Pub Date : 2025-01-22DOI: 10.1016/j.annemergmed.2024.12.016
Julian M Williams, Jaimi H Greenslade, Angela Z Hills, Mercedes T Ray
Study objectives: Concentrated albumin early in sepsis resuscitation remains largely unexplored. Objectives were to determine 1) feasibility of early intervention with concentrated albumin in emergency department (ED) patients with suspected infection and hypoperfusion and 2) whether early albumin therapy improves outcomes.
Methods: ED patients with suspected infection and hypoperfusion (systolic blood pressure [SBP]<90 mmHg or lactate ≥4.0 mmol/L) were randomized to receive either 400 mL 20% albumin over 4 hours or no albumin. All patients were treated with crystalloids, antibiotics, and other therapies at the treating team's discretion. Primary outcome was SBP at 24 hours; secondary outcomes included SBP at 6 hours, fluid and organ support requirements, organ dysfunction, and mortality. Quantile and logistic regressions were used to calculate differences (and 95% CI) between study groups.
Results: Compliance with study protocol was more than 95%, and infection was confirmed in 95% of the 464 study patients enrolled. SBP at 24 hours did not differ between intervention (110.5 mmHg) and standard care arms (110 mmHg). In patients treated with albumin, SBP was higher at 6 hours, less total fluid was infused at 72 hours, fewer patients required vasopressor therapy at 24 and 72 hours, and organ function was improved. Mortality was not significantly different.
Conclusions: Early identification, trial enrollment, and intervention in ED patients with sepsis is feasible. In this pilot study, concentrated albumin given early in resuscitation did not improve SBP at 24 hours. Albumin was associated with less total fluid and vasopressor requirements and improved organ dysfunction. A multicenter study is indicated.
{"title":"Intervention With Concentrated Albumin for Undifferentiated Sepsis in the Emergency Department (ICARUS-ED): A Pilot Randomized Controlled Trial.","authors":"Julian M Williams, Jaimi H Greenslade, Angela Z Hills, Mercedes T Ray","doi":"10.1016/j.annemergmed.2024.12.016","DOIUrl":"https://doi.org/10.1016/j.annemergmed.2024.12.016","url":null,"abstract":"<p><strong>Study objectives: </strong>Concentrated albumin early in sepsis resuscitation remains largely unexplored. Objectives were to determine 1) feasibility of early intervention with concentrated albumin in emergency department (ED) patients with suspected infection and hypoperfusion and 2) whether early albumin therapy improves outcomes.</p><p><strong>Methods: </strong>ED patients with suspected infection and hypoperfusion (systolic blood pressure [SBP]<90 mmHg or lactate ≥4.0 mmol/L) were randomized to receive either 400 mL 20% albumin over 4 hours or no albumin. All patients were treated with crystalloids, antibiotics, and other therapies at the treating team's discretion. Primary outcome was SBP at 24 hours; secondary outcomes included SBP at 6 hours, fluid and organ support requirements, organ dysfunction, and mortality. Quantile and logistic regressions were used to calculate differences (and 95% CI) between study groups.</p><p><strong>Results: </strong>Compliance with study protocol was more than 95%, and infection was confirmed in 95% of the 464 study patients enrolled. SBP at 24 hours did not differ between intervention (110.5 mmHg) and standard care arms (110 mmHg). In patients treated with albumin, SBP was higher at 6 hours, less total fluid was infused at 72 hours, fewer patients required vasopressor therapy at 24 and 72 hours, and organ function was improved. Mortality was not significantly different.</p><p><strong>Conclusions: </strong>Early identification, trial enrollment, and intervention in ED patients with sepsis is feasible. In this pilot study, concentrated albumin given early in resuscitation did not improve SBP at 24 hours. Albumin was associated with less total fluid and vasopressor requirements and improved organ dysfunction. A multicenter study is indicated.</p>","PeriodicalId":8236,"journal":{"name":"Annals of emergency medicine","volume":" ","pages":""},"PeriodicalIF":5.0,"publicationDate":"2025-01-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143021931","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-01-18DOI: 10.1016/j.annemergmed.2024.12.011
Lois K Lee,Fahd A Ahmad
{"title":"FASTER-But Not Fast Enough: Bridging the Gap Between Data Collection and Injury Prevention in Firearm Injury Surveillance.","authors":"Lois K Lee,Fahd A Ahmad","doi":"10.1016/j.annemergmed.2024.12.011","DOIUrl":"https://doi.org/10.1016/j.annemergmed.2024.12.011","url":null,"abstract":"","PeriodicalId":8236,"journal":{"name":"Annals of emergency medicine","volume":"74 1","pages":""},"PeriodicalIF":6.2,"publicationDate":"2025-01-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142991721","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-01-18DOI: 10.1016/j.annemergmed.2024.11.020
Diane Kuhn,Peter S Pang,Olena Mazurenko,Nancy K Glober,Thomas A Lardaro,Xiaochun Li,Christopher A Harle,Paul I Musey
