Academic Emergency Medicine最新文献

Objectives: This portion of the Geriatric Emergency Department (GED) Guidelines 2.0 focuses on delirium in the emergency department (ED).

Methods: A multidisciplinary group applied the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence and develop recommendations related to older ED patients with possible delirium.

Results: The GED Guidelines 2.0 Delirium Work Group derived six evidence-based recommendations for risk stratification, diagnosis, and brain imaging. To reduce universal screening, the Delirium Risk Score may be used to identify older adults at low risk for delirium, though the evidence certainty is very low. In adults over 65 admitted to ED observation units, Zucchelli's risk assessment tool (threshold ≥ 4) may stratify delirium risk, also with very low certainty. For adults over 75, the REDEEM Score may be used to identify low- or high-risk individuals, again with very low certainty. For diagnosis, 4AT, bCAM, CAM-ICU, mCAM, AMT-4, or RASS may be used to rule delirium in or out, based on very low certainty. The Delirium Triage Screen (DTS) may be used to rule out, but not to rule in, delirium, also with very low certainty. For diagnostic imaging, there is very low certainty of evidence to recommend for or against obtaining a head CT as part of the evaluation for older ED patients with delirium. All recommendations are conditional, reflecting very low certainty of evidence due to the lack of high-quality ED-based studies and comparative effectiveness research.

Conclusion: Rigorous ED-based research is needed to strengthen evidence and guide delirium care for older adults in geriatric emergency medicine.

Objective: To determine if the utilization of an Electronic Health Record-integrated clinical pathway increased the provision of recommended medical and forensic care to adult sexual assault survivors in the ED.

Methods: This was a retrospective chart review of 552 adult survivors of sexual assault who received care at a health care system in the Northeast between January 1, 2020, and December 31, 2022. Our six outcomes were the proportion of patients who were offered a consultation with a sexual assault advocate, the proportion of patients who had the sexual assault forensic evidence kit collected, pregnancy test ordered, emergency contraception ordered, HIV post-exposure prophylaxis ordered, and sexually transmitted infection prophylaxis ordered. Primary analysis compared the impact of the pathway on outcomes before and after the implementation. Secondary analysis included the impact on outcomes of pathway use compared to non-pathway use after implementation.

Results: The pathway was used in 128 (51%) patient encounters after it was implemented. Offering consultation with a sexual assault advocate and ordering HIV post-exposure prophylaxis improved post-implementation compared to pre-implementation. In the post-implementation period, there was an improvement in recommended medical and forensic care across all outcomes, including offering an advocate, collecting forensic evidence, ordering STI prophylaxis, HIV PEP, pregnancy tests, and emergency contraception. Patients were less likely to have a SAFE kit collected if the pathway was not used compared to pre-implementation.

Conclusions: Pathway usage led to improved medical and forensic care of sexual assault survivors. Implementation of Electronic Health Record-integrated clinical pathways requires active use of the pathway rather than indirect learning from the presence of the pathway.

Background: Optimal emergency contraception (EC) can prevent approximately 95% of rape-related pregnancies. However, time to presentation, weight, and BMI influence efficacy of EC, and disparities in access to care, race and ethnicity, language, and socioeconomic status may modify rape-related pregnancy risk. We aimed to increase effective EC administration and eliminate potential health disparities in all sexual assault (SA) survivors managed in the emergency department (ED).

Methods: We conducted a 5-year retrospective review evaluating race and ethnicity, language, selected socioeconomic indicators, and obesity factors in EC administration. We implemented a quality improvement (QI) initiative over 2 years across three urban EDs, with interventions focused on care standardization (e.g., pharmaceutical changes, electronic health record optimizations, and checklists), multimodal and inter-disciplinary education, and sustainability of change (e.g., quality assurance reviews and bi-directional feedback). Statistical process control charts (SPCs) were used to evaluate temporal changes in EC administration to SA survivors. The Pearson Chi-squared was used to analyze differences across race and ethnicity groups in pre- and post-intervention cohorts. We estimated rape-related pregnancy preventions based on estimated pharmaceutical efficacy and previously reported marginal risks of pregnancy.

Results: Through two QI improvement cycles, within a pre-initiative cohort of 291 patients and post-initiative cohort of 156 patients, we increased any EC administration from 73.7% to 100% and effective EC from 44.1% to 100%, both of which were sustained for 14 months. Differences in effective EC administration across race and ethnicity groups pre-initiative (p = 0.005) were eliminated post-initiative (p = 0.840). An estimated 2.7-9.1 rape-related pregnancies were prevented in our post-initiative cohort.

Conclusions: We achieved sustained effective EC administration to SA survivors and eliminated race and ethnicity disparities. Multi-modal interventions focusing on care standardization, education, and sustainability demonstrated success in patient preventative health goals and health equity.

Background: Emergency Department (ED) Triage identifies patients with urgent needs. Frailty is not routinely identified and older patients presenting atypically may be inappropriately triaged as low priority. The introduction of a frailty modifier at triage is recommended in international guidelines, but is not yet widely-adopted.

