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Background: Syncope is a common chief complaint among older adults in the Emergency Department (ED), and orthostatic vital signs are often a part of their evaluation. We assessed whether abnormal orthostatic vital signs in the ED are associated with composite 30-day serious outcomes in older adults presenting with syncope.Methods: We performed a secondary analysis of a prospective, observational study at 11 EDs in adults ≥ 60 years who presented with syncope or near syncope. We excluded patients lost to follow up. We used the standard definition of abnormal orthostatic vital signs or subjective symptoms of lightheadedness upon standing to define orthostasis. We determined the rate of composite 30-day serious outcomes, including those during the index ED visit, such as cardiac arrhythmias, myocardial infarction, cardiac intervention, new diagnosis of structural heart disease, stroke, pulmonary embolism, aortic dissection, subarachnoid hemorrhage, cardiopulmonary resuscitation, hemorrhage/anemia requiring transfusion, with major traumatic injury from fall, recurrent syncope, and death) between the groups with normal and abnormal orthostatic vital signs.Results: The study cohort included 1974 patients, of whom 51.2% were male and 725 patients (37.7%) had abnormal orthostatic vital signs. Comparing those with abnormal to those with normal orthostatic vital signs, we did not find a difference in composite 30-serious outcomes (111/725 (15.3%) vs 184/1249 (14.7%); unadjusted odds ratio, 1.05 [95%CI, 0.81-1.35], p = 0.73). After adjustment for gender, coronary artery disease, congestive heart failure (CHF), history of arrhythmia, dyspnea, hypotension, any abnormal ECG, physician risk assessment, medication classes and disposition, there was no association with composite 30-serious outcomes (adjusted odds ratio, 0.82 [95%CI, 0.62-1.09], p = 0.18).Conclusions: In a cohort of older adult patients presenting with syncope who were able to have orthostatic vital signs evaluated, abnormal orthostatic vital signs did not independently predict composite 30-day serious outcomes. [ABSTRACT FROM AUTHOR]

Introduction/objective: Little is known about the long-term outcomes of injured older adults cared for in trauma systems. We sought to describe mortality and causes of death over time, and the independent association of injury severity, comorbidities, and other factors on 12-month mortality among injured older adults transported by emergency medical services (EMS).Materials and Methods: This was a population-based cohort study of injured adults ≥ 65 years in the United States transported by 44 EMS agencies to 51 hospitals from January 1, 2011 to December 31, 2011, with 12-month follow-up through December 31, 2012. The primary outcomes were time to death and causes of death. We used descriptive statistics and Cox proportional hazards models to generate adjusted hazard ratios (HR).Results: 15,649 injured older adults were transported by EMS, frequently after a fall (84.5%). Serious injuries (Injury Severity Score [ISS] ≥ 16) occurred in 3.5%, with serious extremity injury (Abbreviated Injury Scale score ≥ 3) being most common (17.8%). Mortality rates were: 1.6% in-hospital, 5.1% at 30 days, 9.4% at 90 days and 20.3% at 1 year. The adjusted HR for patients in the highest comorbidity quartile was 2.20 (versus lowest quartile, 95% CI 1.97-2.46, p <  .001), while the HR for ISS ≥ 25 was 2.69 (versus ISS 0-8, 95% CI 1.60-4.51, p =  .001). Cardiovascular etiologies (53.3%) and dementia (32.7%) were the most common causes of death, with injury listed in 12.8% of death certificates.Conclusions: Injury requiring EMS transport is a sentinel event among older adults, with death typically occurring months later, often due to cardiovascular causes and dementia. A heavy comorbidity burden had an adjusted mortality risk comparable to severe injury. [ABSTRACT FROM AUTHOR]

