Academic Emergency Medicine最新文献

Background: Oregon introduced a state policy, HB 3090, on October 6, 2017, which increased requirements on emergency departments (EDs) to improve transitions to outpatient mental health care. The objective of this study was to examine the policy's impact among low-income adolescent patients who face severe barriers to follow-up.

Methods: This was a retrospective cohort study of visits by Medicaid enrollees ages 14-18 presenting to any Oregon ED for a mental health concern between January 1, 2016, and December 31, 2019. We calculated standardized mean differences and used interrupted time series models to evaluate the association of HB 3090 with 14-day mental health follow-up, in-ED services, and inpatient admissions, adjusting for gender, race/ethnicity, primary language, and calendar months.

Results: Among 26,071 adolescent mental health-related ED visits, we found an estimated increase of 3.63 percentage points (pp; 95% confidence interval [CI] 0.27 to 6.99) in the adjusted probability of a 14-day outpatient mental health claim postpolicy. However, this effect was attenuated over time, with a slope change of -0.25 pp (95% CI -0.5 to 0) for each month thereafter. The probability of receiving mental health services in the ED or inpatient admission did not change in association with the policy.

Conclusions: There was a small increase in short-term outpatient mental health visits after the policy, but the association weakened over time, and other key outcomes did not change. Putting pressure on EDs to perform better in this area is likely to be a minimally effective strategy without accompanying strengthening of mental health resources.

Introduction: Alcohol withdrawal syndrome (AWS) is a common condition prompting emergency department (ED) presentation. However, there are limited recent, large-scale, robust data available on the incidence, admission, and medical treatment of AWS in the ED.

Methods: This was a retrospective cohort study of ED presentations for AWS from January 1, 2016, to December 31, 2023, using Epic Cosmos. All ED visits with ICD-10 codes corresponding to AWS were included. Outcomes included percentage of total ED visits, percentage admitted, length of stay (LOS), and medications administered. Binary logistic regression models were used to measure the relationship between time and dependent variables and reported as odds ratios (ORs) with 95% confidence intervals (CIs).

Results: Out of 242,804,798 ED encounters, 670,430 (0.28%) visits were due to AWS with a rise over time (OR 1.074, 95% CI 1.072-1.075). Of these, 386,618 (57.7%) were admitted (46.2% inpatient floor, 11.5% ICU). Median (IQR) hospital LOS was 3 (2-5) days and median (IQR) ICU LOS was 2 (1-4) days. Among all ED patients, benzodiazepine use declined over time (84.9% to 77.1%; OR 0.917, 95% CI 0.914-0.920), while phenobarbital (4.0% to 21.2%; OR 1.255, 95% CI 1.250-1.259) and gabapentin (11.0% to 16.3%; OR 1.054, 95% CI 1.050-1.057) use increased. Oral and intravenous (IV) benzodiazepines were common (63.1% and 66.6%, respectively). Among IV benzodiazepines, lorazepam was most common (59.9%). Among those discharged from the ED, 29.0% were prescribed benzodiazepines (chlordiazepoxide 21.1%, lorazepam 5.5%, diazepam 1.9%). Anticraving medications, such as gabapentin (1.5%), naltrexone (0.4%), and acamprosate (<0.1%) were uncommon, but rising over time.

Conclusions: AWS represents a common reason for ED presentation, with most patients being admitted. We identified a rising incidence with a shift in management to include agents such as phenobarbital and gabapentin. These findings provide important evidence on current trends in AWS to inform health policy and knowledge translation efforts as well as emphasizing the need for ongoing research and evaluation of clinical practices to optimize outcomes for patients with AWS.

Objectives: Identifying patients in the emergency department (ED) at higher risk for in-hospital mortality can inform shared decision making and goals-of-care discussions. Electronic health record systems allow for integrated multivariable logistic regression (LR) modeling, which can provide early predictions of mortality risk in time for crucial decision making during a patient's initial care. Many commonly used LR models require blood gas analysis values, which are not frequently obtained in the ED. The goal of this study was to develop an all-cause mortality prediction model, derived from commonly collected ED data, which can assess mortality risk early in ED care.

Methods: Data were obtained for all patients, age 18 and older, admitted from the ED to Atrium Health Wake Forest Baptist from April 1, 2016, through March 31, 2020. Initial vital signs including heart rate, respiratory rate, systolic blood pressure, diastolic blood pressure, mean arterial pressure, pulse oximetry, weight, body mass index, comprehensive metabolic panel, and a complete blood count were electronically retrieved for all patients. The prediction model was developed using LR. The ED early mortality (EDEM) model was compared with the rapid Emergency Medicine Score (REMS) for performance analysis.