STUDY OBJECTIVEPatient experience is an essential measure of patient-centered emergency care. However, emergency department (ED) patient experience scores may be influenced by patient demographics as well as clinical and operational characteristics unrelated to actual patient-centeredness of care. This study aimed to determine whether there are characteristics associated with patient experience scores that have not yet been proposed for risk adjustment by the Centers for Medicare and Medicaid Services (CMS).METHODSThis is a cross-sectional study of patient visits for 13 EDs across a regional health system from January 1, 2022, to December 31, 2023. We used a multivariable mixed-effects regression with physician-site random effects to examine the relationship between patient, clinical, and operational characteristics and ED patient experience scores. The dependent variable was a patient's likelihood to recommend rating (0-10 scale), treated as a continuous variable. The independent variables included patient (age, race, gender, ethnicity, interpreter need, and payer type), clinical (radiology and laboratory studies, opioid administration, patient acuity, and initial pain score), and operational characteristics (door-to-doc times, hallway bed placement, and National Emergency Department Overcrowding Scale [NEDOCS] level).RESULTSA total of 58,622 unique patient visits were included in the analysis. The patient experience survey response rate was 7.1% of discharged ED patients during the study period. Black or African American patients, those with Medicaid insurance, and adults aged younger than 40 years were underrepresented relative to the expected proportions based on population data. Several clinical and operational characteristics were significantly associated with experience ratings, including hallway bed placement (-0.38 [95% confidence interval, -0.53 to -0.23]), receiving radiology studies (0.27 [0.20 to 0.35]), initial pain scores (-0.08 [-0.09 to -0.06]), and NEDOCS level.CONCLUSIONWe found several clinical and operational characteristics associated with patient experience scores, which CMS does not currently use for risk adjustment. Our findings raise concerns that there are elements of care associated with patients' overall experience ratings which have an unclear relationship with patient-centered constructs such as communication and coordination of care.
{"title":"Use of Hallway Beds, Radiology Studies, and Patients in Pain on Arrival to the Emergency Department Are Associated With Patient Experience.","authors":"Diane Kuhn,Peter S Pang,Olena Mazurenko,Nancy K Glober,Thomas A Lardaro,Xiaochun Li,Christopher A Harle,Paul I Musey","doi":"10.1016/j.annemergmed.2024.11.020","DOIUrl":"https://doi.org/10.1016/j.annemergmed.2024.11.020","url":null,"abstract":"STUDY OBJECTIVEPatient experience is an essential measure of patient-centered emergency care. However, emergency department (ED) patient experience scores may be influenced by patient demographics as well as clinical and operational characteristics unrelated to actual patient-centeredness of care. This study aimed to determine whether there are characteristics associated with patient experience scores that have not yet been proposed for risk adjustment by the Centers for Medicare and Medicaid Services (CMS).METHODSThis is a cross-sectional study of patient visits for 13 EDs across a regional health system from January 1, 2022, to December 31, 2023. We used a multivariable mixed-effects regression with physician-site random effects to examine the relationship between patient, clinical, and operational characteristics and ED patient experience scores. The dependent variable was a patient's likelihood to recommend rating (0-10 scale), treated as a continuous variable. The independent variables included patient (age, race, gender, ethnicity, interpreter need, and payer type), clinical (radiology and laboratory studies, opioid administration, patient acuity, and initial pain score), and operational characteristics (door-to-doc times, hallway bed placement, and National Emergency Department Overcrowding Scale [NEDOCS] level).RESULTSA total of 58,622 unique patient visits were included in the analysis. The patient experience survey response rate was 7.1% of discharged ED patients during the study period. Black or African American patients, those with Medicaid insurance, and adults aged younger than 40 years were underrepresented relative to the expected proportions based on population data. Several clinical and operational characteristics were significantly associated with experience ratings, including hallway bed placement (-0.38 [95% confidence interval, -0.53 to -0.23]), receiving radiology studies (0.27 [0.20 to 0.35]), initial pain scores (-0.08 [-0.09 to -0.06]), and NEDOCS level.CONCLUSIONWe found several clinical and operational characteristics associated with patient experience scores, which CMS does not currently use for risk adjustment. Our findings raise concerns that there are elements of care associated with patients' overall experience ratings which have an unclear relationship with patient-centered constructs such as communication and coordination of care.","PeriodicalId":8236,"journal":{"name":"Annals of emergency medicine","volume":"32 1","pages":""},"PeriodicalIF":6.2,"publicationDate":"2025-01-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142991723","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-01-17DOI: 10.1016/j.annemergmed.2024.12.002
Megan A Rech,Christopher R Carpenter,Neelum T Aggarwal,Ula Hwang
