Prosthetic hip dislocations: Is relocation in the emergency department by emergency medicine staff better?

Objective: Prosthetic hip dislocation is common. This study compares prosthetic hip relocations attempted within the ED by emergency doctors and those under orthopaedic care in the ED or operating theatre (OT). Methods: Retrospective cohort study of patients presenting to Auckland City Hospital Adult Emergency Department with prosthetic hip dislocations between 1 January 2003 and 14 April 2008. Primary outcomes were proportion of successful relocation attempts and length of hospital stay. Secondary outcomes were: time to relocation, complications, post‐procedural advice, representation rate and long‐term outcomes for first‐time dislocations. There were 410 eligible presentations during the study period. Results: Emergency medicine (EM) was successful in 254/323 attempts (79%, 95% confidence interval [CI] 74–83). Orthopaedics were successful in 25/35 reductions in the ED (71%, 95% CI 55–84) and 49/51 OT attempts (96%, 95% CI 86–100), P = 0.004 for location OT versus ED. Median times to discharge were 8.8 h for EM, 28.3 h for orthopaedics in the ED and 81 h for orthopaedics in the OT, P < 0.001 for EM versus orthopaedics. Mechanical complications of procedures and early redislocations were infrequent. Complication of sedation were more often seen in OT compared to ED (23/47 [49%, 95% CI 35–63]vs 37/318 [12%, 95% CI 9–16]). Conclusion: There was no difference between EM and orthopaedics in the proportion of hips successfully relocated or complications in the ED; however, EM patients were discharged much sooner, with important resource implications. Procedures carried out in the OT were more successful than in the ED but resulted in prolonged hospital stays and were associated with more complications.     

Short‐term risk of adverse outcome is significantly higher in patients returning an abnormal troponin result when tested in the emergency department

Objective: Describe short‐term mortality and hospitalization outcomes in patients undergoing troponin testing in Western Australia tertiary public hospital ED. Methods: Retrospective cohort study of adults presenting to urban tertiary ED between July 2000 and December 2004, and undergoing troponin inhibitory or tropomyosin binding testing. Patient data relating to ED attendance, troponins, hospitalization and death were linked using probabilistic data linkage. Troponin results were dichotomized (normal/abnormal) according to hospitals' cut‐offs across various time periods. Presentations undergoing ED troponin testing, provided that it was not within 28 days of a previous discharge involving ED troponin testing, met study inclusion criteria. Logistical regression analyses quantified risk of subsequent hospitalization and death. Results: A total of 119 646 troponin tests were performed during 83 635 ED presentations involving 54 214 patients. For the 73 965 ED presentations meeting the study criteria, 6779 (9.2%) recorded an abnormal peak troponin level and 168 (2.5%) of these presentations were discharged directly from ED. After adjusting for covariates, those discharged directly from ED with abnormal troponin results were significantly more likely to die within 2 days (OR 60.4, 95% CI 31.9–114.2), 7 days (OR 31.2, 95% CI 17.9–54.3) and 28 days (OR 19.4, 95% CI 12.5–30.1) of discharge, compared with those with normal troponin results. Adjusted odds of subsequent hospital admission within 28 days following discharge from ED were 3.3 (95% CI 2.4–4.5) times greater for presentations with abnormal versus normal troponin results. Conclusion: An abnormal ED troponin result appears to be associated with increased risk of subsequent hospitalization and death within 28 days of discharge.     

Once or twice‐daily,algorithm‐based intravenous cephazolin for home‐based cellulitis treatment

