Academic Emergency Medicine最新文献

Background: Antimicrobial resistance among Enterobacterales continues to be a growing problem, particularly in those with urinary infections. Previous studies have demonstrated safety and efficacy with the use of single-dose aminoglycosides in uncomplicated cystitis. However, data in complicated infections are limited. Single-dose aminoglycosides may provide a convenient alternative for those with or at risk for resistant pathogens causing complicated urinary infections, especially when oral options are unavailable due to resistance, allergy, intolerance, or interactions with other medications. This study evaluated the safety and effectiveness of single-dose aminoglycosides in treatment of complicated cystitis in the emergency department (ED).

Methods: This was a multicenter, prospective study performed between July 2022 and March 2023 of patients who met criteria for complicated cystitis and were otherwise stable for discharge at an academic ED. Primary outcomes were clinical or microbiologic failure within 14 days of treatment. Safety was assessed by review of adverse events. Descriptive statistics were used.

Results: Thirteen patients were included. Complicating factors were male sex (n = 4), kidney stone (n = 2), urinary catheter (n = 6), recent urologic procedure (n = 1), urinary hardware (n = 1), antibiotic allergy precluding use of alternate oral options (n = 4), immunocompromised status (n = 2), and <1-year history of multidrug-resistant organisms on urine culture (n = 8). Eleven patients (85%) had positive urine cultures in the preceding 12 months with no oral antimicrobial option. Eight patients (62%) received amikacin (median dose 15 mg/kg), four patients (31%) received gentamicin (median dose 5 mg/kg), and one patient (8%) received tobramycin (5 mg/kg) for treatment. Ten patients (77%) reported resolved urinary symptoms after treatment and 11 patients (85%) reported no new urinary symptoms since discharge. No patient required hospital admission for treatment failure, and no adverse events were noted.

Conclusions: Single-dose aminoglycosides appear to be a reasonably effective and safe treatment for complicated cystitis, which avoided hospital admission in this cohort.

Background: Cervical spine computed tomography (CSCT) scans are frequently performed in older emergency department (ED) trauma patients based on the 65-year-old high-risk criterion of the Canadian Cervical Spine Rule (CCR). We sought to determine the positivity rate of CSCT scans in symptomatic and asymptomatic patients to assess the current applicability of age in the CCR.

Methods: We reviewed CSCT ED reports from two institutional hospitals from 2018 to 2023. The primary variable was age; however, we also recorded fracture types and sites and type of treatments. Patients were separated into symptomatic and asymptomatic cohorts. We used a Fisher's exact test to compare variables between the asymptomatic and symptomatic groups and chi-square tests for comparison between age groups.

Results: Of 9455 CSCTs performed in patients ≥ 65 years, 192 (2.0%) fractures were identified (113 females); 28 (0.30%) were in asymptomatic patients. The rates of fractures (1.6%) and asymptomatic fractures (0.18%) were lowest in the 65- to 70-year age group. There were no distinguishing features as to the level or part of the vertebra fractured or surgical treatment rate between asymptomatic and symptomatic patients.

Conclusions: Cervical spine fractures in posttrauma patients ≥ 65 years are uncommon, with the lowest incidence in those 65 to 70 years old. Excluding asymptomatic individuals aged 65-70 from routine CSCT presents a minimal risk of missed fractures (0.18%). This prompts consideration for refining age-based screening and integrating shared decision making into the clinical protocol for this demographic, reflecting the low incidence of fractures and the changing health profile of the aging population.

Background: Precision health is a burgeoning scientific discipline that aims to incorporate individual variability in biological, behavioral, and social factors to develop personalized health solutions. To date, emergency medicine has not deeply engaged in the precision health movement. However, rapid advances in health technology, data science, and medical informatics offer new opportunities for emergency medicine to realize the promises of precision health.

Methods: In this article, we conceptualize precision emergency medicine as an emerging paradigm and identify key drivers of its implementation into current and future clinical practice. We acknowledge important obstacles to the specialty-wide adoption of precision emergency medicine and offer solutions that conceive a successful path forward.

Results: Precision emergency medicine is defined as the use of information and technology to deliver acute care effectively, efficiently, and authentically to individual patients and their communities. Key drivers and opportunities include leveraging human data, capitalizing on technology and digital tools, providing deliberate access to care, advancing population health, and reimagining provider education and roles. Overcoming challenges in equity, privacy, and cost is essential for success. We close with a call to action to proactively incorporate precision health into the clinical practice of emergency medicine, the training of future emergency physicians, and the research agenda of the specialty.