Purpose Suicide attempts by adolescents most commonly involve the overdose of medications. To date, there has been little information on the over-the-counter or prescription medicines that adolescents ingest for self-harm. Identification of medications chosen in suicide attempts may help guide anticipatory guidance to parents by primary care providers and Poison Centers in prevention programs. Methods This was a retrospective observational study using the American Association of Poison Control Center's National Poison Data System. Data were collected on patients aged 13–19 years old at the time of their substance ingestion, between the years 2004 and 2013 and that were coded as reason for ingestion of “intentional-suspected suicide.” Results During the 10-year study period, there were 390,560 poison center calls for intentional-suspected suicide in the United States between 2004 and 2013, accounting for 80.3% of all “intentional” ingestion calls in the adolescent population. Over the entire age range, the most common substance ingested included acetaminophen (10.9%), ibuprofen (9%), selective serotonin reuptake inhibitors (7.7%), atypical antipsychotic (6%), and antihistamines (5%). The most common medications coded as resulting in major clinical effects or death were antidepressants and atypical antipsychotics. Conclusions Adolescent ingestion choices for suicide attempts have remained relatively consistent over the past 10 years. However, there was a recent decrease in selective serotonin reuptake inhibitor ingestions. The most common medications used in an overdose attempt were ibuprofen and acetaminophen. Further preventative efforts are needed in this at-risk population from multiple providers at various levels. [ABSTRACT FROM AUTHOR]

Cardiopulmonary ultrasound (CPUS) is commonly used to assess cardiac function and preload status in patients with septic shock. However, the reliability of CPUS findings at the point of care is unknown. To assess interrater reliability (IRR) of CPUS in patients with suspected septic shock between treating emergency physicians (EPs) vs emergency ultrasound (EUS) experts. Single-center, prospective, observational cohort enrolling patients (n = 51) with hypotension and suspected infection. Treating EPs performed and interpreted CPUS for cardiac function parameters (left ventricular [LV] function and right ventricular [RV] function and size) and preload volume parameters (inferior vena cava [IVC] diameter and pulmonary B-lines). The primary outcome was IRR (assessed by Kappa values [κ] and intraclass correlation coefficient [ICC]) between EP and EUS-expert consensus. Secondary analyses examined the effects on IRR of operator experience, respiratory rate, and known difficult views on a Cardiology-performed echocardiogram. IRR was fair for LV function, κ = 0.37, 95% confidence interval (CI) 0.1–0.64; poor for RV function, κ = −0.05, 95% CI −0.6–0.5; moderate for RV size, κ = 0.47, 95% CI 0.07–0.88; and substantial for B-lines, κ = 0.73, 95% CI 0.51–0.95 and IVC size, ICC = 0.87, 95% CI 0.2–0.99. Involvement of ultrasound-trained faculty was associated with improved IRR of RV size (p = 0.002), but not other CPUS domains. Our study demonstrated high IRR for preload volume parameters (IVC size and presence of B-lines), but not for cardiac parameters (LV function and RV function and size) in patients presenting with concern for septic shock. Future research must focus on determining sonographer and patient-specific factors affecting CPUS interpretation in real-time. [ABSTRACT FROM AUTHOR]

1. Integrating a qualitative approach, participants will understand the clinical context and depth of patient-family-/clinician communication influencing in-the-moment medical-care decision-making of patients with POLST for limited treatment/comfort measures. 2. Participants will be able to demonstrate an understanding of the importance of high-quality communication around prognosis, risks/benefits/complications, expected recovery, and implications for quality of life during hospitalizations. Patients with POLST for limited-treatment/comfort measures sometimes receive intensive treatment not aligned with their POLST-preferences. We found most care received was goal-concordant with patients' 'in-the-moment' preferences despite being POLST-discordant, which was influenced by clinician rescue mindset, lack of patient understanding illness trajectory, and decisional regret, implying need for high-quality communication. POLST aim to ensure patients receive goal-concordant care. Despite POLST orders for treatment limitations or comfort measures only (CMO), patients sometimes receive intensive treatment that is POLST-discordant (i.e., not aligned with their documented preferences). To understand the clinical context in which patients with POLST orders for treatment limitations/CMO receive POLST-discordant care. This was a secondary analysis of a retrospective study of patients presenting to an emergency department between April 2015-October 2016. Using the Oregon POLST Registry, we identified 1,769 patients with completed POLST, of which 848 selected limited treatment/CMO. From this cohort, 32 patients received intensive treatment (e.g., ICU admission, intubation/mechanical ventilation, hemodialysis). We performed thematic content analysis of documentation within the electronic health record to understand the context in which patients received POLST-discordant care. Mean age was 73 (SD=13); 31% had POLST orders for CMO. The majority of hospitalizations (78%) were related to acute illness requiring procedural interventions; within the context of such interventions, mechanical ventilation was the most common form of intensive treatment received (78%), followed by ICU admission (44%). Patients primarily consented themselves (72%). We identified several themes pertaining to the clinical context of POLST-discordant care, including: clinicians' rescue mindset, lack of understanding of patients' trajectory for recovery within the context of chronic illness, and decisional regret. Only 34% were discharged to their prior level of independence. Among patients with treatment limitations/CMO on POLST who present to the emergency department, POLST-discordant care may still represent goal-concordant care within the context of acute illness. However, miscommunication around goals and lack of consideration of patients' acute illness within the broader context of their chronic illness trajectory may contribute to patient/family regret. Patients' preferences and goals should be assessed with high-quality communication around prognosis, risks/benefits/complications, expected recovery, and implications for quality-of-life during hospitalizations. Advanced care planning/shared decision making/Qualitative and mixed methods research [ABSTRACT FROM AUTHOR]

