's knowledge of the specific research protocol and consent procedure before he or she is allowed to obtain consent from research subjects.
Conclusions:  It is common practice in academic EDs for clinical investigators to rely on on-duty health care personnel to obtain research informed consent from potential research subjects. This practice raises questions regarding the sufficiency of the information received by research subjects, and further study is needed to determine the compliance of this consent process with federal guidelines.     

Application of the Sequential Organ Failure Assessment (SOFA) score in patients with advanced cancer who present to the ED

Background

There is limited literature describing clinical predictors for critically ill patients with cancer who present to the emergency department (ED).

Purpose

The aim of this study was to investigate the usefulness of the Sequential Organ Failure Assessment (SOFA) score at the time of ED presentation for predicting short-term mortality in patients with advanced cancer.

Methods

This was a prospective observational study of 108 consecutive patients with advanced cancer who presented to the ED. The outcome was defined as death within 14 days after admission.

Results

The median survival time of the study subjects was 26.5 days (interquartile range, 9.0-78.0 days), and 31 patients (28.7%) died within 14 days after admission. In univariate analysis, SOFA score (≥4), previous chemotherapy, and altered mental status were predictive of 14-day mortality. Of those variables, only SOFA score was an independent predictor in multivariate analysis.

Conclusions

The use of the SOFA score is an acceptable method for risk stratification and prognosis of patients with advanced cancer in the ED. This score can help clinicians to predict 14-day mortality and plan appropriate treatment for critically ill patients with cancer who present to the ED.     

Effectiveness of Increasing Emergency Department Patients' Self-perceived Risk for Being Human Immunodeficiency Virus (HIV) Infected Through Audio Computer Self-interview–based Feedback About Reported HIV Risk Behaviors

Objectives: Prior research has demonstrated that emergency department (ED) patient acceptance of human immunodeficiency virus (HIV) screening is partially dependent on patients’ self-perceived risk of infection. The primary objective of this study was to determine the effectiveness of audio computer-assisted self-interview (ACASI)-based feedback. The intervention aimed to increase patient’s self-perceived risk of being HIV infected by providing immediate feedback on their risk behaviors. Methods: This 1-year, randomized, controlled trial at a U.S. ED enrolled a random sample of 18- to 64-year-old subcritically ill or injured adult patients who were not known to be HIV infected. All participants completed an anonymous, ACASI-based questionnaire about their HIV risk behaviors related to injection drug use and sex, as well as their self-perceived risk for being HIV infected. Participants were randomly assigned to one of two study groups: an intervention group in which participants received immediate ACASI-based feedback in response to each of their reported risk behaviors or a no-intervention group without feedback. Participants were asked to indicate their level of HIV risk on a five-point scale before and after they answered the questions. Change in level of self-perceived HIV risk was calculated and compared by study group using Pearson’s chi-square test. An HIV risk behavior score that summarized reported HIV risk behavior was devised. Because HIV risk behaviors differ by sex, scores were calculated separately for each sex. Linear regression models that adjusted for study group and same subject covariance were employed to determine if higher HIV risk behavior scores were associated with an increase in self-perceived HIV risk. Results: Of the 566 trial participants, the median age was 29 years (interquartile range [IQR] = 22–43 years), 62.2% were females, and 66.9% had been tested previously for HIV. After answering the reported HIV risk behavior questions, 12.6% of participants had an increase, 79.9% had no change, and 7.5% had a decrease in self-perceived HIV risk. Of the 46.6% of participants who initially indicated that they were not at risk for HIV, 11.4% had an increase in self-perceived HIV risk after answering the reported HIV risk behavior questions. Change in self-perceived HIV risk did not differ by study group (p = 0.77). There were no differences in reported HIV risk scores between the intervention and no-intervention groups for females (p = 0.78) or males (p = 0.86). In the linear regression models, a greater increase in self-perceived HIV risk was associated with higher reported HIV risk behavior scores for females (β = 0.59, 95% confidence interval [CI] = 0.15, 1.04) but not for males (β = 1.00, 95% CI = −0.13 to 2.14). Conclusions: Some ED patients can be moved, although modestly, to recognize their risk for being HIV infected by asking about their HIV risk behaviors. However, ACASI-based feedback messages about HIV risk behaviors do not increase subjects’ self-perceived HIV risk. Female ED patients appear to increase their self-perceived HIV risk more than males when queried about their HIV risk behaviors.     

