ED antibiotic use for acute respiratory illnesses since pneumonia performance measure inception

Objective

The study aimed to determine if emergency department (ED)–administered antibiotics for patients discharged home with nonpneumonia acute respiratory tract infections (ARIs) have increased since national pneumonia performance measure implementation, including antibiotic administration within 4 hours of arrival.

Methods

Design: Time series analysis. Setting: Six university and 7 Veterans Administration EDs participating in the Improving Antibiotic Use for Acute Care Treatment (IMPAACT) trial (randomized educational intervention to reduce antibiotics for bronchitis). Participants: Randomly selected adult (age >18 years) ED visits for acute cough, diagnosed with nonpneumonia ARIs, discharged home during winters (November-February) of 2003 to 2007. Main outcome: Time trend in ED-administered antibiotics, adjusted for patient demographics, comorbidities, vital signs, ED length of stay, IMPAACT intervention status, geographic region, Veterans Administration/university setting, and site and provider level clustering.

Results

Six thousand four hundred seventy-six met study criteria. Three hundred ninety-four (6.1%) received ED-administered antibiotics. Emergency department–administered antibiotics did not increase across the study period among all IMPAACT sites (odds ratio [OR], 0.88; 95% confidence interval [CI], 0.76-1.01) after adjusting for age, congestive heart failure history, temperature higher than 100°F, heart rate more than 100, blood cultures obtained, diagnoses, and ED length of stay. The ED-administered antibiotic rate decreased at IMPAACT intervention (OR, 0.80; 95% CI, 0.69-0.93) but not nonintervention sites (OR, 1.04; 95% CI, 0.91-1.19). Adjusted proportions receiving ED-administered antibiotics were 6.1% (95% CI, 2.7%-13.2%) for 2003 to 2004; 4.8% (95% CI, 2.2%-10.0%) for 2004 to 2005; 4.6% (95% CI, 2.7%-7.8%) for 2005 to 2006; and 4.2% (95% CI, 2.2%-8.0%) for 2006 to 2007.

Conclusions

Emergency department–administered antibiotics did not increase for patients with acute cough discharged home with nonpneumonia ARIs since pneumonia antibiotic timing performance measure implementation in these academic EDs.     

Radiologic diagnoses of patients who received imaging for venous thromboembolism despite negative D-dimer tests

Objective

The literature supports a negative D-dimer (−DD) excluding venous thromboembolic disease (VTE) in low-risk patients. We determined the radiologic diagnoses in patients where imaging was ordered despite a −DD.

Methods

This is a retrospective chart review of patients with a −DD (Tinaquant; Roche Diagnostics, Mannheim, Germany) and a radiologic study within 48 hours, sought to determine radiologic diagnosis (primary outcome), treatment of VTE, and consensus diagnosis of acute VTE.

Results

Among 3462 DD tests, 1678 met the inclusion criteria. Of 1362 patients with DD values of 350 ng/mL or less, 166 (12.2%) had radiologic studies: 93.4% of the final radiologic diagnoses were negative for VTE, 3.6% were indeterminate, and 3.0% (1.0%-6.9%) were positive; 1.8% ultimately had a consensus diagnosis of acute VTE. In 316 patients with DD values between 351 and 500 ng/mL, 88 (27.8%) had radiologic studies: 95.5% were negative, 1.1% were indeterminate, and 3.4% (0.7%-9.6%) were positive.

Conclusions

Of patients who receive radiologic studies despite −DD tests, 3.0% have positive radiologic diagnoses for acute VTE; only 1.8% had acute VTE after the review of their hospital course.     

Hyperacute T-waves: Wolff-Parkinson-White Pattern or Acute Coronary Syndrome?

Background

Pre-excitation syndromes can elicit electrocardiogram (ECG) abnormalities that are nearly identical to those associated with acute myocardial ischemia. In the presence of atypical symptoms, stable hemodynamics, and unremarkable levels of cardiac enzymes, the decision whether to subject these patients to coronary angiography, or even non-invasive testing, can be difficult.

Objective

To understand that pre-excitation syndrome can mimic acute myocardial injury, but should not preclude a complete ischemic work-up.