Alzheimer's disease is the neurodegenerative disorder responsible for approximately 60% to 70% of all cases of dementia and is expected to affect 152 million by 2050. Recently, anti-amyloid therapies have been developed and approved by the Food and Drug Administration as disease-modifying treatments given as infusions every 2 to 5 weeks for Alzheimer's disease. Although this is an important milestone in mitigating Alzheimer's disease progression, it is critical for emergency medicine clinicians to understand what anti-amyloid therapies are and how they work to recognize, treat, and mitigate their adverse effects. Anti-amyloid therapies may be underrecognized contributors to emergency department visits because they carry the risk of adverse effects, namely amyloid-related imaging abnormalities. Amyloid-related imaging abnormalities are observed as abnormalities on magnetic resonance imaging as computed tomography is not sensitive enough to detect the microvasculature abnormalities causing vasogenic edema (amyloid-related imaging abnormalities-E) microhemorrhages and hemosiderin deposits (amyloid-related imaging abnormalities-H). Patients presenting with amyloid-related imaging abnormalities may have nonspecific neurologic symptoms, including headache, lethargy, confusion, and seizures. Anti-amyloid therapies may increase risk of hemorrhagic conversion of ischemic stroke patients receiving thrombolytics and complicate the initiation of anticoagulation. Given the novelty of anti-amyloid therapies and limited real-world data pertaining to amyloid-related imaging abnormalities, it is important for emergency medicine clinicians to be aware of these agents.
{"title":"Anti-Amyloid Therapies for Alzheimer's Disease and Amyloid-Related Imaging Abnormalities: Implications for the Emergency Medicine Clinician.","authors":"Megan A Rech,Christopher R Carpenter,Neelum T Aggarwal,Ula Hwang","doi":"10.1016/j.annemergmed.2024.12.002","DOIUrl":"https://doi.org/10.1016/j.annemergmed.2024.12.002","url":null,"abstract":"Alzheimer's disease is the neurodegenerative disorder responsible for approximately 60% to 70% of all cases of dementia and is expected to affect 152 million by 2050. Recently, anti-amyloid therapies have been developed and approved by the Food and Drug Administration as disease-modifying treatments given as infusions every 2 to 5 weeks for Alzheimer's disease. Although this is an important milestone in mitigating Alzheimer's disease progression, it is critical for emergency medicine clinicians to understand what anti-amyloid therapies are and how they work to recognize, treat, and mitigate their adverse effects. Anti-amyloid therapies may be underrecognized contributors to emergency department visits because they carry the risk of adverse effects, namely amyloid-related imaging abnormalities. Amyloid-related imaging abnormalities are observed as abnormalities on magnetic resonance imaging as computed tomography is not sensitive enough to detect the microvasculature abnormalities causing vasogenic edema (amyloid-related imaging abnormalities-E) microhemorrhages and hemosiderin deposits (amyloid-related imaging abnormalities-H). Patients presenting with amyloid-related imaging abnormalities may have nonspecific neurologic symptoms, including headache, lethargy, confusion, and seizures. Anti-amyloid therapies may increase risk of hemorrhagic conversion of ischemic stroke patients receiving thrombolytics and complicate the initiation of anticoagulation. Given the novelty of anti-amyloid therapies and limited real-world data pertaining to amyloid-related imaging abnormalities, it is important for emergency medicine clinicians to be aware of these agents.","PeriodicalId":8236,"journal":{"name":"Annals of emergency medicine","volume":"23 1","pages":""},"PeriodicalIF":6.2,"publicationDate":"2025-01-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142988613","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
STUDY OBJECTIVENon-physician practitioners, including nurse practitioners and physician assistants, increasingly practice in emergency departments, especially in rural areas, where they help mitigate physician shortages. However, little is known about non-physician practitioner durability and demographic trends in emergency departments. Our objective was to examine attrition rates and ages among non-physician practitioners in emergency medicine.METHODSWe conducted a repeated cross-sectional analysis using the Medicare Data on Provider Practice and Specialty and Medicare Provider Utilization and Payment Data. The study included non-physician practitioners providing at least 25 independent evaluation and management services annually for Medicare beneficiaries between 2014 and 2021. Attrition rates, defined as the absence of emergency medicine clinical services in subsequent years, were stratified by gender, clinician type, and practice urbanicity.RESULTSThe emergency medicine non-physician practitioner workforce grew from 14,559 to 17,679 between 2014 and 2021. Women non-physician practitioners comprised 64.6% of the workforce, and rural non-physician practitioners accounted for 15.7%. Across study years, the weighted annual attrition rate was 13.8%, rising from 12.1% in 2014 to 17.6% in 2019. Attrition rates were higher among physician assistants as well as women and rural non-physician practitioners, with median ages at attrition of 40.2 years for women and 45.9 years for men, and 38.6 years for urban non-physician practitioners versus 43.6 years for rural non-physician practitioners.CONCLUSIONThe rate of non-physician practitioner attrition from the emergency medicine workforce is considerably higher and occurs at younger ages than prior work evaluating emergency physician attrition, with similar identified gender and geographic disparities. Targeted retention strategies are needed to support a more durable emergency medicine workforce and reduce disparities.
