Reduction in emergency department (ED) overcrowding is a major Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) initiative. One major source of ED overcrowding is patients ...waiting for telemetry beds.
To determine whether, in patients admitted with a potential acute coronary syndrome, a negative evaluation for underlying coronary artery disease would reduce ED and hospital revisits over the subsequent year compared with patients who did not receive an evaluation for underlying coronary artery disease.
Nine hundred ninety-nine consecutive patients admitted for potential acute coronary syndromes through the ED during a one-year period were screened for inclusion. Patients who had a negative evaluation for underlying coronary disease were compared with patients who were not evaluated for underlying coronary artery disease for subsequent ED visits, hospital admissions, and cardiac resource utilization over the year following the index visit via a health system-wide computerized record review. Patients with positive tests or biomarkers at the index visit were excluded. Each repeat visit was rated as "potentially cardiac" or "noncardiac." Results of echocardiograms, stress tests, and catheterizations and information about in-hospital deaths were obtained.
Six hundred ninety-two patients met the inclusion criteria: 556 patients received no evaluation for underlying coronary artery disease, 116 had a negative stress test, and 20 had a negative cardiac catheterization during the index visit. Patients with no evaluation for underlying coronary artery disease and patients with a negative evaluation had similar likelihoods of a repeat ED visit (negative test 39.0% vs. no test 40.3%; p = 0.85) and repeat hospital admission (28.7% vs. 31.5%; p = 0.61). The rates of a potentially cardiac-related ED visit (21.3 vs. 23.4%; p = 0.65) and hospital admission (17.7% vs. 20.7%; p = 0.48) were not significantly different. The two populations had similar utilization rates of echocardiograms, stress tests, and catheterizations (p > 0.70 for all).
For patients admitted to the authors' institution with a potential acute coronary syndrome, there was no association between a negative evaluation for underlying coronary artery disease and overall or potentially cardiac ED visits, admissions, or cardiac resource test utilization over the year following the index visit.
We compared the predictive properties of an initial absolute creatine kinase-MB (CK-MB) to creatine kinase-MB relative index (CK-MB RI) for detecting acute myocardial infarction (AMI), acute coronary ...syndromes (ACS), and serious cardiac events (SCE). Consecutive patients > 24 years of age with chest pain who received an electrocardiogram (EKG) as part of their Emergency Department (ED) evaluation had CK and CK-MB drawn at presentation. Patients were followed prospectively during their hospital course. The main outcome was AMI, ACS or SCE (death, AMI, dysrhythmias, CHF, PTCA/stent, CABG) within 30 days. The sensitivity, specificity, PPV and NPV of CK-MB and CK-MB RI to predict AMI, ACS, and SCE were calculated with 95% CIs. We enrolled 2028 patients. There were 105 patients (5.2%) with AMI, 266 (13.1%) with ACS, and 150 with SCE (7.4%). Absolute CK-MB had a higher sensitivity than CK-MB RI for AMI (52.0 vs. 46.9, respectively), ACS (23.5 vs. 20.8, respectively), and SCE (39.6 vs. 36.0, respectively), but a lower specificity than CK-MB RI for AMI (93.2 vs. 96.1, respectively), ACS (93.1 vs. 96.1, respectively) and SCE (93.3 vs. 96.3, respectively); and lower PPV for AMI (35.7 vs. 46.5, respectively), ACS (42.0 vs. 53.4, respectively) and SCE (38.5 vs. 50.5, respectively). The negative predictive values were similar for all outcomes. We conclude that the risk stratification of ED chest pain patients by absolute CK-MB has higher sensitivity, similar NPV, but a lower specificity and PPV than CK-MB relative index for detection of AMI, ACS, and SCE. The optimal test depends upon the relative importance of the sensitivity or specificity for clinical decision-making in an individual patient.
Emergency incident rehabilitation (EIR) is the process by which firefighters receive medical screening and monitoring as well as oral rehydration while on the scene of intense or extended fire or ...rescue operations. A crucial parameter in EIR medical monitoring is temperature determination because heat-related illnesses are common. The objective of this study was to compare the use of oral temperature versus infrared tympanic temperature determinations of firefighters in the outdoor environment of EIR operations.
This was a prospective observational study of firefighters participating in training scenarios involving heavy smoke and fire conditions at municipal fire training facilities. Outdoor temperature and relative humidity were obtained for each training session. Subjects were outfitted fully for fire fighting duties including full protective clothing and self-contained breathing apparatus (SCBA). Immediately on exiting the fire building, firefighters removed their SCBA masks, protective hoods, and helmets, and had simultaneous oral and tympanic temperatures taken (time 0). The subjects then sat outdoors for 10 minutes and their temperatures were again obtained (time 10). Oral and tympanic temperatures for both time points were calculated as means +/- SD. An intraclass correlation coefficient was calculated to determine how closely the simultaneously obtained oral and tympanic temperatures determinations at T-0 and T-10 correlated with each other.
Forty-two firefighters (mean age, 44.6 years; SD 9.6) were enrolled during four separate training days. There was poor correlation between oral and tympanic temperatures in firefighters both at time 0 (r = 0.10) and at time 10 (r = 0.18).
There is poor correlation between tympanic and oral temperature determinations in the EIR setting. Oral temperature determinations may be preferable to tympanic temperature determination in the EIR setting.
