Postdischarge Adverse Events for 1-Day Hospital Admissions in Older Adults Admitted From the Emergency Department.

Ann Emerg Med. 2010 Feb 25;

Authors: Pines JM, Mongelluzzo J, Hilton JA, Hollander JE, Shofer FS, Souder J, Synnestvedt M, Weiner MG, Datner EM

STUDY OBJECTIVE: We assess hospital readmission and death within 60 days in older adults admitted from the emergency department (ED) and discharged by an inpatient service within 24 hours. METHODS: This was a retrospective review of ED patients aged 64 years or older, admitted from 2 hospitals (2004 to 2006), who were discharged home within 24 hours. Excluded were inhospital deaths, observation admissions, transfers to other facilities, patients who left against medical advice, and hospice patients. Outcomes were 72-hour and 30-day readmissions and postdischarge deaths that occurred within 60 days of ED admission. Logistic regression was used to assess for predictors of readmission. A chart review of deaths after discharge was performed to assess for potential contributors to adverse outcomes. RESULTS: A total of 1,470 admissions met inclusion criteria as 1-day admissions. Of those, 22 (1.5%) patients returned for hospital readmission within 72 hours and 156 (10.6%) within 30 days of discharge. In the multivariable analysis, previous admissions (odds ratio [OR] 1.3; 95% confidence interval [CI] 1.1 to 1.4) and an admission diagnosis of heart failure (OR 2.2; 95% CI 1.0 to 5.0) were associated with 30-day readmission. In 841 individual patients with greater than or equal to one 1-day admission, there were 15 deaths (1.8%) within 60 days. Of those, 11 (73%) patients had abnormal ED ECG results, 6 (40%) were ruled out for acute myocardial infarction while hospitalized, and 3 (20%) had definitive follow-up arranged at discharge. CONCLUSION: One-day admissions in hospitalized older adults through the ED do not represent a group at low risk for postdischarge adverse outcomes.

PMID: 20189266 [PubMed - as supplied by publisher]

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Postdischarge Adverse Events for 1-Day Hospital Admissions in Older Adults Admitted From the Emergency Department.

Ann Emerg Med. 2010 Feb 25;

Authors: Pines JM, Mongelluzzo J, Hilton JA, Hollander JE, Shofer FS, Souder J, Synnestvedt M, Weiner MG, Datner EM

STUDY OBJECTIVE: We assess hospital readmission and death within 60 days in older adults admitted from the emergency department (ED) and discharged by an inpatient service within 24 hours. METHODS: This was a retrospective review of ED patients aged 64 years or older, admitted from 2 hospitals (2004 to 2006), who were discharged home within 24 hours. Excluded were inhospital deaths, observation admissions, transfers to other facilities, patients who left against medical advice, and hospice patients. Outcomes were 72-hour and 30-day readmissions and postdischarge deaths that occurred within 60 days of ED admission. Logistic regression was used to assess for predictors of readmission. A chart review of deaths after discharge was performed to assess for potential contributors to adverse outcomes. RESULTS: A total of 1,470 admissions met inclusion criteria as 1-day admissions. Of those, 22 (1.5%) patients returned for hospital readmission within 72 hours and 156 (10.6%) within 30 days of discharge. In the multivariable analysis, previous admissions (odds ratio [OR] 1.3; 95% confidence interval [CI] 1.1 to 1.4) and an admission diagnosis of heart failure (OR 2.2; 95% CI 1.0 to 5.0) were associated with 30-day readmission. In 841 individual patients with greater than or equal to one 1-day admission, there were 15 deaths (1.8%) within 60 days. Of those, 11 (73%) patients had abnormal ED ECG results, 6 (40%) were ruled out for acute myocardial infarction while hospitalized, and 3 (20%) had definitive follow-up arranged at discharge. CONCLUSION: One-day admissions in hospitalized older adults through the ED do not represent a group at low risk for postdischarge adverse outcomes.

PMID: 20189266 [PubMed - as supplied by publisher]

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Coronary Artery Calcium Scoring in the Emergency Department: Identifying Which Patients With Chest Pain Can Be Safely Discharged Home.