Case Report

A 53-year-old man with Wolff-Parkinson-White pattern and coronary artery disease risk factors presented with new-onset substernal chest pain. A baseline ECG was significant for hyperacute T waves. After refusing cardiac catheterization, he was admitted to the cardiac care unit for intravenous heparin and eptifibatide. Although his stay was unremarkable and resting echocardiogram showed normal contractility and valve function, treadmill stress testing was negative for ischemic change, but revealed ST-segment depression with maximum stress in the lateral precordial leads. This was thought to be a “false positive” secondary to his conduction abnormality.

Conclusion

No reliable algorithm exists for making an ECG diagnosis of myocardial infarction in the presence of a pre-excitation syndrome. Similarly, current non-invasive modalities have limitations in detecting jeopardized myocardium. If acute or hyperacute injury is suspected, the patient should be emergently referred for cardiac catheterization.     

Responding to suspected smallpox cases in the Los Angeles County from 2002 to 2006: identifying areas for education

Introduction

Although smallpox has been eradicated, health care providers in emergency departments (EDs) need to remain vigilant to its recognition. Smallpox can be confused with chickenpox. We describe suspected smallpox cases reported in Los Angeles County from 2002 to 2006 and highlight areas for education.

Methods

We retrospectively reviewed suspected smallpox reports from 2002 to 2006. Laboratory testing was performed. Photographs of rashes were taken.

Results

Five suspected smallpox cases were reported. Two presented first to an ED. Smallpox was suspected based on rash features. Previous history of chickenpox or varicella vaccination may have caused increased suspicion for smallpox. All 5 were determined to have a final diagnosis of chickenpox. Health care providers notified public health appropriately and responses were immediate.

Conclusions

Public health investigated 5 suspected smallpox cases in the past 5 years. Two presented initially to EDs. Education differentiating smallpox from chickenpox and collaboration between public health, EDs, and health care providers remains important. The ability to respond rapidly to a potential bioterrorism emergency was tested.     

Pediatric Visits to United States Emergency Departments for Alcohol-Related Disorders

Background

The use of alcohol by pediatric patients has not been thoroughly examined in the United States (US). Patients with complaints related to alcohol use frequently present to the Emergency Department initially.

Objective

Our aim was to determine the number of pediatric patients (ages 17 years and younger) presenting to Emergency Departments (EDs) in the US from 2006 to 2008 for alcohol-related disorders and examine selected clinical and demographic features of this population.

Methods

This was a retrospective cohort study using 3 years (2006–2008) of data from the Nationwide Emergency Department Sample. This database was used to identify patients younger than 18 years of age with an alcohol-related ED visit, and clinical and demographic features were examined.

Results

From 2006 to 2008, a total of 218,514 pediatric patients presented to US EDs and received a subsequent diagnosis of an alcohol-related disorder. Mean age of patients was 15.61 years. Most patients were male and tended to be from higher-income communities.

Conclusions

There were 218,514 visits to US EDs by patients younger than 18 years of age for alcohol-related disorders, accounting for >$850 million dollars in charges. ED-based brief alcohol interventions shown to work in adult populations should be explored for use in pediatric patients.     

Undertriage of major trauma patients in the US emergency departments

Background

There is evidence that regionalized trauma care and appropriate triage of major trauma patients improve patient outcomes. However, the national rate of undertriage and diagnoses of undertriaged patients are unknown.

Methods

We used the 2010 Nationwide Emergency Department Sample to estimate the national rate of undertriage, identify the prevalent diagnoses, and conduct a simulation analysis of the capacity increase required for level I and II trauma centers (TCs) to accommodate undertriaged patients. Undertriaged patients were those with major trauma, injury severity score ≥ 16, who received definitive care at nontrauma centers (NTCs), or level III TCs. The rate of undertriage was calculated with those receiving definitive care at an NTC center or level III center as a fraction of all major trauma patients.

Results

The estimated number of major trauma patient discharges in 2010 was 232 448. Level of care was known for 197 702 major trauma discharges, and 34.0% were undertriaged in emergency departments (EDs). Elderly patients were at a significantly higher risk of being undertriaged. Traumatic brain injury (TBI) was the most common diagnosis, 40.2% of the undertriaged patient diagnoses. To accommodate all undertriaged patients, level I and II TCs nationally would have to increase their capacity by 51.5%.

