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Emergency department (ED) crowding continues to be a major challenge and has important ramifications for patient care quality. One strategy to decrease ED crowding has been to implement alternative pathways to traditional hospital admission. Through a survey-based retrospective cohort study, we aimed to assess the patient experience for those who agreed to transfer and admission to an affiliated community hospital from a large, academic center’s ED. In all, 85% of participants rated their overall experience as either great or good, 92% did not find it hard to make the decision to be transferred, and 95% found the transfer process itself to be easy.

Study objective The effect of urgent cares on local emergency department (ED) patient volumes is presently unknown. In this paper, we aimed to assess the change in low-acuity ED utilization at 2 academic medical centers in relation to patient proximity to an affiliated urgent care. Methods We created a geospatial database of ED visits occurring between April 2016 and March 2018 to 2 academic medical centers in an integrated health care system, geocoded by patient home address. We used logistic regression to characterize the relationship between the likelihood of patients visiting the ED for a low-acuity condition, based on ED discharge diagnosis, and urgent care center proximity, defined as living within 1 mile of an open urgent care center, for each of the academic medical centers in the system, adjusting for spatial, temporal, and patient factors. Results We identified a statistically significant reduction in the likelihood of ED visits for low-acuity conditions by patients living within 1 mile of an urgent care center at 1 of the 2 academic medical centers, with an adjusted odds ratio of 0.87 (95% confidence interval 0.78 to 0.98). There was, however, no statistically significant reduction at the other affiliated academic medical center. Further analysis showed a statistically significant temporal relationship between time since urgent care center opening and likelihood of a low-acuity ED visit, with approximately a 1% decrease in the odds of a low-acuity visit for every month that the proximal urgent care center was open (odds ratio 0.99; 95% confidence interval 0.985 to 0.997). Conclusion Although further research is needed to assess the factors driving urgent care centers' variable influence on low-acuity ED use, these findings suggest that in similar settings urgent care center development may be an effective strategy for health systems hoping to decrease ED utilization for low-acuity conditions at academic medical centers.

Objective Prior data suggest Emergency Department (ED) visits for many emergency conditions decreased during the initial COVID-19 surge. However, the pandemic's impact on the wide range of conditions seen in EDs, and the resources required for treating them, has been less studied. We sought to provide a comprehensive analysis of ED visits and associated resource utilization during the initial COVID-19 surge. Methods We performed a retrospective analysis from 5 hospitals in a large health system in Massachusetts, comparing ED encounters from 3/1/2020–4/30/2020 to identical weeks from the prior year. Data collected included demographics, ESI, diagnosis, consultations ordered, bedside procedures, and inpatient procedures within 48 h. We compared raw frequencies between time periods and calculated incidence rate ratios. Results ED volumes decreased by 30.9% in 2020 compared to 2019. Average acuity of ED presentations increased, while most non-COVID-19 diagnoses decreased. The number and incidence rate of all non-critical care ED procedures decreased, while the occurrence of intubations and central lines increased. Most subspecialty consultations decreased, including to psychiatry, trauma surgery, and cardiology. Most non-elective procedures related to ED encounters also decreased, including craniotomies and appendectomies. Conclusion Our health system experienced decreases in nearly all non-COVID-19 conditions presenting to EDs during the initial phase of the pandemic, including those requiring specialty consultation and urgent inpatient procedures. Findings have implications for both public health and health system planning.

INTRODUCTION: Emergency clinicians on the frontline of the coronavirus pandemic experience a range of emotions including anxiety, fear, and grief. Debriefing can help clinicians process these emotions, but the coronavirus pandemic makes it difficult to create a physically and psychologically safe space in the emergency department (ED) to perform this intervention. In response, we piloted a video-based debriefing program to support emergency clinician well-being. We report the details of our program and results of our evaluation of its acceptability and perceived value to emergency clinicians during the pandemic. METHODS: ED attending physicians, resident physicians, and non-physician practitioners (NPP) at our quaternary-care academic medical center were invited to participate in role-based, weekly one-hour facilitated debriefings using Zoom. ED attendings with experience in debriefing led each session and used an explorative approach that focused on empathy and normalizing reactions. At the end of the pilot, we distributed to participants an anonymous 10-point survey that included multiple-answer questions and visual analogue scales. RESULTS: We completed 18 debriefings with 68 unique participants (29 attending physicians, 6 resident physicians, and 33 NPPs. A total of 76% of participants responded to our survey and 77% of respondents participated in at least two debriefings. Emergency clinicians reported that the most common reasons to participate in the debriefings were "to enhance my sense of community and connection" (81%) followed by "to support colleagues" (75%). Debriefing with members of the same role group (92%) and the Zoom platform (81%) were considered to be helpful aspects of the debriefing structure. Although emergency clinicians found these sessions to be useful (78.8 +/- 17.6) interquartile range: 73-89), NPPs were less comfortable speaking up (58.5 +/- 23.6) than attending physicians (77.8 +/- 25.0) (p = < 0.008). CONCLUSION: Emergency clinicians participating in a video-based debriefing program during the coronavirus pandemic found it to be an acceptable and useful approach to support emotional well-being. Our program provided participants with a platform to support each other and maintain a sense of community and connection. Other EDs should consider implementing a debriefing program to safeguard the emotional well-being of their emergency clinician workforce.

Patient–provider communication has been recognized as a critical area of focus for improved health care quality, with a mounting body of evidence tying patient satisfaction and provider communication to important health care outcomes. Despite this, few programs have been studied in the emergency department (ED) setting. The authors designed a communication curriculum and conducted trainings for all ED clinical staff. Although only 72% of clinicians believed the course would be a valuable use of their time before taking it, 97% reported that it was a valuable use of their time after ( P < .001). Pre-course self-evaluation of knowledge, skill, and ability were high. Despite this, post-course self-efficacy improved statistically significantly. This study suggests that it is possible, in a brief training session, to deliver communication content that participants felt was relevant to their practice, improved their skills and knowledge, changed their attitude, and was perceived to be a valuable use of their time.

Background Variability in the management of atrial fibrillation ( AF ) in the emergency department ( ED ) leads to avoidable hospital admissions and prolonged length of stay ( LOS ). In a retrospective single‐center study, a multidisciplinary AF treatment pathway was associated with a reduced hospital admission rate and reduced LOS . To assess the applicability of the AF pathway across institutions, we conducted a 2‐center study. Methods and Results We performed a prospective, 2‐stage study at 2 tertiary care hospitals. During the first stage, AF patients in the ED received routine care. During the second stage, AF patients received care according to the AF pathway. The primary study outcome was hospital admission rate. Secondary outcomes included ED LOS and inpatient LOS . We enrolled 104 consecutive patients in each stage. Patients treated using the AF pathway were admitted to the hospital less frequently than patients who received routine care (15% versus 55%; P LOS was shorter in the AF pathway cohort than in the routine care cohort (64 versus 105 hours, respectively; P =0.01). There was no significant difference in the average ED LOS between AF pathway and routine care cohorts (14 versus 12 hours, respectively; P =0.32). Conclusions In this prospective 2‐stage, 2‐center study, utilization of a multidisciplinary AF treatment pathway resulted in a 3.7‐fold reduction in admission rate and a 1.6‐fold reduction in average hospital LOS for admitted patients. Utilization of the AF pathway was not associated with a significant change in ED LOS .

Background Development of emergency department (ED) triage systems that accurately differentiate and prioritize critically ill from stable patients remains challenging. We used machine learning models to predict clinical outcomes, and then compared their performance with that of a conventional approach—the Emergency Severity Index (ESI). Methods Using National Hospital and Ambulatory Medical Care Survey (NHAMCS) ED data, from 2007 through 2015, we identified all adult patients (aged ≥ 18 years). In the randomly sampled training set (70%), using routinely available triage data as predictors (e.g., demographics, triage vital signs, chief complaints, comorbidities), we developed four machine learning models: Lasso regression, random forest, gradient boosted decision tree, and deep neural network. As the reference model, we constructed a logistic regression model using the five-level ESI data. The clinical outcomes were critical care (admission to intensive care unit or in-hospital death) and hospitalization (direct hospital admission or transfer). In the test set (the remaining 30%), we measured the predictive performance, including area under the receiver-operating-characteristics curve (AUC) and net benefit (decision curves) for each model. Results Of 135,470 eligible ED visits, 2.1% had critical care outcome and 16.2% had hospitalization outcome. In the critical care outcome prediction, all four machine learning models outperformed the reference model (e.g., AUC, 0.86 [95%CI 0.85–0.87] in the deep neural network vs 0.74 [95%CI 0.72–0.75] in the reference model), with less under-triaged patients in ESI triage levels 3 to 5 (urgent to non-urgent). Likewise, in the hospitalization outcome prediction, all machine learning models outperformed the reference model (e.g., AUC, 0.82 [95%CI 0.82–0.83] in the deep neural network vs 0.69 [95%CI 0.68–0.69] in the reference model) with less over-triages in ESI triage levels 1 to 3 (immediate to urgent). In the decision curve analysis, all machine learning models consistently achieved a greater net benefit—a larger number of appropriate triages considering a trade-off with over-triages—across the range of clinical thresholds. Conclusions Compared to the conventional approach, the machine learning models demonstrated a superior performance to predict critical care and hospitalization outcomes. The application of modern machine learning models may enhance clinicians’ triage decision making, thereby achieving better clinical care and optimal resource utilization. Electronic supplementary material The online version of this article (10.1186/s13054-019-2351-7) contains supplementary material, which is available to authorized users.

