Academic Emergency Medicine最新文献

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: 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: Federal Exception from Informed Consent (EFIC) regulations allow emergency care research without a priori consent under limited conditions by integrating feedback from community consultation and notification of communities through public disclosure (CC/PD) activities (21 CFR 50.24). Our objectives were to evaluate community acceptance of a pediatric emergency care trial using a commercial survey tool and to determine the characteristics associated with supportive respondents.

Methods: The Pediatric Prehospital Airway Resuscitation Trial (Pedi-PART) is an EFIC trial designed to compare pediatric prehospital airway management strategies. Pedi-PART conducted community consultation/public disclosure (CC/PD) activities in March-April 2024. The CC/PD process used a commercial marketing research platform (Qualtrics Inc.) to provide study information and solicit feedback via an 18-question survey. Participants indicated support for the study through three specific questions and provided demographic characteristics. We determined the predictors of trial approval among survey respondents.

Results: A total of 6753 individuals completed surveys. The median age was 42 (IQR: 30-59) years, 62% were female, 13% were Black, and 15% were Hispanic. Survey respondents indicated support for conducting Pedi-PART in their community as follows: 90% of males, 91% of females, 89% of Blacks, 92% of Hispanics, 92% of Whites, 90% of other race/ethnicities, and 93% of parents of a child < 18 years. Among respondents with less than a high school education, 84% approved of the study compared to 93% in those with a post-graduate degree. Among those with an annual household income < $20,000, 85% approved of the study compared to 94% of those with an > $100,000 annual household income. In multivariable analysis, higher education and being the parent/guardian of a minor child were associated with support of the trial.

Conclusions: Survey respondents largely supported the Pedi-PART trial. Respondents who were parents or who had higher education were more likely to support the trial.

Background and objectives: Telemedicine psychiatry has become increasingly prevalent in emergency medicine settings. Given the limited prior research, we evaluated the interrater agreement between emergency physicians (EPs) and telemedicine psychiatrists regarding the assessment of safe disposition for mental health patients in the emergency department (ED).

Methods: This prospective, observational study was conducted at an urban, community teaching hospital. A convenience sample of adult ED patients presenting with mental health-related complaints was included for analysis. Following their evaluations, EPs completed structured forms documenting history findings and assessments of appropriate disposition. Subsequently, each patient was evaluated by a telemedicine psychiatrist, and their assessments were recorded. Categorical data were analyzed using chi-square tests, and multivariate logistic regression was performed to control for confounding variables. Interrater agreement was assessed using Cohen's kappa (κ) statistic.

Results: A total of 118 subjects were enrolled; mean age was 39 ± 15 years, 48% were female, 43% Hispanic, and 47% non-Hispanic white. Among participants, 64% presented with suicidal ideation. Agreement between EPs and psychiatrists was moderate for prior suicide attempts (κ = 0.48) and substantial for prior psychiatric history (κ = 0.71), prior ED visits for psychiatric complaints (κ = 0.75), and prior inpatient psychiatric care (κ = 0.75). Agreement on current suicidal ideation was substantial (κ = 0.71), but agreement on disposition safety was fair (κ = 0.29). Multivariate logistic regression revealed no patient characteristics or historical features significantly associated with EPs recommending more conservative dispositions.

Conclusion: Interrater agreement between EPs and telemedicine psychiatrists was fair regarding the safe disposition of ED patients with mental health complaints, with EPs tending toward more conservative assessments.

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.

Background: Geriatric screening and multidisciplinary assessment of older adults in the Emergency Department (ED) decrease hospitalizations and ED revisits. The impact on patient-reported outcomes of health-related quality of life (HRQoL) and functional status is not known.

Methods: A hybrid type II implementation/effectiveness prospective cohort study was conducted in an academic ED. The intervention bundle was geriatric screening for delirium, fall risk, and transition of care needs, and multidisciplinary assessment. All older adults (≥ 65 years) placed in the ED observation unit were eligible. HRQoL and functional status were obtained at the ED visit, 30, and 90 days, and were compared between the pre- and post-intervention implementation cohorts. Secondary outcomes included ED revisits, falls, mortality, and intervention adoption measures.

Results: From 2019 to 2023, 368 adults participated in the study: Most were community-dwelling (97%) and had multiple comorbidities. The pre (n = 138) and post (n = 230) cohorts did not differ in baseline functional status or HRQoL. The rate of geriatric screening improved from 12.3% in the pre-implementation cohort to 91.3% in the post-implementation cohort (p < 0.01). Multispecialty consultation also increased (68.1%-91.3%, p < 0.01). The proportion who had a post-ED visit decline in functional status did not differ between cohorts. Physical HRQoL declined similarly in both cohorts (-0.73 vs. -0.33, p = 0.61) at 90 days. Mental HRQoL improved in both cohorts; improvement was greater in the pre-cohort (2.35 vs. 0.32, p = 0.02). ED revisits and re-hospitalizations were unchanged (30 days: 23.0% vs. 17.2%, p = 0.18, and 90 days: 37.8% vs. 34.8%, p = 0.57). The intervention decreased falls at 30 and 90 days (30 days: 9.7% vs. 3.2%, p = 0.04; 90 days: 22.1% vs. 7.9%, p < 0.01).

Conclusions: Geriatric screening in the ED increased identification of geriatric syndromes and multidisciplinary consultation. The intervention was associated with decreased falls but did not affect HRQoL or reduce functional decline post ED visit.

Trial registration: clinicaltrials.gov: NCT04068311.

Study objective: Treatment strategies in severe hyponatremia aim at rapid sodium correction to prevent or treat cerebral edema but limit sodium rise to prevent osmotic demyelination syndrome (ODS). The true risk of edema or ODS in ED patients is unknown.

Methods: We performed a retrospective study of patients admitted to the ED of a tertiary hospital from January 2013 to December 2018 with plasma sodium ≤ 125 mmol/L. The rate of cerebral edema at presentation and the rate of ODS that developed during the stay were determined based on imaging studies and clinical evaluation. Secondary analyses looked at the association between overly rapid sodium correction (> 8 mmol/L) at 24 h, ODS risk, mortality, and length of stay.

Results: The primary analysis group comprised 852 patients; 318 (37%) of these presented with severe symptoms. Four patients (0.5%) with cerebral edema and 11 patients (1.3%) with ODS were detected. Alcoholism, liver disease, and malnutrition were identified as risk factors for ODS. While overly rapid correction showed no association with ODS in the primary analysis group, it became the predominant risk factor in a reduced dataset with a more accurate estimate of 24-h sodium correction. Correction rate had no impact on mortality or length of stay.

Conclusions: Given the low rate of cerebral edema even in severely symptomatic patients, aggressive treatment may not be necessary in most cases. The risk to develop ODS seems to be higher than the risk of brain edema. Since we found no beneficial impact of a liberal correction strategy, current treatment limits should stay in place.