Conclusions

We found that more than one-third of US ED major trauma patients were undertriaged, and more than 40% of undertriaged diagnoses were TBIs. A significant capacity increase at level I and II TCs to accommodate these patients appears not feasible.     

Validating the Traumatic Brain Injury-4 Screening Measure for Veterans Seeking Mental Health Treatment With Psychiatric Inpatient and Outpatient Service Utilization Data

Objective

To determine whether a positive screen on the Traumatic Brain Injury-4 (TBI-4) can be used to identify veterans who use more inpatient and outpatient mental health services.

Design

Validation cohort.

Setting

Medical center.

Participants

Individuals seeking Veterans Health Administration mental health services (N=1493).

Interventions

Not applicable.

Main Outcome Measures

One year of inpatient and outpatient mental health utilization data after the TBI-4 screen date.

Results

In the year postmental health intake, those who answered positively to any of the 4 TBI-4 screening questions (criterion 1) or question 2 (criterion 2; ever having been knocked out) had significantly more psychiatric hospitalizations than those who met neither criterion. Those who were positive by criterion 2 also had significantly fewer outpatient mental health contacts.

Conclusions

Veterans screening positive for history of traumatic brain injury on the TBI-4 had more hospital stays in the year postmental health intake. Those who reported having been knocked out also had fewer outpatient mental health visits. These findings may suggest an overall relation in this population between greater needs for mental health care and likelihood of prior injury. For those with a history of loss of consciousness, the reduced use of outpatient care may reflect greater problems engaging in treatment or with preventive aspects of the health care system during non-crisis periods. Using a screener (eg, the TBI-4) could facilitate identification of veterans who might benefit from targeted and intensive outpatient interventions to avoid frequent inpatient psychiatric hospitalization.     

Pediatric Preparedness of Lebanese Emergency Departments

Background

The pediatric preparedness of Lebanese Emergency Departments (EDs) has not been evaluated.

Study Objectives

To describe the number, regional location, and characteristics of EDs in Lebanon providing care to children and to describe the staffing, equipment, and support services of these EDs.

Methods

We surveyed hospitals in Lebanon caring for children in an ED setting between September 2009 and September 2010. The survey was provided in English and Arabic and could be completed in person, by telephone, or on the Web.

Results

We identified 115 EDs that cared for children in Lebanon; 72 (63%) completed the survey, most of which were urban (54%). Ninety-three percent of the EDs had <20,000 total patient visits annually; children (variably defined) accounted for <29% of the patients at 89% of the sites. Physicians caring for children in the EDs had varied medical training; and a pediatrician was “usually involved” in the management of pediatric patients in 95% of the EDs. Only 27% of EDs had attending physicians present 24 h/day to care for children. Half of the hospitals had an intensive care unit that could care for children (48%). Most EDs had endotracheal tubes (95%) and intravenous catheters (90%) in all pediatric sizes.

Conclusion

The emergency care of children in Lebanon is provided at numerous hospitals throughout the country, with a wide range of staffing patterns and available support services.     

The new Vancouver Chest Pain Rule using troponin as the only biomarker: an external validation study

Objectives

To externally evaluate the accuracy of the new Vancouver Chest Pain Rule and to assess the diagnostic accuracy using either sensitive or highly sensitive troponin assays.

Methods

Prospectively collected data from 2 emergency departments (EDs) in Australia and New Zealand were analysed. Based on the new Vancouver Chest Pain Rule, low-risk patients were identified using electrocardiogram results, cardiac history, nitrate use, age, pain characteristics and troponin results at 2 hours after presentation. The primary outcome was 30-day diagnosis of acute coronary syndrome (ACS), including acute myocardial infarction, and unstable angina. Sensitivity, specificity, positive predictive values and negative predictive values were calculated to assess the accuracy of the new Vancouver Chest Pain Rule using either sensitive or highly sensitive troponin assay results.

Results

Of the 1635 patients, 20.4% had an ACS diagnosis at 30 days. Using the highly sensitive troponin assay, 212 (13.0%) patients were eligible for early discharge with 3 patients (1.4%) diagnosed with ACS. Sensitivity was 99.1% (95% CI 97.4-99.7), specificity was 16.1 (95% CI 14.2-18.2), positive predictive values was 23.3 (95% CI 21.1-25.5) and negative predictive values was 98.6 (95% CI 95.9-99.5). The diagnostic accuracy of the rule was similar using the sensitive troponin assay.

