Entries Tagged as 'Acad Emerg Med'
Racial disparities in emergency department length of stay for admitted patients in the United States.
Acad Emerg Med. 2009 May;16(5):403-10
Authors: Pines JM, Russell Localio A, Hollander JE
OBJECTIVES: Recent studies have demonstrated the adverse effects of prolonged emergency department (ED) boarding times on outcomes. The authors sought to examine racial disparities across U.S. hospitals in ED length of stay (LOS) for admitted patients, which may serve as a proxy for boarding time in data sets where the actual time of admission is unavailable. Specifically, the study estimated both the within- and among-hospital effects of black versus non-black race on LOS for admitted patients. METHODS: The authors studied 14,516 intensive care unit (ICU) and non-ICU admissions in 408 EDs in the National Hospital Ambulatory Medical Care Survey (NHAMCS; 2003-2005). The main outcomes were ED LOS (triage to transfer to inpatient bed) and proportion of patients with prolonged LOS (>6 hours). The effects of black versus non-black race on LOS were decomposed to distinguish racial disparities between patients at the same hospital (within-hospital component) and between hospitals that serve higher proportions of black patients (among-hospital component). RESULTS: In the unadjusted analyses, ED LOS was significantly longer for black patients admitted to ICU beds (367 minutes vs. 290 minutes) and non-ICU beds (397 minutes vs. 345 minutes). For admissions to ICU beds, the within-hospital estimates suggested that blacks were at higher risk for ED LOS of >6 hours (odds ratio [OR] = 1.42, 95% confidence interval [CI] = 1.01 to 2.01), while the among-hospital differences were not significant (OR = 1.08 for each 10% increase in the proportion of black patients, 95% CI = 0.96 to 1.23). By contrast, for non-ICU admissions, the within-hospital racial disparities were not significant (OR = 1.12, 95% CI = 0.94 to 1.23), but the among-hospital differences were significant (OR = 1.13, 95% CI = 1.04 to 1.22) per 10% point increase in the percentage of blacks admitted to a hospital. CONCLUSIONS: Black patients who are admitted to the hospital through the ED have longer ED LOS compared to non-blacks, indicating that racial disparities may exist across U.S. hospitals. The disparity for non-ICU patients might be accounted for by among-hospital differences, where hospitals with a higher proportion of blacks have longer waits. The disparity for ICU patients is better explained by within-hospital differences, where blacks have longer wait times than non-blacks in the same hospital. However, there may be additional unmeasured clinical or socioeconomic factors that explain these results.
PMID: 19245372 [PubMed - indexed for MEDLINE]
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Tags: Acad Emerg Med
Statin therapy is associated with decreased mortality in patients with infection.
Acad Emerg Med. 2009 Mar;16(3):230-4
Authors: Donnino MW, Cocchi MN, Howell M, Clardy P, Talmor D, Cataldo L, Chase M, Al-Marshad A, Ngo L, Shapiro NI
OBJECTIVES: The objective was to investigate the association between statin therapy and mortality in emergency department (ED) patients with suspected infection. METHODS: A secondary analysis of a prospective, observational cohort study was conducted at an urban, academic ED with approximately 50,000 annual visits. Data were collected between December 2003 and September 2004. Inclusion criteria consisted of age > or = 18 years, clinical suspicion of infection, and hospital admission. Patients were divided by those receiving statin therapy and those not receiving statins while hospitalized. Medication data were collected from an inpatient pharmacy database. Comparisons were conducted with Fisher's exact test or Wilcoxon rank sum test. To adjust for baseline differences, multivariable logistic regression analysis controlling for gender, severity of illness (Mortality in Emergency Department Sepsis [MEDS] score), Charlson Comorbidity Index, and duration of statin therapy was performed. RESULTS: Of 2,132 patients with suspected infection, 2,036 (95%) had interpretable pharmacy data and were analyzed. The cohort had a median age of 61 years (interquartile range [IQR] = 46-78 years) and a mortality of 3.9% (95% confidence interval [CI] = 3.1% to 4.8%). Patients who received statins (n = 474) had a lower unadjusted crude mortality (1.9%; 95% CI = 0.6% to 3.3%) compared to those who did not (4.5%; 95% CI = 3.4% to 5.4%; p </= 0.01). When adjusting for gender, MEDS score, Charlson Comorbidity Index, and duration of statin therapy, the odds of death for statin patients was 0.27 (95% CI = 0.1 to 0.72; p < or = 0.01). CONCLUSIONS: Patients who were admitted to the hospital with infection and received statin therapy while hospitalized had a significantly lower in-hospital mortality compared to patients who did not receive a statin.