Ann Emerg Med. 2010 Feb 5;

Authors: Nabi F, Chang SM, Pratt CM, Paranilam J, Peterson LE, Frias ME, Mahmarian JJ

STUDY OBJECTIVE: Coronary artery calcium scoring (CACS) is a simple and readily available test for identifying coronary artery disease. Our objective is to evaluate whether a CACS of zero will identify chest pain patients who can be safely discharged home, without need for further cardiac testing. METHODS: This was a prospective observational cohort study conducted at an urban tertiary care hospital of stable patients presenting to the emergency department (ED) with chest pain of uncertain cardiac cause. Patients with a normal initial troponin level, nonischemic ECG, and no history of coronary artery disease had stress myocardial perfusion imaging (SPECT) and CACS within 24 hours of ED admission. Cardiac events were defined as an acute coronary syndrome during the index hospitalization or in follow-up. CACS results were assessed in relation to SPECT findings and cardiac events. RESULTS: The 1,031 patients enrolled (mean [SD] age 54 [13] years) had a median CACS of 0 (61% with CACS of 0). The frequency of an abnormal SPECT ranged from 0.8% (CACS of 0) to17% (CACS>400). Cardiac events occurred in 32 patients (3.1%) during the index hospitalization (N=28) or after hospital discharge (N=4) (mean 7.4 [3.3] months). Only 2 events occurred in 625 patients with a CACS of 0 (0.3%; 95% confidence interval 0.04% to 1.1%). Thus, 2 of 32 patients with a cardiac event had a CACS of 0 (6%; 95% confidence interval 0.8% to 21%). Both of these patients developed increased troponin levels during their index visit but had normal serial ECG and SPECT study results and no cardiac events at 6-month follow-up. CONCLUSION: A majority of patients (61% in our sample) evaluated for chest pain of uncertain cardiac cause have a CACS of 0, which predicts both a normal SPECT result and an excellent short-term outcome. Our results suggest that patients with a CACS of 0 can be discharged home, without further cardiac testing.

PMID: 20138399 [PubMed - as supplied by publisher]

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A Prospective Evaluation of Emergency Department Bedside Ultrasonography for the Detection of Acute Cholecystitis.

Ann Emerg Med. 2010 Feb 4;

Authors: Summers SM, Scruggs W, Menchine MD, Lahham S, Anderson C, Amr O, Lotfipour S, Cusick SS, Fox JC

STUDY OBJECTIVE: We assess the diagnostic accuracy of emergency physician-performed bedside ultrasonography and radiology ultrasonography for the detection of cholecystitis, as determined by surgical pathology. METHODS: We conducted a prospective, observational study on a convenience sample of emergency department (ED) patients presenting with suspected cholecystitis from May 2006 to February 2008. Bedside gallbladder ultrasonography was performed by emergency medicine residents and attending physicians at an academic institution. Emergency physicians assessed for gallstones, a sonographic Murphy’s sign, gallbladder wall thickness, and pericholecystic fluid, and the findings were recorded before formal imaging. The test characteristics of bedside and radiology ultrasonography were determined by comparing their respective results to pathology reports and clinical follow-up at 2 weeks. RESULTS: Of the 193 patients enrolled, 189 were evaluated by bedside ultrasonography. Forty-three emergency physicians conducted the ultrasonography, and each physician performed a median of 2 tests. After the bedside ultrasonography, 125 patients received additional radiology ultrasonography. Twenty-six patients underwent cholecystectomy, 23 had pathology-confirmed cholecystitis, and 163 were discharged home to follow-up. Twenty-five were excluded (23 lost to follow-up and 2 unavailable pathology). The test characteristics of bedside ultrasonography were sensitivity 87% (95% confidence interval [CI] 66% to 97%), specificity 82% (95% CI 74% to 88%), positive likelihood ratio 4.7 (95% CI 3.2 to 6.9), negative likelihood ratio 0.16 (95% CI 0.06 to 0.46), positive predictive value 44% (95% CI 29% to 59%), and negative predictive value 97% (95% CI 93% to 99%). The test characteristics of radiology ultrasonography were sensitivity 83% (95% CI 61% to 95%), specificity 86% (95% CI 77% to 92%), positive likelihood ratio 5.7 (95% CI 3.3 to 9.8), negative likelihood ratio 0.20 (95% CI 0.08 to 0.50), positive predictive value 59% (95% CI 41% to 76%), and negative predictive value 95% (95% CI 88% to 99%). CONCLUSION: The test characteristics of emergency physician-performed bedside ultrasonography for the detection of acute cholecystitis are similar to the test characteristics of radiology ultrasonography. Patients with a negative ED bedside ultrasonography result are unlikely to require cholecystectomy or admission for cholecystitis within 2 weeks of their initial presentation.

