Academic Emergency Medicine最新文献

Background: Older adults have high rates of falls after Emergency Department (ED) discharge; yet existing screening tools either underperform or are too difficult to deploy. This study aimed to evaluate a parsimonious predictive model for falls within 6 months post-ED discharge, utilizing both typical electronic health record (EHR) data and brief ED-based screenings.

Methods: In a prospective cohort study from September 2023 to May 2024, 412 community-dwelling adults aged ≥ 60 years who ambulate without assistance were enrolled during ED visits. Baseline data included EHR-derived variables (e.g., comorbidities, medication use) and ED screens (e.g., living situation, fall history). Participants were followed for 6 months to document fall occurrences. Multivariable LASSO logistic regression models to predict any fall were then constructed: Model 1 (EHR), Model 2 (ED screens), and Model 3 (combined). Model performance was evaluated using discrimination and calibration metrics, including area under the receiver operating characteristic (AUC) curves.

Results: Of the 356 participants with complete follow-up, 104 (29.2%) experienced at least one fall. Model 3 demonstrated superior predictive performance (AUC = 0.75) compared to Model 1 (AUC = 0.67) and Model 2 (AUC = 0.71). Significant predictors in the combined model included anemia (OR = 3.19), use of oral hypoglycemics (OR = 2.26), living with less than two other people (OR = 3.79), infrequently leaving home (OR = 1.97), and a history of ≥ 3 falls in the prior 6 months (OR = 12.11). A risk score made up of 9 items (6 EHR; 3 ED screen) categorizing participants as high risk (score 6-25) or low risk (score 0-5) resulted in sensitivity = 64%, specificity = 75%, positive likelihood ratio = 2.54, and negative likelihood ratio = 0.49.

Conclusions: Integrating EHR data with brief ED-based screenings enhances the prediction of fall risk among older adults post-ED discharge. The developed risk score effectively stratifies patients into low versus high risk, facilitating targeted prevention interventions. Further validation in independent cohorts is needed.

Background: The increasing prevalence of dementia poses significant challenges for emergency department (ED) care, as persons living with dementia (PLWD) more frequently experience adverse outcomes such as delirium, prolonged stays, and higher mortality rates. Despite advancements in care strategies, a critical gap remains in understanding how ED interventions impact outcomes in this vulnerable population. This systematic review aims to identify evidence-based ED care interventions tailored to PLWD to improve outcomes.

Methods: A systematic review was conducted in Ovid MEDLINE, Cochrane Library (Wiley), Scopus (Elsevier), and ProQuest Dissertations & Theses Global through September 2024. The review protocol was registered on PROSPERO (CRD42024586555). Eligible studies included randomized controlled trials, observational studies, and quality improvement initiatives focused on ED interventions for PLWD. Data extraction and quality assessment were performed independently by two reviewers, with disagreements resolved through discussion. Outcomes included patient satisfaction, ED revisits, functional decline, and mortality.

Results: From 3305 screened studies, six met the inclusion criteria. Interventions included nonpharmacologic therapies (e.g., music and light therapy), specialized geriatric ED units, and assessment tools, such as for pain. Tailored interventions including geriatric emergency units and community paramedic care transitions were effective in reducing 30-day ED revisits and hospitalizations. However, heterogeneity in study designs and outcomes precluded meta-analysis. Risk of bias ranged from low to moderate.

Conclusion: This review underscores the urgent need for standardized and evidence-based interventions in ED settings for PLWD. Approaches including multidisciplinary care models and nonpharmacologic therapies demonstrated potential for improving outcomes. Future research should prioritize consistent outcome measures, interdisciplinary collaboration, and person-centered care strategies to enhance the quality and equity of ED services for PLWD.

Objective: To evaluate the diagnostic accuracy of a novel point of care (POC) high-sensitivity troponin (hs-cTn) assay, used alone or incorporated within validated decision aids, for acute myocardial infarction (AMI) in the prehospital setting.

Methods: A pre-specified secondary analysis of the Prehospital Evaluation of Sensitive Troponin (PRESTO) prospective diagnostic accuracy study, conducted in four ambulance services and 12 Emergency Departments (EDs; February 2019-March 2020). Paramedics included consenting adults with suspected AMI and no other reason for conveyance. Clinical data and venous blood were collected at the scene, and samples conveyed to hospital with participants. Plasma samples were later analyzed for hs-cTn using a novel POC hs-cTn assay (Abbott Point of Care i-STAT hs-TnI). The target condition was an adjudicated index diagnosis of type 1 AMI.

Results: Of 817 consenting participants, 704 were eligible for inclusion in this analysis, with type 1 AMI occurring in 89 (12.6%). At the limit of detection (< 2 ng/L), POC hs-cTn had 100.0% sensitivity (95% CI 95 9%-100.0%) but only 4.6% specificity (95% CI 3.1%-6.5%). A Troponin-only Manchester Acute Coronary Syndromes (T-MACS) very-low risk outcome identified 134 (19.7%) patients for non-conveyance with 98.9% sensitivity (95% CI 94.9%-100.0%), 99.3% negative predictive value (NPV, 95% CI 95.0%-99.9%), and 22.5% specificity (95% CI 19.2%-26.1%). A low-risk modified HEART score identified 150 (22.0%) patients with 93.2% sensitivity (95% CI 85.8%-97.5%), 96.0% NPV (91.6%-98.1%), and 24.3% specificity (95% CI 20.9%-27.9%). In an exploratory analysis, hs-cTn < 5 ng/L identified 295 (41.9%) patients with 98.9% sensitivity (93.9%-100.0%), 99.7% NPV (97.7%-100.0%), and 47.8% specificity (95% CI 43.8%-51.8%).

Conclusions: This novel POC hs-cTn assay achieves high sensitivity and NPV when used alongside the T-MACS decision aid, but efficiency may be greater at a 5 ng/L threshold without requiring any decision aid.

Trial registration: ClinicalTrials.gov identifier: NCT03561051.