To evaluate the efficiency and safety of emergency department (ED) coronary computed tomography angiography (CTA) during a 3-year clinical experience. Single-center registry of coronary CTA in consecutive ED patients with suspicion of acute coronary syndrome (ACS). The primary outcome was efficiency of coronary CTA defined as the length of hospitalization. Secondary endpoints of safety were defined as the rate of downstream testing, normalcy rates of invasive coronary angiography (ICA), absence of missed ACS, and major adverse cardiac events (MACE) during follow-up, and index radiation exposure. One thousand twenty two consecutive patients were referred for clinical coronary CTA with suspicion of ACS. Overall, median time to discharge home was 10.5 (5.7-24.1) hours. Patient disposition was 42.7 % direct discharge from the ED, 43.2 % discharge from emergency unit, and 14.1 % hospital admission. ACS rate during index hospitalization was 9.1 %. One hundred ninety two patients underwent additional diagnostic imaging and 77 underwent ICA. The positive predictive value of CTA compared to ICA was 78.9 % (95 %-CI 68.1-87.5 %). Median CT radiation exposure was 4.0 (2.5-5.8) mSv. No ACS was missed; MACE at follow-up after negative CTA was 0.2 %. Coronary CTA in an experienced tertiary care setting allows for efficient and safe management of patients with suspicion for ACS. • ED Coronary CTA using advanced systems is associated with low radiation exposure. • Negative coronary CTA is associated with low rates of MACE. • CTA in ED patients enables short median time to discharge home. • CTA strategy is characterized by few downstream tests including unnecessary ICA.

Introduction: The objective of this study was to investigate the factors associated with first-pass success in pediatric intubation in the emergency department (ED). Methods: We analyzed the data from two multicenter prospective studies of ED intubation in 17 EDs between April 2010 and September 2014. The studies prospectively measured patient’s age, sex, principal indication for intubation, methods (e.g., rapid sequence intubation [RSI]), devices, and intubator’s level of training and specialty. To evaluate independent predictors of first-pass success, we fit logistic regression model with generalized estimating equations. In the sensitivity analysis, we repeated the analysis in children

Background The United States is battling obesity and heart failure (HF) epidemics. Although studies have suggested relationships between obesity and HF morbidity, little is known regarding the effects of substantial weight reduction in obese patients with HF. Objectives This study investigated whether bariatric surgery is associated with a decreased rate of HF exacerbation. Methods We performed a self-controlled case series study of obese patients with HF who underwent bariatric surgery, using the population-based emergency department (ED) and inpatient sample in California, Florida, and Nebraska. Primary outcome was ED visit or hospitalization for HF exacerbation from 2005 to 2011. We used conditional logistic regression to compare the outcome event rate during sequential 12-month periods, using pre-surgery months 13 to 24 as the reference period. Results We identified 524 patients with HF who underwent bariatric surgery. During the reference period, 16.2% of patients had an ED visit or hospitalization for HF exacerbation. The rate remained unchanged in the subsequent 12-month pre-surgery period (15.3%; p = 0.67). In the first 12-month period after bariatric surgery, we observed a nonsignificantly reduced rate (12.0%; p = 0.052). However, the rate was significantly lower in the subsequent 13 to 24 months after bariatric surgery (9.9%; adjusted odds ratio: 0.57; p = 0.003). By contrast, there was no significant reduction in the rate of HF exacerbation among obese patients who underwent nonbariatric surgery (i.e., cholecystectomy, hysterectomy). Conclusions Our findings indicate that bariatric surgery is associated with a decline in the rate of HF exacerbation requiring ED evaluation or hospitalization among obese patients with HF.

The prevalence of back pain is rising, as is the use of high-cost imaging in the ED. The objective of our study was to determine if an MRI in the ED for patients with back pain resulted in a lower incidence of ED return visit and to determine if these patients had longer ED length of stay (LOS) and use of ED observation.A retrospective cohort study of consecutive patients seen with back pain was conducted at an urban, university-affiliated ED between 1 January 2012 and 11 July 2014. The association of MRI on return within 7 days was assessed using a χDuring the study period, 6094 patients were evaluated in the ED with back pain as the primary diagnosis. Of these, 797 (13%) received an MRI. Among all patients with back pain, 277 (4.5%) returned within 7 days. Univariate analysis found that patients who received an MRI were no less likely to return within 7 days than patients who did not (4.3% vs 4.6%; p=0.68). Patients who had an MRI were more likely to be admitted to observation (74.2% vs 10.8%; p0.0001) and had a longer ED LOS (median 4.8 hours vs 2.7; p0.0001). Multivariable regression confirmed that MRI did not decrease the rate of a 7-day return visit (OR=0.98; 95% CI 0.68 to 1.42).In patients with uncomplicated back pain, performing an MRI will not mitigate their likelihood of return; however, it leads to a longer ED LOS and more ED observation admissions.

AIMS Studies have suggested relationships between obesity and cardiovascular disease (CVD) morbidity. However, little is known about whether substantial weight reduction affects the risk of CVD-related acute care use in obese patients with CVD. The objective of this study was to determine whether bariatric surgery is associated with decreased risk of CVD-related acute care use. METHODS AND RESULTS We performed a self-controlled case series study of obese adults with CVD who underwent bariatric surgery, using population-based emergency department (ED), and inpatient samples in California, Florida, and Nebraska from 2005 to 2011. The primary outcome was ED visit or unplanned hospitalization for CVD. We used conditional logistic regression to compare the risk during sequential 12-month periods, using pre-surgery months 13-24 as the reference period. We identified 11 106 obese adults with CVD who underwent bariatric surgery. During the reference period, 20.6% [95% confidence interval (CI), 19.8-21.3%] of patients had an ED visit or unplanned hospitalization for CVD. The risk did not significantly change in the subsequent 12-month pre-surgery period [adjusted odds ratio (aOR) 0.98; 95% CI, 0.93-1.04; P = 0.42]. By contrast, in the first 12-month period after bariatric surgery, the risk significantly decreased (aOR 0.91; 95% CI, 0.86-0.96; P = 0.002). The risk remained reduced in the subsequent 13-24 months post-bariatric surgery (aOR 0.84; 95% CI, 0.79-0.89; P < 0.001). There was no reduction in the risk in separate obese populations that underwent non-bariatric surgery (i.e. cholecystectomy, hysterectomy). By CVD category, the risk of acute care use for coronary artery disease (CAD), heart failure (HF), and hypertension decreased after bariatric surgery, whereas that of dysrhythmia and venous thromboembolism transiently increased (Bonferroni corrected P < 0.05 for all comparisons). CONCLUSION Bariatric surgery is associated with a lower risk of overall CVD-related ED visit or unplanned hospitalization. The decline was mainly driven by reduced risk of acute care use for CAD, HF, and hypertension after bariatric surgery.

