Clinical and Experimental Emergency Medicine最新文献

Objective: This study assessed the efficacy of electrocardiogram (ECG) compared to pulse oximetry (PO) in detecting heart rate (HR) during high-risk newborn resuscitation.

Methods: A prospective observational study was performed with high-risk delivery cases to measure the time required for HR detection. A conventional PO and a standard ECG monitor were used for HR assessment.

Results: Forty-one infants were analyzed in the study, and 11 needed resuscitation. The study population was divided according to gestational age (GA): 9 were GA <32 weeks, 28 were GA 32-35 weeks, and 4 were GA ≥36 weeks. Time from ECG placement to HR detection (median, 30 seconds; interquartile range [IQR], 20-43.5 seconds) was significantly faster than that from PO placement (median, 125 seconds; IQR, 100-175 seconds; P<0.001). Time from ECG placement to HR detection was shortest in infants with GA <32 weeks at birth (19 seconds [IQR, 11.5-30.0] for GA <32 weeks vs. 34.5 seconds [IQR, 25.0-44.3] for GA 32-35 weeks vs. 39.5 seconds [IQR, 30.0-64.8] for GA ≥36 weeks; P=0.039).

Conclusion: ECG effectively evaluated HR during neonatal resuscitation compared to PO. Low- GA infants who require resuscitation may benefit from HR evaluation with nearby standard ECG.

Objective: Tricuspid annular plane systolic excursion (TAPSE) is an echocardiographic parameter that serves as a prognostic indicator for the severity of chronic obstructive pulmonary disease (COPD) clinical course. This study, consisting of a systematic review and meta-analysis, evaluates the current literature to elucidate the relationship between TAPSE measurement in COPD patients versus control subjects to discern baseline evidence of right heart strain.

Methods: PubMed, Scopus, CINAHL, Web of Science, and Cochrane Library databases were searched from their beginnings through November 1, 2023, for eligible studies. Outcomes included the difference of TAPSE measurement and right ventricular (RV) wall thickness between COPD patients and control patients. The Newcastle-Ottawa Scale was applied to assess risk of bias, Q-statistics and I2 values were used to assess for heterogeneity, and Egger and Begg tests were used to assess publication bias.

Results: The search yielded 11 studies reporting TAPSE values involving 1,671 patients, 800 (47.9%) of which had COPD. The unadjusted mean TAPSE value for COPD patients was 18.9±4.0 mm, while the mean TAPSE value for control patients was 22.2±0.8 mm. The presence of COPD was significantly associated with decreased TAPSE values, with the meta-analysis reporting the mean difference in TAPSE value at -3.0 (95% confidence interval, -4.3 to -1.7; P=0.001) between COPD and control patients. Six studies reported the RV free wall thickness. The unadjusted mean RV free wall thickness for COPD patients was 4.9±1.2 mm, and for control patients was 3.4±0.7 mm.

Conclusion: This meta-analysis demonstrated statistically significant lower TAPSE values and thicker RV free wall among COPD patients as compared with control patients.

Introduction: Urinary tract infections are a common consideration among pediatric patients with fever. With rising resistance rates and increased focus on antibiotic stewardship, there is a need to better understand the current management. This study reports the incidence and antibiotic distribution among a nationwide cohort of Emergency Department (ED) patients with cystitis and pyelonephritis over an eight-year period.

Methods: We performed a cohort study from 1/1/2016-12/31/2023 using Epic Cosmos. Pediatric (<18 years) ED patients with an ICD-10 code corresponding to cystitis or pyelonephritis were included. Outcomes included total number of ED presentations, outpatient antibiotic prescriptions, and antibiotics administered in the ED for admitted patients with cystitis or pyelonephritis. Binary logistic regression models were used to measure the relationship between year and dependent variables.

Results: Among 46,774,814 total pediatric ED visits, 730,863 (1.5%) were for cystitis and 82,717 (0.18%) were for pyelonephritis. Among those admitted, the most common antibiotics were third-generation cephalosporins (cystitis:55.6%, pyelonephritis:62.3%), first-generation cephalosporins (cystitis:13.8%, pyelonephritis:13.7%), and ampicillin (cystitis:10.8%, pyelonephritis:6.6%). First-generation cephalosporin use rose over time, while ampicillin and ciprofloxacin use declined. Among discharged patients, the most common antibiotics were first-generation cephalosporins (cystitis:43.1%, pyelonephritis:33.7%), third-generation cephalosporins (cystitis:20.8%, pyelonephritis:25.8%), and trimethoprim-sulfamethoxazole (cystitis:13.5%, pyelonephritis:11.8%). First-generation cephalosporin use rose over time, while trimethoprim-sulfamethoxazole and ciprofloxacin use declined. Among those with cystitis specifically, third-generation cephalosporins declined over time.

