Delirium screening tools in the emergency department: A protocol for systematic review and meta-analysis

Background:Delirium is a common type of acute brain dysfunction among emergency department (ED) patients. The prevalence of delirium in the ED is up to 40%. Although screening instruments used to identify delirium have been developed, it is unclear which tool is the most accurate in the ED. To address this challenging, we systematically examine the accuracy of delirium screening tools used to assess the ED patients.Methods:This study has been registered at the International Platform of Registered Systematic Review and Meta-Analysis Protocols (INPLASY), and the registration number is INPLASY202110041. We will search the PubMed, EMBASE, PsycINFO, and the Cochrane Library. Studies involving patients which compared diagnostic instruments with the criteria in Diagnostic and Statistical Manual of Mental Disorders (DSM) as a reference standard will be included. We will use STATA 15.1 and MetaDiSC to make careful analysis of the results. The quality of included studies will be assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 scale.Results:In this study, the accuracy of different screening methods among ED patients is assessed by a high-quality synthesis. The number of tools available for screening delirium in the ED, the information of studies including the countries, the study design, the sample size and the characteristic of studies, the quality of the studies and the results of meta-analysis. The systematic review and meta-analysis will be published in a peer-reviewed journal.Conclusion:According to the conclusion of the systematic review, evidence will be provided to judge which screening method is the best for the ED patients. The results will bring better understanding of screening methods in the ED and highlight gaps for future research.     

Screening for sickle-cell trait in the emergency department

Objective: To determine: 1) whether young adult black patients in an emergency department (ED) are familiar with sickle-cell anemia and 2) how many of these patients know their own sickle-cell trait status. Design: Black patients in an ED were interviewed. Women aged 18 to 40 years and men aged 18 to 50 were included. Sickle-cell screening was offered to the patients. Setting: The ED of a large urban university hospital with an annual census of 50,000, approximately 25% of whom are black. Patients: A convenience sample of 147 black patients presenting to the ED with minor medical conditions. Interventions: The subjects were interviewed to determine their knowledge base regarding sickle-cell anemia and to determine how many knew their sickle-cell trait status. The subjects were tested for sickle-cell trait. Measurements and main results: 98% of the patients had heard of sickle-cell anemia and 73% knew that it was a genetic disorder. Only 31% of the patients knew their sickle-cell status. Women were more likely than men to know their status. Approximately half of the patients who had family histories of the trait or the disease knew their own status. Two of the 47 patients (4%) tested had positive sickle-cell screen results. Conclusions: Most black patients of childbearing age presenting to the ED have heard of sickle-cell anemia and know that it runs in families, but few know their own trait status. Until access to primary care providers is improved, ED physicians who care for patients at risk for sickle-cell trait have an obligation to ask them about prior screening and either screen them or refer them for screening. Received from the Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee.     

Screening for hypertension using emergency department blood pressure measurements can identify patients with undiagnosed hypertension: A systematic review with meta‐analysis

Hypertension is the leading risk factor for death globally. A significant percentage of patients admitted to hospital have undiagnosed hypertension, yet recognition of elevated blood pressure (BP) in hospital and referral for post‐discharge assessment are poor. Physician perception that elevated inhospital BP is attributable to anxiety, pain, or white coat syndrome may underlie an expectation that BP will normalize following discharge. However, these patients frequently remain hypertensive. The authors conducted a systematic review to evaluate the extent to which elevated inhospital BP can predict the presence of hypertension in previously undiagnosed adults. The authors included cohort studies in which hospital patients whose BP exceeded the study threshold underwent further post‐discharge BP assessment following discharge. Twelve studies were identified as eligible for inclusion; a total of 2627 participants met review eligibility criteria, and follow‐up BP data were available for 1240 (47.2%). Median percentage of patients remaining hypertensive following discharge was 43.6% (range: 14.2‐76.5). Across 7 studies which identified people with possible hypertension using an index test threshold of 140/90, the pooled proportion subsequently identified with hypertension at follow‐up was 43.4% (95% CI: 25.1%‐61.8%). This review indicates that screening for hypertension in the emergency hospital environment consistently identifies groups of patients with undiagnosed hypertension. Unscheduled hospital attendance therefore offers an important public health opportunity to identify patients with undiagnosed hypertension.     

Early prediction models for prognosis of diabetic ketoacidosis in the emergency department: A protocol for systematic review and meta-analysis

Background:Diabetic ketoacidosis (DKA) is one of the most serious complications after diabetes poor control, which seriously threatens human life, health, and safety. DKA can rapidly develop within hours or days leading to death. Early evaluation of the prognosis of DKA patients and timely and effective intervention are very important to improve the prognosis of patients. The combination of several variables or characteristics is used to predict the poor prognosis of DKA, which can allocate resources reasonably, which is beneficial to the early classification intervention and clinical treatment of the patients.Methods:For the acquisition of required data of eligible prospective/retrospective cohort study or randomized controlled trials (RCTs), we will search for publications from PubMed, Web of science, EMBASE, Cochrane Library, Google scholar, China national knowledge infrastructure (CNKI), Wanfang and China Science and Technology Journal Database (VIP). Two independent reviewers will read the full English text of the articles, screened and selected carefully, removing duplication. Then we evaluate the quality and analyses data by Review Manager (V.5.4). Results data will be pooled and meta-analysis will be conducted if there''s 2 eligible studies considered.Results:This systematic review and meta-analysis will evaluate the value of the prediction models for the prognosis of DKA in the emergency department.Conclusions:This systematic review and meta-analysis will provide clinical basis for predicting the prognosis of DKA. It helps us to understand the value of predictive models in evaluating the early prognosis of DKA. The conclusions drawn from this study may be beneficial to patients, clinicians, and health-related policy makers.Study registration number:INPLASY202150023.     

