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History and physical exam are key features to narrow the differential diagnosis of central versus peripheral causes in patients presenting with acute vertigo. We conducted a systematic review and meta-analysis of the diagnostic test accuracy of physical exam findings.Patient-intervention-control-outcome (PICO) question, (P) adult ED patients with vertigo/dizziness; (I) presence/absence of specific physical exam findings; (O) central (ischemic stroke, hemorrhage, others) versus peripheral etiology. Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) was assessed.From 6,309 titles, 460 articles were retrieved, and 43 met the inclusion criteria. General Neurologic Exam: 5 studies, 869 patients, pooled sensitivity 46.8% (CI 32.3%-61.9%, moderate certainty) and specificity 92.8% (CI 75.7%-98.1%, low certainty). Limb weakness/Hemiparesis: 4 studies, 893 patients, sensitivity 11.4% (5.1%-23.6%, high) and specificity 98.5% (97.1%-99.2%, high). Truncal/Gait Ataxia: 10 studies, 1,810 patients. Increasing severity of truncal ataxia had an increasing sensitivity for central etiology. Sensitivity 69.7% (43.3%-87.9%, low) and specificity 83.7% (52.1%-96.0%, low). Dysmetria signs: 4 studies, 1,135 patients, sensitivity 24.6% (15.6%-36.5%, high) and specificity 97.8% (94.4%-99.2%, high). Head Impulse Test (HIT): 17 studies, 1,366 patients, sensitivity 76.8% (64.4%-85.8%, low) and specificity 89.1% (75.8%-95.6%, moderate). Spontaneous Nystagmus: 6 studies, 621 patients, sensitivity 52.3% (29.8%-74.0%, moderate) and specificity 42.0% (15.5%-74.1%, moderate). Nystagmus Type: 16 studies, 1,366 patients. Bidirectional, vertical, direction changing, or pure torsional nystagmus are consistent with a central cause of vertigo. Sensitivity 50.7% (41.1%-60.2%, moderate) and specificity 98.5% (91.7%-99.7%, moderate). Test of Skew: 15 studies, 1,150 patients. Skew deviation is abnormal and consistent with central etiology. Sensitivity was 23.7% (15%-35.4%, moderate) and specificity 97.6% (96%-98.6%, moderate). HINTS (Head Impulse, Nystagmus, Test of Skew): 14 studies, 1,781 patients, sensitivity 92.9% (79.1%-97.9%, high), specificity 83.4% (69.6%-91.7%, moderate). HINTS+: 5 studies, 342 patients, sensitivity 99.0% (73.6%-100%, high) and specificity 84.8% (70.1%-93.0%, high).Most neurological exam findings have low sensitivity and high specificity for a central cause in patients with acute vertigo or dizziness. In acute vestibular syndrome (monophasic, continuous, persistent dizziness), HINTS and HINTS+ have high sensitivity when performed by trained clinicians.

Medical encounters require an efficient and focused history of present illness (HPI) to create differential diagnoses and guide diagnostic testing and treatment. Our aim was to compare the HPI of notes created by an automated digital intake tool versus standard medical notes created by clinicians.Prospective trial in a quaternary academic Emergency Department (ED). Notes were compared using the 5-point Physician Documentation Quality Instrument (PDQI-9) scale and the Centers for MedicareMedicaid Services (CMS) level of complexity index. Reviewers were board certified emergency medicine physicians blinded to note origin. Reviewers received training and calibration prior to note assessments. A difference of 1 point was considered clinically significant. Analysis included McNemar's (binary), Wilcoxon-rank (Likert), and agreement with Cohen's Kappa.A total of 148 ED medical encounters were charted by both digital note and standard clinical note. The ability to capture patient information was assessed through comparison of note content across paired charts (digital-standard note on the same patient), as well as scores given by the reviewers. Reviewer agreement was kappa 0.56 (CI 0.49-0.64), indicating moderate level of agreement between reviewers scoring the same patient chart. Considering all 18 questions across PDQI-9 and CMS scales, the average agreement between standard clinical note and digital note was 54.3% (IQR 44.4-66.7%). There was a moderate level of agreement between content of standard and digital notes (kappa 0.54, 95%CI 0.49-0.60). The quality of the digital note was within the 1 point clinically significant difference for all of the attributes, except for conciseness. Digital notes had a higher frequency of CMS severity elements identified.Digitally generated clinical notes had moderate agreement compared to standard clinical notes and within the one point clinically significant difference except for the conciseness attribute. Digital notes more reliably documented billing components of severity. The use of automated notes should be further explored to evaluate its utility in facilitating documentation of patient encounters.

