Academic Emergency Medicine最新文献

Objectives: Understanding how physicians make diagnoses is challenging because cognitive processes are unobservable and partly unconscious, making it difficult for physicians to describe how they arrived at a diagnosis. Physicians who work in emergency departments (EDs) are especially vulnerable to making diagnostic errors because the ED is a fast-paced, dynamic setting where complex decision-making occurs under severe time, information, and resource constraints. The purpose of our study was to describe how the diagnostic process evolves for ED clinicians in both pediatric and adult ED settings.

Methods: We used a qualitative, video ethnography study design to capture in situ, real-time ED physician practice for 11 participants from February 2022 to July 2023. Participants wore a head-mounted video camera while providing care to ED patients, and in subsequent stimulated recall interviews, revealed their thinking throughout the diagnostic process.

Results: We recorded 24.42 h of video overall (average 2.22 h per participant). We identified four major themes in the ED diagnostic process: (1) quality communication facilitates information flow, (2) cognition is complex and distributed across patients and the ED team, (3) artifacts can enhance the diagnostic process, and (4) there is a need to balance efficiency with safety and accuracy.

Conclusions: Illustrating physicians' cognitive processes through video ethnography coupled with stimulated recall interviews helped advance our understanding of the diagnostic process and is a foundational step for identifying improvement opportunities.

Background: Morbidity and mortality in cardiogenic pulmonary edema have been reduced by noninvasive positive-pressure airway maneuvers. The value of continuous positive airway pressure (CPAP) for the treatment of high-altitude pulmonary edema (HAPE) is uncertain. The purpose of this study was to evaluate the efficacy and speed of CPAP for HAPE resolution.

Methods: A prospective, investigator-initiated, multicenter, randomized, double-blind controlled trial of high-flow oxygen with CPAP versus sham CPAP with high-flow oxygen (oxygen-only group) was conducted. Sixty-four dyspneic adults with maximum oxygen saturation < 85%, recent arrival at high altitude, and noncardiogenic pulmonary edema on chest radiography were randomized to receive CPAP treatment plus usual care or usual care (oxygen-only) delivered through a sham CPAP mask. The primary endpoint was the clinical resolution of HAPE.

Results: HAPE resolution in the CPAP plus high FiO₂ group and the high flow oxygen alone group was similar. However, this finding should be interpreted cautiously due to this study being slightly underpowered. There was no significant difference in time to resolution (CPAP ~158 min vs. oxygen ~178 min, p = 0.297). Both therapies were effective, with a mean time to resolution of HAPE of approximately 2.5 to 3 h. No treatment-related adverse outcomes, intubations, or mortality were observed in either group.

Conclusion: Both CPAP with high-flow oxygen and high-flow oxygen alone are highly effective for the treatment of HAPE. CPAP conferred no improvement in the time to resolution of HAPE. High-flow oxygen therapy requires significantly less resource utilization for similar benefits in the treatment of HAPE.

Trial registration: ClinicalTrials.gov identifier: NCT04186598.

Objective: We quantified the magnitude of systolic blood pressure (SBP) adverse effects associated with intravenous furosemide (IVFu), compared to other factors, during treatment for acute decompensated heart failure (ADHF).

Methods: Continuous BP monitoring (598.2 person-hours, 91,210 observations) before and after IVFu was performed in a prospective multicenter ADHF cohort (n = 253). Multivariable-adjusted mixed effects regression was used to determine the amount of SBP reduction and the risk of hypotension attributable to IVFu administration, as opposed to confounders (e.g., non-IVFu treatments and baseline patient characteristics).

Results: Median SBP was 124 mmHg (IQR: 105-149) at baseline. Hypotension occurred in 5515 observations (6.0%). The multivariable models explained 79.6% and 58.1% of variance in SBP and risk of hypotension, respectively. Only 1.4% of variance in SBP and 1.7% of hypotension risk were related to IVFu, with the remainder accounted for by confounders. After multivariable adjustment, SBP dropped -11.9 mmHg on average after 80 mg IVFu, reaching a nadir at 147 min (-15.2 mmHg) and partial return to baseline by 6 h (-8.5 mmHg). IVFu-related risk of hypotension after multivariable adjustment depended predominantly on baseline SBP and dose. Risk of hypotension associated with 80 mg IVFu was ≤ 2% with baseline SBP ≥ 120 mmHg. For 40 mg, IVFu-associated hypotensive risk was ≤ 2% with SBPs of 90-100 mmHg, and < 1% with SBP ≥ 110 mmHg. IVFu-associated risk of hypotension returned to zero at 6 h after administration, regardless of dose.

Conclusions: Blood pressure reductions after IVFu during ADHF treatment are modest, and hypotension is rare and transient. Most variance in SBP during ADHF treatment is due to other factors.

