Academic Emergency Medicine最新文献

Objectives: Rapid multiplex point-of-care (POC) PCR tests may reduce unnecessary antibiotic prescribing by quickly identifying viral etiologies in patients with acute respiratory infections (ARI). We evaluated the impact of a rapid (~15 min) multiplex PCR test on antibiotic prescribing, provider confidence, patient satisfaction, and emergency department (ED) length of stay (LOS).

Methods: We conducted a prospective, single-center study (March 2024-January 2025) enrolling adults presenting to an urban academic ED with ARI symptoms. Participants underwent rapid multiplex PCR testing (BIOFIRE SPOTFIRE Respiratory Panel), with results provided to clinicians in real time. Antibiotic prescribing, provider and patient perceptions, and ED LOS were assessed through surveys and electronic health record review. A propensity-matched control cohort was used to compare antibiotic prescribing and LOS. The primary outcome was antibiotic prescribing among patients with a confirmed viral etiology; secondary outcomes included overall antibiotic prescribing, ED LOS, and provider-and patient-reported measures.

Results: A total of 200 patients were enrolled (mean age 43 years; 56.5% female). Common presenting symptoms included cough (80%), congestion (65%), and sore throat (55%). Patients with confirmed viral infections were significantly less likely to receive antibiotics than those with no detected pathogen (6.5% vs. 20.2%; OR 0.28; 95% CI 0.10-0.68; p = 0.009). Overall antibiotic prescribing rates were similar between experimental and control cohorts (14.9% vs. 12.0%; p = 0.392), but median ED LOS was significantly shorter in the experimental group (4.3 vs. 6.5 h; OR 0.66; 95% CI 0.59-0.74; p < 0.001). Provider diagnostic confidence was high (76%), and most patients reported high satisfaction with testing (92%).

Conclusions: Rapid multiplex PCR testing was associated with reduced antibiotic prescribing for viral infections, shorter ED LOS, high provider confidence, and high patient satisfaction. These findings support the value of ultra-rapid diagnostics for antimicrobial stewardship and patient-centered care in the ED.

Objective: Low-risk chest pain (LRCP) is one of the most common conditions presenting in the emergency department (ED) and is strongly associated with anxiety. The purpose of this study is to determine the prevalence of other psychological comorbidities and clinical factors associated with severe anxiety in LRCP.

Methods: Baseline data is analyzed from the PACER trial comparing the effectiveness of two telehealth interventions for LRCP patients with anxiety. Key eligibility criteria are a HEART score < 7 and either a GAD-7 anxiety score ≥ 8 or a positive PHQ screener for panic disorder. Psychological comorbidity measures included the Patient Health Questionnaire 8-item (PHQ-8) depression scale, the PHQ-14 somatization scale, the Primary Care Posttraumatic Stress Disorder Screen, the Sheehan Disability Scale, and the General Self-Efficacy Scale. Multivariable modeling is used to determine factors associated with severe anxiety.

Results: The 375 patients had a mean age of 39.9; 70.9% were women; 62.9% were White, 32.6% Black, and 4.5% other race. The majority (75%) screened positive for panic disorder, and 42% of participants had severe anxiety (GAD-7 ≥ 15). Non-anxiety psychological comorbidity was very high; the proportion of patients exceeding scale cut points was 58% for depression, 57% for PTSD, 52% for somatization, 59% for high disability, and 31% for low self-efficacy; each was significantly associated with severe anxiety on univariable analysis. Four patient characteristics were independently associated with severe anxiety in multivariable models: odds ratios (95% CI) were 2.7 (1.5-4.9) for depression, 2.3 (1.4-3.9) for low self-efficacy, 2.1 (1.2-3.6) for low education (high school or less), and 1.8 (1.0 to 3.3) for female sex.

Conclusions: LRCP is accompanied not only by anxiety but also by other potentially treatable psychological comorbidities Severe anxiety is more common in individuals with depression, low self-efficacy, lower education, and possibly women.

Trail registration: PACER is registered in clinicaltrials.gov identifier: NCT04811521.