PMID: 20138397 [PubMed - as supplied by publisher]

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Influenza Testing and Antiviral Prescribing Practices Among Emergency Department Clinicians in 9 States During the 2006 to 2007 Influenza Season.

Ann Emerg Med. 2010 Jan;55(1):32-39

Authors: Mueller MR, Smith PJ, Baumbach JP, Palumbo JP, Meek JI, Gershman K, Vandermeer M, Thomas AR, Long CE, Belflower R, Spina NL, Martin KG, Lynfield R, Openo KP, Kirley PD, Pasutti LE, Barnes BG, Schaffner W, Kamimoto L

STUDY OBJECTIVE: Influenza causes significant widespread illness each year. Emergency department (ED) clinicians are often first-line providers to evaluate and make treatment decisions for patients presenting with influenza. We sought to better understand ED clinician testing and treatment practices in the Emerging Infections Program Network, a federal, state, and academic collaboration that conducts active surveillance for influenza-associated hospitalizations. METHODS: During 2007, a survey was administered to ED clinicians who worked in Emerging Infections Program catchment area hospitals' EDs. The survey encompassed the role of the clinician, years since completing clinical training, hospital type, influenza testing practices, and use of antiviral medications during the 2006 to 2007 influenza season. We examined factors associated with influenza testing and antiviral use. RESULTS: A total of 1,055 ED clinicians from 123 hospitals responded to the survey. A majority of respondents (85.3%; n=887) reported they had tested their patients for influenza during the 2006 to 2007 influenza season (Emerging Infections Program site range: 59.3 to 100%; P<.0001). When asked about antiviral medications, 55.7% (n=576) of respondents stated they had prescribed antiviral medications to some of their patients in 2006 to 2007 (Emerging Infections Program site range 32.9% to 80.3%; P<.0001). A positive association between influenza testing and prescribing antiviral medications was observed. Additionally, the type of hospital, location in which an ED clinician worked, and the number of years since medical training were associated with prescribing antiviral influenza medications. CONCLUSION: There is much heterogeneity in clinician-initiated influenza testing and treatment practices. Additional exploration of the role of hospital testing and treatment policies, clinicians' perception of influenza disease, and methods for educating clinicians about new recommendations is needed to better understand ED clinician testing and treatment decisions, especially in an environment of rapidly changing influenza clinical guidelines. Until influenza testing and treatment guidelines are better promulgated, clinicians may continue to test and treat influenza with inconsistency.

PMID: 20116012 [PubMed - as supplied by publisher]

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Prospective Double-Blinded Study of Abdominal-Pelvic Computed Tomography Guided by the Region of Tenderness: Estimation of Detection of Acute Pathology and Radiation Exposure Reduction.

Ann Emerg Med. 2010 Jan 12;