Methods: A Frailty Trigger was developed following a systematic review and two-round eDelphi. To investigate diagnostic test accuracy for frailty, we recruited consecutive adults aged ≥ 70 attending a university hospital ED between December 2021 and February 2022, comparing the Trigger to the Clinical Frailty Scale (CFS), Variable indicative of Placement (VIP), and PRISMA-7. An independent comprehensive geriatric assessment (CGA) determined frailty status.

Results: In total, 313 adults aged ≥ 70 years were available, median age 78 ± 9 years and 46% were female. Half (51%) were frail based on the CGA. The Frailty Trigger had excellent diagnostic accuracy for frailty, Area Under the Curve (AUC) of 0.822, 95% confidence interval (CI): 0.780-0.865, similar to the VIP (AUC 0.820, p = 0.937), although significantly lower than the PRISMA-7 (AUC 0.896) and CFS (AUC 0.946). Mean administrative time was 25.5 s (SD ±10.9 s). Scoring positive on the Frailty Trigger was associated with increased length of stay (LOS), median 6.4 versus 2.3 days (p < 0.001). After adjustment for age, sex, and co-morbidity, a positive score was associated with reduced survival at 1 year (Hazard Ratio 2.2; 95% CI 1.15-4.33, p = 0.017).

Conclusion: When applied as part of ED triage, the Frailty Trigger showed excellent diagnostic accuracy for frailty when compared to validated screens and was quick to use. It predicted LOS and mortality. Studies are required to examine feasibility and its effect on frailty pathways from triage.

Background: Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo, yet it remains underdiagnosed and undertreated in emergency departments (EDs). Despite evidence-based guidelines recommending bedside diagnostic maneuvers (Dix-Hallpike and supine roll test) and canalith repositioning maneuvers (CRMs), these are infrequently utilized, leading to unnecessary imaging, prolonged symptoms, and increased healthcare utilization.

Objective: This study aimed to implement an educational strategy to improve the diagnosis and treatment of BPPV in the ED by increasing adherence to guideline-based practices.

Methods: We conducted a multicenter interrupted time series study from August 2020 to September 2023. The intervention, developed using the CAN-Implement framework, included online training, quick-reference tools, and a mobile app. Due to the COVID-19 pandemic, in-person training was canceled. The primary clinical outcome was the proportion of patients receiving the appropriate CRM based on positional test results. Implementation outcomes included fidelity, appropriateness, adoption, penetration, and system impact, reported using the Standards for Reporting Implementation Studies (StaRI) guidelines.

Results: We included 1682 patients (1252 pre-intervention, 430 post-intervention). There was no significant change in the primary outcome (appropriate CRM use, OR = 1.08, 95% CI: 0.76-1.40). However, selective CT use improved (OR = 1.29, 95% CI: 1.09-1.49), supine roll testing increased from 14.2% to 23.5%, and neurology consults decreased from 7.1% to 4.0%. Documentation of diagnostic test descriptors improved, while neurological exam documentation declined.

Conclusion: The intervention did not significantly increase appropriate CRM use but led to improvements in selective imaging, neurology consultation, and horizontal canal testing. Provision of educational tools alone was insufficient to overcome identified environmental barriers. To effectively improve BPPV management in the ED, future efforts should combine hands-on training with system-level supports and workflow integration.

Background: Prolonged emergency department waiting times are associated with increased mortality among older patients. In January 2025, the ED of Linkoping University Hospital, Sweden, implemented a low-resource routine to expedite the workup of older patients living with frailty by prioritized physician assessment and subsequent workup.

Aim: To investigate if a frailty alert using the Clinical Frailty Scale followed by prioritized clinical assessment influences ED operating metrics.

Design: This was an observational before and after study of a pre-implementation group (control) and a post-implementation group (intervention) between October 2024 and February 2025.

Setting/participants: Consecutive patients aged > 64 years, with a documented CFS assessment during the ED visit at the Linkoping University Hospital, Sweden, who consented to participation, were included.

Method: Standard ED operating metrics, Time to physician, ED length of stay (LOS), and admission rates were compared between a pre-implementation group and a post-implementation group.

Results: A total of 542 ED visits were analyzed (248 pre-implementation, 294 post-implementation). Time to physician was shorter in the post-implementation group at 31 min (IQR 15, 65) versus 44 min (IQR 20, 94) (p < 0.001). ED LOS was reduced from 352 (IQR 266, 515) to 319 (IQR 240, 458) minutes (p = 0.014). The admission rate was unchanged at 59% and 60% (p = 0.4).

Conclusion: Frailty alerts based on the CFS with prioritized workup reduced ED LOS and time to physician in older patients living with frailty in this single center study and may be a low-resource intervention to reduce the risks of adverse events in the ED.

Trial registration: ClinicalTrials.gov identifier: NCT06869148.