{"title":"Workforce Attrition Among Emergency Medicine Non-Physician Practitioners.","authors":"Cameron J Gettel,Rohini Ghosh,Craig Rothenberg,Thomas Balga,Sharon Chekijian,Stephanie Colella,Pooja Agrawal,Michael Holmes,Arjun K Venkatesh","doi":"10.1016/j.annemergmed.2024.12.013","DOIUrl":"https://doi.org/10.1016/j.annemergmed.2024.12.013","url":null,"abstract":"STUDY OBJECTIVENon-physician practitioners, including nurse practitioners and physician assistants, increasingly practice in emergency departments, especially in rural areas, where they help mitigate physician shortages. However, little is known about non-physician practitioner durability and demographic trends in emergency departments. Our objective was to examine attrition rates and ages among non-physician practitioners in emergency medicine.METHODSWe conducted a repeated cross-sectional analysis using the Medicare Data on Provider Practice and Specialty and Medicare Provider Utilization and Payment Data. The study included non-physician practitioners providing at least 25 independent evaluation and management services annually for Medicare beneficiaries between 2014 and 2021. Attrition rates, defined as the absence of emergency medicine clinical services in subsequent years, were stratified by gender, clinician type, and practice urbanicity.RESULTSThe emergency medicine non-physician practitioner workforce grew from 14,559 to 17,679 between 2014 and 2021. Women non-physician practitioners comprised 64.6% of the workforce, and rural non-physician practitioners accounted for 15.7%. Across study years, the weighted annual attrition rate was 13.8%, rising from 12.1% in 2014 to 17.6% in 2019. Attrition rates were higher among physician assistants as well as women and rural non-physician practitioners, with median ages at attrition of 40.2 years for women and 45.9 years for men, and 38.6 years for urban non-physician practitioners versus 43.6 years for rural non-physician practitioners.CONCLUSIONThe rate of non-physician practitioner attrition from the emergency medicine workforce is considerably higher and occurs at younger ages than prior work evaluating emergency physician attrition, with similar identified gender and geographic disparities. Targeted retention strategies are needed to support a more durable emergency medicine workforce and reduce disparities.","PeriodicalId":8236,"journal":{"name":"Annals of emergency medicine","volume":"25 1","pages":""},"PeriodicalIF":6.2,"publicationDate":"2025-01-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142988611","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-01-17DOI: 10.1016/j.annemergmed.2024.11.019
Fabrizio Ricci,Chiara Martini,Davide Maria Scordo,Davide Rossi,Sabina Gallina,Artur Fedorowski,Luigi Sciarra,C Anwar A Chahal,H Pendell Meyers,Robert Herman,Stephen W Smith
The traditional management of acute coronary syndrome has relied on the identification of ST-segment elevation myocardial infarction (STEMI) as a proxy of acute coronary occlusion. This conflation of STEMI with acute coronary occlusion has historically overshadowed non-ST-segment elevation myocardial infarction (NSTEMI), despite evidence suggesting 25% to 34% of NSTEMI cases may also include acute coronary occlusion. Current limitations in the STEMI/NSTEMI binary framework underscore the need for a revised approach to chest pain and acute coronary syndrome management. The emerging paradigm distinguishing occlusion myocardial infarction from nonocclusion myocardial infarction (NOMI) seeks to enhance diagnostic accuracy and prognostic effect in acute coronary syndrome care. This approach not only emphasizes the urgency of reperfusion therapy for high-risk ECG patterns not covered by current STEMI criteria, but also emphasizes the broader transition from viewing acute coronary syndrome as a disease defined by the ECG to a disease defined by its underlying pathology, for which the ECG is an important but insufficient surrogate test. This report outlines the emerging occlusion myocardial infarction paradigm, detailing specific ECG patterns linked to acute coronary occlusion, and proposes a new framework that could enhance triage accuracy and treatment strategies for acute coronary syndrome. Although further validation is required, the occlusion myocardial infarction pathway holds promise for earlier acute coronary occlusion detection, timely cath lab activation, and improved myocardial salvage-offering potentially significant implications for both clinical practice and future research in acute coronary syndrome management.
