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Background: Given the many causes of seizures, emergency physicians often utilize brain computed tomography (CT) to evaluate for intracranial pathology. However, a CT exposes patients to 100 times more radiation than a chest radiograph. Previously, we developed a four‐item clinical decision instrument (CDI) to determine which patients with status epilepticus (SE) do not require emergent neuroimaging. In this study, we seek to prospectively validate our CDI in patients with a history of seizures with both SE and generalized tonic–clonic seizures. Methods: This was a prospective observational study of 1,739 consecutive patients who were recruited from two urban hospitals in Philadelphia, Pennsylvania. All patients, 18 years and older, who presented with a chief complaint of seizure and had emergency neuroimaging performed were eligible for inclusion. Patients were excluded from analysis if this was a first‐time seizure, had a ventriculoperitoneal shunt, or had focal neurologic deficits. Results: A total of 376 patients were in the final analysis. Of the 376 patients, 10 patients (3%) had positive CTs. Nine of the 10 of the patients were identified by our CDI, resulting in a negative predictive value (NPV) of 99.5%. On secondary analysis, we refined our CDI from four to three criteria: 1) history of intracranial hemorrhage (ICH), 2) active malignancy, and 3) trauma. These criteria also had a NPV of >99% when applied to patients in SE. Conclusion: The validation of our CDI showed improved NPV when compared to the derivation set. Use of the criteria of history of ICH, active malignancy, and trauma could have reduced the use of emergent neuroimaging in our cohort by up to 49%. This CDI should be validated in a larger subset of patients and in multiple centers prior to widespread adoption. [ABSTRACT FROM AUTHOR]

The article focuses on return hospital admissions among 1419 COVID-19 patients discharged from Five U.S. Emergency Departments (ED). It mentions patient characteristics associated with return hospital admission and study cohort if they tested positive for COVID-19 within 7 days before or after the ED encounter. It also mentions selection of covariates occurred prior to analysis and was based on previous literature on risk factors for severe COVID-19 illness.

Objective: Many emergency department (ED) transfers of children may be avoidable. Identifying hospital‐level variables associated with avoidable transfers may guide system‐level interventions to improve pediatric emergency care. We sought to examine hospital characteristics associated with ED transfers deemed "probably avoidable" in a large state Medicaid program. Methods: We performed a retrospective cohort study using 2009 to 2013 claims data for Pennsylvania Medicaid beneficiaries. We categorized all ED transfers of children < 17 years old as "probably avoidable," "possibly avoidable", or "unavoidable" based on ultimate disposition and procedures (including subspecialty consultations) at the receiving ED. Using descriptive statistics and multivariable regression, we examined hospital characteristics associated with probably avoidable transfers. Results: Among 2,839,379 pediatric visits to EDs across 158 Pennsylvania hospitals, 20,304 resulted in transfer. Among these, 3,764 (18.5%) were categorized as probably avoidable and 6,091 (30.0%) as possibly avoidable transfers. In adjusted analysis, compared to hospitals with no pediatric‐specific capabilities, probably avoidable transfers were less likely from referring hospitals with pediatric‐specific EDs and no other pediatric‐specific capabilities (adjusted odds ratio [aOR] = 0.38, 95% confidence interval [CI] = 0.21–0.71) and from referring hospitals with pediatric‐specific EDs and inpatient capabilities (aOR = 0.36, 95% CI = 0.20–0.64). Probably avoidable transfers were more likely from referring hospitals in large metropolitan areas (aOR = 2.64, 95% CI = 1.46–4.80) compared to those in rural areas. Conclusions: Among pediatric emergency transfers in a large state Medicaid program with a nearly 20% probably avoidable transfer rate, there was significant hospital‐level variation in the proportion of probably avoidable transfers. Transfers from hospitals in large metropolitan areas and transfers from hospitals without pediatric‐specific capabilities had increased odds of being probably avoidable transfers, such that these hospitals may represent targets for interventions to reduce these transfers. [ABSTRACT FROM AUTHOR]

