Study objective Clinical guidelines are known to be underused by practitioners. In response to the challenges of treating pain amid a prescription opioid epidemic, the American College of Emergency ...Physicians (ACEP) published an evidence-based clinical policy for opioid prescribing in 2012. Evidence-based narratives, an effective method of communicating health information in a variety of settings, offer a novel strategy for disseminating guidelines to physicians and engaging providers with clinical evidence. We compare whether narrative vignettes embedded in the ACEP daily e-newsletter improved dissemination of the clinical policy to ACEP members, and engagement of members with the clinical policy, compared with traditional summary text. Methods A prospective randomized controlled study, titled Stories to Promote Information Using Narrative trial, was performed. Derived from qualitative interviews with 61 ACEP physicians, 4 narrative vignettes were selected and refined, using a consensus panel of clinical and implementation experts. All ACEP members were then block randomized by state of residence to receive alternative versions of a daily e-mailed newsletter for a total of 24 days during a 9-week period. Narrative newsletters contained a selection of vignettes that referenced opioid prescription dilemmas. Control newsletters contained a selection of descriptive text about the clinical policy, using length and appearance similar to that of the narrative vignettes. Embedded in the newsletters were Web links to the complete vignette or traditional summary text, as well as additional links to the full ACEP clinical policy and a Web site providing assistance with prescription drug monitoring program enrollment. The newsletters were otherwise identical. Outcomes measured were the percentage of subjects who visited any of the Web pages that contained additional guideline-related information and the odds of any unique physician visiting these Web pages during the study. Results There were 27,592 physicians randomized, and 21,226 received the newsletter during the study period. When each physician was counted once during the study period, there were 509 unique visitors in the narrative group and 173 unique visitors in the control group (4.8% versus 1.6%; difference 3.2%; 95% confidence interval CI 2.7% to 3.7%). There were 744 gross visits from the e-newsletter to any of the 3 Web pages in the narrative group compared with 248 in the control group (7.0% versus 2.3%; odds ratio 3.2; 95% CI 2.7 to 3.6). During the study, the odds ratio of any physician in the narrative group visiting one of the 3 informational Web sites compared with the control group was 3.1 (95% CI 2.6 to 3.6). Conclusion Among a national sample of emergency physicians, narrative vignettes outperformed traditional guideline text in promoting engagement with an evidence-based clinical guideline related to opioid prescriptions.
Study objective Coronary computed tomographic (CT) angiography has excellent performance characteristics relative to coronary angiography and exercise or pharmacologic stress testing. We hypothesize ...that coronary CT angiography can identify a cohort of emergency department (ED) patients with a potential acute coronary syndrome who can be safely discharged with a less than 1% risk of 30-day cardiovascular death or nonfatal myocardial infarction. Methods We conducted a prospective cohort study at an urban university hospital ED that enrolled consecutive patients with potential acute coronary syndromes and a low TIMI risk score who presented to the ED with symptoms suggestive of a potential acute coronary syndrome and received a coronary CT angiography. Our intervention was either immediate coronary CT angiography in the ED or after a 9- to 12-hour observation period that included cardiac marker determinations, depending on time of day. The main clinical outcome was 30-day cardiovascular death or nonfatal myocardial infarction. Results Five hundred sixty-eight patients with potential acute coronary syndrome were evaluated: 285 of these received coronary CT angiography immediately in the ED and 283 received coronary CT angiography after a brief observation period. Four hundred seventy-six (84%) were discharged home after coronary CT angiography. During the 30-day follow-up period, no patients died of a cardiovascular event (0%; 95% confidence interval CI 0% to 0.8%) or sustained a nonfatal myocardial infarction (0%; 95% CI 0 to 0.8%). Conclusion ED patients with symptoms concerning for a potential acute coronary syndrome with a low TIMI risk score and a nonischemic initial ECG result can be safely discharged home after a negative coronary CT angiography test result.
Abstract Objective Research on how race affects access to analgesia in the emergency department (ED) has yielded conflicting results. We assessed whether patient race affects analgesia administration ...for patients presenting with back or abdominal pain. Methods This is a retrospective cohort study of adults who presented to 2 urban EDs with back or abdominal pain for a 4-year period. To assess differences in analgesia administration and time to analgesia between races, Fisher exact and Wilcoxon rank sum test were used, respectively. Relative risk regression was used to adjust for potential confounders. Results Of 20 125 patients included (mean age, 42 years; 64% female; 75% black; mean pain score, 7.5), 6218 (31%) had back pain and 13 907 (69%) abdominal pain. Overall, 12 109 patients (60%) received any analgesia and 8475 (42%) received opiates. Comparing nonwhite (77 %) to white patients (23%), nonwhites were more likely to report severe pain (pain score, 9-10) (42% vs 36%; P < .0001) yet less likely to receive any analgesia (59% vs 66%; P < .0001) and less likely to receive an opiate (39% vs 51%; P < .0001). After controlling for age, sex, presenting complaint, triage class, admission, and severe pain, white patients were still 10% more likely to receive opiates (relative risk, 1.10; 95% confidence interval, 1.06-1.13). Of patients who received analgesia, nonwhites waited longer for opiate analgesia (median time, 98 vs 90 minutes; P = .004). Conclusions After controlling for potential confounders, nonwhite patients who presented to the ED for abdominal or back pain were less likely than whites to receive analgesia and waited longer for their opiate medication.
