Academic Emergency Medicine最新文献

Objectives: The use of potentially inappropriate medications (PIMs) in older adults in the emergency department (ED) is associated with increased risk of readmissions and adverse drug reactions. We sought to assess the impact of electronic health record (EHR)-based geriatric clinical decision support (CDS) on adherence to geriatric recommendations for targeted PIMs prescribed to older adults while in the ED and at ED discharge.

Methods: We performed a multicenter pre-post implementation cohort study comparing adherence to geriatric recommendations before and after implementation of ED geriatric CDS for patients 65 years or older for a targeted list of 12 PIMs. ED geriatric CDS consisted of custom order panels with clinical guidance for preferred alternative agents or preferred geriatric dosing if providers opted to proceed with ordering a targeted PIM; CDS was implemented for both medications ordered during the ED visit as well as outpatient prescriptions ordered at discharge. The primary outcomes were the proportions of ED orders and discharge prescriptions adherent to ED geriatric CDS recommendations.

Results: A total of 6745 ED orders and 1440 discharge prescriptions were eligible for study inclusion. The proportion of targeted PIMs consistent with geriatric CDS recommendations was higher in the postimplementation group compared to preimplementation group for both ED orders (52% vs. 71%; difference 19%, 95% confidence interval [CI] 16.8%-21.3%) and discharge prescriptions (0.5% vs. 31.7%; difference 31.1%, 95% CI 27.5%-34.7%). In the postimplementation period, geriatric CDS order panel utilization for targeted PIMs was 62.1% for ED orders and 36.7% for discharge prescriptions. Among orders placed through ED geriatric CDS order panels, 90% of ED orders and 80.4% of discharge prescriptions were adherent to geriatric CDS recommendations.

Conclusions: EHR-based CDS for older adults in the ED increased the proportion of ED orders and discharge prescriptions adherent to geriatric drug therapy recommendations.

Objective: We sought to characterize patients presenting to emergency departments (EDs) with abdominal pain and to validate risk categories defined by the Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE-2) for low-risk recurrent abdominal pain.

Methods: We conducted a retrospective cohort study of patients presenting with abdominal pain between November 2019 and November 2023 across 21 EDs in Arizona, the Midwest, and Florida. Patients were categorized per GRACE-2 into recurrent and non-recurrent pain as well as low- and high-risk groups. Primary outcomes included 72-h returns and mortality at 30 and 90 days.

Results: The study included 162,494 visits (112,896 unique patients; median age 46 years; 61.2% female). Among these, 4.3% had low-risk recurrent abdominal pain. Patients with recurrent and non-recurrent low-risk pain had similar ED length of stay and discharge rates to each other, compared to patients with high-risk pain who had longer length of stay and lower discharge rates. At 30 days after the ED encounter, patients with low-risk recurrent abdominal pain had similar mortality to patients with low-risk non-recurrent pain (0.4% vs. 0.3%; adjusted RR = 1.31, 95% CI: 0.85-2.03), while they had significantly lower mortality than patients with high-risk recurrent abdominal pain (0.4% vs. 2.3; adjusted RR = 3.14, 95% CI: 2.02-4.89).

Conclusions: This study highlights the heterogeneity in patients presenting to the ED with abdominal pain. Among these patients, those with low-risk recurrent pain demonstrated similar lengths of stay, discharges, and mortality rates to those with low-risk non-recurrent pain and less favorable lengths of stay, discharges, and mortality rates compared to those with any high-risk features. These findings suggest that low- and high-risk features may be more useful than recurrent or non-recurrent pain in identifying patients who could benefit from more robust ED evaluations.