Introduction: Our goal was to assess whether use of a standardized clinical protocol improves efficiency for patients who present to the emergency department (ED) with symptoms of transient ischemic attack (TIA). Methods: We performed a structured, retrospective, cohort study at a large, urban, tertiary care academic center. In July 2012 this hospital implemented a standardized protocol for patients with suspected TIA. The protocol selected high-risk patients for admission and low/intermediate-risk patients to an ED observation unit for workup. Recommended workup included brain imaging, vascular imaging, cardiac monitoring, and observation. Patients were included if clinical providers determined the need for workup for TIA. We included consecutive patients presenting during a six-month period prior to protocol implementation, and those presenting between 6-12 months after implementation. Outcomes included ED length of stay (LOS), hospital LOS, use of neuroimaging, and 90-day risk of stroke or TIA. Results: From 01/2012 to 06/2012, 130 patients were evaluated for TIA symptoms in the ED, and from 01/2013 to 06/2013, 150 patients. The final diagnosis was TIA or stroke in 45% before vs. 41% after (p=0.18). Following the intervention, the inpatient admission rate decreased from 62% to 24% (p

Background Increasing the value of health care delivery is a national priority, and providers face growing pressure to reduce cost while improving quality. Ample opportunity exists to increase efficiency and quality simultaneously through the application of systems engineering science. Objective We examined the hypothesis that Lean-based reorganization of laboratory process flow would improve laboratory turnaround times (TAT) and reduce waste in the system. Methods This study was a prospective, before-after analysis of laboratory process improvement in a teaching hospital emergency department (ED). The intervention included a reorganization of laboratory sample flow based in systems engineering science and Lean methodologies, with no additional resources. The primary outcome was the median TAT from sample collection to result for 6 tests previously performed in an ED kiosk. Results After the intervention, median laboratory TAT decreased across most tests. The greatest decreases were found in "reflex tests" performed after an initial screening test: troponin T TAT was reduced by 33 minutes (86 to 53 minutes; 99% confidence interval, 30-35 minutes) and urine sedimentation TAT by 88 minutes (117 to 29 minutes; 99% confidence interval, 87-90 minutes). In addition, troponin I TAT was reduced by 12 minutes, urinalysis by 9 minutes, and urine human chorionic gonadotropin by 10 minutes. Microbiology rapid testing TAT, a "control," did not change. Conclusions In this study, Lean-based reorganization of laboratory process flow significantly increased process efficiency. Broader application of systems engineering science might further improve health care quality and capacity while reducing waste and cost.

Atrial fibrillation (AF) and obesity are major health problems in the United States. However, little is known about whether bariatric surgery affects AF-related morbidities. This study investigated whether bariatric surgery is associated with short-term and long-term changes in the risk of emergency department (ED) visits or hospitalizations for AF. We performed a self-controlled case series study of obese adults with AF who underwent bariatric surgery by using population-based ED and inpatient databases in California, Florida, and Nebraska from 2005 to 2011. The primary outcome was ED visit or hospitalization for AF. We used conditional logistic regression to compare each patient's risk of the outcome event during sequential 12-month periods, using presurgery months 13 to 24 as a reference period. Our sample consisted of 523 obese adults with AF who underwent bariatric surgery. The median age was 57 years (interquartile range 48 to 64 years), 59% were female, and 84% were non-Hispanic white. During the reference period, 15.9% (95% confidence interval [CI] 12.7% to 19.0%) of patients had an ED visit or hospitalization for AF. The risk remained similar in the subsequent 12-month presurgery period (adjusted OR [aOR] 1.29 [95% CI, 0.94 to 1.76] p = 0.11). In contrast, the risk significantly increased within 12 months after bariatric surgery (aOR 1.53 [95% CI 1.13 to 2.07] p = 0.006). The risk remained elevated during 13-24 months after bariatric surgery (aOR 1.41 [95% CI, 1.03 to 1.91] p = 0.03). In conclusion, this population-based study demonstrated that bariatric surgery was associated with an increased risk of AF episodes requiring an ED visit or hospitalization for at least 2 years after surgery among obese patients with AF.

Background As the numbers of emergency department (ED) visits and inpatient admissions continue to increase, there is growing interest in alternatives to inpatient hospitalization. Objective Our aim was to investigate a novel approach to expediting discharges from the ED with multidisciplinary discharge services to prevent an avoidable admission into the hospital. Methods This pilot study was conducted at a large urban tertiary-care ED in 2016. All patients presenting to the ED with planned inpatient or observation admission were considered for discharge with enhanced discharge planning services. The patients selected, discharge diagnoses, and outcomes were analyzed by descriptive statistics. This study was approved by the study site's Institutional Review Board, including waiver of patient consent. Results During the pilot period, 57 out of 143 (40%) selected patients with planned admission were discharged with enhanced discharge planning services. Median ED length of stay was 17.2 h and mean patient age was 73 years old. Of these patients, 7 (12%) returned within 72 h and 4 (0.07%) were subsequently admitted to the hospital. Conclusions In this pilot study, a novel approach to expediting discharges from the ED with multidisciplinary discharge services was feasible and resulted in fewer admissions to the hospital.

Objective To determine whether the success rate of repeated attempts at tracheal intubation by a single intubator was lower than those by alternate intubators in the emergency department (ED). Methods An analysis of data from a multicentre prospective registry (Japanese Emergency Airway Network Registry) of 13 academic and community EDs in Japan between April 2010 and August 2012. We included all adult and paediatric patients who underwent repeated attempts at tracheal intubation in the ED. We compared the intubation success rates at the second and third attempts between attempts at intubation by a single intubator who performed the previous attempts, and the attempts by alternate intubators. Results We recorded 4094 patients (capture rate, 96%); 1289 patients with repeated attempts at tracheal intubation were eligible for this study. Among these, 871 patients (68%) had a second attempt at intubation by single intubators. At the second attempt, tracheal intubation by a single intubator was associated with a decreased success rate (adjusted odds ratio or AOR, 0.50; 95% CI 0.36 to 0.71), compared with alternate intubators. At the third attempt, intubation by a single intubator was also associated with a decreased success rate (58% vs 70%; unadjusted OR, 0.58; 95% CI 0.38 to 0.89). However, after adjustment for potential confounders, the association lost statistical significance (AOR, 0.89; 95% CI 0.52 to 1.56). Conclusions In this large multicentre study of ED patients undergoing tracheal intubation, second attempts at intubation by a single intubator, compared with those by alternate intubators, were independently associated with a decreased success rate.

Introduction: While emergency department (ED) crowding has myriad causes and negative downstream effects, applying systems engineering science and targeting throughput remains a potential solution to increase functional capacity. However, the most effective techniques for broad application in the ED remain unclear. We examined the hypothesis that Lean-based reorganization of Fast Track process flow would improve length of stay (LOS), percent of patients discharged within one hour, and room use, without added expense. Methods: This study was a prospective, controlled, before-and-after analysis of Fast Track process improvements in a Level 1 tertiary care academic medical center with >95,000 annual patient visits. We included all adult patients seen during the study periods of 6/2010-10/2010 and 6/2011-10/2011, and data were collected from an electronic tracking system. We used concurrent patients seen in another care area used as a control group. The intervention consisted of a simple reorganization of patient flow through existing rooms, based in systems engineering science and modeling, including queuing theory, demand-capacity matching, and Lean methodologies. No modifications to staffing or physical space were made. Primary outcomes included LOS of discharged patients, percent of patients discharged within one hour, and time in exam room. We compared LOS and exam room time using Wilcoxon rank sum tests, and chi-square tests for percent of patients discharged within one hour. Results: Following the intervention, median LOS among discharged patients was reduced by 15 minutes (158 to 143 min, 95%CI 12 to 19 min, p

Background— Although most research on patients with acute heart failure syndrome (AHFS) has focused on readmissions, this may provide an incomplete picture of health-care utilization. We examined the proportion and characteristics of patients with frequent emergency department (ED) visits for AHFS and associated health-care utilization. Methods and Results— A retrospective cohort study of adults with at least 1 ED visit for AHFS between 2010 and 2011 was performed, derived from population-based multipayer data of state ED and inpatient databases for 2 large and diverse states, California and Florida. The analytic sample comprised 113 033 patients with 175 491 ED visits for AHFS. During the 1-year follow-up period, 30.8% of patients had ≥2 (frequent) visits, accounting for 55.4% (95% confidence interval, 55.2–55.5%) of all ED visits for AHFS. In the multivariable model, significant predictors of frequent ED visits were non-Hispanic black race, Hispanic ethnicity, Medicaid insurance, and lower median household income (all P Conclusions— In this large cohort study, we found that one third (31%) of ED patients with AHFS had frequent ED visits for this condition and that minority race/ethnicity and lower socioeconomic status were associated with frequent ED visits. Individuals with frequent ED visits accounted for the majority of ED visits, hospitalizations, and hospital charges.