Study objective A clinical decision rule that identifies patients at low risk for appendicitis may reduce the reliance on computed tomography (CT) for diagnosis. We seek to prospectively evaluate the ...accuracy of a low modified Alvarado score in emergency department (ED) patients with suspected appendicitis and compare the score to clinical judgment. We hypothesize that a low modified Alvarado score will have a sufficiently high sensitivity to rule out acute appendicitis. Methods We performed a prospective observational study of adult patients with suspected appendicitis at 2 academic urban EDs. A low modified Alvarado score was defined as less than 4. The sensitivity and specificity were calculated with 95% confidence interval (CI) for a low modified Alvarado score, and a final diagnosis of appendicitis was confirmed by CT, laparotomy, or 7-day follow-up. Results Two hundred sixty-one patients were included for analysis (mean age 35 years range 18 to 89 years, 68% female patients, 52% white). Fifty-three patients (20%) had acute appendicitis. The modified Alvarado score test characteristics demonstrated a sensitivity and specificity of 72% (95% CI 58% to 84%) and 54% (95% CI 47% to 61%), respectively. Unstructured clinical judgment that appendicitis was either the most likely or second most likely diagnosis demonstrated a sensitivity and specificity of 93% (95% CI 82% to 98%) and 33% (95% CI 27% to 40%), respectively. Conclusion With a sensitivity of 72%, a low modified Alvarado score is less sensitive than clinical judgment in excluding acute appendicitis.
Background Current guidelines recommend an immediate (eg, <10 minutes) 12-lead electrocardiogram (ECG) to identify ST-elevation myocardial infarction (STEMI) among patients presenting to the ...emergency department (ED) with chest pain. Yet, one third of all patients with myocardial infarction do not have chest pain. Our objective was to develop a practical approach to identify patients, especially those without chest pain, who require an immediate ECG in the ED to identify STEMI. Methods An ECG prioritization rule was derived and validated using classification and regression tree analysis among >3 million ED visits to 107 EDs from 2007 to 2008. Results The final study population included 3,575,178 ED patient visits; of these, 6,464 (0.18%) were diagnosed with STEMI. Overall, 1,413 (21.9%) of patients with STEMI did not present to the ED with chest pain. Major predictors of those requiring an immediate ECG in the ED included age ≥30 years with chest pain; age ≥50 years with shortness of breath, altered mental status, upper extremity pain, syncope, or generalized weakness; and those with age ≥80 years with abdominal pain or nausea/vomiting. When the ECG prioritization rule was applied to a validation sample, it had a sensitivity of 91.9% (95% CI 90.9%-92.8%) for STEMI and a negative predictive value 99.98% (95% CI 99.98%-99.98%). Conclusion A simple ECG prioritization rule based on age and presenting symptoms in the ED can identify patients during triage who are at high risk for STEMI and therefore should receive an immediate 12-lead ECG, often before they are seen by a physician.
The aim of this study was to assess the feasibility of
F-fluorodeoxyglucose (FDG)-positron emission tomography/computed tomography (PET/CT) to systematically detect and quantify differential effects ...of chronic tobacco use in organs of the whole body.
Twenty healthy male subjects (10 nonsmokers and 10 chronic heavy smokers) were enrolled. Subjects underwent whole-body FDG-PET/CT, diagnostic unenhanced chest CT, mini-mental state examination, urine testing for oxidative stress, and serum testing. The organs of interest (thyroid, skin, skeletal muscle, aorta, heart, lung, adipose tissue, liver, spleen, brain, lumbar spinal bone marrow, and testis) were analyzed on FDG-PET/CT images to determine their metabolic activities using standardized uptake value (SUV) or metabolic volumetric product (MVP). Measurements were compared between subject groups using two-sample t tests or Wilcoxon rank-sum tests as determined by tests for normality. Correlational analyses were also performed.
FDG-PET/CT revealed significantly decreased metabolic activity of lumbar spinal bone marrow (MVPmean: 29.8 ± 9.7 cc vs 40.8 ± 11.6 cc, P = 0.03) and liver (SUVmean: 1.8 ± 0.2 vs 2.0 ± 0.2, P = 0.049) and increased metabolic activity of visceral adipose tissue (SUVmean: 0.35 ± 0.10 vs 0.26 ± 0.06, P = 0.02) in chronic smokers compared to nonsmokers. Normalized visceral adipose tissue volume was also significantly decreased (P = 0.04) in chronic smokers. There were no statistically significant differences in the metabolic activity of other assessed organs.
Subclinical organ effects of chronic tobacco use are detectable and quantifiable on FDG-PET/CT. FDG-PET/CT may, therefore, play a major role in the study of systemic toxic effects of tobacco use in organs of the whole body for clinical or research purposes.