Background Brain injury is a leading cause of death and disability in trauma patients. Ethanol (EtOH) use near the time of injury may contribute to worse outcomes in these patients by exacerbating coagulopathy. There are limited data regarding the effects of EtOH on coagulation and progression of traumatic intracranial hemorrhage (TICH). Methods We performed a retrospective analysis of a prospective observational study of 168 trauma patients with TBI at an urban level 1 trauma center. Thromboelastography (TEG) was performed on admission and over the subsequent 48 hours. Demographic, physiologic, and outcomes data were collected. Computed tomography imaging of the head performed within the first 48 hours of admission was analyzed for progression of TICH. Results Thirty-six percent of patients ( n = 61) had positive blood EtOH on admission (median EtOH level = 198 mg/dL [range, 16–376 mg/dL]). EtOH-positive patients were less severely injured than EtOH-negative patients ( P = 0.01). Other admission demographic and physiologic variables were similar between groups. There were no significant differences in TEG values between EtOH-positive and EtOH-negative patients on admission or during the subsequent 48 hours. There were no differences in radiographic progression of hemorrhage, the need for neurosurgical procedure, or mortality between EtOH-positive and EtOH-negative patients. Conclusions EtOH use near the time of traumatic injury was not associated with alterations in coagulation, as measured by traditional coagulation tests or by TEG, in patients with TICH. Furthermore, a positive blood alcohol at admission was not associated with increased mortality or need for neurosurgical procedure these patients. [ABSTRACT FROM AUTHOR]

Study Objective: Cardiac arrhythmia is a life-threatening condition in older adults who present to the emergency department (ED) with syncope. Previous work suggests the initial ED ECG can predict arrhythmia risk; however, specific ECG predictors have been variably specified. Our objective is to identify specific ECG abnormalities predictive of 30-day serious cardiac arrhythmias in older adults presenting to the ED with syncope.Methods: We conducted a prospective, observational study at 11 EDs in adults aged 60 years or older who presented with syncope or near syncope. We excluded patients with a serious cardiac arrhythmia diagnosed during the ED evaluation from the primary analysis. The outcome was occurrence of 30-day serous cardiac arrhythmia. The exposure variables were predefined ECG abnormalities. Independent predictors were identified through multivariate logistic regression. The sensitivities and specificities of any predefined ECG abnormality and any ECG abnormality identified on adjusted analysis to predict 30-day serious cardiac arrhythmia were also calculated.Results: After exclusion of 197 patients (5.5%; 95% confidence interval [CI] 4.7% to 6.2%) with serious cardiac arrhythmias in the ED, the study cohort included 3,416 patients. Of these, 104 patients (3.0%; 95% CI 2.5% to 3.7%) had a serious cardiac arrhythmia within 30 days from the index ED visit (median time to diagnosis 2 days [interquartile range 1 to 5 days]). The presence of nonsinus rhythm, multiple premature ventricular conductions, short PR interval, first-degree atrioventricular block, complete left bundle branch block, and Q wave/T wave/ST-segment abnormalities consistent with acute or chronic ischemia on the initial ED ECG increased the risk for a 30-day serious cardiac arrhythmia. This combination of ECG abnormalities had a similar sensitivity in predicting 30-day serious cardiac arrhythmia compared with any ECG abnormality (76.9% [95% CI 67.6% to 84.6%] versus 77.9% [95% CI 68.7% to 85.4%]) and was more specific (55.1% [95% CI 53.4% to 56.8%] versus 46.6% [95% CI 44.9% to 48.3%]).Conclusion: In older ED adults with syncope, approximately 3% receive a diagnosis of a serious cardiac arrhythmia not recognized on initial ED evaluation. The presence of specific abnormalities on the initial ED ECG increased the risk for 30-day serious cardiac arrhythmias. [ABSTRACT FROM AUTHOR]