Objective: Cellulitis is a common presentation to the ED and a significant cause of hospitalization that can be managed in hospital‐in‐the‐home programmes. Current clinical‐practice guidelines recommend once or twice‐daily i.v. antibiotics; however, there is an absence of data describing the impact of these guidelines in real‐world practice‐based settings. This study aims to describe the safety and effectiveness of home‐based cellulitis treatment according to an online treatment algorithm. Methods: Over 12 months, 301 patients with a diagnosis of uncomplicated cellulitis requiring i.v. antibiotics and eligible for home‐based therapy completed once‐daily (cephazolin plus probenecid) or twice‐daily (cephazolin alone) treatment, according to the treatment algorithm. Time (days) until non‐progression of cellulitis was the primary outcome measure. Length of stay and treatment‐related side‐effects were also recorded. Results: The mean time until non‐progression was 2.11 (95% confidence interval [CI] 1.98–2.23) days versus 2.13 (95% CI 1.81–2.45) days for the once‐daily (n = 213) and twice‐daily (n = 88) regimens, respectively (P = 0.92, difference in means 0.02 [95% CI ?0.36–0.33]). The corresponding mean length of stay was 6.55 (95% CI 5.96–7.15) days versus 7.67 (95% CI 6.69–8.65) days (P = 0.06, difference in means 1.12 [CI 0.03–1.23]). Treatment‐related side‐effects were reported in 15.5% (33/213 [95% CI 10.6–20.3]) of patients receiving the once‐daily regimen compared with 9.1% (8/88 [95% CI 3.1–15.1]) treated twice‐daily. Application of the once‐daily strategy increased hospital‐in‐the‐home cellulitis‐related treatment capacity by 52% (1396/2688 [95% CI 50–54]). Conclusions: An online decision support algorithm can support the effective use of a once or twice‐daily treatment regimen for uncomplicated cellulitis. This approach can increase the efficiency and capacity of home‐based therapy, resulting in better alignment of treatment options with clinicians and patients' preferences.     

Factors influencing inappropriate use of ED visits among type 2 diabetics in an evidence‐based management programme

Object This study analyses inappropriate use of emergency department (ED) services among type 2 diabetics under an evidence‐based management programme. Methods Using 1999‐2006 databases of Louisiana Health Care Services Division (HCSD) eight public hospitals ED visits among the uninsured and other patients in Louisiana, we termed urgent ED visits appropriate and less‐urgent visits inappropriate. Eliminating weekend ED visits, 17 458 urgent and 22 395 less‐urgent visits by 8596 patients were analysed, using generalized estimating equation methods. Results Caucasians were 0.82 times (95% CI: 0.751–0.889) less likely to use the ED inappropriately compared with African Americans. Patients with commercial insurance, Medicaid and Medicare used the ED more inappropriately than uninsured, with odds ratios of 1.28, 1.32 and 1.28, respectively. Patients hospitalized the prior year were 0.84 times (95% CI: 1.08–1.31) less likely for inappropriate. Patients in larger hospitals used the ED more inappropriately, with an odds ratio of 1.44 (95% CI: 1.32–1.56). Conclusions The study suggests that inappropriate use of the ED among diabetic patients in an evidence‐based management programme is more likely to occur among African American, patients with insurance coverage and those seeking care in larger hospitals. Reinforcing the regular use of clinic services for diabetes management, providing clinic access in off‐hours, and engaging the health plans in providing incentives for more appropriate use of the ED might reduce inappropriate ED visits. Notably, uninsured patients with diabetes from HCSD were more efficient users of the ED.     

Point‐of‐care Glucose and Hemoglobin A1c in Emergency Department Patients without Known Diabetes: Implications for Opportunistic Screening

Objectives: The objectives were to evaluate the correlation between random glucose and hemoglobin A1c (HbA1c) in emergency department (ED) patients without known diabetes and to determine the ability of diabetes screening in the ED to predict outpatient diabetes. Methods: This was a cross‐sectional study at an urban academic ED. The authors enrolled consecutive adult patients without known diabetes during eight 24‐hour periods. Point‐of‐care (POC) random capillary glucose and HbA1c levels were tested, as well as laboratory HbA1c in a subset of patients. Participants with HbA1c ≥ 6.1% were scheduled for oral glucose tolerance test (OGTT). Results: The 265 enrolled patients were 47% female and 80% white, with a median age of 42 years. Median glucose and HbA1c levels were 93 mg/dL (interquartile range [IQR] = 82–108) and 5.8% (IQR = 5.5–6.2), respectively. The correlation between POC and laboratory HbA1c was r = 0.96, with mean difference 0.33% (95% confidence interval [CI] = 0.27% to 0.39%). Glucose threshold ≥ 120 mg/dL had 89% specificity and 26% sensitivity for predicting the 76 (29%) patients with abnormal HbA1c; ≥ 140 mg/dL had 98% specificity and 14% sensitivity. The correlation between random glucose and HbA1c was moderate (r = 0.60) and was affected by age, gender, prandial status, corticosteroid use, and current injury. Only 38% of participants with abnormal HbA1c returned for OGTTs; 38% had diabetes, 34% had impaired fasting glucose/impaired glucose tolerance, and 28% had normal glucose tolerance. Conclusions: ED patients have a high prevalence of undiagnosed diabetes. Although screening with POC random glucose and HbA1c is promising, improvement in follow‐up with confirmatory testing and initiation of treatment is needed before opportunistic ED screening can be recommended.     