Reduction in emergency department (ED) overcrowding is a major Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) initiative. One major source of ED overcrowding is patients ...waiting for telemetry beds. Objective: To determine whether, in patients admitted with a potential acute coronary syndrome, a negative evaluation for underlying coronary artery disease would reduce ED and hospital revisits over the subsequent year compared with patients who did not receive an evaluation for underlying coronary artery disease. Methods: Nine hundred ninety‐nine consecutive patients admitted for potential acute coronary syndromes through the ED during a one‐year period were screened for inclusion. Patients who had a negative evaluation for underlying coronary disease were compared with patients who were not evaluated for underlying coronary artery disease for subsequent ED visits, hospital admissions, and cardiac resource utilization over the year following the index visit via a health system–wide computerized record review. Patients with positive tests or biomarkers at the index visit were excluded. Each repeat visit was rated as “potentially cardiac” or “noncardiac.” Results of echocardiograms, stress tests, and catheterizations and information about in‐hospital deaths were obtained. Results: Six hundred ninety‐two patients met the inclusion criteria: 556 patients received no evaluation for underlying coronary artery disease, 116 had a negative stress test, and 20 had a negative cardiac catheterization during the index visit. Patients with no evaluation for underlying coronary artery disease and patients with a negative evaluation had similar likelihoods of a repeat ED visit (negative test 39.0% vs. no test 40.3%; p = 0.85) and repeat hospital admission (28.7% vs. 31.5%; p = 0.61). The rates of a potentially cardiac‐related ED visit (21.3 vs. 23.4%; p = 0.65) and hospital admission (17.7% vs. 20.7%; p = 0.48) were not significantly different. The two populations had similar utilization rates of echocardiograms, stress tests, and catheterizations (p > 0.70 for all). Conclusions: For patients admitted to the authors' institution with a potential acute coronary syndrome, there was no association between a negative evaluation for underlying coronary artery disease and overall or potentially cardiac ED visits, admissions, or cardiac resource test utilization over the year following the index visit.
Objective: New diagnostic and treatment options for emergency department (ED) patients with congestive heart failure (CHF) may facilitate the ED discharge of some patients. However, some patients ...require admission to exclude concurrent acute coronary syndrome (ACS) as the precipitant of CHF. The objective of this study was to identify the incidence, clinical characteristics, and hospital course of CHF patients who present to the ED with and without concurrent ACS. Methods: This was a prospective cohort study of consecutive patients >23 years of age who presented to the ED with chest pain, received an electrocardiogram (ECG), and either had a known history of CHF or presented with new‐onset CHF, between July 1999 and April 2001. The hospital course of each patient was followed daily, and telephone follow‐up occurred at 30 days. The main outcomes were the incidence of ACS and comparisons of lengths of hospital stay (LOSs), rates of admission to the intensive care unit (ICU), intubations, and death rates among patients with and without ACS. Results: Two hundred ninety‐eight CHF patients presented 380 times. The incidence of ACS in the 380 patient visits was 32% (95% CI = 27% to 36%). Compared with patients who did not have ACS, patients who had concurrent ACS were more likely to have known coronary artery disease (CAD) (67% vs. 42%; p < 0.0001) and hypercholesterolemia (36% vs. 18%; p = 0.0002). Patients with concurrent ACS were also more likely to be admitted to the hospital (97% vs 82%; p < 0.0001), had a longer LOS (5.2 3.9‐6.5 vs 3.2 2.6‐3.8 days; p = 0.006), had higher rates of ICU admission (44% vs. 13%; p < 0.0001), were more likely to be intubated (8% vs. 1%, p = 0.002), and were more likely to die (15 vs 7 deaths; p < 0.0001). Conclusions: The incidence of ACS in ED CHF patients with chest pain was 32%. Patients with CHF complicated by ACS had more prolonged hospital stays, required higher levels of care, and had a higher incidence of death than those patients without ACS. Strategies tailored to early identification and management of these patients would be desirable.
BACKGROUND: Diagnostic testing of women with suspected coronary artery disease (CAD) is challenging due to its poor specificity. OBJECTIVE: Validate a previously derived model identifying women who ...would benefit from further evaluation of CAD after an initial negative ED evaluation for ischemia. METHODS: A retrospective analysis of women from a prospective registry of patients who presented to a university ED with chest pain from 7/99-3/02. This site was independent from the derivation site. Subjects were excluded if the initial ECG or cardiac injury markers were consistent with infarction or ischemia. CAD was defined as subsequent elevation of cardiac injury markers, a positive diagnostic study, or death during the 30 day follow-up period. Predictors of CAD and their weighted value were hypertension (2), history of CAD (2), hypercholesterolemia (1), age >/=60 (3), high clinical suspicion (6). Low risk was defined as a score </= 4, moderate risk >4 and < 10, high risk >/=10. Chi square analyses and logistic regression were used for group comparisons. RESULTS: The validation set comprised 2440 women, mean age 50 yrs, SD12. Compared with the derivation set, the validation set was younger (diff -9 yrs, 95% CI-2.2-12), less likely to have a history of CAD (OR 0.7, 95%CI 0.5-0.8), and less often considered at high clinical suspicion (OR 0.7, 95%CI 0.6-0.8). A final diagnosis of CAD was found in 8/1523 (.5%), 30/618 (5%), and 55/393 (14%) in the low, moderate and high risk groups respectively. The relative risk of CAD was greater in the moderate risk group (OR 10, 95% CI 5-22) and high risk group (OR 35, 95%CI 16-74) compared with the low risk group. CONCLUSION: We successfully validated a model that utilizes cardiac risk factors and clinical suspicion for risk stratification in women after an initial negative ED evaluation. These data suggest this model can identify women who are high risk and would therefore benefit from comprehensive diagnostic testing to identify CAD.
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