Intravenous magnesium sulfate treatment for acute asthma in the emergency department: a systematic review of the literature

STUDY OBJECTIVES: There is some evidence that magnesium, when infused into asthmatic patients, can produce bronchodilation in addition to that obtained from standard treatments. This systematic review examined the effect of intravenous magnesium sulfate used for patients with acute asthma managed in the emergency department. METHODS: Only randomized controlled trials were eligible for inclusion. Studies were included if patients presented with acute asthma and were treated with intravenous magnesium sulfate versus placebo. Trials were identified from the Cochrane Airways Review Group register, which consists of a combined search of EMBASE, MEDLINE, and CINAHL databases and hand-searching of 20 key respiratory journals. Bibliographies from included studies and known reviews were searched. Primary authors and content experts were contacted. Data were extracted and methodologic quality was assessed independently by 2 reviewers. Missing data were obtained from authors. RESULTS: Seven trials (5 adult, 2 pediatric) involving a total of 668 patients were included. Overall, admission to hospital was not statistically reduced using magnesium sulfate (odds ratio [OR] 0.31, 95% confidence interval [CI] 0.09 to 1.02). In the severe subgroup, admissions were reduced in those receiving magnesium sulfate (OR 0.10, 95% CI 0.04 to 0.27). Overall, patients receiving magnesium sulfate demonstrated nonsignificant improvements in peak expiratory flow rates (PEFR) when all studies were pooled (weighted mean difference [WMD] 29 L/min, 95% CI -3 to 62). In studies of patients with severe acute asthma, PEFR WMD improved by 52 L/min (95% CI 27 to 78) favoring magnesium sulfate treatment. The absolute FEV(1) also improved by 10% predicted (95% CI 4 to 16) in patients with severe acute asthma. No clinically important changes in vital signs or side effects were reported. CONCLUSION: Current evidence does not clearly support routine use of intravenous magnesium sulfate in all patients with acute asthma presenting to the ED. However, magnesium sulfate appears to be safe and beneficial for patients who present with severe acute asthma. Practice guidelines need to be changed to reflect these results.     

The emergency physician and patient confidentiality: A review

Confidentiality is a promise rooted in tradition, law andmedical ethics. Emergency physicians treat a variety of patients to whom confidentiality is of vital importance: employees, celebrities, victims of violence or disaster, minors, students, criminals, drug abusers, and patients with STDs. EDs should develop methods of ensuring confidentiality for all patients.³⁴Although confidentiality is an important principle thatshould be respected and guarded, it is not absolute. Various laws mandate disclosure of certain patient information; in addition, an overriding moral duty may occasionally require, a breach of confidentiality. As Beauchamp and Childress noted, “the therapeutic role may sometimes have to yield to ones role as citizen and as protector of the interests of others”.¹⁹ In general, however, circumstances requiring a breach of confidentiality are rare.     

Using continuous quantitative capnography for emergency department procedural sedation: a systematic review and cost-effectiveness analysis

End-tidal CO₂ has been advocated to improve safety of emergency department (ED) procedural sedation by decreasing hypoxia and catastrophic outcomes. This study aimed to estimate the cost-effectiveness of routine use of continuous waveform quantitative end-tidal CO₂ monitoring for ED procedural sedation in prevention of catastrophic events. Markov modeling was used to perform cost-effectiveness analysis to estimate societal costs per prevented catastrophic event (death or hypoxic brain injury) during routine ED procedural sedation. Estimates for efficacy of capnography and safety of sedation were derived from the literature. This model was then applied to all procedural sedations performed in US EDs with assumptions selected to maximize efficacy and minimize cost of implementation. Assuming that capnography decreases the catastrophic adverse event rate by 40.7% (proportional to efficacy in preventing hypoxia), routine use of capnography would decrease the 5-year estimated catastrophic event rate in all US EDs from 15.5 events to 9.2 events (difference 6.3 prevented events per 5 years). Over a 5-year period, implementing routine end-tidal CO₂ monitoring would cost an estimated $2,830,326 per prevented catastrophic event, which translates into $114,007 per quality-adjusted life-year. Sensitivity analyses suggest that reasonable assumptions continue to estimate high costs of prevented catastrophic events. Continuous waveform quantitative end-tidal CO₂ monitoring is a very costly strategy to prevent catastrophic complications of procedural sedation when applied routinely in ED procedural sedations.