Authors: Broder JS, Hollingsworth CL, Miller CM, Meyer JL, Paulson EK

STUDY OBJECTIVE: Computed tomography (CT) is increasingly used for emergency department (ED) patients with abdominal tenderness. CT-related radiation contributes to 2% of US cancers. We hypothesized that in the ED patient with nontraumatic abdominal tenderness, the tender region accurately delineates acute pathology. z axis-restricted CT guided by this region could detect pathology while reducing radiation dose. METHODS: This was a prospective double-blinded observational trial with informed consent and was institutional review board-approved and registered with ClinicalTrials.gov. A convenience sample of ED patients undergoing abdominal CT was recruited, excluding pregnant women, patients with altered mental status or abdominal sensation, preverbal children, and patients with abdominal trauma or surgery in the previous month. Before standard CT, physicians demarcated the tender region with labels invisible to radiologists on abdominal windows. Radiologists blinded to the tender region recorded cephalad-caudad limits of pathology on CT. Personnel blinded to pathology location recorded label positions on lung windows. Two hypothetical CT strategies were then explored: CT restricted to the tender region and CT from the cephalad skin marker to the lower caudad limit of the usual CT. The percentage of the pathologic region contained within the extent of the 2 hypothetical z axis restricted CTs was calculated. z axis reduction, which is linearly related to radiation reduction, from the restricted CTs was determined. RESULTS: One hundred two subjects were enrolled, 93 with complete data for analysis. Fifty-one subjects had acute pathology on CT. CT limited to the tender region would reduce z axis (radiation exposure) by 69% (95% confidence interval [CI] 60% to 78%). All acute pathology was included within these boundaries in 17 of the 51 abnormal cases (33%; 95% CI 22% to 47%). CT from the cephalad marker through the caudad abdomen and pelvis would reduce z axis (radiation exposure) by 38% (95% CI 29% to 48%). All acute pathology was included within these boundaries in 36 of 51 abnormal cases (71%; 95% CI 57% to 81%). With both strategies 1 and 2, the pathologic region was at least partially included within the CT region in the majority of cases (84% and 92%, respectively). CONCLUSION: CT with z axis restriction based on abdominal tenderness could reduce radiation exposure but with a potentially unacceptably high rate of misdiagnosis, using our current methods. Further prospective study may be warranted to determine the diagnostic utility of partially visualized pathology.

PMID: 20074835 [PubMed - as supplied by publisher]

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A Prospective Observational Study of Medication Errors in a Tertiary Care Emergency Department.

Ann Emerg Med. 2010 Jan 12;

Authors: Patanwala AE, Warholak TL, Sanders AB, Erstad BL

STUDY OBJECTIVE: We determine the rate and severity of medication errors, as well as factors associated with error occurrence in the emergency department (ED). METHODS: This was a prospective observational study conducted between May 1, 2008, and February 1, 2009. The pharmacist observer was present in the ED for 28 shifts (12 hours each). Information was collected on the medication use process by observing the activities of nurses caring for the patients. Errors were categorized by severity. Logistic regression was used to analyze factors associated with a risk of medication error. RESULTS: The observer identified 178 medication errors in 192 patients during the data collection period. At least 1 error occurred in 59.4% of patients, and 37% of patients overall had an error that reached them. No errors in the study resulted in permanent harm to the patient or contributed to initial or prolonged hospitalization; however, interventions were performed to prevent patient harm that likely influenced the severity of error. Errors categorized according to stage were prescribing (53.9%), transcribing (10.7%), dispensing (0.6%), and administering (34.8%). Variables predictive of medication errors were boarded patient status (odds ratio [OR] 2.15; 95% confidence interval [CI] 1.03 to 4.5), number of medication orders (OR 1.25; 95% CI 1.12 to 1.39), number of medications administered (OR 1.22; 95% CI 1.07 to 1.38), and nursing employment status (less error if full time) (OR 0.37; 95% CI 0.16 to 0.86). CONCLUSION: Medication errors in the ED are common, and most errors occur in the prescribing and administering phases. Boarded patient status, increasing number of medications orders, increasing number of medications administered, and part-time nursing status are associated with an increased risk of medication error.

PMID: 20074833 [PubMed - as supplied by publisher]

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Testing Low-Risk Patients for Suspected Pulmonary Embolism: A Decision Analysis.