Study Objective: Emergency department (ED) crowding and patient boarding are associated with increased mortality and decreased patient satisfaction. This study uses a positive deviance methodology to identify strategies among high-performing, low-performing, and high-performance improving hospitals to reduce ED crowding.Methods: In this mixed-methods comparative case study, we purposively selected and recruited hospitals that were within the top and bottom 5% of Centers for Medicare & Medicaid Services case-mix-adjusted ED length of stay and boarding times for admitted patients for 2012. We also recruited hospitals that showed the highest performance improvement in metrics between 2012 and 2013. Interviews were conducted with 60 key leaders (physicians, nurses, quality improvement specialists, and administrators).Results: We engaged 4 high-performing, 4 low-performing, and 4 high-performing improving hospitals, matched on hospital characteristics including geographic designation (urban versus rural), region, hospital occupancy, and ED volume. Across all hospitals, ED crowding was recognized as a hospitalwide issue. The strategies for addressing ED crowding varied widely. No specific interventions were associated with performance in length-of-stay metrics. The presence of 4 organizational domains was associated with hospital performance: executive leadership involvement, hospitalwide coordinated strategies, data-driven management, and performance accountability.Conclusion: There are organizational characteristics associated with ED decreased length of stay. Specific interventions targeted to reduce ED crowding were more likely to be successfully executed at hospitals with these characteristics. These organizational domains represent identifiable and actionable changes that other hospitals may incorporate to build awareness of ED crowding. [ABSTRACT FROM AUTHOR]

Background: Migraine headaches are a common reason for pediatric emergency department (ED) visits. Small studies suggest the potential efficacy of sub-anesthetic doses of propofol for migraine with a favorable side effect profile and potentially decreased length of stay (LOS).Objective: The objective of this study was to compare the efficacy of low-dose propofol (LDP) to standard therapy (ST) in pediatric migraine treatment.Methods: We conducted a prospective, pragmatic randomized controlled trial from April 2014 through June 2016 in the ED at two pediatric hospitals. Patients aged 7-19 years were eligible if they were diagnosed with migraine by the emergency physician and had a presenting visual analog pain score (VAS) of 6-10. Primary outcome was the percent of pain reduction. Secondary outcomes were ED LOS, 24-h rebound headache, return visits to the ED, and adverse reactions.Results: Seventy-four patients were enrolled, but 8 were excluded, leaving 66 patients in the final analysis (36 ST, 30 LDP). Pain reduction was 59% for ST and 51% for LDP (p = 0.34) with 72.2% vs. 73.3% achieving a VAS ≤ 4 with initial therapy (p = 0.92). There was a nonsignificant trend toward shorter median LOS from drug administration to final disposition favoring propofol (79 min vs. 111 min; p = 0.09). Rebound headache was significantly more common in the ST vs. LDP group (66.7% vs. 25.0%; p = 0.01).Conclusions: LDP did not achieve better pain reduction than ST, however, LDP was associated with significantly fewer rebound headaches and a nonsignificant trend toward shorter median LOS from drug administration to disposition. [ABSTRACT FROM AUTHOR]