Implementation of a nurse-led family centered engagement intervention for caregivers of extremely premature infants in the neonatal intensive care unit

ObjectiveThe objective of this feasibility study was to examine the implementation and usefulness of an intervention for extremely premature infant (EPI) caregivers.ResultsOne caregiver and five nurses provided feedback with a mean score of 4.4 out of 5 pertaining to helpfulness.ConclusionsImplementation of the Caregiver's Guide was feasible and was positively received by NICU nurses and caregivers. We recommend implementing a revised version of this tool based on nurse and caregiver feedback. The delivery of education should be divided between dayshift and nightshift nurses so that one nurse is not responsible for providing all the information. The education should be categorized by gestational age and day of life and only given when it is pertinent to the care of the child. A section should be added to include a quick reference guide for the medical jargon used in the NICU.     

Spectrum of acute allergic diseases in an emergency department: An evaluation of one years’ experience

Objective: There is limited available literature on the incidence of allergic diseases in ED. The objective of this study was to investigate the clinical records of patients admitted to the ED with a suspected allergic reaction. Methods: A 1 year retrospective study was carried out and data were collected from the patients’ computerized medical reports. Results: A total of 324 patients were admitted for an allergic event. Of those, 165 patients (50.9%) were female and their mean age was 55 ± 18.5 years. Diagnoses included: asthma in 100 patients (30.9%); hymenoptera allergy in 78 patients (24.1%); food allergy in 31 patients (9.5%); drug allergy in 25 patients (7.7%); and allergic conjunctivitis in 12 patients (3.7%). No diagnosis was found in the medical records of 78 patients (24.1%). Anaphylactic shock was observed in 12 patients (3.7%) with a diagnosis of food allergy (six cases), drug allergy (three cases) and hymenoptera allergy (three cases). Ninety patients (27.7%) were hospitalized in the following units: 38 in allergy unit (42.2%); 20 in intensive care unit (22.2%); 10 in pulmonary unit (11.1%); eight in the dermatology unit (8.9%); six in the internal medicine unit (6.7%); and eight in other units (8.9%). Overall, 42 patients (12.9%) were evaluated by an allergologist after ED discharge with positive allergy results in 28 cases (66.6%). Conclusions: Acute allergic diseases are not rare in ED, representing 1% of the annual visits in our series. A low rate of allergologist referral was observed. Emergency physicians must work closely with allergologists to ensure a better evaluation, long‐term care and preventive management of patients with allergic diseases admitted to the ED.     

Smoking Habits of Emergency Department Patients: An Opportunity for Disease Prevention

Objective: To determine smoking habits, levels of addiction, readiness to quit, and access to primary care among ED patients.
Methods: A questionnaire was administered prospectively to all non-critical adult patients who presented to one university hospital ED during 23 randomly selected four-hour time blocks; 336 (89%) of 376 eligible patients responded. Self-reported smoking was validated by carbon monoxide breath testing in a pilot sample of 49 patients.
Results: The study patients were mostly young (mean age = 35 ± 15 years), female (59%), white (62%), and high school-educated (73%). Of the 336 ED patients, 41% were current smokers (95% CI = 0.36–0.46); 42% of these were "moderately" to "very highly" dependent on nicotine (Fagerstrom Test for Nicotine Dependence > 4). Of those who smoked, 68% stated they wanted to quit, and 49% wanted to quit within the month. Fifty-six percent of all those who smoked stated that they had never been told to quit smoking by any physician. Thirty-five percent of the ED sample (118 patients) relied upon EDs for most or all of their routine, primary health care; 55% (95% CI = 0.46–0.64) of these patients were current smokers.
Conclusions: The prevalence rates of smoking and nicotine addiction among ED patients are high. Almost half of ED smokers are ready to quit, but most state they have never been told by a physician to do so. Finally, a large proportion of ED smokers receive their primary care in EDs. Therefore, the ED may be an underused setting for smoking cessation intervention.     

A Call for a Reconsideration of the Use of Fecal Occult Blood Testing in Emergency Medicine

BackgroundFecal occult blood testing (FOBT) was developed to detect microscopic bleeding caused by colorectal neoplasms. The role of FOBT in the emergency department (ED) is typically used for 5 different clinical workups: trauma, anemia, syncope, hypotension, and before the administration of systemic anticoagulants or thrombolytics.ObjectiveWe scrutinized the literature to assess the utility of FOBT for its 5 most common applications in the emergent setting.DiscussionLogic and clinical evidence advocating for FOBT usage in the aforementioned situations are lacking. The test itself requires specific drug and dietary restrictions that are often violated or never met when patients present to the ED with acute pathologies. In addition, the poor sensitivity and specificity of the test in these scenarios dictate that neither a negative nor positive FOBT should change the subsequent clinical workup of patients presenting to the ED.ConclusionClinical decision making should seldom be predicated on the results of a FOBT in the ED setting.