Object When patients present to the emergency department (ED) with acute headache concerning for subarachnoid hemorrhage (SAH) and a lumbar puncture (LP) shows blood in the CSF, it is difficult to distinguish the results of a traumatic LP from those of SAH. CT angiography (CTA) is often performed, but the long-term outcome for patients with a positive LP and normal neurovascular imaging remains uncertain. The primary objective of this study was to determine whether patients who presented to the ED with acute headache and had red blood cells (RBCs) in their CSF on LP but negative cerebrovascular imaging suffered subsequent SAH. Methods A case series study of consecutive adult ED patients who incurred charges for LP between 2001 and 2009 was performed from 2010 through 2011. Inclusion criteria were: headache, > 5 RBCs/mm3 in CSF, noncontrast head CT with no evidence of hemorrhage, and cerebrovascular CTA or MRA without aneurysm or vascular lesion within 2 weeks of the ED visit. Patients with less than 6 months of available follow-up were excluded. The primary outcomes were 1) subsequent nontraumatic SAH and 2) new vascular lesion. Secondary outcomes were complications related to SAH, or LP or angiography. Results Of 4641 ED patients billed for an LP, 181 patients (mean age 42 years) were included in this study. Over a median follow-up of 53 months, 0 (0%) of 181 patients (95% CI 0%–2.0%) had a subsequent SAH or new vascular lesion identified. Although not the primary outcome, there was 1 patient who was ultimately diagnosed with vasculitis. Eighteen (9.9%) of 181 patients (95% CI 6.0%–15.3%) had an LP-related complication and 0 (0%) of 181 patients (95% CI 0%–2.0%) had an angiography-related complication. Conclusions Patients who present to the ED with acute headache concerning for SAH and have a finding of bloody CSF on LP but negative findings on cerebrovascular imaging are at low risk for subsequent SAH and thus are likely to be safe for discharge. Replacement of the CT/LP with a CT/CTA diagnostic algorithm merits further investigation.

A 52-year-old man was brought to the emergency department with chest pain and ST-segment elevation. Seconds after his arrival, cardiac arrest occurred. CPR was begun, and nine external countershocks were administered, without resolution. Management decisions were made.

Objectives The problem of emergency department (ED) crowding is well recognized; however, little data exist on the sustainability of potential solutions, including physician triage and screening. The authors hypothesized that a physician triage screening program (Supplemented Triage and Rapid Treatment [START]) sustainably improves standard ED performance metrics. Methods This retrospective, observational, before-and-after study compared performance measures over 4 years in a tertiary care urban academic medical center with approximately 90,000 annual ED visits. Patients seen between December 2006 and November 2010 were included. Outcome measures included length of stay (LOS) for ED patients, percentage of patients who left without completing assessment (LWCA), percentage of patients treated and dispositioned by START without using monitored beds, and door-to-room time. Descriptive statistics were used. Results Median LOS for START patients was 56 minutes/patient lower when comparing 2010 to 2007 (p

Introduction: The American College of Emergency Physicians (ACEP) Task Force on Boarding described high-impact initiatives to decrease crowding. Furthermore, some emergency departments (EDs) have implemented a novel initiative we term “vertical patient flow,” i.e. segmenting patients who can be safely evaluated, managed, admitted or discharged without occupying a traditional ED room. We sought to determine the degree that ACEP-identified high-impact initiatives for ED crowding and vertical patient flow have been implemented in academic EDs in the United States (U.S.). Methods: We surveyed the physician leadership of all U.S. academic EDs from March to May 2010 using a 2-minute online survey. Academic ED was defined by the primary site of an emergency residency program. Results: We had a response rate of 73% (106/145) and a completion rate of 71% (103/145). The most prevalent hospital-based initiative was inpatient discharge coordination (46% [47/103] of respondents) while the least fully initiated was surgical schedule smoothing (11% [11/103]). The most prevalent ED-based initiative was fast track (79% [81/103]) while the least initiated was physician triage (12% [12/103]). Vertical patient flow had been implemented in 29% (30/103) of responding EDs while an additional 41% (42/103) reported partial/in progress implementation. Conclusion: We found great variability in the extent academic EDs have implemented ACEP’s established high-impact ED crowding initiatives, yet most (70%) have adopted to some extent the novel initiative vertical patient flow. Future studies should examine barriers to implementing these crowding initiatives and how they affect outcomes such as patient safety, ED throughput and patient/provider satisfaction. [West J Emerg Med 2013;14(2):85-89.]

Objectives There is little information on geriatric emergency airway management. We sought to describe intubation practices and outcomes for emergency department (ED) geriatric and younger patients in Japan. Method We formed the Japanese Emergency Airway Network, a consortium of 11 medical centers, and prospectively collected data on ED intubations between 2010 and 2011. All patients 18 years or older who underwent emergent airway management were included in our study. Patients were divided to into 2 groups: 18 to 64-year olds and 65 years or older. We present descriptive data as proportions with 95% confidence intervals (CI). Results The database recorded 3277 patients (capture rate 96%), and 3178 met the inclusion criteria. Of 3178 patients, 1844 (58%) were 65 years or older, 1334 (42%) were 18 to 64 years old, 809 (25%) were 80 years or older, and 407 (50%) of them were in the state of cardiac arrest. The geriatric group, compared to the younger group, had a higher success rate on the initial attempt (71% vs 64%; difference 7%; 95% CI 4%-10%;) and in 2 attempts (90% vs 88%; difference 3%; 95% CI 1%-5%) or less. There was no significant difference in the adverse event rates by age group (difference 0%; 95% CI −2% to 3%). Conclusion In our multicenter study involving a large geriatric population, we found that geriatric patients were intubated with a higher success rate, compared to younger patients. These data provide implications for the geriatric ED airway practice that may lead to better patient-centered emergency care.

BACKGROUND Time to antibiotic delivery in patients with diagnosis of pneumonia is a publicly reported quality measure. OBJECTIVE We aim to describe the impact of emergency department (ED) physician-assisted triage (PAT) on The Joint Commission (TJC) and Centers for Medicare and Medicaid Services (CMS) pneumonia core quality measures of timing to antibiotic delivery. METHODS Retrospective case series studies of patients admitted to the hospital through the ED with diagnosis of community-acquired pneumonia were identified over a period of 48 months. Patients were included in the study if they met TJC/CMS PN-5 (antibiotic timing) criteria. We compared antibiotic delivery timing before and after implementation of PAT in moderate-acuity patients using Wilcoxon rank sum tests. A linear regression analysis was done to account for age, sex, ED volume, and acuity level. RESULTS A total of 659 patients were identified: 497 patients and 162 patients enrolled pre- and post-implementation of a PAT, respectively. The median antibiotic delivery times for moderate-acuity patients during open hours of operation of PAT were 180min (pre) and 195min (post), p=0.027; this was unchanged when ED volume, age, sex, and acuity level were accounted for. A total of 43 patients (9%) and 13 patients (8%) failed to receive antibiotics within 6h of ED presentation before and after implementation of PAT, respectively. CONCLUSION In this study, implementation of PAT did not result in overall decrease in antibiotic delivery time in patients admitted to the hospital with CAP. We postulate several explanations for this delay in antibiotic delivery time.

Early triage of patients presenting to the emergency department (ED) with the chief complaint of chest pain suggestive of acute coronary syndrome (ACS) remains a diagnostic challenge. Elements of the chest pain history are associated with increased or decreased likelihoods of ACS.1 Sensitive troponin assays and initial electrocardiogram (ECG) provide important information in the initial decision.2–4 However, clinical history, a single set of cardiac biomarkers, and the initial ECG alone or in combination cannot identify the group of patients who can be safely discharged without further diagnostic testing. The percentage of patients who present to the ED with ACS and are inappropriately discharged is low (around 2%).5 However, discharged subjects have a two to three times increased risk of dying.5 Therefore, the standard of care for subjects with acute chest pain typically includes serial ECG and cardiac biomarkers followed by a stress test with or without imaging.6–9 The standard work-up decreases the risk of diagnostic errors. However, the complete “rule-out myocardial infarction” protocol is time-consuming and costly. Clinical risk scores (e.g., Thrombolysis in Myocardial Infarction [TIMI],10 Goldman,11 and Sanchis12) and triage algorithms are available to predict adverse cardiac events and facilitate the triage decision.10–14 However, the performance of these tools is not optimal.15 Risk scores used for the prediction of future cardiovascular events (e.g., Framingham Risk Score) and risk factors for coronary artery disease (CAD) have only limited value for the confirmation or exclusion of ACS in the ED.16,17 Coronary computed tomography angiography (CTA) permits detection of coronary stenosis and atherosclerotic plaque with high sensitivity, specificity, and negative predictive value.18–22 In patients who present to the ED with acute chest pain, exclusion of a significant coronary stenosis and plaque by coronary CTA has a high negative predictive value for ACS.23–32 In contrast, patients with a significant coronary stenosis detected by computed tomography (CT) have a high likelihood of ACS. However, there is a significant proportion of patients in whom coronary atherosclerotic plaque is present, without significant stenosis. In the Rule Out Myocardial Infarction Using Computer-Assisted Tomography (ROMICAT) trial, we observed approximately one-third (113 of 368) of patients with nonobstructive plaque.28 The quantitative assessment of coronary plaque and the combination of coronary plaque burden with clinical risk scores could possibly improve the accuracy for the diagnosis as well as the exclusion of ACS. We determined the association of four dichotomized (low- vs. intermediate- to high-risk categories) clinical risk scores and of the coronary atherosclerotic plaque burden as detected by CT with the outcome of ACS in patients who presented to the ED with the chief complaint of chest pain and inconclusive initial evaluation (negative cardiac biomarkers, nondiagnostic ECG changes), and no history of CAD. We hypothesized that the combination of risk scores and plaque burden improves the discriminatory capacity for the diagnosis of ACS.