Background: Pediatric patients attended to by emergency medical services (EMS) but not transported to the hospital are an at‐risk population. We aimed to evaluate risk factors associated with nontransport by EMS in pediatric patients. Methods: We reviewed medical records of 24 agencies in a regional EMS system in Southwestern Pennsylvania between January 1, 2014, and December 31, 2017. We abstracted demographics (age, sex, medical complaint, median household income by zip code, race, ethnicity), clinical characteristics (abnormal vital signs by age, procedures done), and transport characteristics. We excluded patients ≥ 18 years, interfacility transfers, scene assists, cardiac arrest, and those without a patient encounter. We used unadjusted and adjusted logistic regression to identify factors associated with nontransport, reporting adjusted odds ratios (aOR) with 95% confidence intervals (CIs). Results: We included 30,663 pediatric patients (52.9% male, mean ± SD age = 8.5 ± 6.2 years), of whom 5,002 (16.3%) were nontransports. In adjusted analysis (aOR, 95% CI), nontransports were associated with medical categories of trauma (4.32, 3.57–5.23), respiratory (4.03, 3.09–5.26), toxicologic (2.53, 1.66–3.86), and syncope (5.97, 3.78–9.41). Nontransports were less likely for psychiatric (0.52, 0.34–0.79) complaints; for black patients compared to white (0.31, 0.26–0.37); and in patients 6 to <12 years (0.76, 0.65–0.90), 2 to <6 years (0.77, 0.65–0.91), 1 to <2 years (0.53, 0.42–0.66), and 1 month to 1 year (0.52, 0.40–0.66) compared to patients ≥ 12 years of age. Nontransport was associated with longer scene time (1.03, 1.02–1.04) and with fall compared to winter (1.29, 1.08–1.54) and was less likely in those with abnormal mental status (0.45, 0.33–0.62), medication administration (0.16, 0.08–0.31), or monitor application (0.10, 0.06–0.15). Conclusion: Pediatric nontransports are associated with traumatic, respiratory, and toxicologic complaints and older age. These findings can facilitate development of refusal protocols and research on outcomes of these at‐risk patients. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: We determined the impact of including race, ethnicity, and poverty in risk adjustment models for emergency care–sensitive conditions mortality that could be used for hospital pay‐for‐performance initiatives. We hypothesized that adjusting for race, ethnicity, and poverty would bolster rankings for hospitals that cared for a disproportionate share of nonwhite, Hispanic, or poor patients. Methods: We performed a cross‐sectional analysis of patients admitted from the emergency department to 157 hospitals in Pennsylvania with trauma, sepsis, stroke, cardiac arrest, and ST‐elevation myocardial infarction. We used multivariable logistic regression models to predict in‐hospital mortality. We determined the predictive accuracy of adding patient race and ethnicity (dichotomized as non‐Hispanic white vs. all other Hispanic or nonwhite patients) and poverty (uninsured, on Medicaid, or lowest income quartile zip code vs. all others) to other patient‐level covariates. We then ranked each hospital on observed‐to‐expected mortality, with and without race, ethnicity, and poverty in the model, and examined characteristics of hospitals with large changes between models. Results: The overall mortality rate among 170,750 inpatients was 6.9%. Mortality was significantly higher for nonwhite and Hispanic patients (adjusted odds ratio [aOR] = 1.27, 95% confidence interval [CI] = 1.19–1.36) and poor patients (aOR = 1.21, 95% CI = 1.12–1.31). Adding race, ethnicity, and poverty to the risk adjustment model resulted in a small increase in C‐statistic (0.8260 to 0.8265, p = 0.002). No hospitals moved into or out of the highest‐performing decile when adjustment for race, ethnicity, and poverty was added, but the three hospitals that moved out of the lowest‐performing decile, relative to other hospitals, had significantly more nonwhite and Hispanic patients (68% vs. 11%, p < 0.001) and poor patients (56% vs. 10%, p < 0.001). Conclusions: Sociodemographic risk adjustment of emergency care–sensitive mortality improves apparent performance of some hospitals treating a large number of nonwhite, Hispanic, or poor patients. This may help these hospitals avoid financial penalties in pay‐for‐performance programs. [ABSTRACT FROM AUTHOR]

Objectives Higher resource utilization in the management of pediatric patients with undifferentiated vomiting and/or diarrhea does not correlate consistently with improved outcomes or quality of care. Performance feedback has been shown to change physician practice behavior and may be a mechanism to minimize practice variation. We aimed to evaluate the effects of e-mail-only, provider-level performance feedback on the ordering and admission practice variation of pediatric emergency physicians for patients presenting with undifferentiated vomiting and/or diarrhea. Methods We conducted a prospective, quality improvement intervention and collected data over 3 consecutive fiscal years. The setting was a single, tertiary care pediatric emergency department. We collected admission and ordering practices data on 19 physicians during baseline, intervention, and postintervention periods. We provided physicians with quarterly e-mail-based performance reports during the intervention phase. We measured admission rate and created four categories for ordering practices: no orders, laboratory orders, pharmacy orders, and radiology orders. Results There was wide (two- to threefold) practice variation among physicians. Admission rates ranged from 15% to 30%, laboratory orders from 19% to 43%, pharmacy orders from 29% to 57%, and radiology orders from 11% to 30%. There was no statistically significant difference in the proportion of patients admitted or with radiology or pharmacy orders placed between preintervention, intervention, or postintervention periods (p = 0.58, p = 0.19, and p = 0.75, respectively). There was a significant but very small decrease in laboratory orders between the preintervention and postintervention periods. Conclusions Performance feedback provided only via e-mail to pediatric emergency physicians on a quarterly basis does not seem to significantly impact management practices for patients with undifferentiated vomiting and/or diarrhea. [ABSTRACT FROM AUTHOR]