Conclusions

The new Vancouver Chest Pain Rule should be used for the identification of low risk patients presenting to EDs with symptoms of possible ACS, and will reduce the proportion of patients requiring lengthy assessment; however we recommend further outpatient investigation for coronary artery disease in patients identified as low risk.     

State of affairs of emergency medicine in the Veterans Health Administration

Background

The Veterans Health Administration (VHA) has reformed its emergency medical services.

Objectives

This study updates an overview of emergency medicine within VHA.

Methods

This is a cross-sectional survey of VHA medical facilities offering emergency medical care.

Results

Sixty-eight percent (95/140) of facilities had emergency departments (EDs) only, 12% (16/140) had both ED and urgent care centers (UCCs), and 16% (23/140) had only UCCs. The mean (SD) ED/UCC census was 13?371 (7664). A mean (SD) of 53% (27%) of facility admissions were admitted through ED/UCCs. The median of all ED/UCC admissions admitted to intensive care unit level care was 11% (interquartile range, 7-16). Of physicians with any board certification, 16% (209/1331) of physicians had emergency medicine board certification.

Conclusions

Emergency medical care is now available at most VHA facilities. The specialty of emergency medicine has an important but minority presence within clinical emergency medical care at VHA.     

Emergency Department Characteristics and Capabilities in Beijing, China

Background

Emergency Departments (EDs) are a critical, yet heterogeneous, part of international emergency care.

Objectives

We sought to describe the characteristics, resources, capabilities, and capacity of EDs in Beijing, China.

Methods

Beijing EDs accessible to the general public 24 h per day/7 days per week were surveyed using the National ED Inventories survey instrument (www.emnet-nedi.org). ED staff were asked about ED characteristics during the calendar year 2008.

Results

Thirty-six EDs participated (88% response rate). All were located in hospitals and were independent hospital departments. Participating EDs saw a median of 80,000 patients (interquartile range 40,000–118,508). The vast majority (91%; 95% confidence interval [CI] 78–98%) had a contiguous layout, with medical and surgical care provided in one area. Most EDs (55%) saw only adults; 39% saw both adults and children, and 6% saw only children. Availability of technological and consultant resource in EDs was high. The typical ED length of stay was between 1 and 6 h in 49% of EDs (95% CI 32–67%), whereas in the other half, patients reportedly remained for over 6 h; 36% (95% CI 21–54%) of respondents considered their ED over capacity.

Conclusions

Beijing EDs have high volume, long length of stay, and frequent reports of EDs being over capacity. To meet its rapidly growing health needs in urban areas, China should consider improving urban ED capacity and training more Emergency Medicine specialists capable of efficiently staffing its crowded EDs.     

The impact of poison control centers on poisoning-related visits to EDs--United States, 2003

Purpose

This study analyzes the association between center usage rates and the rates of nonadmitted visits to emergency departments (EDs) for poisoning.

Basic Procedures

With a log-normal regression model, we analyzed the association between the number of human exposure calls per hospitalized poisoning patient and the number of nonhospitalized ED visits. The data were from 14 states at county level.

Main Findings

A 1% higher poison control center (PCC) human exposure call rate for unintentional poisoning is associated, but not necessarily causally, with a 0.18% lower ED visit rate (P < .0001). If the observed association is causative, 15.5 PCC human poison exposure calls prevent one nonadmitted ED visit, yielding a $205 net cost saving and a benefit-cost ratio of 1.4. The savings ignore any reduction in hospital admissions.

Principal Conclusions

Increased PCC exposure calls appear to be associated with reduced ED use for unintentional poisoning and appear to reduce net medical spending.     

Systemic and bronchoalveolar cytokines as predictors of in-hospital mortality in severe community-acquired pneumonia

Objectives

The aim of this study was to determine whether cytokine expression (interleukin [IL]-1β, IL-6, IL-8, IL-10, and tumor necrosis factor [TNF]-α), C-reactive protein, and endotoxins on the first day of intensive care unit (ICU) admission are associated with hospital mortality in severe community-acquired pneumonia (CAP).

Design

This was a prospective study with bronchoalveolar lavage (BAL) and blood sampling.