{"title":"ECG Patterns of Occlusion Myocardial Infarction: A Narrative Review.","authors":"Fabrizio Ricci,Chiara Martini,Davide Maria Scordo,Davide Rossi,Sabina Gallina,Artur Fedorowski,Luigi Sciarra,C Anwar A Chahal,H Pendell Meyers,Robert Herman,Stephen W Smith","doi":"10.1016/j.annemergmed.2024.11.019","DOIUrl":"https://doi.org/10.1016/j.annemergmed.2024.11.019","url":null,"abstract":"The traditional management of acute coronary syndrome has relied on the identification of ST-segment elevation myocardial infarction (STEMI) as a proxy of acute coronary occlusion. This conflation of STEMI with acute coronary occlusion has historically overshadowed non-ST-segment elevation myocardial infarction (NSTEMI), despite evidence suggesting 25% to 34% of NSTEMI cases may also include acute coronary occlusion. Current limitations in the STEMI/NSTEMI binary framework underscore the need for a revised approach to chest pain and acute coronary syndrome management. The emerging paradigm distinguishing occlusion myocardial infarction from nonocclusion myocardial infarction (NOMI) seeks to enhance diagnostic accuracy and prognostic effect in acute coronary syndrome care. This approach not only emphasizes the urgency of reperfusion therapy for high-risk ECG patterns not covered by current STEMI criteria, but also emphasizes the broader transition from viewing acute coronary syndrome as a disease defined by the ECG to a disease defined by its underlying pathology, for which the ECG is an important but insufficient surrogate test. This report outlines the emerging occlusion myocardial infarction paradigm, detailing specific ECG patterns linked to acute coronary occlusion, and proposes a new framework that could enhance triage accuracy and treatment strategies for acute coronary syndrome. Although further validation is required, the occlusion myocardial infarction pathway holds promise for earlier acute coronary occlusion detection, timely cath lab activation, and improved myocardial salvage-offering potentially significant implications for both clinical practice and future research in acute coronary syndrome management.","PeriodicalId":8236,"journal":{"name":"Annals of emergency medicine","volume":"6 1","pages":""},"PeriodicalIF":6.2,"publicationDate":"2025-01-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142988612","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
STUDY OBJECTIVEExtracorporeal cardiopulmonary resuscitation (eCPR) is a rescue therapy for selected patients when conventional cardiopulmonary resuscitation (CPR) fails. Current evidence suggests that the success of eCPR depends on well-structured in- and out-of-hospital protocols. This article describes the Vienna eCPR program, and the interventions implemented to improve clinical processes and patient outcomes.METHODSIn this retrospective study, we report on all patients with inhospital and out-of-hospital cardiac arrest treated with eCPR at our department between 2020 and 2023. During this period, the program was restructured, including the introduction of out-of-hospital and inhospital algorithms and interprofessional training. The primary endpoint was survival with favorable neurologic outcomes at 6 months, defined as a cerebral performance category score of 1 or 2.RESULTSOverall, 192 patients were treated with eCPR. The proportion of patients with favorable neurologic outcomes was 25% (n=48), increasing each year: 15% (5/34) in 2020, 19% (8/42) in 2021, 23% (12/53) in 2022, and 37% (23/63) in 2023. This was particularly true for out-of-hospital cardiac arrest patients: 7% (2/29), 14% (4/29), 17% (7/41), and 32% (16/50), respectively. Simultaneously, rates of witnessed arrest, bystander CPR, and initial shockable rhythm increased, whereas low-flow durations decreased.CONCLUSIONAfter restructuring the Vienna eCPR program, we were able to improve survival rates with favorable neurologic outcomes after eCPR. This improvement was accompanied with increased case volumes, rates of witnessed arrest, bystander CPR, and initial shockable rhythm, and decreased low-flow durations. The learning curve we observed illustrates that outcomes can improve with experience, a summation effect of training, patient selection, and process standardization.
