Academic Emergency Medicine最新文献

CONFLICT OF INTEREST STATEMENT

The author declares no conflicts of interest.

Background: Patient-centered care (PCC) is an essential component of high-quality health, yet patients with non-English language preferences (NELP) experience worse PCC outcomes. Additionally, there are likely unique aspects to PCC for patients with NELP in the emergency department (ED). To inform the development of strategies to improve PCC for NELP in the ED, we sought to understand how Spanish-speaking ED patients experience care and the factors that influenced their perceptions of the patient-centeredness of that care.

Methods: We conducted a single-center qualitative study using semistructured interviews with adult, Spanish-speaking patients who had been discharged home from the ED. Interviews were conducted using an interview guide, recorded, transcribed, and analyzed iteratively in Spanish using inductive and deductive thematic analysis.

Results: We conducted 19 interviews with participants from 24 to 72 years old. Participants were born in seven different Spanish-speaking countries. Participants identified three domains of PCC: patient, medical team's skills, and system. Several of the identified themes such as shared decision making, open communication, compassionate care, and coordination of follow-up care are often incorporated into PCC definitions. However, other themes, including uncertainty leading to fear, use of professional interpreters to promote understanding, receiving equitable care, technical proficiency, and efficiency of care expand upon existing domains in PCC definitions.

Conclusions: We now have a more nuanced understanding of how Spanish-speaking patients with NELP experience PCC in the ED and what matters to them. Several of the themes identified in this analysis add details about what matters to patients within the domains of previous PCC definitions. This suggests that the conceptualization of PCC may vary based on the setting where care is provided and the population who is receiving this care. Future work should consider patient population and setting when conceptualizing PCC.

Background: A quarter of patients who present to emergency departments (EDs) have difficult intravenous access (DIVA), making it challenging for clinicians to successfully place a peripheral intravenous catheter (PIVC). Some literature suggests that guidewire PIVC improves first-insertion success rate.

Aim: The aim was to determine the clinical and cost-effectiveness of a novel long PIVC (5.8 cm) with a retractable coiled guidewire (GW-PIVC) for patients with DIVA, compared with standard care PIVCs.

Methods: A pragmatic randomized controlled trial was conducted in two Australian EDs. Eligible participants were adults assessed as meeting DIVA criteria. Participants were randomized (1:1 ratio; stratified by hospital) to either GW-PIVC (long) or standard care group (short or long PIVC). The use of ultrasound was discretionary in the standard care group and was recommended in the GW-PIVC group due to the pragmatic design that was primarily testing the GW-PIVC rather than the ultrasound use. Primary outcome was first-insertion success and secondary outcomes included all-cause device failure, patient and staff satisfaction, and cost-effectiveness. The analysis was intention to treat.

Results: A total of 446 participants were randomized and 409 received PIVCs. The use of GW-PIVC, compared with standard PIVC, had a lower first-insertion success rate (68% vs. 77%, odds ratio [OR] 0.65, 95% confidence interval [CI] 0.43-0.99, p < 0.05). There was no difference in PIVC failure (134.0 per 1000 catheter days [GW-PIVC] vs. 111.8 [standard PIVC] per 1000 catheter days, hazard ratio 1.18, 95% CI 0.72-1.95). Both participant (8/10 vs. 9/10, median difference [MD] -1.00, 95% CI -1.37 to -0.63) and clinician (8/10 vs. 10/10, MD -2.00, 95% CI -2.37 to -1.63) satisfaction was lower with GW-PIVCs compared with standard PIVCs. More nurses inserted standard PIVCs than GW-PIVCs (56.9% vs. 36.5%) and had less confidence in their ultrasound skills (28.0% vs. 46.6% self-claimed as advanced/expert users). The cost per participant of GW-PIVC insertions was 2.46 times greater than standard PIVC insertions ($AU80.24 vs. $AU32.57).

Conclusions: GW-PIVCs had significantly lower first-insertion success and non-significantly higher all-cause catheter failure. Additional training and device design familiar to clinicians are vital factors to enhance the likelihood of successful future implementation of GW-PIVCs.

Background: Data comparing the performance of sex-specific to overall (non-sex-specific) high-sensitivity cardiac troponin (hs-cTn) cut-points for diagnosing acute coronary syndrome (ACS) are limited. This study aims to compare the safety and efficacy of sex-specific versus overall 99th percentile high-sensitivity cardiac troponin T (hs-cTnT) cut-points.

Methods: We conducted a secondary analysis of the STOP-CP cohort, which prospectively enrolled emergency department patients ≥ 21 years old with symptoms suggestive of ACS without ST-elevation on initial electrocardiogram across eight U.S. sites (January 25, 2017-September 6, 2018). Participants with both 0- and 1-h hs-cTnT measures less than or equal to the 99th percentile (sex-specific 22 ng/L for males, 14 ng/L for females; overall 19 ng/L) were classified into the rule-out group. The safety outcome was adjudicated cardiac death or myocardial infarction (MI) at 30 days. Efficacy was defined as the proportion classified to the rule-out group. McNemar's test and a generalized score statistic were used to compare rule-out and 30-day cardiac death or MI rates between strategies. Net reclassification improvement (NRI) index was used to further compare performance.

Results: This analysis included 1430 patients, of whom 45.8% (655/1430) were female; the mean ± SD age was 57.6 ± 12.8 years. At 30 days, cardiac death or MI occurred in 12.8% (183/1430). The rule-out rate was lower using sex-specific versus overall cut-points (70.6% [1010/1430] vs. 72.5% [1037/1430]; p = 0.003). Among rule-out patients, the 30-day cardiac death or MI rates were similar for sex-specific (2.4% [24/1010]) vs. overall (2.3% [24/1037]) strategies (p = 0.79). Among patients with cardiac death or MI, sex-specific versus overall cut-points correctly reclassified three females and incorrectly reclassified three males. The sex-specific strategy resulted in a net of 27 patients being incorrectly reclassified into the rule-in group. This led to an NRI of -2.2% (95% CI -5.1% to 0.8%).

Conclusions: Sex-specific hs-cTnT cut-points resulted in fewer patients being ruled out without an improvement in safety compared to the overall cut-point strategy.