Background: Patients with chronic pain frequently visit the emergency department (ED) due to accessibility of care, but the impact is underestimated. This study examines the prevalence and characteristics of patients who visited the ED for chronic pain at an urban safety-net hospital.

Methods: A systematic sampling strategy was used to survey adult ED patients between June and August 2024. We categorized participants who visited the ED as having (1) chronic pain, (2) acute pain, or (3) nonpain conditions. The study collected data on self-reported demographics and health access information, and hospital records on ED wait time, length of stay, insurance, and arrival time. Chi-square tests and regression models compared differences across groups.

Results: Of the 602 participants (64% Medicaid, 78% Hispanic/Latino), 18% visited the ED for chronic pain. This group of participants was more likely to report worse health status, visiting the ED as a usual place for care, despite being more likely to have seen a health care provider within a week before their ED visit. Furthermore, they had a longer ED length of stay and were more likely to arrive after business hours (4:30 pm) and perceive their ED visit as an emergency compared to those who visited the ED for acute pain and nonpain conditions. There is no difference in ED workup, specialty service involvement, and consultation.

Discussion: Chronic pain is highly prevalent in a safety-net ED patient population. Patients with chronic pain present to the ED because they feel the condition is emergent. The lack of different ED treatment strategies highlights that perhaps ED providers have a general approach to painful conditions regardless of chronicity. Health systems need to better assess the burden of chronic pain in the ED and develop programs to help manage such patients in an effective and efficient manner.

Objectives: We aimed to identify the most diagnostically challenging features in first-trimester point-of-care ultrasound (FT-POCUS) images. We also sought to determine the physician image review behaviors associated with increased diagnostic accuracy.

Methods: We conducted a multicenter prospective cross-sectional study in a convenience sample of emergency physicians in the United States and Canada. The web-based intervention included 400 FT-POCUS cases acquired via the transabdominal or transvaginal approach. Participants reviewed FT-POCUS cases to identify pregnancy-related imaging findings. We captured clickstream-level data with each case encounter, including the correctness of a participant's response and physician image review behaviors.

Results: We enrolled 317 participants, who collectively generated 16,295 case interpretations. The most diagnostically challenging imaging findings included eccentrically located gestational sac and endometrial collection/heterogeneous uterine material (p < 0.001 for all comparisons). Participants who reported "definite" certainty, as opposed to "probable," demonstrated a significantly higher odds of getting the diagnosis of intrauterine pregnancy (IUP) present or absent correct (OR = 4.48; 95% CI 4.00, 5.01) and a lower odds of time spent reviewing cases (OR = 0.46; 95% CI 0.40, 0.51). Those who reviewed a higher proportion of available views per case were more likely to accurately identify a fetal heartbeat (OR = 1.51; 95% 1.34, 1.69), multiple IUPs (OR = 1.33; 95% CI 1.10, 1.61), and adnexal structures (OR = 1.11; 95% CI 1.04, 1.17), but less likely to correctly identify an IUP (OR = 0.93; 95% CI 0.88, 0.99) and endometrial fluid collection/heterogeneous uterine material (OR = 0.96; 95% CI 0.92, 0.99).

Conclusions: Emergency physicians interpreting FT-POCUS images encountered specific diagnostic challenges that may increase risks to patient safety. We found that higher diagnostic confidence correlated with greater diagnostic accuracy and efficiency. Reviewing a larger proportion of available images improved diagnostic accuracy for some findings, but not for others.

Objective: To determine if the utilization of an Electronic Health Record-integrated clinical pathway increased the provision of recommended medical and forensic care to adult sexual assault survivors in the ED.

Methods: This was a retrospective chart review of 552 adult survivors of sexual assault who received care at a health care system in the Northeast between January 1, 2020, and December 31, 2022. Our six outcomes were the proportion of patients who were offered a consultation with a sexual assault advocate, the proportion of patients who had the sexual assault forensic evidence kit collected, pregnancy test ordered, emergency contraception ordered, HIV post-exposure prophylaxis ordered, and sexually transmitted infection prophylaxis ordered. Primary analysis compared the impact of the pathway on outcomes before and after the implementation. Secondary analysis included the impact on outcomes of pathway use compared to non-pathway use after implementation.

Results: The pathway was used in 128 (51%) patient encounters after it was implemented. Offering consultation with a sexual assault advocate and ordering HIV post-exposure prophylaxis improved post-implementation compared to pre-implementation. In the post-implementation period, there was an improvement in recommended medical and forensic care across all outcomes, including offering an advocate, collecting forensic evidence, ordering STI prophylaxis, HIV PEP, pregnancy tests, and emergency contraception. Patients were less likely to have a SAFE kit collected if the pathway was not used compared to pre-implementation.

Conclusions: Pathway usage led to improved medical and forensic care of sexual assault survivors. Implementation of Electronic Health Record-integrated clinical pathways requires active use of the pathway rather than indirect learning from the presence of the pathway.