Timed Up and Go test is not useful as a discharge risk screening tool

Objective: To determine whether the ‘Timed Up and Go’ (TUG) test is a useful test for predicting re‐attendance at an ED, emergency hospital admission or death within 90 days in elderly patients discharged from the ED. Methods: This was a prospective blinded cohort study at a tertiary referral ED. Patients completed a TUG test during their Allied Health assessment prior to discharge from the department. After 90 days, patient ED attendances, emergency admissions to hospital or deaths were recorded and confirmed by phone. Data were analysed using logistic regression and reported as odds ratios (OR) or log‐transformation and Pearson analysis. Results: One hundred patients were enrolled: 78 (78%, 95% confidence interval [CI] 70–86%) patients remained event free, 22 (22%, 95% CI 14–30%) patients re‐attended an ED and 15 (15%, 95% CI 8–22%) were admitted to hospital as an emergency admission. There was no significant difference between TUG test times and whether patients re‐attended an ED (OR 1.0 [0.93–1.06]P = 0.9) or were admitted to hospital (OR 0.99 [0.91–1.07]P = 0.74). There was no significant correlation between a patient's TUG test time and the number of days to ED re‐attendance (Pearson correlation coefficient 0.38 [?0.04 to 0.69]P = 0.08) or admission (Pearson correlation coefficient 0.32 [?0.23 to 0.71]P = 0.25). Conclusion: This study did not detect any predictive value of the TUG test for ED re‐attendance or hospital admission within 90 days of discharge among aged ED patients.     

Butylscopolammonium bromide does not provide additional analgesia when combined with morphine and ketorolac for acute renal colic

Objective: To evaluate the effect of adding butylscopolammonium bromide (BB) to morphine and ketorolac in the treatment of acute renal colic in the ED. Methods: A prospective, double‐blind, randomized controlled trial of i.v. triple therapy (morphine, ketorolac and BB) versus double therapy (morphine and ketorolac) in adult ED patients with a clinical diagnosis of acute renal colic and a pain rating greater than five on a 10 cm visual analogue scale (VAS). VAS was recorded at time 0, 20 and 40 min. Patients received rescue morphine at 20 or 40 min according to the protocol if needed. We compared pain reduction and the need for rescue analgesia at 4 min between two groups. Results: Eighty‐nine patients were randomized over a 13 month period. A total of 46 (51.7%) patients received BB in addition to morphine and ketorolac. The mean difference in change in pain score in the triple therapy group and double therapy group was 7.1 cm (95% CI 6.4–7.8) and 5.9 cm (95% CI 5.1–6.7), respectively (P= 0.024). Rescue morphine was required by 7/46 (15.2% [95% CI 4.4–20.6]) patients in the triple therapy group and 14/43 (32.6% [95% CI 18.0–47.1]) in the double therapy group (OR 0.37 [95% CI 0.133–1.038]). Conclusions: Although the addition of BB to morphine and ketorolac appeared to show a statistically significant reduction in pain compared with morphine and ketorolac alone, a reduction of 1.2 cm on VAS is unlikely to be clinically significant.     