Background: Care transitions from the emergency department (ED) to the community represent a critical period that can significantly impact clinical outcomes of older adults, yet there is a lack of standardized tools to measure patient-reported experiences and outcomes during this transition. Our objective was to develop and validate the Patient-Reported Outcome Measure-Older adult care Transitions in the ED (PROM-OTED) tool to measure care transition outcomes within 4-10 days after ED discharge.

Methods: Older adults (65+ years) discharged from four EDs were enrolled between November 2021 and April 2024 in a multiphase process: qualitative interviews, item generation, member checking, cognitive debriefing, technical expert panel review, and psychometric evaluation and validation. We employed descriptive statistics, item analysis, interitem correlation, and factor analyses to assess the tool's validity and reliability.

Results: Across all phases, we enrolled 290 older adults. The final 18-item PROM-OTED tool included items that addressed understanding of discharge instructions, medication management, follow-up care, and quality of life. The tool demonstrated feasibility with a mean (±SD) completion time of 4.97 (±3.04) min and was able to be administered electronically or via telephone. The tool additionally demonstrated excellent internal consistency (Cronbach's alpha 0.9376, McDonald's omega 0.9988) and good test-retest reliability (r = 0.8437). Exploratory factor analysis supported a robust factor structure and significant correlations between the PROM-OTED tool with the Care Transitions Measure-3, a general measure of hospital discharge quality of care, support its concurrent validity.

Conclusions: The PROM-OTED tool is a reliable and preliminarily valid instrument for use during the immediate post-ED period, with potential clinical applications in enhancing discharge practices and assessing care transition outcomes of older adults during observational or interventional studies.

Background: The increasing prevalence of methamphetamine-associated "overdoses" in the surveillance literature necessitates a better understanding of self-reported symptoms associated with acute methamphetamine toxicity events. This study describes and compares the prevalence, self-reported symptoms, and behavioral correlates of acute methamphetamine toxicity, opioid overdose, and mixed drug overdose events.

Methods: We surveyed 420 people who use drugs in Nevada and New Mexico. Participants reported on their experiences of acute methamphetamine toxicity, opioid overdose, and mixed drug overdose events, including symptoms and healthcare utilization. We conducted descriptive analyses and compared demographics, drug use behaviors, and health indicators across groups experiencing different types of events.

Results: Of 217 participants reporting any event, 24% experienced only methamphetamine toxicity, 35% only opioid overdose, 5% only mixed drug overdose, and 36% multiple types. Methamphetamine toxicity events were characterized by anxiety (43%), heart pounding (34%), and rapid heart rate (33%), while opioid overdoses primarily involved loss of consciousness (86%). The methamphetamine-only group reported significantly lower prevalence of recent use of various substances and less frequent naloxone availability.

Conclusions: Acute methamphetamine toxicity events present distinctly from opioid overdoses, with implications for emergency recognition and response. Lower naloxone availability among people who use methamphetamine is concerning given the prevalence of polydrug use. These findings underscore the need for targeted interventions addressing methamphetamine-related harm reduction efforts.

Objectives: Multicenter research of geriatric emergency department (GED) care remains limited. Our objectives were to: 1. Prospectively collect data prioritized by the Geriatric Emergency care Applied Research (GEAR) network, a transdisciplinary taskforce for GED care, and create a multicenter GED research repository of prospective and electronic health record (EHR) data, 2. Assess concordance between prospective and EHR data.

Methods: The GEAR Standardization Study (GEARSS) is a multicenter, prospective study of older emergency department (ED) patients (65+) focusing on the 4Ms of age-friendly care (mobility, medication safety, mentation, what matters) and elder mistreatment. Demographic and clinical data were collected via interviews by trained research assistants (RA) on Days 0, 4, 30, and 90 and linked to EHR. Prevalence of chronic comorbidities and incident delirium were measured and reported using descriptive statistics. Prospective and EHR data concordance was assessed with Cohen's Kappa.