Background Physician screening is one of many front-end interventions being implemented to improve emergency department (ED) efficiency. Study objective We aimed to quantify the operational and financial impact of this intervention at an urban tertiary academic center. Methods We conducted a 2-year before-after analysis of a physician screening system at an urban tertiary academic center with 90 000 annual visits. Financial impact consisted of the ED and inpatient revenue generated from the incremental capacity and the reduction in left without being seen (LWBS) rates. The ED and inpatient margin contribution as well as capital expenditure were based on available published data. We summarized the financial impact using net present value of future cash flows performing sensitivity analysis on the assumptions. Operational outcome measures were ED length of stay and percentage of LWBS. Results During the first year, we estimate the contribution margin of the screening system to be $2.71 million and the incremental operational cost to be $1.86 million. Estimated capital expenditure for the system was $1 200 000. The NPV of this investment was $2.82 million, and time to break even from the initial investment was 13 months. Operationally, despite a 16.7% increase in patient volume and no decrease in boarding hours, there was a 7.4% decrease in ED length of stay and a reduction in LWBS from 3.3% to 1.8%. Conclusions In addition to improving operational measures, the implementation of a physician screening program in the ED allowed for an incremental increase in patient care capacity leading to an overall positive financial impact.

Objectives Emergency medicine is increasingly recognized as a medical specialty in Japan. However, comprehensive studies evaluating emergency airway management practice are lacking. We describe emergency department (ED) airway management using a large multi-center registry. Methods We formed the Japanese Emergency Airway Network, a consortium of 10 academic and community medical centers in Japan, and prospectively collected data on ED intubations from April 2010 to February 2011. All patients undergoing emergency intubation were eligible for inclusion. Data were entered in real time by the intubator using a standardized data form. Variables included patient's age, sex, weight, indication for intubation, methods of intubation, drugs, level of training and specialty of the intubator, number of attempts, success or failure, and adverse events. We present descriptive data as proportions with 95% confidence intervals. Results We recorded 1486 intubations (compliance rate 99%). Intubation was ultimately successful in 99.7%. The initial method of intubation varied substantially among the hospitals, including rapid sequence intubation (0–79%), sedation without paralysis (4–88%), paralysis without sedation (0–18%), and oral without medication (12–67%), in non-cardiac arrest encounters. Success rates in first and ≤3 attempts ranged from 40 to 83% and from 74 to 100%, respectively. The overall adverse event rate was 11%, without significant difference by the method used. Conclusions In this multi-center study characterizing ED airway management across Japan, we observed a high overall success rate but a high degree of variation among hospitals in the methods of intubation and success rates.

Background Antibiotic selection made within the first hour of recognition of severe sepsis and septic shock has been shown to decrease mortality. Objective The purpose of this study was to determine what antibiotics are being prescribed and to identify factors influencing ineffective antibiotic coverage in patients with severe sepsis or septic shock. In addition, we explore an alternative method for antibiotic selection that could improve organism coverage. Methods This was a retrospective review of emergency department (ED) patients admitted to an intensive care unit (ICU) over a 12-month period with a culture-positive diagnosis of either severe sepsis or septic shock. Appropriate antibiotic therapy was defined as effective coverage of the offending organism based on final culture results. Results Of the 1400 patients admitted to the ICU, 137 patients were culture positive and met the criteria for severe sepsis or septic shock. Effective antibiotic coverage was prescribed by emergency physicians in 82% (95% confidence interval [CI] .74–.88) of cases. Of the 25 patients who received ineffective antibiotics, the majority had infections caused by resistant Gram-negative organisms. Health care-associated pneumonia guidelines were applied to all patients, regardless of the source of infection, and were 100% sensitive (95% CI .93–1) for selecting patients who had infections caused by highly resistant organisms. Conclusion Emergency physicians achieved 82% effective antibiotic coverage in patients with severe sepsis or septic shock. The gap seems to be in coverage of highly resistant Gram-negative organisms. An alternative approach to antibiotic prescription, utilizing a set of guidelines for community- and health care-associated infections, was found to be 100% sensitive in selecting patients who had infections caused by the more resistant organisms.

Objectives: To measure the degree of overlap and diagnostic yield for evaluations of acute coronary syndrome (ACS), pulmonary embolism (PE), and aortic dissection (AD) among Emergency Department (ED) patients. Methods: We conducted a cross-sectional descriptive study of consecutive adult patients seen in the ED of a 78,000-annual-visit urban academic medical center. Patients who had received at least one of eight of the tests used in our ED to diagnose these three diseases were identified through three methods, and a final study population list was created. Overlap of evaluations and diagnostic yields were calculated by simple descriptive statistics. Results: Over a 2-week period, 626 patient encounters among 622 unique patients were identified. Among these 626 visits, 139 (22%) included diagnostic tests for more than one of the three diagnoses of interest. The majority of these multiple tests were for ACS plus PE (n = 121, 87% of all multiple tests), whereas a minority of patients received tests for ACS plus AD (n = 14, 10% of all multiple tests) or for the “triple work-up” of ACS plus PE plus AD (n = 4, 2.9% of all multiple tests). Conclusion: Although the “triple work-up” evaluation for ACS, PE, and AD is relatively uncommon, a significant number of ED patients who are evaluated for at least one of these three major chest pain syndromes receive simultaneous testing for one of the others.

Dr. Lisa Thomas: Today’s case is that of a 30-year-old man who presented to the Emergency Department (ED) complaining of 3 days of fever and 1 day of a new rash. The patient was in his usual state of health until 4 days before ED presentation, when he developed diffuse myalgias and severe exhaustion followed by sore throat, neck pain, and subjective fevers. On the morning of presentation, his temperature was 40.6 C (105 F) orally and he also noted the onset of a new erythematous, macular rash that began on his upper chest and spread quickly over his torso, face, arms, and legs. The rash was not itchy or painful. He was worried about the high fever and new rash and so he presented to the ED. The patient had no significant past medical history and he was fully immunized. His only medications were acetaminophen 650 mg and ibuprofen 800 mg as needed for fever and myalgias over the past 3 days. There were no known drug allergies. The social history revealed no tobacco, alcohol, or drug use. The patient lived alone and was recently single after breaking up with his only male sexual partner 2 weeks previously. He had no history of sexually transmitted diseases (STDs) and had no newpartners since the breakup. He had also had negative human immunodeficiency virus (HIV)/STD testing 2 weeks prior. The patient had worked as a spiritual educator but had become unemployed 6weeks prior. Hewas volunteering at a church and actively seeking employment. The patient denied new products, pets, recent travel, significant outdoor exposures, or tick bites. The family history was non-contributory.

