Academic Emergency Medicine最新文献

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.

Background: The population aged over 75 is the fastest growing demographic presenting to the emergency department (ED). Various ED models have been implemented to address the needs of older patients, including care coordination and dedicated care zones. We describe the impact of the Geriatric Emergency Department Innovation (GEDI) with the aim of evaluating the proportion of older patients not admitted to hospital. Secondary outcomes of interest were ED length of stay (EDLOS), rate of admission to the secondary (Repatriation) campus, short stay unit (SSU) utilization, and re-presentation rates.

Method: This single site study at a quaternary hospital with a main (Austin) campus and a secondary (Repatriation) campus employed interrupted time series analysis to assess the impact of GEDI while accounting for temporal trends.

Results: Before the introduction of GEDI, the rate of nonadmission of older patients to hospital was increasing by 0.1% per month (monthly change 1.001, 5% CI: 0.999, 1.002). After GEDI Implementation, this rate increased by 1.2% per month (1.012; 95% CI: 1.004, 1.020). The EDLOS increased by 0.08 (95% CI: 0.062, 0.099) hours per month prior to GEDI but then reduced by 0.207 (95% CI: -0.344, -0.069) hours per month afterwards. SSU utilization, re-presentations, and admissions to the Repatriation campus did not adversely change after GEDI introduction.

Conclusion: The introduction of GEDI reduced EDLOS and inpatient admissions in older patients. Further research on economic benefit, patient-related outcome, and experience measures are needed to further evaluate the success of this program.