{"title":"Extracorporeal Cardiopulmonary Resuscitation: Outcomes Improve With Center Experience.","authors":"Ingrid Magnet,Wilhelm Behringer,Felix Eibensteiner,Florian Ettl,Jürgen Grafeneder,Gottfried Heinz,Michael Holzer,Mario Krammel,Elisabeth Lobmeyr,Heidrun Losert,Matthias Müller,Alexander Nürnberger,Julia Riebandt,Christoph Schriefl,Thomas Staudinger,Alexandra-Maria Stommel,Christoph Testori,Christian Zauner,Andrea Zeiner-Schatzl,Michael Poppe","doi":"10.1016/j.annemergmed.2024.12.004","DOIUrl":"https://doi.org/10.1016/j.annemergmed.2024.12.004","url":null,"abstract":"STUDY OBJECTIVEExtracorporeal cardiopulmonary resuscitation (eCPR) is a rescue therapy for selected patients when conventional cardiopulmonary resuscitation (CPR) fails. Current evidence suggests that the success of eCPR depends on well-structured in- and out-of-hospital protocols. This article describes the Vienna eCPR program, and the interventions implemented to improve clinical processes and patient outcomes.METHODSIn this retrospective study, we report on all patients with inhospital and out-of-hospital cardiac arrest treated with eCPR at our department between 2020 and 2023. During this period, the program was restructured, including the introduction of out-of-hospital and inhospital algorithms and interprofessional training. The primary endpoint was survival with favorable neurologic outcomes at 6 months, defined as a cerebral performance category score of 1 or 2.RESULTSOverall, 192 patients were treated with eCPR. The proportion of patients with favorable neurologic outcomes was 25% (n=48), increasing each year: 15% (5/34) in 2020, 19% (8/42) in 2021, 23% (12/53) in 2022, and 37% (23/63) in 2023. This was particularly true for out-of-hospital cardiac arrest patients: 7% (2/29), 14% (4/29), 17% (7/41), and 32% (16/50), respectively. Simultaneously, rates of witnessed arrest, bystander CPR, and initial shockable rhythm increased, whereas low-flow durations decreased.CONCLUSIONAfter restructuring the Vienna eCPR program, we were able to improve survival rates with favorable neurologic outcomes after eCPR. This improvement was accompanied with increased case volumes, rates of witnessed arrest, bystander CPR, and initial shockable rhythm, and decreased low-flow durations. The learning curve we observed illustrates that outcomes can improve with experience, a summation effect of training, patient selection, and process standardization.","PeriodicalId":8236,"journal":{"name":"Annals of emergency medicine","volume":"22 1","pages":""},"PeriodicalIF":6.2,"publicationDate":"2025-01-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142991724","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-01-14DOI: 10.1016/j.annemergmed.2024.12.003
K Noelle Tune,Kori S Zachrison,Jesse M Pines,Hui Zheng,Emily M Hayden
STUDY OBJECTIVEWe use national emergency department (ED) data to identify the proportion of "telehealth-able" ED visits, defined as potentially conductible by Video Only or Video Plus (with limited outpatient testing).METHODSWe used ED visits by patients 4 years of age and older from the 2019 National Hospital Ambulatory Medical Care Survey and applied survey weighting for national representativeness. Two raters categorized patient-described Reasons for Visit (RFV) as telehealth-able (yes, no, uncertain) for both Video Only and Video Plus visits. This categorization was stratified by age (4 to 17 years old, 18 to 35, 36 to 64, and 65 and older). Visit characteristics that were used to remove further nontelehealth-able visits included admission, procedures, diagnostic testing, acuity level, and pain score.RESULTSOur sample included 133.6 million United States ED visits in 2019 for patients aged 4 years or older. Of those, between 3.4% and 8.8% of visits were telehealth-able by Video Only and between 5.0% and 9.7% by Video Plus, considering only the first RFV. Visits by younger patients were more often telehealth-able, with the proportion of telehealth-able visits decreasing with advancing age. Considering all RFVs, between 0% to 6.6% of ED visits were telehealth-able with Video Only and 0.02% to 7.6% with Video Plus.CONCLUSIONBetween 3% and 10% of United States ED visits may be potentially telehealth-able for patients aged 4 years and older, considering the first listed RFV and ED visit characteristics. Fewer visits may be telehealth-able when all reasons for visits are considered.
{"title":"Estimating the Proportion of Telehealth-Able United States Emergency Department Visits.","authors":"K Noelle Tune,Kori S Zachrison,Jesse M Pines,Hui Zheng,Emily M Hayden","doi":"10.1016/j.annemergmed.2024.12.003","DOIUrl":"https://doi.org/10.1016/j.annemergmed.2024.12.003","url":null,"abstract":"STUDY OBJECTIVEWe use national emergency department (ED) data to identify the proportion of \"telehealth-able\" ED visits, defined as potentially conductible by Video Only or Video Plus (with limited outpatient testing).METHODSWe used ED visits by patients 4 years of age and older from the 2019 National Hospital Ambulatory Medical Care Survey and applied survey weighting for national representativeness. Two raters categorized patient-described Reasons for Visit (RFV) as telehealth-able (yes, no, uncertain) for both Video Only and Video Plus visits. This categorization was stratified by age (4 to 17 years old, 18 to 35, 36 to 64, and 65 and older). Visit characteristics that were used to remove further nontelehealth-able visits included admission, procedures, diagnostic testing, acuity level, and pain score.RESULTSOur sample included 133.6 million United States ED visits in 2019 for patients aged 4 years or older. Of those, between 3.4% and 8.8% of visits were telehealth-able by Video Only and between 5.0% and 9.7% by Video Plus, considering only the first RFV. Visits by younger patients were more often telehealth-able, with the proportion of telehealth-able visits decreasing with advancing age. Considering all RFVs, between 0% to 6.6% of ED visits were telehealth-able with Video Only and 0.02% to 7.6% with Video Plus.CONCLUSIONBetween 3% and 10% of United States ED visits may be potentially telehealth-able for patients aged 4 years and older, considering the first listed RFV and ED visit characteristics. Fewer visits may be telehealth-able when all reasons for visits are considered.","PeriodicalId":8236,"journal":{"name":"Annals of emergency medicine","volume":"55 1","pages":""},"PeriodicalIF":6.2,"publicationDate":"2025-01-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142988667","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-01-10DOI: 10.1016/j.annemergmed.2024.11.021
Jonathan Kei, Travis Eurick, Tom A Hauck
Study objective: This study analyzes emergency medicine airway management trends and outcomes among community emergency departments.