Background: Few data exist on the frequency with which multidetector computed axial tomography (MDCT) scan of the coronary arteries changes the admission decisions of emergency physicians (EP) caring for patients with possible acute coronary syndrome (ACS). We measured if and how often these changes in decision-making would occur. Methods: The theoretical dispositions of 27 emergency department patients who presented with possible ACS were determined by four board-certified EPs after case presentations. Paired disposition decisions were made before and after knowledge of the MDCT scan results. Patients were selected from a sample of 103 from a prior study. Results: The study included 27 patients with a mean age of 55 ± 9 years; 58% were male. The low-, intermediate-, and high-risk MDCT scan results were evenly distributed, as were the original providers' standard clinical risk assessments of ACS. Three patients had ACS and all were admitted both before and after review of MDCT scan results. Among 24 patients without ACS, a decision to admit was changed to discharge in 16 of 90 admission decisions (18%, 95% confidence interval [CI] 10–26%). Among 6 patients with projected discharges, 2 were inappropriately admitted after review of MDCT scan results. The odds ratio of discharge for patients without ACS increased by 3.95 (95% CI 1.96–7.95) after introduction of the MDCT scan results. Conclusion: An MDCT scan of the coronary arteries will likely change emergency physicians' decisions on the disposition of patients presenting with possible ACS, many to appropriate discharges but also a minority to inappropriate admissions.

OBJECTIVES There is limited information on the financial implications of an emergency department ultrasound (ED US) program. The authors sought to perform a fiscal analysis of an integrated ED US program. METHODS A retrospective review of billing data was performed for fiscal year (FY) 2007 for an urban academic ED with an ED US program. The ED had an annual census of 80,000 visits and 1,101 ED trauma activations. The ED is a core teaching site for a 4-year emergency medicine (EM) residency, has 35 faculty members, and has 24-hour availability of all radiology services including formal US. ED US is utilized as part of evaluation of all trauma activations and for ED procedures. As actual billing charges and reimbursement rates are institution-specific and proprietary information, relative value units (RVUs) and reimbursement based on the Centers for Medicare & Medicaid Services (CMS) 2007 fee schedule (adjusted for fixed diagnosis-related group [DRG] payments and bad debt) was used to determine revenue generated from ED US. To estimate potential volume, assumptions were made on improvement in documentation rate for diagnostic scans (current documentation rates based on billed volume versus diagnostic studies in diagnostic image database), with no improvements assumed for procedural ED US. Expenses consist of three components-capital costs, training costs, and ongoing operational costs-and were determined by institutional experience. Training costs were considered sunken expenses by this institution and were thus not included in the original return on investment (ROI) calculation, although for this article a second ROI calculation was done with training cost estimates included. For the purposes of analysis, certain key assumptions were made. We utilized a collection rate of 45% and hospitalization rates (used to adjust for fixed DRG payments) of 33% for all diagnostic scans, 100% for vascular access, and 10% for needle placement. An optimal documentation rate of 95% was used to estimate potential revenue. RESULTS In FY 2007, 486 limited echo exams of abdomen (current procedural terminology [CPT] 76705) and 480 limited echo cardiac exams were performed (CPT 93308) while there were 78 exams for US-guided vascular access (CPT 76937) and 36 US-guided needle placements when performing paracentesis, thoracentesis, or location of abscess for drainage (CPT 76492). Applying the 2007 CMS fee schedule and above assumptions, the revenue generated was 578 RVUs and $35,541 ($12,934 in professional physician fees and $22,607 in facility fees). Assuming optimal documentation rates for diagnostic ED US scans, ED US could have generated 1,487 RVUs and $94,593 ($33,953 in professional physician fees and $60,640 in facility fees). Program expenses include an initial capital expense (estimated at $120,000 for two US machines) and ongoing operational costs ($68,640 per year to cover image quality assurance review, continuing education, and program maintenance). Based on current revenue, there would be an annual operating loss, and thus an ROI cannot be calculated. However, if potential revenue is achieved, the annual operating income will be $22,846 per year with an ROI of 4.9 years to break even with initial investment. CONCLUSIONS Determining an ROI is a required procedure for any business plan for establishing an ED US program. Our analysis demonstrates that an ED US program that captures charges for trauma and procedural US and achieves the potential billing volume breaks even in less than 5 years, at which point it would generate a positive margin.

Management of atrial fibrillation (AF) in the emergency department (ED) is variable because of the absence of universally adopted treatment guidelines. To address potentially preventable hospital admissions and prolonged length of stay, an AF treatment pathway was co-developed by physicians from the cardiac electrophysiology service and the department of emergency medicine at our institution. The impact of this AF pathway on patient outcomes was evaluated with a prospective, observational study conducted in a single tertiary care center from July 1, 2013, to June 30, 2014. The primary study outcome was the rate of hospital admission. The secondary outcomes were duration of ED visit and inpatient length of stay. The 94 patients treated according to the AF pathway during the study period were less likely to be admitted than the 265 patients who received routine care (16% vs 80%, p0.001). For admitted patients, the mean length of stay was shorter for patients treated according to the AF pathway (32 vs 85 hours, p = 0.002). The time spent in the ED was longer for patients in the AF pathway (16 vs 85 hours, p0.001). Utilization of a multidisciplinary pathway for management of AF in the ED led to a significant reduction in the rate of hospital admission. Patients who were admitted after receiving care according to the AF pathway had a shorter length of stay. In conclusion, utilization of a multidisciplinary AF pathway resulted in a 5-fold reduction in admission rate and2-fold reduction length of stay for admitted patients.

n r. David McCann: Today’s case is that of a 20-yearld woman who presented to the Emergency Department ED) with complaint of an allergic reaction. The patient as in her usual state of health until 2 days prior, when he presented to an outside ED complaining of redness nd watery discharge of the eyes, swelling and pain of he lips, and sore throat. At that time, she was diagnosed ith an “allergic reaction” and was treated with acetminophen and oxycodone for pain and sent home. Since hat time, her symptoms worsened, and she developed loughing of the lips, purulent appearing discharge of the yes, mild cough, shortness of breath, fever to 38.3°C 101°F), and a rash. Review of systems was otherwise egative. Dr. Eric Nadel: Are there any questions about the atient’s history of present illness? Dr. Derek Barclay: Where did the rash start and was t pruritic or painful? Dr. McCann: The rash was first noted distally on the ands and arms, and then spread centripetally to the chest nd back. The rash was mildly pruritic and painless, lthough the sloughing on the lips was painful. Dr. Todd Listwa: Did the patient have any other edical history, any recent new medications, any sick ontacts, or any travel history? Dr. McCann: The patient reported that 3 weeks prior o the onset of symptoms, she had started to take an ver-the-counter diet pill. Additionally, she had her first ntra-muscular injection of medroxyprogesterone acetate

Background No method integrating amino-terminal pro-brain natriuretic peptide (NT-proBNP) testing with clinical assessment for the evaluation of patients with suspected acute heart failure (HF) has been described. Methods Amino-terminal pro-brain natriuretic peptide results and clinical factors from 599 patients with dyspnea were analyzed. The β coefficients of the 8 independent predictors of HF were used to assign a weighted integeric score for predictor. The sum of these integers provided a diagnostic HF “score” for each patient. Receiver operating characteristic curve analysis determined the optimal cut point for the diagnosis of acute HF. The performance of the score was evaluated in the development cohort and subsequently in a patient population from a separate clinical trial of patients with dyspnea conducted in Christchurch, New Zealand. Results Eight factors comprised the score: elevated NT-proBNP (4 points), interstitial edema on chest x-ray (2 points), orthopnea (2 points), absence of fever (2 points), loop diuretic use, age >75 years, rales, and absence of cough (all 1 point). Median scores in patients with acute HF were higher than those without acute HF (9 vs 3 points, P < .001). At a cut point of ≥6 points, the score had a sensitivity of 96% and a specificity of 84% for the diagnosis of acute HF (P < .001). The score improved diagnostic accuracy over NT-proBNP testing alone and retained discriminative capacity in patients in whom clinical uncertainty was present. Lastly, the accuracy of the score was validated in the external data set of patients with suspected acute HF. Conclusion We report a simple and accurate scoring system combining NT-proBNP testing and clinical assessment for the diagnosis or exclusion of acute HF in patients with dyspnea.