Results: 999 participants were recruited from 5 EDs (3/25/2021-6/30/2022) across 3 institutions: Grady Health System, Northwestern Memorial Hospital, and Yale New Haven Health. The cohort was 57.0% female, 55.2% White, 39.1% Black, and 3.4% Hispanic, and the mean age was 75.1 years. For rheumatologic disease, peptic ulcer disease, diabetes, renal disease, and cancer, prevalence differed between prospective and EHR data by > 10%. About two-thirds of participants were at risk for falls. Concordance between prospective and EHR data was good for ethnicity (K = 0.73); excellent for sex (K = 1.00), age (K = 1.00), and race (K = 0.98); fair for disposition (K = 0.53); slight for ED observation status (K = 0.33) and dementia diagnosis (K = 0.24); poor for delirium presence (K = 0.07).

Conclusion: In GEARSS, demographic variables aligned strongly between prospective and EHR data, while diagnosis, disposition, and mentation factors did not. This multicenter data source provides preliminary findings for common geriatric syndromes and conditions. Choice of measures using these data should be driven by GED research questions.

Background: The optimal sequence of epinephrine administration and advanced airway management (AAM) successfully delivered during pediatric out-of-hospital cardiac arrest (OHCA) is unclear. Our objective was to determine whether the sequence of first successful epinephrine administration and first successful AAM is associated with survival and functional outcomes in pediatric OHCA.

Methods: We performed a secondary analysis of the Resuscitation Outcomes Consortium Epidemiologic Registry-Cardiac Arrest, a prospective database from 10 US and Canadian regions (2011-2015). We included children (age < 18 years) with non-traumatic OHCA who received epinephrine and/or AAM (endotracheal intubation or supraglottic airway). Our exposure was the sequence of first successful epinephrine administration versus first successful AAM (epinephrine-first or AAM-first). The primary outcome was survival at hospital discharge. Secondary outcomes were a favorable functional outcome at discharge (modified Rankin Scale ≤ 3) and return of spontaneous circulation (ROSC) at hospital arrival. We adjusted for group differences using inverse-probability-of-treatment weighting derived from a propensity score and compared outcomes with logistic regression.

Results: Of 886 eligible patients, 297 (33.5%) received AAM as the first successful intervention, 558 (63.0%) received epinephrine as the first successful intervention, and 31 (3.5%) received these at the same recorded second. There was no significant difference in survival at discharge between the epinephrine-first and AAM-first groups (odds ratio [OR], 1.03; 95% confidence interval [CI], 0.69-1.52). Relative to the AAM-first group, the epinephrine-first group was associated with higher odds of ROSC at hospital arrival (OR, 1.38; 95% CI, 1.06-1.80) but lower odds of favorable functional outcome at hospital discharge (OR, 0.32; 95% CI, 0.13-0.76).

Conclusions: In this large observational study of pediatric OHCA, the observed sequence of first successful epinephrine administration and first successful AAM was not associated with survival to hospital discharge.

Background: Syncope is a frequent reason for hospitalization from the emergency department (ED), but the benefit of hospitalization is unclear. This systematic review and meta-analysis (SRMA) aims to cohere and synthesize the best current evidence regarding the potential benefit of hospitalization for ED syncope patients for developing an evidence-based ED syncope management guideline.

Methods: We conducted a SRMA according to the patient-intervention-control-outcome (PICO) framework: In patients 16 years of age or older who present to the ED with syncope (population), does hospitalization (intervention) or direct ED discharge (comparison) improve short-term outcomes (outcome)? The primary outcome was a composite of all adverse events as defined by individual studies, up to 30 days. Two reviewers independently assessed articles for inclusion and methodological quality. We measured heterogeneity among included studies with I-squared statistic and used GRADE criteria to assess the quality of evidence.

Results: Our search strategy identified 2140 publications and included 18 publications (510,545 participants) in the analysis. All studies reported higher rates of adverse events in hospitalized patients (0.7%-43.8%) compared to discharged patients (0%-3.7%). Our meta-analysis detected considerable statistical heterogeneity. The GRADE assessment for all adverse events and all-cause mortality revealed risk ratios of >5 favoring ED discharge for both outcomes at a median follow-up of 30 days. However, point estimates are limited by serious risk of bias, inconsistency, imprecision, indirectness, and publication bias.