Patient perceptions of privacy infringements in an emergency department

Objective: To identify the nature, severity, impact, frequency and risk factors for patient perceived privacy infringements in the ED of St Vincent's Health Melbourne with 32 000 emergency attendances per annum. Methods: Patients 18 years and older attending emergency over a 2‐week period were offered a nine‐item questionnaire using a Likert scale. A privacy incident was defined as: (i) overhearing medical or personal information; (ii) being overheard; (iii) having private body parts exposed or (iv) seeing others’ body parts. Differences between demographic, emergency environment, length of stay and other factors suspected of affecting patient privacy were quantified. Results: From 1169 emergency presentations, 235 patients returned questionnaires, with 105 of these (45%) reporting a total of 159 privacy incidents. Seventy‐eight patients (33%, 95% CI 28–36%) reported a definite privacy incident and 81 (35%, 95% CI 29–37%) reported a probable privacy incident. Ninety‐six patients (41%, 95% CI 35–47%) reported overhearing other patient's conversations with the staff whereas 36 (15%, 95% CI 11–21%) felt their conversations with staff were overheard by others. Twenty‐seven patients (11%, 95% CI 6–14%) experienced or observed inappropriate exposure of private body parts. Ten patients (4%, 95% CI 2–7%) changed or withheld information from staff because they felt others may overhear it and two refused part of their physical examination because they felt they may be seen by inappropriate people. Twenty‐four patients (10%, 95% CI 6–14%) did not have their expectations of privacy met. The longer a patient was in emergency the greater the number of privacy incidents they experienced (Spearman correlation P < 0.01). Patients in walled cubicles experienced fewer privacy incidents than those in curtained cubicles (P < 0.05). Conclusions: Patient privacy incidents occur frequently in an ED, risk factors being length of stay and absence of a walled cubicle. Patients who have their conversations overheard are more likely to withhold information from staff and less likely to have had their expectations of privacy met.     

Comparison of two clinical scoring systems for emergency department risk stratification of suspected acute coronary syndrome

Objective: To compare two methods of risk stratification for suspected acute coronary syndrome (ACS) in the ED. Methods: A prospective observational multicentre study was undertaken of patients undergoing evaluation in the ED for possible ACS. We compared the National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand (NHF/CSANZ) guideline and the Thrombolysis in Myocardial Infarction (TIMI) risk score for differentiating high‐ and low‐risk patients. Composite outcome was all cause death, myocardial infarction or coronary revascularisation within 30 days. Results: Of 1758 enrolments, 223 (13%) reached the study outcome. Area under the receiver operator characteristic (ROC) curve was 0.79 (95% CI 0.76–0.81) for the NHF/CSANZ group and 0.71 (0.68–0.75) for TIMI score based on initial troponin result (P < 0.001), and 0.82 (95% CI 0.80–0.84) and 0.76 (0.73–0.79) respectively when the 8–12 h troponin result is included (P = 0.001). Thirty day event rates were 33% for NHF/CSANZ high‐risk vs 1.5% for combined low/intermediate risk (P < 0.001). For TIMI score, 30 day event rates were 23% for a score ≥2 and 4.8% for TIMI < 2 (P < 0.001). The NHF/CSANZ guideline identified more patients as low risk compared with the TIMI risk score (61% vs 48%, P < 0.001). Conclusions: The NHF/CSANZ guideline is superior to the TIMI risk score for risk stratification of suspected ACS in the ED.     

Malnutrition associated with increased risk of frail mechanical falls among older people presenting to an emergency department

Objective: To identify associations between malnutrition falls risk and hospital admission among older people presenting to ED. Methods: A prospective convenience sample of patients, aged 60 years or more, presenting to an Australian tertiary teaching hospital ED were included in this cross‐sectional study. Malnutrition Screening Tool and Subjective Global Assessment tool were administered to 126 non‐consecutive participants. Participants were categorized as non‐fallers, frail mechanical or active mechanical fallers. Self‐reported falls in past 6 months and hospital admission were documented. Results: Participant age and sex (median age 74, interquartile range 65–82 years; male 59%, 74/126, 95% CI 50–67%) were representative of older people presenting to the ED. Malnutrition prevalence was 15% (19/126, 95% CI 9–21%). There was an increased risk of being assessed as malnourished when a frail mechanical faller relative to: a non‐faller (relative risk [RR]: 1.5, 95% CI 1.0–2.3, P= 0.001), an active mechanical faller (RR: 3.1, 95% CI 1.0–10.9, Fisher's Exact test P= 0.02) or a non‐faller and active mechanical faller combined (RR: 1.5, 95% CI 1.0–2.1, P= 0.001). Malnourished participants had an increased risk of self‐reported falls over 6 months (RR: 1.5, 95% CI 1.0–2.5, P= 0.03). There was over five times the risk of hospital admission if malnourished than if well‐nourished (RR: 5.3, 95% CI 1.4–20.0, Fisher's exact test P= 0.001). The Malnutrition Screening Tool captured 84% (16/19, 95% CI 78–92%) of participants assessed as malnourished by Subjective Global Assessment. Conclusions: Older people presenting to ED should be nutritionally screened. Malnutrition prevalence of 15% was documented and was associated with an increased risk of frail mechanical falls and hospital admission. The Malnutrition Screening Tool was a simple and practical screen for ED.     