We compared the sensitivity of three commonly used cardiac markers between two subpopulations, those who came to the Emergency Department (ED) late (6-24 h) after their symptoms began, and those who arrived earlier (

a t i r. David Peak: Today’s case is that of a 23-year-old ale who was brought to the Emergency Department ED) by Emergency Medical Services (EMS) after being tabbed repeatedly by an assailant who broke into his partment. Paramedics found him seated with multiple tab wounds to his anterior chest and abdomen. The atient was awake, alert and agitated. Vital signs were: eart rate (HR) 120 beats per minute, systolic blood ressure (BP) 110 mm Hg, and respiratory rate (RR) 18 reaths per minute. Breath sounds were reportedly symetrical. He was placed on oxygen by non-rebreather ace mask, two large-bore antecubital intravenous (i.v.) ines were inserted, and boluses of normal saline were dministered. During the brief transport to the hospital, is mental status deteriorated from agitation to lethargy. Dr. Eric Nadel: Are there any questions about the nitial presentation? Dr. Tracy Wimbush: Was there any other informaion about the patient or the weapon used? Dr. Peak: The patient was an otherwise healthy male ith no past medical or surgical history, allergies or edications. There was no evidence of drug parapheralia at the scene. Details on the knife were unavailable. The patient arrived in the ED at 6:55 a.m., approxiately 20 minutes after being stabbed. Vital signs were P 90/50 mm Hg, HR 130 beats/minute, RR 30 breaths/ inute, and oxygen saturation 92% on the non-rereather oxygen mask. The primary survey revealed that e was somnolent, verbalizing only with physical stim

The utility of aminoterminal pro-brain natriuretic peptide (NT-proBNP) testing in the emergency department to rule out acute congestive heart failure (CHF) and the optimal cutpoints for this use are not established. We conducted a prospective study of 600 patients who presented in the emergency department with dyspnea. The clinical diagnosis of acute CHF was determined by study physicians who were blinded to NT-proBNP results. The primary end point was a comparison of NT-proBNP results with the clinical assessment of the managing physician for identifying acute CHF. The median NT-proBNP level among 209 patients (35%) who had acute CHF was 4,054 versus 131 pg/ml among 390 patients (65%) who did not (p0.001). NT-proBNP at cutpoints of450 pg/ml for patients50 years of age and900 pg/ml for patientsor=50 years of age were highly sensitive and specific for the diagnosis of acute CHF (p0.001). An NT-proBNP level300 pg/ml was optimal for ruling out acute CHF, with a negative predictive value of 99%. Increased NT-proBNP was the strongest independent predictor of a final diagnosis of acute CHF (odds ratio 44, 95% confidence interval 21.0 to 91.0, p0.0001). NT-proBNP testing alone was superior to clinical judgment alone for diagnosing acute CHF (p = 0.006); NT-proBNP plus clinical judgment was superior to NT-proBNP or clinical judgment alone. NT-proBNP measurement is a valuable addition to standard clinical assessment for the identification and exclusion of acute CHF in the emergency department setting.

The objective of the study was to measure the utilization and diagnostic value of tests used in the Emergency Department (ED) on patients with undifferentiated non-traumatic abdominal or flank pain. Specific goals were to measure how often these tests led to changes in diagnosis or disposition, which tests were most commonly used, and which tests providers considered most helpful. We conducted a pilot single-center, prospective descriptive study, enrolling all eligible adult patients who presented to our ED with non-traumatic abdominal or flank pain during defined hours of our intake period. Based on serial provider interviews pre- and post-testing, we measured the frequency of change of most likely diagnosis and disposition, which tests were performed, and the provider-perceived value of tests. We enrolled 124 subjects with a mean age of 44 years; 27% were admitted. Testing led to a change in most likely diagnosis in 37% of subjects, and in disposition in 41%. Frequency of diagnostic test use varied from a high of 93% for CBC to 6% for a blood or urine culture. Overall, 65% of patients had at least one imaging study performed, and 39% had an abdominal/pelvic computed tomography (CT) scan. Over all subjects, providers identified the most useful tests as the CT scan (31%) and urinalysis (17%). In conclusion, among ED patients who presented with non-traumatic abdominal or flank pain to one academic center, the pre-test most likely diagnosis and disposition were changed based on the ED evaluation in over one-third of subjects. Almost all received blood tests and two-thirds received one or more imaging studies. Based on providers' subjective opinions, the most valuable tests were the abdomino/pelvic CT scan and the urinalysis.

*Division of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, †Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, and ‡Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts Reprint Address: David F. M. Brown, MD, Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit St., Bullfinch 105, Boston, MA 02114

Delays in seeking medical attention for patients with acute coronary syndromes (ACS) preclude early application of life-saving treatment and diminish efficacy. Previous studies suggest 3-hour delays between onset of symptoms and ED arrival in patients with typical presentations of acute myocardial infarction (AMI). A prospective observational study was conducted in an urban ED measuring lag time (LT) among adults presenting within 48 hours of onset of symptoms suggestive of ACS. Univariate and multiple regression analyses were performed on 5 predictors: age, sex, symptoms at presentation, and 2 different outcomes (AMI and ACS). Three hundred seventy-four patients were enrolled. Mean age was 63 years with 38% 70 years or older. Seventy-three percent of all patients with suspected ACS presented with chest pain, 27% with atypical symptoms. Overall mean LT was 8.7 hours (standard deviation 11). In subgroup analysis, patients aged >/=70 years were more likely to have LTs >12 hours (29% vs. 19% P =.043) and patients without chest pain had longer mean LTs (11.6 vs. 7.6 hours, P =.01). Delay in ED presentation is group specific. Advanced age and patients with atypical symptoms are predictive of longer LTs. Contrary to previously published data, patients with symptoms suspicious for ACS can delay an average of 9 hours, which might alter current thinking in the prevention and care of these patients.

Dr. Nathan Mick: Today’s case is that of a 46-year-old man who was struck by a car traveling at approximately 35 mph. According to witnesses, the patient was facing the car when he was hit and thrown 20 feet. When first responders arrived, the patient was found to have a Glascow Coma Scale (GSC) score of 6 and obvious bilateral lower extremity deformities. Pre-hospital personnel at the scene called for helicopter evacuation to a trauma center. The helicopter transport team found the patient supine on a long board with his cervical spine immobilized. The GCS was 6 with sonorous respirations. Vitals signs were as follows: heart rate (HR) 120 beats per minute, systolic blood pressure (BP) 120 mm Hg, and respiratory rate (RR) 10 breaths per minute. Two large bore antecubital intravenous (i.v.) lines were placed. He was pre-oxygenated and then intubated using rapid sequence induction with etomidate 20 mg i.v. and succinylcholine 100 mg i.v. Endotracheal tube placement was confirmed with a colorimetric end-tidal CO2 detector; the patient received midazolam 2 mg i.v. and vecuronium 8 mg i.v. En route to the hospital, the patient received 2000 cc of crystalloid i.v. and was noted to be persistently tachycardic. Dr. Eric Nadel: Are there any questions regarding the pre-hospital course? Dr. Barbara Masser: Why did the on-scene personnel elect to call the helicopter rather than transport the patient via ground ambulance? Dr. Stephen Thomas: Due to the extent of the patient’s injuries and the fact that rush hour traffic would delay transport to the nearest level I trauma center, I think that their choice was a prudent one. The question of when and how to best utilize aeromedical transport vehicles in the urban trauma setting has been long debated. It is generally accepted that the combination of timedistance factors and injury severity reliably predicts who might benefit from air transport to a Level I trauma center (1). Dr. Nathan Mick: The patient arrived in the Emergency Department (ED) at 1900 hours, approximately 45 minutes after being struck. The primary survey revealed that he was sedated, chemically paralyzed, and orally intubated; endotracheal tube placement was confirmed by auscultation of bilateral breath sounds and capnography. Femoral and carotid pulses were 2 and equal. The vital signs were BP 80/56 mm Hg, HR 115 beats/minute, mechanically ventilated RR 12 breaths/minute, oxygen saturation 100%. Secondary survey revealed a GCS of 3. There was a 2-cm laceration over the right eye with pupils that were 3 mm, symmetric and non-reactive. There was soft tissue swelling over the left parietal scalp without palpable deformity. The neck was immobilized; the trachea was midline. Examination of the chest revealed bilateral breath sounds with no crepitance or flail segments. The abdomen was non-distended without palpable masses.