Abstract Introduction Prescription opioid overdoses and deaths constitute a public health epidemic, and recent studies show that emergency department (ED) prescribers may contribute to this crisis. ...We hypothesized that a multidisciplinary educational intervention would decrease ED opioid packs dispensed at discharge. Methods This prospective study implemented a “bundle” of interdisciplinary educational modalities: lectures, journal clubs, case discussions, and an electronic medical record decision support tool. Implementation occurred in 2 urban EDs in the same health system at different times (“affiliate,” September 2011; “primary,” January 2012) to better distinguish its effects. The primary outcome was preintervention/postintervention change in opioid discharge packs dispensed to all patients treated and discharged through August 2012 and was assessed by 2-way analysis of variance. The secondary outcome was bivariate analysis (using Fisher exact test) of change in opioid dispensing among patients with known risk factors for prescription opioid dependence: age less than 65 years, history of substance abuse, chronic pain, or psychiatric disorders. Results A total of 71,512 and 45,746 patients were evaluated and discharged from primary and affiliate EDs, respectively. Orders for opioid discharge packs decreased from 13.9% to 8.4% and 4.7% to 1.9% at the primary and affiliate hospitals ( P < .0001). Dispensing among individuals at risk for opioid dependence at the primary ED decreased from 21.8% to 13.9%. Conclusions A staged, multidisciplinary intervention targeting nurses, residents, nurse practitioners, and attending physicians was associated with decreased orders for opioid discharge packs in 2 urban EDs. Opioid discharge pack orders decreased slightly more among patients with risk factors for prescription opioid dependence.
Background Emergency medical services (EMS) are critical in the treatment of ST-segment elevation myocardial infarction (STEMI). Prehospital system delays are an important target for improving timely ...STEMI care, yet few limited data are available. Methods Using a deterministic approach, we merged EMS data from the North Carolina Pre-hospital Medical Information System (PreMIS) with data from the Reperfusion of Acute Myocardial Infarction in Carolina Emergency Departments—Emergency Response (RACE-ER) Project. Our sample included all patients with STEMI from June 2008 to October 2010 who arrived by EMS and who had primary percutaneous coronary intervention (PCI). Prehospital system delays were compared using both RACE-ER and PreMIS to examine agreement between the 2 data sources. Results Overall, 8,680 patients with STEMI in RACE-ER arrived at a PCI hospital by EMS; 21 RACE-ER hospitals and 178 corresponding EMS agencies across the state were represented. Of these, 6,010 (69%) patients were successfully linked with PreMIS. Linked and notlinked patients were similar. Overall, 2,696 patients were treated with PCI only and were taken directly to a PCI-capable hospital by EMS; 1,750 were transferred from a non-PCI facility. For those being transported directly to a PCI center, 53% reached the 90-minute target guideline goal. For those transferred from a non-PCI facility, 24% reached the 120-minute target goal for primary PCI. Conclusions We successfully linked prehospital EMS data with inhospital clinical data. With this linked STEMI cohort, less than half of patients reach goals set by guidelines. Such a data source could be used for future research and quality improvement interventions.
Abstract Background Wide variation in out-of-hospital cardiac arrest (OHCA) survival has been reported, with low survival in urban settings. We sought to describe the epidemiology of OHCA in ...Philadelphia, Pennsylvania, the fifth largest U.S. city, and identify potential areas for targeted interventions to improve survival. Methods and Results Retrospective chart review of adult, non-traumatic, OHCA occurring in Philadelphia between 2008 and 2012. We determined incidence and epidemiological factors including: demographics, initial cardiac rhythm, bystander cardiopulmonary resuscitation, automated external defibrillator use, return of spontaneous circulation and 30-day survival. 5,198 cases of adult, non-traumatic OHCA were identified. The incidence was 81.5/100,000. The majority of cases occurred in a residence (76.2%); 30.4% were witnessed events; the initial cardiac rhythm was pulseless ventricular tachycardia or ventricular fibrillation in 6.2% of cases, pulseless electrical activity in 21.0%, asystole in 38.3% and was unknown or undocumented in the remaining 34.5%. Multivariate logistic regression analysis demonstrated increased 30-day survival with younger age, shockable cardiac rhythms, and daytime arrest. 30-day survival was 8.1% for EMS-assessed patients and 8.6% for EMS-transported patients. Conclusions Philadelphia's reported incidence is consistent with urban settings although the survival rate is higher than other urban centers.
An abstract of the study by Gallagher et al determining the frequency of consideration and appropriate testing practices among pediatric emergency department (PED) providers for sexually transmitted ...infections (STIs) and human immunodeficiency virus (HIV), is presented. Methods used in this study such as the retrospective chart review of patients with eligible complaints such as pharyngitis or throat pain and anal or rectal pain and abstracted from medical records of patient demographics. Also noted the results where patients has an STI documented in the medical decision-making and HIV testing for oropharyngeal or anorectal complaints.
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