Results: A total of 45,004 patients met inclusion criteria, comprising a total of 77,117 admissions. In this cohort, 52.8% of patients were male and 47.2% were female. The model used 35 variables and yielded an area under the receiver operating characteristic curve (AUC) of 0.889 (95% CI 0.874-0.905) with a sensitivity of 0.828 (95% CI 0.791-0.860), a specificity of 0.788 (95% CI 0.783-0.794), a negative predictive value of 0.995 (95% CI 0.994-0.996), and a positive predictive value of 0.084 (95% CI 0.076-0.092). This outperformed REMS in this data set, which yielded an AUC of 0.500 (95% CI 0.455-0.545).

Conclusions: The EDEM model was predictive of in-hospital mortality and was superior to REMS.

Objectives: We applied three electronic triggers to study frequency and contributory factors of missed opportunities for improving diagnosis (MOIDs) in pediatric emergency departments (EDs): return visits within 10 days resulting in admission (Trigger 1), care escalation within 24 h of ED presentation (Trigger 2), and death within 24 h of ED visit (Trigger 3).

Methods: We created an electronic query and reporting template for the triggers and applied them to electronic health record systems of five pediatric EDs for visits from 2019. Clinician reviewers manually screened identified charts and initially categorized them as "unlikely for MOIDs" or "unable to rule out MOIDs" without a detailed chart review. For the latter category, reviewers performed a detailed chart review using the Revised Safer Dx Instrument to determine the presence of a MOID.

Results: A total of 2937 ED records met trigger criteria (Trigger 1 1996 [68%], Trigger 2 829 [28%], Trigger 3 112 [4%]), of which 2786 (95%) were categorized as unlikely for MOIDs. The Revised Safer Dx Instrument was applied to 151 (5%) records and 76 (50%) had MOIDs. The overall frequency of MOIDs was 2.6% for the entire cohort, 3.0% for Trigger 1, 1.9% for Trigger 2, and 0% for Trigger 3. Brain lesions, infections, or hemorrhage; pneumonias and lung abscess; and appendicitis were the top three missed diagnoses. The majority (54%) of MOIDs cases resulted in patient harm. Contributory factors were related to patient-provider (52.6%), followed by patient factors (21.1%), system factors (13.2%), and provider factors (10.5%).

Conclusions: Using electronic triggers with selective record review is an effective process to screen for harmful diagnostic errors in EDs: detailed review of 5% of charts revealed MOIDs in half, of which half were harmful to the patient. With further refining, triggers can be used as effective patient safety tools to monitor diagnostic quality.

Objective: The Pediatric Emergency Care Applied Research Network (PECARN) derived and externally validated a clinical prediction rule to identify children with blunt torso trauma at low risk for intraabdominal injuries undergoing acute intervention (IAI^AI). Little is known about the risk for IAI^AI when only one or two prediction rule variables are positive. We sought to determine the risk for IAI^AI when either one or two PECARN intraabdominal injury rule variables are positive.

Methods: We performed a planned secondary analysis of a prospective, multicenter study that included 7542 children (<18 years old) with blunt torso trauma evaluated in six emergency departments from December 2016 to August 2021. Patients with only one or two PECARN rule variables positive were included. The outcome was IAI^AI (IAI undergoing therapeutic laparotomy, angiographic embolization, blood transfusion, or two or more nights of intravenous fluids).

Results: Among the 7542 children enrolled, 2986 (39.6%, 95% confidence interval [CI] 38.5%-40.7%) had one or two PECARN variables positive and were included. Of this subpopulation, 227 (7.6%, 95% CI 6.7%-8.6%) had intraabdominal injuries. In the 1639 patients with only one rule variable positive, 21 (1.3%, 95% CI 0.8%-2.0%) had IAI^AI. In the 1347 patients with two rule variables positive, 27 (2.0%, 95% CI 1.3%-2.9%) had IAI^AI. Risk for IAI^AI for each variable was highest for Glasgow Coma Scale (GCS) score <14 (16/291, 5.5%, 95% CI 3.2%-8.8%) and abdominal wall trauma (three of 321, 0.9%, 95% CI 0.2%-2.7%). Risk for IAI^AI when two variables were present was highest when decreased breath sounds (three of 44, 6.8%, 95% CI 1.4%-18.7%) and GCS <14 (10/207, 4.8%, 95% CI 2.3%-8.7%) were present with one other variable.

Conclusions: Few children with blunt torso trauma and one or two PECARN predictor variables present have IAI^AI. Those with GCS score <14, however, are at highest risk for IAI^AI.

Background: This study aimed to clarify the appropriate timing for epinephrine administration in adults with out-of-hospital cardiac arrest (OHCA), particularly those cases with nonshockable rhythms, by addressing resuscitation time bias.

Methods: We performed a retrospective observational study utilizing a multicenter OHCA registry involving 95 hospitals in Japan between June 2014 and December 2020. We included patients with OHCA and nonshockable rhythms who received epinephrine during resuscitation. The primary and secondary outcomes were favorable 30-day neurological status and survival, respectively. A favorable neurological outcome was defined as a cerebral performance category score of 1 or 2. The time from emergency medical service (EMS) personnel contact to epinephrine administration was categorized in 5-min intervals. We used the Fine-Gray regression to calculate the time-dependent propensity score in each group. After risk set matching, we employed a generalized estimating equation (GEE) to adjust for within-patient clustering.