Conclusions: Precision emergency medicine leverages new technology and data-driven artificial intelligence to advance diagnostic testing, individualize patient care plans and therapeutics, and strategically refine the convergence of the health system and the community.

Objectives: The integrated practice unit (IPU) aims to improve care for patients with complex medical and social needs through care coordination, medication reconciliation, and connection to community resources. This study examined the effects of IPU enrollment on emergency department (ED) utilization and health care costs among frequent ED utilizers with complex needs.

Methods: We extracted electronic health records (EHR) data from patients in a large health care system who had at least four distinct ED visits within any 6-month period between March 1, 2018, and May 30, 2021. Interrupted time series (ITS) analyses were performed to evaluate the impact of IPU enrollment on monthly ED visits and health care costs. A control group was matched to IPU patients using a propensity score at a 3:1 ratio.

Results: We analyzed EHRs of 775 IPU patients with a control group of 2325 patients (mean [±SD] age 43.6 [±17]; 45.8% female; 50.9% White, 42.3% Black). In the single ITS analysis, IPU enrollment was associated with a decrease of 0.24 ED visits (p < 0.001) and a cost reduction of $466.37 (p = 0.040) in the first month, followed by decreases of 0.11 ED visits (p < 0.001) and $417.61 in costs (p < 0.001) each month over the subsequent year. Our main results showed that, compared to the matched control group, IPU patients experienced 0.20 more ED visits (p < 0.001) after their fourth ED visit within 6 months, offset by a reduction of 0.02 visits (p < 0.001) each month over the next year. No significant immediate or sustained increase in costs was observed for IPU-enrolled patients compared to the control group.

Conclusions: This quasi-experimental study of frequent ED utilizers demonstrated an initial increase in ED visits following IPU enrollment, followed by a reduction in ED utilization over subsequent 12 months without increasing costs, supporting IPU's effectiveness in managing patients with complex needs and limited access to care.

Traditionally, researchers have evaluated the quality of emergency care using subsequent adverse events, like mortality or return hospital visits. The selection of these well-defined, single events as outcomes for epidemiological studies has strengths, including ease of interpretation. Yet any particular outcome only captures part of the story of how patients fare after receiving care in the emergency department (ED).

For example, mortality is a clinically significant outcome. It fails, however, to capture quality of life decrements that may be important to patients and families.^{1, 2} Furthermore, its rarity necessitates prohibitively large sample sizes. By contrast, composite outcome measures such as major adverse cardiac events require less statistical power but assume that all component parts (e.g., death and hospitalization) are valued equally by patients.

Hospital-free days (HFD) offer a potential solution, naturally combining morbidity and mortality to create an easily calculated, patient-centered measure sensitive to high-quality emergency care. Essentially synonymous with days alive and out of hospital (DAOH), and similar in concept to other metrics including healthy days at home (HDAH), HFD is gaining acceptance in health services, epidemiological, and comparative effectiveness research.^{3, 4} However, these metrics have only recently been used in emergency medicine research.⁵ In this commentary, we outline the HFD approach, discuss unique considerations to using HFD to study emergency medicine outcomes, and propose development of standardized approaches for emergency medicine research.

Calculating HFDs

Unlike event counts such as mortality rates and revisit rates, the HFD approach aims to measure a conceptual construct of health health rather than illness. Like some longstanding measures, such as disability-adjusted life year, HFD begins with an idealized amount of “full health,” a quota from which illness and death are subtracted.

To calculate HFD, a time period after an anchor event (e.g., presentation to the ED or discharge from the ED or hospital) must be selected. For ED encounters, 30 days has often been used to measure mortality or readmissions after ED visits and may also represent an appropriate window to calculate HFD.^{6, 7} For outcomes expected to be highly responsive to ED treatment, a 9-day time window may be most appropriate.⁸ Depending on the specific research question and context, time frames of 60 or 90 days might also be appropriate.

Next, the number of days in which patients are neither alive nor hospitalized are then subtracted from the total days in the chosen time period. Importantly, there is no single definition for which types of services should be counted, highlighting the importance of transparent reporting of how HFD, HDAH, or DAOH are defined for