Relative utility of serum troponin and the OESIL score in syncope

Objective: To investigate the utility of both a random troponin T level taken greater than 4 h after a syncopal event and the Osservatorio Epidemiologico sulla Sincope nel Lazio (OESIL) score in predicting outcome post syncope. Methods: We prospectively enrolled 113 adult patients who presented to our ED after a syncopal event. Each patient had a troponin T level taken at least 4 h after the event. The relevant history of the syncope, background medical history and ECG were collected at presentation. Patients were followed up via telephone after 3–6 months and medical records were also examined. The OESIL risk score was calculated for each patient and the predictive value of both the troponin T and OESIL score were analysed for their utility post syncope. Results: Data were analysed for 100 patients. Twenty percent were believed to have a cardiac cause for their syncope. An elevated troponin T level was found to be highly specific (0.99, 95% confidence interval [CI] 0.96–1.0) for adverse cardiac outcome, but with a very low sensitivity (0.13, 95% CI 0–0.3). The OESIL risk score was found to be predictive of an adverse cardiac outcome (receiver–operating characteristic [ROC] 0.73, 95% CI 0.63–0.84) and return to normal function (ROC 0.74, 95% CI 0.63–0.86). Conclusions: A normal serum troponin T has a poor negative predictive value for adverse cardiac outcomes following syncope. A simple risk stratification system, such as the OESIL score, can predict those patients most at risk after a syncopal episode.     

Alcohol use among young adults presenting to the emergency department

Objectives: To determine the prevalence of young ED patients at risk from hazardous alcohol consumption, to identify high‐risk patient subgroups and evaluate the feasibility of use of the Alcohol Use Disorders Identification Test (AUDIT) in this setting. Methods: We undertook a cross‐sectional survey of 336 ED patients aged 18–30 years, inclusive. All were breathalysed prior to self‐administering the AUDIT. A ‘positive’ AUDIT score (≥8) defined hazardous alcohol consumption. AUDIT scores were correlated with sex and trauma diagnosis. Results: One hundred and thirty‐one (39.0%, 95% confidence interval [CI] 33.8–44.5) patients were classified as AUDIT‐positive. Men were significantly more likely to be AUDIT‐positive (49%vs 23%, P < 0.001) and had significantly higher total AUDIT scores (P < 0.001) than women. Trauma patients were significantly more likely to be AUDIT‐positive (P < 0.001) and had significantly higher AUDIT scores than non‐trauma patients (P < 0.001). Of the six patients who recorded a positive breath alcohol reading, all were AUDIT‐positive. One hundred (76.3%, 95% CI 68.0–83.1) AUDIT‐positive patients did not report others being concerned about their drinking or had not been given advice to cut down. Conclusion: It is feasible to use the AUDIT screening tool in the ED to identify those at risk from hazardous drinking. In our ED there is a high prevalence of hazardous alcohol consumption in young adult patients, many of whom have not previously received advice to cut down on their drinking.     

Comparison of the use of comprehensive point-of-care test panel to conventional laboratory process in emergency department

Background

In this study, we hypothesized that point of care testing (POCT) would reduce length of stay (LOS) in emergency department (ED) when compared to central laboratory testing and be a factor in patient discharge destination.

Methods

A single centre observational study was performed in ED non-ambulatory patients. Blood testing was performed either with POC instruments for blood gases and chemistry panel, full blood count, and CRP, or at central laboratory, or as a combination of both. Blood draw and POCTs were performed by experienced nurses.