Setting

This study was carried out in a 44-bed medical ICU of a 1700-bed university hospital.

Patients

Participants included 112 mechanically ventilated patients with severe CAP.

Interventions

Serum and BAL fluid IL-1β, IL-6, IL-8, IL-10, TNF-α, C-reactive protein, and endotoxins on the first day of ICU admission were obtained.

Measurements and Main Results

The concentrations of TNF-α in BALF and IL-6, IL-8, IL-10, and TNF-α in serum were higher in nonsurvivors than in survivor patients with CAP. Of these 112 patients with severe CAP (39%), 44 developed acute respiratory distress syndrome (ARDS); these patients seemed to have higher serum IL-6, IL-8, and IL-10 levels than did the non-ARDS group. Furthermore, in the ARDS population, we found that the endotoxin levels in the BAL fluid were higher in the survival than in the nonsurvival group and BAL fluid concentrations of IL-6, IL-8, and IL-1β and sera levels of IL-6 and IL-10 were lower in the survival than in the nonsurvival group, and they were associated with a high negative predictive value.

Conclusions

Serum and BAL fluid levels of the studied cytokines on admission may provide valuable prognostic information for patients with severe CAP.     

ED visit volume and quality of care in acute exacerbations of chronic obstructive pulmonary disease

Objective

The purpose of this study is to determine whether emergency department (ED) visit volume is associated with ED quality of care in patients with acute exacerbations of chronic obstructive pulmonary disease (COPD).

Methods

We performed a prospective multicenter cohort study involving 29 EDs in the United States and Canada. Using a standard protocol, we interviewed consecutive ED patients with COPD exacerbation, reviewed their charts, and completed a 2-week telephone follow-up. The associations between ED visit volume and quality of care (process and outcome measures) were examined at both the ED and patient levels.

Results

After adjustment for patient mix in the multivariable analyses, chest radiography was less frequent among patients with COPD exacerbations in the low-volume (odds ratio [OR], 0.2; 95% confidence interval [CI], 0.1-0.4) and high-volume EDs (OR, 0.1; 95% CI, 0.05-0.5), with medium-volume EDs as the reference. Arterial blood gas testing was less frequent in the low-volume EDs (OR, 0.1; 95% CI, 0.02-0.8). Medication use was similar across volume tertiles. With respect to outcome measures, patients in high-volume EDs were more likely to be discharged (OR, 4.2; 95% CI, 2.2-7.7) and to report ongoing exacerbation at a 2-week follow-up (OR, 1.9; 95% CI, 1.02-3.5).

Conclusions

Traditional positive volume-quality relationships did not apply to emergency care of COPD exacerbation. High-volume EDs used less guideline-recommended diagnostic procedures, had a higher admission threshold, and had a worse short-term patient-centered outcome.     

Association Between the Volume of Inpatient Rehabilitation Therapy and the Risk of All-Cause and Cardiovascular Mortality in Patients With Ischemic Stroke

Objective

To investigate the relationship between the volume of inpatient rehabilitation therapy and mortality among patients with acute ischemic stroke, as well as to assess whether the association varies with respect to stroke severity.

Design

A retrospective study with a cohort of consecutive patients who had acute ischemic stroke between January 1, 2008, and June 30, 2009.

Setting

Referral medical center.

Participants

Adults with acute ischemic stroke (N=1277) who were admitted to a tertiary hospital.

Interventions

Not applicable.

Main Outcome Measure

Stroke-related mortality.

Results

During the median follow-up period of 12.3 months (ranging from January 1, 2008, to December 31, 2009), 163 deaths occurred. Greater volume of rehabilitation therapy was associated with a reduced risk of all-cause and cardiovascular mortality (P for trend <.001 for both). Compared with the first tertile, the third tertile of rehabilitation volume was associated with a 55% lower risk of all-cause mortality (hazard ratio [HR]=.45; 95% confidence interval [CI], .30–.65) and a 50% lower risk of cardiovascular mortality (HR=.50; 95% CI, .31–.82). The association did not vary with respect to stroke severity (P for interaction = .45 and .73 for all-cause and cardiovascular mortality, respectively).

Conclusions

The volume of inpatient rehabilitation therapy and mortality were significantly inversely related in the patients with ischemic stroke. Thus, further programs aimed at promoting greater use of rehabilitation services are warranted.     