Conclusions: Due to the uncertainty of the available evidence, this SRMA's findings do not support a recommendation for or against hospitalizing patients presenting to ED with syncope. However, discharging low-risk patients with syncope from the ED is associated with a low risk of short-term adverse events.

Background: Simultaneous exposure to both benzodiazepines and opioids can lead to synergistic respiratory depression, complicating overdose management. Our objective was to report on the detection of prescription and novel benzodiazepine co-exposures among patients treated in emergency departments (EDs) with suspected opioid overdoses. We aimed to describe novel benzodiazepine exposures in this population and to compare the clinical severity of co-exposure to benzodiazepines and opioids versus opioids alone.

Methods: This study utilized data from the Toxicology Investigators Consortium (ToxIC) Fentalog Study, an observational study at 10 ED sites (Sept 2020-Dec 2023). Waste serum samples were analyzed using liquid chromatography quadrupole time-of-flight mass spectrometry (LC-QTOF-MS) for the presence of over 1200 novel psychoactive substances (NPS), drugs, therapeutics, and metabolites. Analyses included demographics, clinical severity, and outcomes among those with prescription benzodiazepines, novel benzodiazepines, or no benzodiazepines.

Results: Among the patients with opioids present (n = 1427), 29.0% of patients had detectable benzodiazepines. 20.5% of patients had detectable prescription benzodiazepines, and 8.5% of patients had detectable novel benzodiazepines. The most commonly detected prescription benzodiazepine was alprazolam (39.3%); the most common novel benzodiazepine was bromazolam (46.3% of novel benzodiazepines). The median age of those with novel benzodiazepines was 34, which was younger than those without benzodiazepines (40) and those with prescription benzodiazepines (41; p = 0.001). Patients without benzodiazepines received naloxone more frequently (p = 0.02), while novel benzodiazepine co-exposure was associated with higher naloxone nonresponse rates (p = 0.03). Patients with novel benzodiazepines (compared to the opioid-only group) had increased odds of requiring mechanical ventilation (aOR: 2.14; 95% CI: 1.07, 4.05) after adjusting for age, gender, race and ethnicity, and the presence of prescription benzodiazepines and/or fentanyl.

Conclusions: Nearly a third of patients with confirmed opioid overdose presenting to the ED also had concomitant benzodiazepine exposures. Those with novel benzodiazepines had significantly higher odds of intubation, suggesting greater severity of overdose.

Background: Little is known about the referral timeframes emergency department (ED) providers recommend following emergency care and the frequency with which patients attend primary care provider (PCP) appointments within these specific timeframes.

Methods: In this retrospective cohort study of adults aged 65 and older discharged home from nine EDs in Michigan, we evaluated patient attendance at PCP appointments within the timeframe recommended by the ED provider. We used descriptive statistics and multivariable regression (logistic and Cox proportional hazards) to identify factors associated with follow-up visit attendance and time to attendance.

Results: Among 1030 older adults, 81.9% of patients were recommended to follow up with a PCP. Of these patients, 39.9% and 13.7% were recommended follow-up within 1-3 days or 4-7 days, respectively. The overall rate of attendance at PCP visits within the recommended timeframe was 26.8% (95% CI 23.8-29.9). Only 15.2% (95% CI 12.3-18.5) of patients who were recommended follow-up within 7 days attended in that timeframe. Patients with shorter-interval follow-up recommendations and those seen at a safety-net ED were less likely to attend follow-up in the recommended timeframe.

Conclusions: More than half of older adults were recommended primary care follow-up within 7 days, yet few attended visits in the timeframe recommended by the ED provider. Further research is needed to define appropriate follow-up timing and solutions to close the gap between a high portion of early follow-up recommendations and low visit attendance shortly after ED discharge.