Results: A total of 36,756 patients were included in the analysis. When involving timing variables and GEE, epinephrine administration significantly affected favorable 30-day neurological status at 1-5 and 6-10 min, with risk ratios (RR; 95% confidence intervals [CIs]) of 9.36 (1.19-73.7) and 3.67 (1.89-7.14), respectively. Epinephrine administration significantly affected 30-day survival at 1-5, 6-10, 11-15, and 16-20 min, with RRs (95% CIs) of 2.33 (1.41-3.85), 2.09 (1.65-2.65), 1.64 (1.32-2.05), or 1.70 (1.29-2.25), respectively.

Conclusions: Epinephrine administration within 10 min of EMS personnel contact may be associated with favorable neurological outcomes in patients with OHCA and nonshockable rhythms.

Objective: Clinical decision instruments (CDIs) could be useful to aid risk stratification and disposition of emergency department (ED) patients with cirrhosis. Our primary objective was to derive and internally validate a novel Cirrhosis Risk Instrument for Stratifying Post-Emergency department mortality (CRISPE) for the outcomes of 14- and 30-day post-ED mortality. Secondarily, we externally validated the existing Model for End-Stage Liver Disease (MELD) scores for explicit use in ED patients and prediction of the same outcomes.

Methods: A cohort of 2093 adults with cirrhosis, at 16 sites in a statewide health system, was analyzed for 119 candidate variables available at ED disposition. LASSO with 10-fold cross-validation was used in variable selection for 14-day (CRISPE-14) and 30-day (CRISPE-30) logistic regression models. Area under the receiver operating characteristic curve (AUROC) was calculated for each variant of the CRISPE and MELD scores and compared via Delong's test. Predictions were compared to actual ED disposition for predictive value and reclassification statistics.

Results: Median (interquartile range [IQR]) characteristics of the cohort were age 62 (53-70) years and MELD 3.0 13.0 (8.0-20.0). Mortality was 4.3% and 8.5% at 14 and 30 days, respectively. CRISPE-14 and CRISPE-30 outperformed each MELD variant, achieving AUROC of 0.824 (95% CI: 0.781-0.866) and 0.829 (0.796-0.861), respectively. MELD 3.0 AUROCs were 0.724 (0.667-0.781) and 0.715 (0.672-0.781), respectively. Compared to ED disposition, CRISPE-14, CRISPE-30, and MELD 3.0 significantly improved positive and negative predictive value and net reclassification index at multiple cutoffs. Applying CRISPE-30 (cutoff 4.5) favorably reclassified one net ED disposition for mortality for every 12 patients, while MELD 3.0 net reclassified one disposition per 84 patients.

Conclusions: CDIs may be useful in risk-stratifying ED patients with cirrhosis and aiding disposition decision making. The novel CRISPE CDI showed powerful performance and requires external validation, while the existing MELD 3.0 score has moderate performance and is now externally-validated in an ED population for short-term mortality.

Objectives: Alcohol use disorder (AUD) is the most common substance use disorder in the United States. Despite availability of four FDA-approved medications, fewer than 10% of patients are prescribed medication. This study aimed to evaluate the impact and feasibility of emergency department (ED)-initiated oral naltrexone in patients with moderate to severe AUD.

Methods: This was a prospective, single-arm, open-label, nonrandomized clinical trial conducted a single ED. Consenting participants were adults with moderate to severe AUD who were provided a single 50-mg dose of oral naltrexone, a 14-day starter pack of naltrexone, and referral for treatment. Follow-up was conducted at 14 and 30 days post-ED visit. The primary outcome was engagement in formal addiction treatment. Secondary outcomes included alcohol consumption, craving, quality-of-life measures, satisfaction, and safety.

Results: Of 761 patients screened, 21 enrolled and received at least one dose of naltrexone. At 14 days, 29% were engaged in treatment, increasing to 33% at 30 days. There was a decrease in the mean (±SD) number of drinks per day from 5.20 (±4.67) at baseline to 2.23 (±4.35) during the follow-up period (p = 0.078). There was a decrease in alcohol craving scores, with median scores dropping from 19 at baseline to 8.27 during the follow-up period (p < 0.001). Quality-of-life measures improved, with a statistically significant increase in the reported number of healthy days (p = 0.006) and decrease in depressive symptoms (p < 0.001). Reported side effects were mild and satisfaction with the screening process was high.

Conclusions: ED-initiated oral naltrexone is feasible and acceptable for patients with moderate to severe AUD. While engagement in treatment was moderate, significant reductions in alcohol craving and improvements in quality of life suggest potential benefits. Further research is warranted to confirm these findings.