Ann Emerg Med. 2010 Jan 8;

Authors: Lessler AL, Isserman JA, Agarwal R, Palevsky HI, Pines JM

STUDY OBJECTIVE: The Pulmonary Embolism Rule-out Criteria (PERC) identifies low-risk patients who are treated in the emergency department for suspected pulmonary embolism and for whom testing may be deferred. The purpose of this study is to develop a decision model to determine whether certain elements not included in the PERC methodology could better estimate the testing threshold for pulmonary embolism (ie, the pretest probability below which a patient should not be tested for pulmonary embolism). In addition, we determine which risks and benefits of pulmonary embolism evaluation and treatment have the greatest effect on the testing threshold. METHODS: We built decision models of low-risk patients with suspected pulmonary embolism, as determined by the PERC. We obtained model inputs from the literature or by using clinical judgment when data were unavailable. One-way sensitivity analysis derived the testing threshold, and 2-way sensitivity analysis was used to determine the main drivers of the testing threshold. RESULTS: We found an average testing threshold of 1.4% across all age and sex cohorts. Two-way sensitivity analysis demonstrated that risk of major bleeding from anticoagulation, mortality from contrast-induced renal failure, risk of cancer from computed tomography scan, and mortality from both treated and untreated pulmonary embolism had the greatest effects on the testing threshold. CONCLUSION: We found a testing threshold for the PERC similar to that calculated by the Pauker and Kassirer method, using somewhat different assumptions. The 5 major drivers for the testing threshold are variables for which there is a paucity of literature to assess accurately for low-risk patients.

PMID: 20061065 [PubMed - as supplied by publisher]

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The Effect of Removal of Point-of-Care Fecal Occult Blood Testing on Performance of Digital Rectal Examinations in the Emergency Department.

Ann Emerg Med. 2010 Jan 6;

Authors: Cleveland NJ, Yaron M, Ginde AA

STUDY OBJECTIVE: We determine whether removing point-of-care fecal occult blood testing from the emergency department (ED) is associated with a decrease in documented digital rectal examinations. METHODS: We performed a retrospective observational chart review study examining documented digital rectal examinations, before and after removal of a point-of-care fecal occult blood test, on all adult patients who presented to our ED with chief complaints that were likely to warrant a fecal occult blood test (intervention-sensitive). We studied the 6 months immediately before and after switching from bedside fecal occult blood testing to immunohistochemical laboratory fecal occult blood testing. We compared the results with those from a similar cohort of patients who presented during the same period, with chief complaints that would warrant a digital rectal examination for reasons other than fecal occult blood test (intervention-insensitive). RESULTS: A total of 4,981 and 5,557 patients met our inclusion criteria during the before and after intervention periods, respectively. We observed an overall reduction of 10% (95% confidence interval [CI] 8% to 12%) in digital rectal examinations in patients with intervention-sensitive chief complaints. The largest relative decreases in digital rectal examinations were observed in patients with chief complaints of abdominal pain, nausea/vomiting, and diarrhea. Smaller decreases were observed in gastrointestinal bleeding, constipation, and rectal problem. There was an overall reduction of 3% (95% CI 0% to 5%) in documented digital rectal examinations in intervention-insensitive chief complaints. After controlling for all covariates, digital rectal examinations decreased in the postintervention period for intervention-sensitive (odds ratio 0.44 [95% CI 0.39 to 0.50]) and, to a lesser extent, for intervention-insensitive (odds ratio 0.67 [95% CI 0.52 to 0.86]) conditions. CONCLUSION: Removal of point-of-care fecal occult blood test from our ED was associated with a reduction in digital rectal examinations, particularly among chief complaints that may require fecal occult blood testing.

PMID: 20060198 [PubMed - as supplied by publisher]

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Nasogastric Aspiration: A Useful Tool in Some Patients With Gastrointestinal Bleeding.

Ann Emerg Med. 2009 Dec 21;

Authors: Anderson RS, Witting MD

PMID: 20031264 [PubMed - as supplied by publisher]

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Patient Identification Errors Are Common in a Simulated Setting.

