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Background: Emergency physicians commonly encounter low-probability/high-morbidity decisions, and chest pain is a prime example. Negative outcomes are improbable but feared, resulting in substantially more patients admitted for chest pain than have important disease. The literature gives little guidance on patient preferences for decision-making when the negative outcomes are unlikely but potentially severe. Objectives: The objective of this pilot study was to assess the tolerance of Emergency Department (ED) patients with chest pain for adverse events occurring within 2 weeks of the episode. Method: We recruited a convenience sample of patients with a chief complaint of chest pain from the ED of an urban tertiary-care referral center. Each subject was interviewed to determine demographic information, perceived health status, insurance status, and tolerance for adverse events related to chest pain. Adverse events were defined loosely but were suggested to be heart attack, the need for emergency cardiac surgery, or death. The risk tolerance question was framed by describing a specific numeric risk and determining at what risk the patient switched from desiring hospital admission to desiring discharge; we termed this the decision threshold. Results: Sixty-eight (68) subjects were included. Fifty-four percent of subjects were male, 60% were African-American, and 35% were white; 40% of the subjects classified themselves as being of average health. Of the 31 subjects who had prior heart trouble, 48% (n = 15) stated they had a prior heart attack and 19% (n = 6) an irregular heartbeat. The median decision threshold, or the acceptable personal risk of an adverse event for a person to forego admission to hospital, was 6.5% (interquartile range 0.5–22.9%). The mode was 0.5%, and 44% (30/68) of subjects had a decision threshold of 2% or less. There was no obvious pattern for most of these explanatory variables, though there was a suggestion that race may affect patients' risk tolerance. Conclusions: There is substantial variation in patients' reported tolerance for adverse events from ED chest pain. Further investigation of this phenomenon may lead to better decision-making.

The effect of dosage of continuous venovenous hemodiafiltration (CVVHDF) on survival in patients with acute renal failure (ARF) is unknown. In this study, 200 critically ill patients with ARF were randomly assigned to receive CVVHDF with prefilter replacement fluid at an effluent rate of either 35 ml/kg per h (high dosage) or 20 ml/kg per h (standard dosage). The primary study outcome, survival to the earlier of either intensive care unit discharge or 30 d, was 49% in the high-dosage arm and 56% in the standard-dosage arm (odds ratio 0.75; 95% confidence interval 0.43 to 1.32; P = 0.32). Among hospital survivors, 69% of those in the high-dosage arm recovered renal function compared with 80% of those in the standard-dosage arm (P = 0.29); therefore, a difference in patient survival or renal recovery was not detected between patients receiving high-dosage or standard-dosage CVVHDF.

Article-at-a-Glance Background Therapeutic hypothermia (TH) is associated with improved neurologically intact survival after out-of-hospital cardiopulmonary arrest. Because of its complex multidisciplinary nature, many hospitals in the United States have resisted implementing TH. A post–cardiac arrest (post-arrest) TH program was implemented at a major urban academic medical center. Implementing the Therapeutic Hypothermia Program After initial efforts at TH at the University of Alabama at Birmingham Hospital nearly failed, the leaders restructured the TH program. Key elements included frequent multidisciplinary meetings involving all stakeholders, development of TH protocols and techniques consistent with customary institutional practices, introduction of cooling technology, and implementation of a TH physician rapid response system. Results During its first 21 months, the program initiated TH on 93 post-arrest patients. Of the 83 patients who achieved goal hypothermia temperature, 30 (36%; 95% confidence interval [CI]: 26%–47%) survived to hospital discharge. Care teams successfully managed expected complications. Of two patients with TH-associated coagulopathy, one required TH termination. Conclusions The program illustrates key lessons for successful TH program implementation, such as the difficulty of organizing and coordinating complex interventions in complex institutions, the importance of overcoming workplace culture, the value of technology, the need for midcourse corrections, and the advantages of a physician-based rapid response system. Many of these lessons are applicable to any quality improvement intervention.