Acute Pancreatitis Complicated by ST-Elevation Myocardial Infarction

Background

Electrocardiographic abnormalities mimicking myocardial ischemia have been reported in intra-abdominal conditions, including acute pancreatitis. However, the occurrence of ST-elevation myocardial infarction (STEMI) is rare.

Objectives

To present a case report of a young man with acute pancreatitis subsequently complicated by acute STEMI. The diagnosis and management of STEMI in acute pancreatitis can present unique diagnostic and therapeutic challenges, which are reviewed.

Case Report

A 31-year-old man with no conventional coronary risk factors presented with acute abdominal pain, elevated pancreatic enzymes, and computed tomography scan findings of acute pancreatitis. The patient developed chest discomfort and presented to us on Day 2 with electrocardiographic evidence of an evolved extensive anterior wall myocardial infarction. Cardiac troponin I levels were elevated, and the electrocardiogram showed regional wall motion abnormalities in the left anterior descending territory (LAD). Coronary angiography done after stabilization showed a thrombus in the LAD, with no atherosclerotic lesions whatsoever. Hemostatic abnormalities are known in acute pancreatitis, and the development of a transient hypercoagulable state may be responsible for thrombotic complications. The overlap of some of the symptoms of the two conditions may cause diagnostic difficulty. Management issues include the choice of revascularization therapy, the safety of antiplatelet and anticoagulant therapy, intravenous fluid administration, and the use of cardiac medications that potentially can cause hypotension.

Conclusion

The diagnosis and management of STEMI in the setting of acute pancreatitis can be challenging. In the absence of guidelines, a multidisciplinary approach individualized to the patient’s clinical situation may be most appropriate.     

Adoption of video laryngoscopy in Massachusetts emergency departments

Background

Previous research suggests that video laryngoscopy may be superior to direct laryngoscopy.

Objectives

We sought to determine the proportion of Massachusetts emergency departments (EDs) that have adopted video laryngoscopy, the characteristics of user and non-user EDs, the reasons why non-users do not use video laryngoscopy, and how the adoption of video laryngoscopy compares to typical technology adoption life cycles.

Methods

Surveys were mailed to directors of all non-federal EDs in Massachusetts (n = 74) in early 2009. Non-responders received repeat mailings and were then contacted via telephone or e-mail.

Results

Sixty-three of 74 (85%) EDs responded and 43% had adopted video laryngoscopy. EDs with video laryngoscopy had a higher median annual visit volume than EDs without video laryngoscopy (48,000 vs. 36,500, p = 0.04), but had similar mean intubations per week (4.5 vs. 4.4, p = 0.97) and mean surgical airways per year (0.7 vs. 1.1, p = 0.19). Half of the EDs affiliated with emergency medicine residency programs had video laryngoscopy available. Among EDs with video laryngoscopy, the technology had been available for > 5 years in 4% (1/27), 1–5 years in 44% (12/27), and < 1 year in 52% (14/27). Although EDs not using video laryngoscopy did not do so primarily because it was too expensive (69% [25/36]), video laryngoscopy adoption has still progressed more rapidly than predicted by the typical technology adoption timeline.

Conclusion

Video laryngoscopy has been adopted by 43% of Massachusetts EDs; results were similar in academic institutions. Cost is the primary barrier to adoption for non-user EDs, but adoption is progressing more rapidly than expected for a new technology.     

Ultrasound diagnosis of acute thrombosis of an abdominal aortic aneurysm: a case report

Background

Point-of-care ultrasound is an effective and reliable method to diagnosis the presence of an abdominal aortic aneurysm. However, there has been limited literature regarding ultrasound diagnosis of acute aortic thrombosis.

Objective

Discuss a patient case with acute aortic thrombosis diagnosed by point-of-care emergency ultrasound. Review common etiologies and treatment options in this rare diagnosis.

Case Report

A patient with a known abdominal aortic aneurysm presented with mottled lower extremities. Point-of-care ultrasound was utilized by her physicians to diagnose acute thrombosis of her abdominal aorta. With conservative treatment the patient survived to hospital discharge.

Conclusion

Aortic thrombosis is a rare and devastating problem that can be diagnosed with point-of-care ultrasound.