Methods: A multicenter, retrospective chart review was conducted on 11,475 intubations from 15 different community emergency departments between January 1, 2015, and December 31, 2022. Data collected included patient's age, sex, rapid sequence intubation medications, use of cricoid pressure, method of intubation, number of attempts, admission diagnosis, and all-cause mortality rates.
Results: Active cardiopulmonary resuscitation occurred in 11.4% of intubations. When rapid sequence intubation was employed, the most frequently used induction agents were etomidate (91.6%), propofol (4.3%), and ketamine (4.1%). From 2015 to 2022, the use of rocuronium (versus succinylcholine) increased from 33.9% to 61.9%, a difference of 28% (95% confidence interval [CI] 21.1% to 34.9%). During the same period, video laryngoscopy (versus direct laryngoscopy) increased from 27.4% to 77.7%, a difference of 50.3% (95% CI 44.2% to 56.4%). Only 46% of intubations used cricoid pressure. Physicians had a first-pass success rate of 80.5% and a failure rate of 0.2%. The most common documented admission diagnoses among intubated patients were respiratory etiologies (27.8%), neurologic causes (21.4%), and sepsis (16.0%). All-cause mortality rates were high for intubated patients at 24 hours (19.7%), 7 days (29.4%), 30 days (38.4%), and 1 year (45.4%).
Conclusion: Physicians intubating in community emergency departments have similar rates of first-pass success and failure seen in academic Level-1 trauma centers despite treating medically sick patients with high all-cause mortality rates. Dramatic shifts in choice of paralytic and method for intubation were seen.
研究目的：分析社区急诊科急诊医学气道管理趋势及结果。方法：对2015年1月1日至2022年12月31日期间来自15个不同社区急诊科的11475例插管进行多中心回顾性图表分析。收集的数据包括患者的年龄、性别、快速序贯插管药物、环状压迫的使用、插管方法、尝试次数、入院诊断和全因死亡率。结果：主动心肺复苏率为11.4%。采用快速序贯插管时，最常用的诱导药物是依托咪酯（91.6%）、异丙酚（4.3%）和氯胺酮（4.1%）。从2015年到2022年，罗库溴铵（相对于琥珀胆碱）的使用率从33.9%增加到61.9%，差异为28%（95%置信区间[CI] 21.1%至34.9%）。在同一时期，视频喉镜检查（与直接喉镜检查相比）从27.4%增加到77.7%，差异为50.3% （95% CI 44.2%至56.4%）。只有46%的插管使用环状压力。医生的一次通过率为80.5%，不良率为0.2%。在插管患者中最常见的入院诊断是呼吸系统病因（27.8%）、神经系统原因（21.4%）和败血症（16.0%）。插管患者的全因死亡率在24小时（19.7%）、7天（29.4%）、30天（38.4%）和1年（45.4%）时较高。结论：在社区急诊科插管的医生与在学术一级创伤中心插管的医生有相似的一次通过成功率和失败率，尽管治疗的是全因死亡率很高的内科病人。在麻痹剂和插管方法的选择上发生了巨大的变化。
{"title":"Intubation Practices in Community Emergency Departments.","authors":"Jonathan Kei, Travis Eurick, Tom A Hauck","doi":"10.1016/j.annemergmed.2024.11.021","DOIUrl":"https://doi.org/10.1016/j.annemergmed.2024.11.021","url":null,"abstract":"<p><strong>Study objective: </strong>This study analyzes emergency medicine airway management trends and outcomes among community emergency departments.</p><p><strong>Methods: </strong>A multicenter, retrospective chart review was conducted on 11,475 intubations from 15 different community emergency departments between January 1, 2015, and December 31, 2022. Data collected included patient's age, sex, rapid sequence intubation medications, use of cricoid pressure, method of intubation, number of attempts, admission diagnosis, and all-cause mortality rates.</p><p><strong>Results: </strong>Active cardiopulmonary resuscitation occurred in 11.4% of intubations. When rapid sequence intubation was employed, the most frequently used induction agents were etomidate (91.6%), propofol (4.3%), and ketamine (4.1%). From 2015 to 2022, the use of rocuronium (versus succinylcholine) increased from 33.9% to 61.9%, a difference of 28% (95% confidence interval [CI] 21.1% to 34.9%). During the same period, video laryngoscopy (versus direct laryngoscopy) increased from 27.4% to 77.7%, a difference of 50.3% (95% CI 44.2% to 56.4%). Only 46% of intubations used cricoid pressure. Physicians had a first-pass success rate of 80.5% and a failure rate of 0.2%. The most common documented admission diagnoses among intubated patients were respiratory etiologies (27.8%), neurologic causes (21.4%), and sepsis (16.0%). All-cause mortality rates were high for intubated patients at 24 hours (19.7%), 7 days (29.4%), 30 days (38.4%), and 1 year (45.4%).</p><p><strong>Conclusion: </strong>Physicians intubating in community emergency departments have similar rates of first-pass success and failure seen in academic Level-1 trauma centers despite treating medically sick patients with high all-cause mortality rates. Dramatic shifts in choice of paralytic and method for intubation were seen.</p>","PeriodicalId":8236,"journal":{"name":"Annals of emergency medicine","volume":" ","pages":""},"PeriodicalIF":5.0,"publicationDate":"2025-01-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142963678","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-01-09DOI: 10.1016/j.annemergmed.2024.11.014
Owen Chauhan, Amy C Plint, Nick Barrowman, Natasha Wills-Ibarra, Tyrus Crawford, Mei Han, Maala Bhatt
Study objective: The peripheral intravenous catheter (IV) is the most common and painful invasive medical device in acute care settings. Our objective was to determine whether adding skin glue to secure IVs reduced catheter failure rate in children.