PMID: 19281494 [PubMed - indexed for MEDLINE]
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Tags: Acad Emerg Med
Tandem measurement of D-dimer and myeloperoxidase or C-reactive protein to effectively screen for pulmonary embolism in the emergency department.
Acad Emerg Med. 2008 Sep;15(9):800-5
Authors: Mitchell AM, Nordenholz KE, Kline JA
OBJECTIVES: The hypothesis was that the tandem measurement of D-dimer and myeloperoxidase (MPO) or C-reactive protein (CRP) could significantly decrease unnecessary pulmonary vascular imaging in emergency department (ED) patients evaluated for pulmonary embolism (PE) compared to D-dimer alone. METHODS: The authors measured the sequential combinations of D-dimer and MPO and D-dimer and CRP in a prospective sample of ED patients evaluated for PE at two centers. Patients were followed for 90 days for venous thromboembolism (VTE, either PE or deep venous thrombosis [DVT]), which required the consensus of two of three blinded physician reviewers. RESULTS: The authors enrolled 304 patients, 22 with VTE (7%; 95% confidence interval [CI] = 5% to 10%). The sensitivity and specificity of a D-dimer alone (cutoff > or = 500 ng/mL) were 100% (95% CI = 85% to 100%) and 59% (95% CI = 53% to 65%), respectively, and was followed by pulmonary vascular imaging negative for PE in 38% (115/304; 95% CI = 32% to 44%). The combination of either a negative D-dimer, or MPO < 22 mg/dL, had a sensitivity of 100% and specificity of 73% (95% CI = 67% to 78%). Thus, tandem measurement of D-dimer and MPO would have decreased the frequency of subsequent negative pulmonary vascular imaging from 38% to 25% (95% CI of the difference of -13% = -5% to -20%). The combination of CRP and D-dimer would not have significantly improved the rate of negative imaging. CONCLUSIONS: The tandem measurement of D-dimer and MPO would have significantly decreased negative pulmonary vascular imaging compared with D-dimer alone and should be validated prospectively.
PMID: 18821859 [PubMed - indexed for MEDLINE]
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Impact of point-of-care testing in the emergency department evaluation and treatment of patients with suspected acute coronary syndromes.
Acad Emerg Med. 2008 Mar;15(3):216-24
Authors: Renaud B, Maison P, Ngako A, Cunin P, Santin A, Hervé J, Salloum M, Calmettes MJ, Boraud C, Lemiale V, Grégo JC, Debacker M, Hémery F, Roupie E
OBJECTIVES: To assess the impact of point-of-care testing (POCT) for troponin I (cTnI) measurement on the time to anti-ischemic therapy (TAIT) for patients with suspected non-ST-segment elevation acute coronary syndrome (NSTE-ACS) presenting to the emergency department (ED). METHODS: This was an open-label, randomized, single-center trial conducted in a university-affiliated hospital. cTnI measurement of patients with suspicion of NSTE-ACS coming to the ED was randomly allocated to POCT or central hospital laboratory testing (CHLT). The authors compared patients' baseline characteristics, time to anti-ischemic therapy, and medical outcomes between the randomized groups, in all study participants and in high-risk NSTE-ACS (cTnI level >or= 0.10 microg/mL), and in those with low suspicion ACS (no chest pain and no ST deviation). RESULTS: Of the 860 patients enrolled, 113 were high-risk NSTE-ACS patients, including 53 (46.9%) allocated to POCT and 60 (53.1%) to CHLT. POCT was associated with decreased time to anti-ischemic therapy of about three-quarters of an hour, which was due to a shorter time to physician notification of cTnI level, in both all and subgroup participants. In contrast, neither ED length of stay nor medical outcomes differed between study groups. CONCLUSIONS: Point-of-care testing for cTnI measurement might be clinically relevant for ED patients with a suspicion of NSTE-ACS, particularly for high-risk patients with a low suspicion of ACS.
PMID: 18304051 [PubMed - indexed for MEDLINE]
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