Conclusion: Cystitis and pyelonephritis remain common ED presentations, representing nearly 2% of all pediatric ED visits, and there have been notable shifts in the antibiotic selection over time. Understanding the current epidemiology can inform public health planning and antibiotic stewardship in the ED.

Objective: Emergency medicine (EM) physicians face high burnout rates, even in academic settings. Research on burnout among EM residency program leaders is limited, despite their role in shaping the training environment and influencing resident well-being. This study aims to measure burnout and professional fulfillment among EM residency program leaders and identify contributing factors.

Methods: A cross-sectional survey using the adapted Stanford Professional Fulfillment Index was conducted in 2023 to assess burnout and professional fulfillment among EM residency program leaders at US programs. The survey, tailored to EM leaders, was distributed to all current EM program directors (PDs) and assistant/associate PDs (APDs) from accredited US programs. Descriptive statistics and odds ratios were used to compare burnout and professional fulfillment across various groups.

Results: A total of 112 of 281 PDs (response rate, 39.9%) and 130 of 577 APDs (response rate, 22.5%) participated. Professional fulfillment was reported by 59.8% of PDs and 58.5% of APDs. Burnout was experienced by 42.0% of PDs and 26.9% of APDs. Higher professional fulfillment correlated with alignment with expectations, positive work environments, and perceived appreciation, while burnout was strongly associated with negative impacts on personal health and relationships. Approximately 27.7% of PDs and 23.8% of APDs expressed an intention to leave their current position within 18 months.

Conclusion: A significant proportion of US EM residency program leaders experience burnout and low professional fulfillment. Addressing well-being in this population has important implications for education and mentorship provided to future physicians in the field.

Objective: Staffing significantly influences emergency department (ED) throughput; however, there is a shortage of registered nurses (RNs), impacting ED flow and crowding. Non-RN providers, like licensed practical nurses (LPNs), could potentially assist with tasks traditionally assigned to RNs. To improve the front-end ED process, we implemented an attending physician-LPN team (PNT) positioned next to triage and utilized existing ED hallway space.

Methods: This study took place at a tertiary care ED with over 110,000 annual visits. We compared postintervention (post-PNT) data (November 1, 2022-February 28, 2023) to preintervention (pre-PNT) data (July 31, 2022-October 31, 2022). The PNT, positioned adjacent to triage, expedited care for ED patients awaiting open rooms. The PNT selected patients from the waiting room to bypass the main ED, evaluated them in a private room, and then moved them to the hallway pending further care. Multivariable regression analysis was utilized to measure the impact of different factors on ED length of stay (LOS).

Results: We analyzed 23,516 patient visits, 10,288 in the pre-PNT period and 13,288 in the postPNT period. Post-PNT consisted of 2,454 PNT visits and 10,834 non-PNT visits. The intervention led to significant improvements, including a decrease in mean ED LOS from 492 to 425 minutes, a decrease in 72-hour revisits from 5.1% to 4.0%, a decrease in left-without-being-seen rate from 6.7% to 3.3%, and a decrease in the mean arrival-to-provider time from 74 to 60 minutes. Multivariable regression analysis showed that ED LOS was significantly lower for post-PNT patients than pre-PNT.

Conclusion: By leveraging the scope of LPNs and utilizing existing ED space, the PNT model successfully reduced front-end bottlenecks, leading to improved throughput and reduced revisitation and left-without-being-seen rates.

Objective: Fluids administered as drug diluents with intravenous (IV) medicine constitute a substantial fraction of fluids in inpatients. Whether physicians are aware of fluid volumes administered with IV antibiotics for patients with suspected infections is unclear. Moreover, whether this leads to adjustments in 24-hour fluid administration/antibiotics is unknown.

Methods: This cross-sectional interview-based study was conducted in three emergency departments. Physicians were interviewed after prescribing around-the-clock IV antibiotics for ≥24 hours to patients with suspected infection. A structured interview guide assessed the physicians' awareness, considerations, and practices when prescribing IV antibiotics. The 24-hour antibiotic fluid volume was calculated.

Results: We interviewed 100 physicians. The 24-hour fluid volume administered with IV antibiotics was 400 mL (interquartile range, 300-400 mL). Overall, 53 physicians (53%) were unaware of the fluid volume administered with IV antibiotics. Moreover, 76 (76%) did not account for the antibiotic fluid volume in the 24-hour fluid administration, and 96 (96%) indicated that they would not adjust prescribed fluids after receiving information about 24-hour antibiotic fluid volume administered for their patient. No comorbidities associated with fluid intolerance were the primary reason for not adjusting prescribed fluids/ antibiotics. Approximately 79 (79%) opted for visibility of fluid volumes administered with IV antibiotics in the medical record.

Conclusion: The majority of physicians were unaware of fluid volumes administered as a drug diluent with IV antibiotics. The majority chose not to make post-prescribing adjustments to their planned fluid administration; they regarded their patient as fluid tolerant. The physicians opted for visibility of fluid volumes administered as diluents during the prescribing process.