Objective We used an emergency department ( ED)-based method to provide targeted, individualized consultation; community notification; and public disclosure and collect data regarding willingness to participate in prospective resuscitation research requiring waiver of consent. Methods We conducted a prospective survey of convenience cohort in an urban ED. We targeted the community of ED patients with pulmonary disease for individualized notification and public disclosure using a 1) large poster, 2) scripted oral presentation describing an emergency intubation clinical trial, and 3) video demonstration. Results Approximately 10% of our annual ED census, 6,936 subjects, enrolled. Of that total, 29 were also subjects in a prospective coincident endotracheal resuscitation intubation study, which enrolled a total of 262 subjects. ED community notification was provided to 22 of the 29 (75.9%) subjects prior to the visit during which they were intubated (13 agreed to participate, six declined, and three undecided) and seven of the 29 subjects subsequent to enrollment in the intubation study (five agreed to participate and two undecided). Fourteen of the 29 patients who participated in both projects had undergone endotracheal intubation at least once prior to community notification: 10 agreed to participate in the study, two declined, and two were undecided. Conclusions Emergency department-based community notification and public disclosure is a viable way to provide information to a target population and collect data about the success of the notification. Feedback data collection is critical to an ethical understanding of the success of community notification for the institutional review board and investigators. Collection of feedback data should be required as a subject protection for exception from informed consent in emergency settings. [ABSTRACT FROM AUTHOR]

ACADEMIC EMERGENCY MEDICINE 2011; 18:934-940 © 2011 by the Society for Academic Emergency Medicine Abstract Objectives: The objective was to evaluate the effect of arrival to the emergency department (ED) by emergency medical services (EMS) on time to initiation of antibiotics, time to initiation of intravenous fluids (IVF), and in-hospital mortality in patients with severe sepsis and septic shock. Methods: The authors performed an evaluation of prospectively collected registry data of patients with a diagnosis of severe sepsis or septic shock who presented to an urban academic ED during a 2-year period from January 1, 2005, to December 31, 2006. Descriptive and multivariate analytic methods were used to analyze the data. Using unadjusted and adjusted models, out-of-hospital patients who presented to the ED by ambulance (EMS) were compared to control patients who arrived by alternative means (non-EMS). Primary outcomes measured were ED time to initiation of antibiotics, ED time to initiation of IVF, and in-hospital mortality. Results: A total of 963 severe sepsis patients were enrolled in the registry. Median time to antibiotics was 116 minutes for EMS (interquartile range [IQR] = 66 to 199) vs. 152 minutes for non-EMS (IQR = 92 to 252, p ≤ 0.001). Median time to initiation of IVF was 34 minutes for EMS (IQR = 10 to 88) and 68 minutes for non-EMS (IQR = 25 to 121, p ≤ 0.001). After adjustment for the Acute Physiology and Chronic Health Evaluation II (APACHE II) score, age, and initial serum lactate level, no significant differences in hospital mortality were seen (adjusted relative risk [aRR] for EMS vs. non EMS = 1.24, 95% confidence interval [CI] = 0.92 to 1.66, p = 0.16). The Cox proportional hazard ratio (HR) comparing EMS to non-EMS care after similar adjustment was HR = 1.27 for IVF (95% CI = 1.10 to 1.47, p = 0.004) and HR = 1.25 for antibiotics (95% CI = 1.08 to 1.44, p = 0.003). Conclusions: Out-of-hospital care was associated with improved in-hospital processes for the care of critically ill patients. Despite shortened ED treatment times for septic patients who arrive by EMS, a mortality benefit could not be demonstrated. [ABSTRACT FROM AUTHOR]

Objectives: Observational studies of patients with cocaine-associated myocardial infarction have suggested more coronary disease than expected on the basis of patient age. The study objective was to determine whether cocaine use is associated with coronary disease in low- to intermediate-risk emergency department (ED) patients with potential acute coronary syndrome (ACS). Methods: The authors conducted a cross-sectional study of low- to intermediate-risk patients < 60 years of age who received coronary computerized tomographic angiography (CTA) for evaluation of coronary artery disease (CAD) in the ED. Patients were classified into three groups with respect to CAD: maximal stenosis <25%, 25% to 49%, and ≥50%. Prespecified multivariate modeling (generalized estimating equations) was used to assess relationship between cocaine and CAD. Results: Of 912 enrolled patients, 157 (17%) used cocaine. A total of 231 patients had CAD ≥25%; 111 had CAD ≥50%. In univariate analysis, cocaine use was not associated with a lesion 25% or greater (12% vs. 14%; relative risk [RR] = 0.89, 95% confidence interval [CI] = 0.5 to 1.4) or 50% or greater (12% vs. 11%; RR = 1.15, 95% CI = 0.6 to 2.3). In multivariate modeling adjusting for age, race, sex, cardiac risk factors, and Thrombosis in Myocardial Infarction (TIMI) score, cocaine use was not associated with the presence of any coronary lesion (adjusted RR = 0.95, 95% CI = 0.69 to 1.31) or coronary lesions 50% or greater (adjusted RR = 0.78, 95% CI = 0.45 to 1.38). There was also no relationship between repetitive cocaine use and coronary calcifications or between recent cocaine use and CAD. Conclusions: In symptomatic ED patients at low to intermediate risk of an ACS, cocaine use was not associated with an increased likelihood of coronary disease after adjustment for age, race, sex, and other risk factors for coronary disease. [ABSTRACT FROM AUTHOR]