Results

During the 4-week study period, 1759 patients underwent sample testing (POCT: n =?160, central lab: n =?951; both n =?648). Median waiting time for blood sampling was 19?min less in POCT than central laboratory (0:52 (95% confidence interval (CI) 0:46–1:02) vs. 1:11 (95% CI 1:05–1:14), p <?0.001). POCT results were available faster in both discharge groups, as expected. When imaging was not required, patients in POCT group were discharged home 55?min faster (4:57 (95% CI 3:59–6:17) vs. 5:52 (95% CI 5:21–6:35), p =?0.012) and 1?h 22?min faster when imaging was performed (5:48 (95% CI 5:26–6:18) vs. 7:10 (95% CI 6:47–8:26), p =?0.010). Similar reduction in sampling time and LOS was not seen among those admitted to hospital.

Conclusions

POCT shortened the laboratory process and made results available faster than the central lab. This allowed patients to be discharged home quicker. Thus, with proper training and education of the ED care team, POCT can be used as an effective tool for improving patient flow.

     

Emergency physicians can reliably assess emergency department patient cardiac output using the USCOM continuous wave Doppler cardiac output monitor

Objectives: 1 To develop a training package for ultrasonic cardiac output monitor (USCOM) cardiac output assessments and determine the number of proctored studies necessary for skill acquisition. 2 To develop criteria for acceptance of cardiac output results obtained with the USCOM. 3 To evaluate the reliability of USCOM cardiac output assessments in the ED. Methods: The authors developed an audiovisual training package. Four emergency physicians and one geriatrician subsequently underwent hands‐on training, and skill acquisition was assessed at the fifth, 10th, 15th and 20th examinations. Six image‐scoring criteria were developed to assess acoustic image quality. Upon completion of training a protocol was developed to optimize interassessor reliability. Two trained emergency physicians then performed blinded examinations on ED patients using the protocol and interassessor reliability was evaluated. Results: During training average image score improved between the fifth and 20th assessed patient from 4.6 (95% CI 4.0–5.3) to 5.5 (95% CI 5.0–6.0, P_t‐test = 0.02) out of 6 and average intra‐assessor cardiac output difference improved from 17% (95% CI 4–25) to 5% (95% CI 0–11, P_t‐test = 0.02). Analysis of 52 cardiac output assessments in 21 ED patients demonstrated excellent interassessor correlation (r = 0.96, 95% CI 0.90–0.98, P < 0.001). The average interassessor difference in cardiac output and index was 0.2 L/min (4%, 95% CI 3–6) and 0.1 L/min/m² (4%, 95% CI 2–6), respectively. Conclusion: Emergency physicians with no prior ultrasonographic experience can be trained to obtain reliable cardiac output estimations upon conscious ED patients with the USCOM over the course of 20 patient assessments.     

Novel analysis of clinically relevant diagnostic errors in point‐of‐care devices

Summary. Background: To ensure proper clinical decision‐making and avoid preventable harm, the quality of point‐of‐care (POC) device measures is routinely assessed. Traditional analyses may not reveal clinically important diagnostic errors. Objectives: To compare results between a novel analytic framework and traditional analyses. Methods: Patients in four anticoagulation clinics provided two measures of the International Normalized Ratio (INR) at the same visit as part of routine quality assurance: one via a venous sample and one fingerstick. These were assessed with Hemochron POC devices. Traditional, quarterly, quality assurance assessments emphasized correlation analysis. The novel analysis used enhanced graphics and a validated assessment of clinical decision‐making. Results: 1518 paired INRs were analyzed. The correlation between the POC and laboratory assessments ranged between 0.84 and 0.91. Traditional quality assurance showed that the Hemochron devices were acceptable for continued use in each quarterly analysis. Enhanced graphical analysis demonstrated that the Hemochron devices never reported seven common INR values. The Hemochron devices systematically inflated values < 3 and deflated values > 4, biasing results towards the target INR range. Consequently, the Hemochron devices lead to a different clinical decision than the clinical laboratory measure in 31% of cases (458/1466; 95% confidence interval [CI] 29–34). When the reference INR was low, the Hemochron devices would not result in appropriate dose increases in 52% of cases (95% CI 48–56), placing these patients at risk for a significant adverse drug event. Conclusions: Our novel, clinically relevant analysis revealed previously undetected deficiencies in our POC INR devices, and our approach should be adopted by industry, regulators, and institutions.     