Methods: We conducted a randomized controlled trial in a tertiary-care pediatric emergency department (ED). ED patients younger than 18 years old with an IV who were anticipated to be admitted to hospital were eligible for enrollment. Children were randomized to receive standard IV securement with cloth-bordered transparent polyurethane dressing (control) or application of cyanoacrylate glue at the catheter insertion site in addition to standard securement (intervention). Participants were followed until device removal due to failure or physician order. The primary outcome was IV failure before the intended treatment course was complete. Patients who were randomized with primary outcome data were included in the intention-to-treat analysis.
Results: Of the 557 participants enrolled between December 2020 and April 2023, 278 (50%) and 279 (50%) were allocated to the glue and control groups, respectively. A total of 527 participants were included in the intention-to-treat analysis. Intravenous failure rates in the glue and control groups were 83 of 265 (31.3%) and 82 of 262 (31.3%), respectively. The odds of intravenous catheter failure were not different between groups (adjusted odds ratio 0.98; 95% confidence interval, 0.67 to 1.42). Time to device failure was similar between groups (hazard ratio 0.99; 95% confidence interval, 0.73 to 1.35).
Conclusions: This study found no benefit in using skin glue to secure IVs in the ED in children.
{"title":"Skin Glue to Reduce Intravenous Catheter Failure in Children.","authors":"Owen Chauhan, Amy C Plint, Nick Barrowman, Natasha Wills-Ibarra, Tyrus Crawford, Mei Han, Maala Bhatt","doi":"10.1016/j.annemergmed.2024.11.014","DOIUrl":"https://doi.org/10.1016/j.annemergmed.2024.11.014","url":null,"abstract":"<p><strong>Study objective: </strong>The peripheral intravenous catheter (IV) is the most common and painful invasive medical device in acute care settings. Our objective was to determine whether adding skin glue to secure IVs reduced catheter failure rate in children.</p><p><strong>Methods: </strong>We conducted a randomized controlled trial in a tertiary-care pediatric emergency department (ED). ED patients younger than 18 years old with an IV who were anticipated to be admitted to hospital were eligible for enrollment. Children were randomized to receive standard IV securement with cloth-bordered transparent polyurethane dressing (control) or application of cyanoacrylate glue at the catheter insertion site in addition to standard securement (intervention). Participants were followed until device removal due to failure or physician order. The primary outcome was IV failure before the intended treatment course was complete. Patients who were randomized with primary outcome data were included in the intention-to-treat analysis.</p><p><strong>Results: </strong>Of the 557 participants enrolled between December 2020 and April 2023, 278 (50%) and 279 (50%) were allocated to the glue and control groups, respectively. A total of 527 participants were included in the intention-to-treat analysis. Intravenous failure rates in the glue and control groups were 83 of 265 (31.3%) and 82 of 262 (31.3%), respectively. The odds of intravenous catheter failure were not different between groups (adjusted odds ratio 0.98; 95% confidence interval, 0.67 to 1.42). Time to device failure was similar between groups (hazard ratio 0.99; 95% confidence interval, 0.73 to 1.35).</p><p><strong>Conclusions: </strong>This study found no benefit in using skin glue to secure IVs in the ED in children.</p>","PeriodicalId":8236,"journal":{"name":"Annals of emergency medicine","volume":" ","pages":""},"PeriodicalIF":5.0,"publicationDate":"2025-01-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142963679","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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