Dr. Adelaide Evans: Today’s case is that of a 25-yearold man with a change in mental status. Paramedics were called to the patient’s house by his wife, who reported that the patient was wandering naked in the apartment building pounding on the doors of his neighbors. According to the patient’s wife, he had become increasingly confused over the past 3 days, associated with nausea and vomiting, malaise, and headache. The past medical history was significant for psoriasis, asthma, and polysubstance abuse. He was on no medications and had no drug allergies. Family history was unremarkable. The patient was married and unemployed, formerly worked as a painter, and now cares for his grandmother. The wife reported that he used 1⁄2 pack cigarettes per day, as well as daily use of marijuana, occasional cocaine use, frequent use of ecstasy, no IV drug use, and no alcohol use. On arrival in the Emergency Department (ED), the patient was awake and alert, confused, agitated, and diaphoretic. Dr. Eric Nadel: Are there any questions about the initial presentation? Dr. Paul Biddinger: Was a finger stick glucose obtained prior to patient transport and was naloxone administered? Also, was there any evidence found by the paramedics leading to suspicion of toxic ingestion? Dr. Evans: A fingerstick glucose was 120 mg/dL. Naloxone 2 mg intramuscularly (IM) was administered without effect. Paramedics reported no open pill bottles or other signs of toxic ingestions. Dr. Jessica Peters: Given his history of psoriasis and asthma, has he recently been on immunosuppressive agents such as steroids? Dr. Evans: According to the patient’s wife, the patient has never used prednisone. On arrival in the ED, vital signs were: temperature 36.4°C (97.6°F), pulse 54 beats per minute, blood pressure 151/37 mm Hg (left arm), 177/39 mm Hg (right arm), respiratory rate 20 breaths per minute, and oxygen saturation 100% on 2 liters nasal canula. In general, the patient was a well-developed man with waxing and waning mental status who was intermittently lucid. Pupils were 4 mm and reactive bilaterally. The neck was supple without meningismus. The lungs were clear to auscultation bilaterally. Heart tones were regular with normal S1 and S2; there was a 3/6 diastolic murmur. The abdomen was soft, nontender, and nondistended with normal bowel sounds. There was no costovertebral angle tenderness. Extremities revealed a few psoriatic lesions; there was no edema or petechiae. Femoral and dorsalis pedis pulses were bounding. Neurologic examination revealed the patient was intermittently oriented, with periods of agitation and confusion. Motor and sensory examinations were grossly normal. The patient was able to ambulate without ataxia. Are there any thoughts as to the initial evaluation or management decisions? Dr. Michelle Finkel: As with any patient who presents with altered mental status, infectious causes, especially meningitis, must be ruled out, even without men

Dr. Shan Liu: Today’s case is that of a 45-year-old woman who presented to the Emergency Department (ED) with a change in mental status. The patient’s employer became concerned when the patient did not arrive for work and was not answering the telephone at her house. The employer called the police, who arrived at the patient’s home, found the patient with slurred speech, and subsequently witnessed a grand mal seizure. Emergency Medical Services (EMS) was called; paramedics arrived and administered 3 mg of naloxone IV, checked a finger stick glucose, which was 40 mg/dL, and subsequently administered 1 ampule of D50 IV. The patient reportedly had minimal improvement in mental status after the administration of glucose. During transport to the hospital, the patient became increasingly agitated. Because of the alteration in mental status, the patient was unable to provide any additional information regarding her past medical history, medications, allergies, family, or social history. Dr. Eric Nadel: Are there any questions regarding the initial presentation? Dr. Hilary Cranmer: Were there any family members or contacts available to provide further information? Dr. Liu: Upon initial presentation to the ED, no other information was available, and no contacts were found. After our initial assessment, the patient’s employer arrived at the hospital and reported that the patient was otherwise healthy as far as he knew, except that she had complained of vague abdominal pain on the day before presentation. The employer also reported that there was a restraining order against a former boyfriend, and that this person may have been the last to see her. Dr. Laura Bontempo: When had the patient been seen before presentation? It would be helpful to know if this was a sudden event or one with gradual onset. Initial assessment should certainly focus on traumatic causes of injury, especially in light of the social history, infectious causes such as sepsis or meningitis, intracranial hemorrhage, or toxicologic causes. Dr. Liu: According to the employer, the patient had not been seen in a number of days, and therefore, no information regarding onset of symptoms was available. Dr. Eric Legome: Although the above information will be helpful in discussing the differential diagnosis of the patient, I am more concerned initially about assessment of the patient’s airway and hemodynamic status. Please tell us how these were handled. Dr. Liu: Initial vital signs revealed: blood pressure 200/110 mm Hg, temperature was 35.5°C (96°F), pulse 125 beats per minute, respiratory rate 18 breaths per minute, and oxygen saturation 100% on oxygen delivered by facemask. After an additional ampule of D50 was administered, the patient remained somnolent with pooled secretions in the mouth. We intubated the patient without difficulty using lidocaine, etomidate, and succinylcholine.

Background: Although studies have suggested links between obesity and morbidities related to cardiovascular disease (CVD), little is known about whether substantial weight reduction affects the risk and cost of CVD-related healthcare utilizations. We aimed to determine whether bariatric surgery is

Emergency department (ED) visits for opioid overdose provide an important marker of acute morbidity. We sought to evaluate national trends of ED visits for opioid overdose.The National Hospital Ambulatory Medical Care Survey, 1993-2010, was used to identify ED visits for opioid overdose.Outcome measures were national ED visit rates for opioid overdose per 100,000 U.S. population and per 100,000 ED visits.From 1993 to 2010, there were approximately 731,000 ED visits (95% CI, 586,000-877,000 visits) for opioid overdose, representing an overall rate of 14 ED visits (95% CI, 12-17 visits) per 100,000 population and 37 ED visits (95% CI, 31-45 visits) per 100,000 ED visits. Of these, 41% (95% CI, 33-50%) were for prescription opioid overdose. Between 1993 and 2010, the national visit rate increased from 7 to 27 per 100,000 population (+307%; Ptrend = 0.03), and from 19 to 63 per 100,000 ED visits (+235%; Ptrend 0.001). Stratified analyses of the visit rate per population showed upward, but nonsignificant, trends across multiple demographic groups and U.S. regions. In stratified analyses of the visit rate per 100,000 ED visits, the rate increased significantly in several groups: age20 years (+1188%; Ptrend = 0.002), age 20-29 years (+155%; Ptrend = 0.04), age ≥50 years (+231%; Ptrend = 0.04), female (+234%; Ptrend = 0.001), male (+80%; Ptrend = 0.04), whites (+187%; Ptrend 0.001), and patients in the South (+371%; Ptrend 0.001).In a nationally representative database of U.S. ED visits, we found that the ED visit rate for opioid overdose quadrupled from 1993 to 2010. Our findings suggest that previous prevention measures may not be adequate.

Dr. Clayton Lawrence: Today’s case concerns a 69year-old diabetic woman who was brought to our Emergency Department (ED) by her daughter with recent onset of confusion. Apparently, the patient complained of a headache and generally “feeling sick.” When the daughter arrived at the patient’s home to check on her, she found her mother to be confused. The patient subsequently vomited twice. The daughter brought her to the hospital by car for further evaluation. Upon presentation to the ED, the patient was irritable and disoriented. She had no complaints, and denied chest pain, shortness of breath, abdominal pain, dysuria, or neck pain. There were no obvious signs of trauma. The patient lived alone and was compliant with her medications. There were no recent hospitalizations and no prior episodes of altered mentation. The past medical history was significant for hypertension and non-insulin-dependent diabetes. There was no history of cardiac disease or prior surgery. Her medications included atenolol and glyburide/metformin. The patient did not have a history of cigarette smoking or alcohol abuse. Dr. Eric Nadel: Are there any questions about the history? Dr. Laura Bontempo: What was the time course of the patient’s mental status changes, and what was the baseline mental status? Dr. Lawrence: According to the daughter, the patient was at baseline one day prior to the initial presentation. The patient usually acted appropriately, completed all of her activities of daily living independently, was an active participant in the family, and often cared for her grandchildren. A few days prior, the patient made a large banquet for a family gathering. There was no history of dementia. Dr. David Peak: Has the patient had any fever or other recent illness? Dr. Lawrence: The daughter was unaware of any fevers, shakes, chills, or any recent illness. The patient had not been exposed to anyone sick, and had no recent travel history. Dr. Andrew Reisner: Was the patient followed by a primary care physician (PCP), and if so, was there any additional information regarding the patient’s medical condition? Dr. Lawrence: The patient was regularly followed by a PCP, and had a normal physical examination within the last 12 months. The patient’s hypertension and diabetes were well controlled, and her medications and dosages had been constant for several years. The patient had taken no new medications, including over the counter preparations or herbal supplements. Dr. Nadel: If there are no further questions, we will proceed with the physical examination. Dr. Lawrence: Physical examination revealed an agitated elderly woman, moaning, and attempting to get out of bed. She was alert, but did not respond appropriately to questions or commands. Vitals signs were as follows: temperature 36.6°C (97.9°F), blood pressure 170/70 mm