Emergency Department Patient Volume and Troponin Laboratory Turnaround Time

Objectives: Increases in emergency department (ED) visits may place a substantial burden on both the ED and hospital‐based laboratories. Studies have identified laboratory turnaround time (TAT) as a barrier to patient process times and lengths of stay. Prolonged laboratory study results may also result in delayed recognition of critically ill patients and initiation of appropriate therapies. The objective of this study was to determine how ED patient volume itself is associated with laboratory TAT. Methods: This was a retrospective cohort review of patients at five academic, tertiary care EDs in the United States. Data were collected on all adult patients seen in each ED with troponin laboratory testing during the months of January, April, July, and October 2007. Primary predictor variables were two ED patient volume measures at the time the troponin test was ordered: 1) number of all patients in the ED/number of beds (occupancy) and 2) number of admitted patients waiting for beds/beds (boarder occupancy). The outcome variable was troponin turnaround time (TTAT). Adjusted covariates included patient characteristics, triage severity, season (month of the laboratory test), and site. Multivariable adjusted quantile regression was carried out to assess the association of ED volume measures with TTAT. Results: At total of 9,492 troponin tests were reviewed. Median TTAT for this cohort was 107 minutes (interquartile range [IQR] = 73–148 minutes). Median occupancy for this cohort was 1.05 patients (IQR = 0.78–1.38 patients) and median boarder occupancy was 0.21 (IQR = 0.11–0.32). Adjusted quantile regression demonstrated a significant association between increased ED patient volume and longer times to TTAT. For every 100% increase in census, or number of boarders over the number of ED beds, respectively, there was a 12 (95% confidence interval [CI] = 9 to 14) or 33 (95% CI = 24 to 42)‐minute increase in TTAT. Conclusions: Increased ED patient volume is associated with longer hospital laboratory processing times. Prolonged laboratory TAT may delay recognition of conditions in the acutely ill, potentially affecting clinician decision‐making and the initiation of timely treatment. Use of laboratory TAT as a patient throughput measure and the study of factors associated with its prolonging should be further investigated. ACADEMIC EMERGENCY MEDICINE 2010; 17:501–507 © 2010 by the Society for Academic Emergency Medicine     

Compliance with advice and appropriateness of emergency presentation following contact with the HealthDirect telephone triage service

Objective: Evaluation of compliance with advice and appropriateness of emergency presentation following contact with a telephone triage service (HealthDirect). Methods: Compliance rates, triage distributions and admission rates were determined using linked HealthDirect and ED records for patients living within 2 km of an ED that presented during 2000. Results: Of 13 019 presentations, 842 (6.5%) were HealthDirect contacts. In the HealthDirect group there were a greater proportion of patients under the age of 15 (290, 34% vs 1598, 13.1%) and women (481, 57% vs 5610, 46%). The triage distributions and admission rates for HealthDirect contacts and other patients were similar (HealthDirect 37.6% admitted, 95% CI 34–41, others 38.4% admitted, 95% CI 38–39, Pχ² = 0.67). Of 3996 callers to HealthDirect, 3167 (79%) complied with advice with 963 (61%) complying with advice to present and 212 (9%, 95% CI 8–10%) presenting despite advice to defer presentation. Triage distributions and admission rates for compliers and non‐compliers were similar (compliers 38% admitted, 95% CI 34–41, non‐compliers, 37% admitted, 95% CI 30–44, Pχ² = 0.89). Conclusions: HealthDirect contacts were of similar appropriateness to non‐HealthDirect presenters and appear to attend the ED independent of HealthDirect advice. HealthDirect has a limited capacity to influence ED utilization or workload.     

EMS blood collection from patients with acute chest pain reduces emergency department length of stay

