Academic Emergency Medicine最新文献

Background: Delirium is missed in over 75% of older adults presenting to the Emergency Department (ED). The study aimed to determine the efficacy of the ED Delirium Detection Program (ED-DDP) to improve delirium detection while evaluating implementation outcomes.

Methods: The ED-DDP consisted of a train-the-trainer model where delirium champions (DCs) trained ED nurses to perform delirium screening using an electronic health record (EHR)-embedded Brief Confusion Assessment Method (bCAM). The ED-DDP was implemented across 3 diverse EDs using a stepped-wedge cluster randomized trial, consisting of control, implementation, and intervention periods. The RE-AIM (Reach, Efficacy, Adoption, Implementation, Maintenance) framework guided outcome assessments. Efficacy was defined as delirium detection between control and intervention periods. Implementation outcomes were assessed via quantitative (surveys, training logs, EHR) and qualitative (semi-structured interviews) methods.

Results: Across the 3 ED sites, 94.4% (n = 17/18) of DCs completed delirium training and 94.4% scored ≥ 80% on the post-workshop assessment (Implementation/Fidelity). Over 90% (91.1%, n = 195/214) of nurses agreed to receive training by DCs (Adoption); the average score during nurse bCAM spot checks was 73.3% (Implementation-Fidelity). After ED-DDP implementation, the odds of delirium screening were 11.5 times higher (95% CI: [6.0, 22.3], p < 0.001), when adjusting for time and site clustering (Penetration); screening varied from 6% to 80% across the 3 sites (Reach). The proportion of older adult encounters with a positive delirium screen increased from 0% to 2.2% (p = 0.002; Efficacy). Qualitative data revealed that although DCs and nurses thought delirium screening was a priority for patient care quality and safety, competing priorities were a barrier to consistent and accurate screening (Maintenance).

Conclusions: Although a comprehensive ED delirium training program successfully increased delirium screening, detection remained low. These findings suggest that sustainable delirium detection in the ED requires not only robust training but also deeply embedded workflow solutions and clear post-detection action pathways.

Background: Syncope places a significant burden on emergency departments (EDs), often prompting extensive testing to exclude life-threatening conditions. However, the diagnostic utility of troponin, B-type natriuretic peptide (BNP), transthoracic echocardiography (TTE), and outpatient cardiac monitoring remains unclear.

Methods: This systematic review assessed the diagnostic accuracy of these tests in adults presenting with syncope. The research question was: In ED patients with syncope, does TTE, cardiac biomarkers (troponin, BNP), or outpatient arrhythmia monitoring, compared with no testing, improve outcomes within 30 days? Primary outcomes included adverse events (death, arrhythmias, structural/ischemic heart disease, and select non-cardiac causes such as pulmonary embolism or aortic dissection) for biomarkers and diagnostic yield for TTE and monitoring. Sensitivity, specificity, and likelihood ratios (LR+ and LR-) were calculated for biomarkers, while diagnostic yield with 95% CI was reported for TTE and monitoring. Risk of bias was assessed using JBI and QUADAS-2.

Results: The database searches identified 1759 citations. After applying inclusion and exclusion criteria, 41 studies (21,557 patients) were included. Significant heterogeneity among the included trials (all with I² > 90%) precluded meta-analysis. For BNP, LR+ ranged 1.4-47 and LR- 0.06-0.4; for troponin, LR+ 1.9-11.2 and LR- 0.2-0.9. TTE diagnostic yield was 0%-29% overall and 8%-28% in high-risk groups. Outpatient monitoring yielded 1%-59% overall and 12%-42% in high-risk patients.

Conclusion: In ED patients with syncope, the diagnostic accuracy and yield of cardiac biomarkers, TTE, and outpatient monitoring show substantial variability, largely due to differences in patient populations, outcome measures, and study methodologies. Based on the existing evidence, these modalities in isolation cannot be recommended for routine use in syncope evaluation. Among these tests, the diagnostic yield of TTE and outpatient monitoring is greater in patients with cardiac risk factors and could potentially contribute to a more accurate diagnosis.

Background: Community consultation (CC) is crucial for exception from informed consent (EFIC) trials. Digital marketing platforms offer a novel and efficient way to gather community input through surveys. This study aimed to determine if the demographics of digital CC survey respondents align with those of their targeted communities.

Methods: We deployed an EFIC CC digital survey for Pedi-PART, a multicenter study on paramedic airway management in critically ill children. A seven-item survey, developed to gauge community perspectives on emergency care research and the trial, was disseminated through a digital marketing platform (Qualtrics Inc.). The survey targeted adults aged 18-65 residing within the geographic service areas of 10 participating EMS agencies. We determined community demographic data from the 2022 American Community Survey (ACS) for the dominant county in each service area. We compared survey respondent demographics (age, sex, race, ethnicity, household income, education) with those of the corresponding communities.

Results: We received 6630 completed surveys (528 to 913 per community). The proportion of individuals over 35 years old was similar between survey and community populations (67.1% vs. 66.5%). Survey respondents were more likely to be female (60.0% vs. 50.9%) and report household incomes < $100,000 (77.5% vs. 60.2%). Survey respondents were less likely to be Black, American Indian, Pacific Islander, or other race (33.9% vs. 52.1%), Hispanic ethnicity (15.3% vs. 34.9%), or have at least a high school education (23.2% vs. 34.9%). Demographic differences between survey respondents and communities varied across the 10 communities.

Conclusions: Demographic differences may exist between digital survey respondents and their targeted communities. Study teams should account for these factors when utilizing such platforms for EFIC CC.