Ann Emerg Med. 2009 Dec 21;

Authors: Henneman PL, Fisher DL, Henneman EA, Pham TA, Campbell MM, Nathanson BH

STUDY OBJECTIVE: We evaluate the frequency and accuracy of health care workers verifying patient identity before performing common tasks. METHODS: The study included prospective, simulated patient scenarios with an eye-tracking device that showed where the health care workers looked. Simulations involved nurses administering an intravenous medication, technicians labeling a blood specimen, and clerks applying an identity band. Participants were asked to perform their assigned task on 3 simulated patients, and the third patient had a different date of birth and medical record number than the identity information on the artifact label specific to the health care workers’ task. Health care workers were unaware that the focus of the study was patient identity. RESULTS: Sixty-one emergency health care workers participated-28 nurses, 16 technicians, and 17 emergency service associates-in 183 patient scenarios. Sixty-one percent of health care workers (37/61) caught the identity error (61% nurses, 94% technicians, 29% emergency service associates). Thirty-nine percent of health care workers (24/61) performed their assigned task on the wrong patient (39% nurses, 6% technicians, 71% emergency service associates). Eye-tracking data were available for 73% of the patient scenarios (133/183). Seventy-four percent of health care workers (74/100) failed to match the patient to the identity band (87% nurses, 49% technicians). Twenty-seven percent of health care workers (36/133) failed to match the artifact to the patient or the identity band before performing their task (33% nurses, 9% technicians, 33% emergency service associates). Fifteen percent (5/33) of health care workers who completed the steps to verify patient identity on the patient with the identification error still failed to recognize the error. CONCLUSION: Wide variation exists among health care workers verifying patient identity before performing everyday tasks. Education, process changes, and technology are needed to improve the frequency and accuracy of patient identification.

PMID: 20031263 [PubMed - as supplied by publisher]

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Just Say No: Gastric Aspiration and Lavage Rarely Provide Benefit.

Ann Emerg Med. 2009 Dec 21;

Authors: Pitera A, Sarko J

PMID: 20031262 [PubMed - as supplied by publisher]

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Exploring Emergency Physician-Hospitalist Handoff Interactions: Development of the Handoff Communication Assessment.

Ann Emerg Med. 2009 Nov 25;

Authors: Apker J, Mallak LA, Applegate EB, Gibson SC, Ham JJ, Johnson NA, Street RL

STUDY OBJECTIVE: We develop and evaluate the Handoff Communication Assessment, using actual handoffs of patient transfers from emergency department to inpatient care. METHODS: This was an observational qualitative study. We derived a Handoff Communication Assessment tool, using categories from discourse coding described in physician-patient communication, previous handoff research in medicine, health communication, and health systems engineering and pilot data from 3 physician-hospitalist handoffs. The resulting tool consists of 2 typologies, content and language form. We applied the tool to a convenience sample of 15 emergency physician-to-hospitalist handoffs occurring at a community teaching hospital. Using discourse analysis, we assigned utterances into categories and determined the frequency of utterances in each category and by physician role. RESULTS: The tool contains 11 content categories reflecting topics of patient presentation, assessment, and professional environment and 11 language form categories representing information-seeking, information-giving, and information-verifying behaviors. The Handoff Communication Assessment showed good interrater reliability for content (kappa=0.71) and language form (kappa=0.84). We analyzed 742 utterances, which provided the following preliminary findings: emergency physicians talked more during handoffs (67.7% of all utterances) compared with hospitalists (32.3% of all utterances). Content focused on patient presentation (43.6%), professional environment (36%), and assessment (20.3%). Form was mostly information-giving (90.7%) with periodic information-seeking utterances (8.8%) and rarely information-verifying utterances (0.4%). Questions accounted for less than 10% of all utterances. CONCLUSION: We were able to develop and use the Handoff Communication Assessment to analyze content and structure of handoff communication between emergency physicians and hospitalists at a single center. In this preliminary application of the tool, we found that emergency physician-to-hospitalist handoffs primarily consist of information giving and are not geared toward question-and-answer events. This critical exchange may benefit from ongoing analysis and reformulation.

PMID: 19944486 [PubMed - as supplied by publisher]

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Against Routine Initiation of Antihypertensive Therapy in the Emergency Department.

Ann Emerg Med. 2009 Dec;54(6):792-793

Authors: Shayne P

PMID: 19942066 [PubMed - as supplied by publisher]

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Initiation of Therapy for Asymptomatic Hypertension in the Emergency Department.

Ann Emerg Med. 2009 Dec;54(6):791-792

Authors: Kinsella K, Baraff LJ

PMID: 19942065 [PubMed - as supplied by publisher]

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