BackgroundExpediting the measurement of serum troponin by leveraging EMS blood collection could reduce the diagnostic time for patients with acute chest pain and help address Emergency Department (ED) overcrowding. However, this practice has not been examined among an ED chest pain patient population in the United States.MethodsA prospective observational cohort study of adults with non-traumatic chest pain without ST-segment elevation myocardial infarction was conducted in three EMS agencies between 12/2016–4/2018. During transport, paramedics obtained a patient blood sample that was sent directly to the hospital core lab for troponin measurement. On ED arrival HEART Pathway assessments were completed by ED providers as part of standard care. ED providers were blinded to troponin results from EMS blood samples. To evaluate the potential impact on length of stay (LOS), the time difference between EMS blood draw and first clinical ED draw was calculated. To determine the safety of using troponin measures from EMS blood samples, the diagnostic performance of the HEART Pathway for 30-day major adverse cardiac events (MACE: composite of cardiac death, myocardial infarction (MI), coronary revascularization) was determined using EMS troponin plus arrival ED troponin and EMS troponin plus a serial 3-h ED troponin.ResultsThe use of EMS blood samples for troponin measures among 401 patients presenting with acute chest pain resulted in a mean potential reduction in LOS of 72.5 ± SD 35.7 min. MACE at 30 days occurred in 21.0% (84/401), with 1 cardiac death, 78 MIs, and 5 revascularizations without MI. Use of the HEART Pathway with EMS and ED arrival troponin measures yielded a NPV of 98.0% (95% CI: 89.6–100). NPV improved to 100% (95% CI: 92.9–100) when using the EMS and 3-h ED troponin measures.ConclusionsEMS blood collection used for core lab ED troponin measures could significantly reduce ED LOS and appears safe when integrated into the HEART Pathway.     

Tropisetron versus metoclopramide for the treatment of nausea and vomiting in the emergency department: A randomized,double‐blinded,clinical trial

Aim: We aimed to compare the relative efficacy of tropisetron and metoclopramide in treating nausea/vomiting in undifferentiated ED patients. Methods: We undertook a randomized, double‐blinded, clinical trial. Adult patients requiring treatment for nausea/vomiting were randomly assigned to either tropisetron (5 mg) or metoclopramide (10 mg), by i.v. bolus. The primary end‐point was incidence of vomiting. Secondary end‐points were decrease in nausea score from baseline (0–100 VAS), the requirement of ‘rescue’ anti‐emetics, ongoing nausea over 48 h and side‐effects. Results: Fifty patients were enrolled in each group. The demographic variables, presenting complaints and nausea scores at baseline did not differ (P > 0.05). By 180 min, two (4.0%) and nine (18.0%) patients had vomited in the tropisetron and metoclopramide groups respectively (difference 14.0%, 95% CI 0.1–28.0, P= 0.05). Also, there were two and 20 episodes of vomiting respectively. Vomiting rates were 0.02 and 0.16 episodes/person‐hour (difference 0.14 episodes/person‐hour, 95% CI 0.07–0.21, P < 0.001) respectively. By 60 min and thereafter, the decrease in nausea score from baseline was greater (although not significantly so) in the tropisetron group. At 180 min, the decreases were 47.9 mm and 37.0 mm respectively (difference 10.9 mm, 95% CI ?0.7–22.6). Five (10.0%) and 13 (26.0%) patients required a rescue anti‐emetic respectively (difference 16.0%, 95% CI ?0.7–32.7, P= 0.07). Of patients followed up, 13/47 (27.7%) and 20/49 (40.8%) had ongoing nausea respectively (difference 13.2%, 95% CI ?7.7–34.0, P= 0.25). The tropisetron group had less akathisia. Conclusions: Tropisetron was associated with a significantly lower vomiting rate and shows promise as an alternative anti‐emetic in the ED.     

Impact of technical assistants for venepuncture and intravenous cannulation on overall emergency department performance

Objective: The objective of the article was to determine the effect of a technical assistant for venepuncture and i.v. cannulation on triage performance and patient length of stay in an ED. Methods: An observational study of daily ED performance was conducted at an inner city tertiary referral ED. Over a period of 158 consecutive days, data on triage performance and average length of stay were collected. A technical assistant was employed for 8–10 h per day to perform venepuncture, i.v. cannulation and electronic order entry. Study groups compared were days staffed by a technical assistant and days that were not staffed. Results: Days staffed by a technical assistant were associated with significantly higher triage performance for triage category three (mean 0.66, 95% CI 0.63–0.69 vs 0.58, 95% CI 0.54–0.62; P= 0.003) and lower average length of stay per patient for triage category two patients (mean length of stay 390 min, 95% CI 369–411 vs 425 min, 95% CI 399–451; P= 0.04). Triage performance thresholds for triage category three (75% of patients seen within 30 min) were met over twice as often on staffed days compared with control (39/96 [38%]vs 10/62 [16%], P= 0.004). Conclusion: Staffing the ED with a technical assistant was associated with improved ED performance for triage category three and average length of stay for triage category two patients.