Patients presenting to the emergency department (ED) with acute vertigo or dizziness represent a diagnostic challenge. Neuroimaging has variable indications and yield. We aimed to conduct a systematic review and meta-analysis of the diagnostic test accuracy of neuroimaging for patients presenting with acute vertigo or dizziness.An electronic search was designed following patient-intervention-control-outcome (PICO) question-(P) adult patients with acute vertigo or dizziness presenting to the ED; (I) neuroimaging including computed tomography (CT), CT angiography (CTA), magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), and ultrasound (US); (C) MRI/clinical criterion standard; and (O) central causes (stroke, hemorrhage, tumor, others) versus peripheral causes of symptoms. Articles were assessed in duplicate. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) was used to assess certainty of evidence in pooled estimates.We included studies that reported diagnostic test accuracy. From 6309 titles, 460 articles were retrieved, and 12 were included: noncontrast CT scan-six studies, 771 patients, pooled sensitivity 28.5% (95% confidence interval [CI] 14.4%-48.5%, moderate certainty) and specificity 98.9% (95% CI 93.4%-99.8%, moderate certainty); MRI-five studies, 943 patients, sensitivity 79.8% (95% CI 71.4%-86.2%, high certainty) and specificity 98.8% (95% CI 96.2%-100%, high certainty); CTA-one study, 153 patients, sensitivity 14.3% (95% CI 1.8%-42.8%) and specificity 97.7% (95% CI 93.8%-99.6%), CT had higher sensitivity than CTA (21.4% and 14.3%) for central etiology; MRA-one study, 24 patients, sensitivity 60.0% (95% CI 26.2%-87.8%) and specificity 92.9% (95% CI 66.1%-99.8%); US-three studies, 258 patients, sensitivity ranged from 30% to 53.6%, specificity from 94.9% to 100%.Noncontrast CT has very low sensitivity and MRI will miss approximately one in five patients with stroke if imaging is obtained early after symptom onset. The evidence does not support neuroimaging as the only tool for ruling out stroke and other central causes in patients with acute dizziness or vertigo presenting to the ED.

To evaluate the association between potential emergency department (ED)-based modifiable risk factors and subsequent development of delirium among hospitalized older adults free of delirium at the time of ED stay.Observational cohort study of patients aged ≥75 years who screened negative for delirium in the ED, were subsequently admitted to the hospital, and had delirium screening performed within 48 h of admission. Potential ED-based risk factors for delirium included ED length of stay (LOS), administration of opioids, benzodiazepines, antipsychotics, or anticholinergics, and the placement of urinary catheter while in the ED. Odds ratios (OR) and mean differences (MD) with 95% confidence intervals (CIs) were calculated.Among 472 patients without delirium in the ED (mean age 84 years, 54.2% females), 33 (7.0%) patients developed delirium within 48 h of hospitalization. The ED LOS of those who developed delirium was similar to those who did not develop delirium (312.1 vs 325.6 min, MD -13.5 min, CI -56.1 to 29.0). Patients who received opioids in the ED were as likely to develop delirium as those who did not receive opioids (7.2% vs 6.9%: OR 1.04, CI 0.44 to 2.48). Patients who received benzodiazepines had a higher risk of incident delirium, the difference was clinically but not statistically significant (37.3% vs 6.5%, OR 5.35, CI 0.87 to 23.81). Intermittent urinary catheterization (OR 2.05, CI 1.00 to 4.22) and Foley placement (OR 3.69, CI 1.55 to 8.80) were associated with a higher risk of subsequent delirium. After adjusting for presence of dementia, only Foley placement in the ED remained significantly associated with development of in-hospital delirium (adjusted OR 3.16, CI 1.22 to 7.53).ED LOS and ED opioid use were not associated with higher risk of incident delirium in this cohort. Urinary catheterization in the ED was associated with an increased risk of subsequent delirium. These findings can be used to design ED-based initiatives and increase delirium prevention efforts.

OBJECTIVE: To assess the QTc interval variation after low-dose droperidol in a population of undifferentiated, stable, and non-agitated patients receiving droperidol in the emergency department. METHODS: Prospective cohort study of patients aged ≥ 12 years of age who received low-dose droperidol (≤ 2.5 mg) for indications other than acute behavioral disturbances. QTc intervals were monitored in real-time during pre-specified observation periods in the ED. Primary outcome was variation of QTc interval after droperidol administration, defined as the maximum delta (change) of QTc interval. Other outcomes included proportion of patients with a QTc ≥ 500 ms after droperidol, delta ≥ +60 ms, and incidence of clinical adverse events. Patients were monitored up to 30 minutes after IV bolus and up to 46 minutes after infusion. RESULTS: A total of 68 patients were included (mean age 42.1 years, 66.2% females). The median dose of droperidol was 1.875 mg (range 0.625 mg, 2.5 mg) and 94.1% received droperidol for headache management. Most patients received droperidol as a 2-minute bolus (n = 41, 60.3%). The mean maximum delta of QTc interval after droperidol across all 68 patients was +29.9 ms (SD 15). A total of 12 patients (17.6%) experienced a QTc interval ≥ 500 ms during the observation period after droperidol, and 3 patients (4.4%) had a delta QTc ≥ +60 ms. There were no serious arrhythmias, such as TdP, or deaths among the 68 participants in this study (0/68). However, 13.2% (n=9) had at least one non-serious adverse event including restlessness and/or anxiety. CONCLUSION: The QTc interval slightly increased after droperidol administration, but these prolongations were brief, mostly below 500 msec and did not lead to serious arrhythmias. The yield of continuous cardiac monitoring in patients receiving low doses of droperidol is likely low.

OBJECTIVES: To evaluate the short-term mortality of adult patients presenting to the emergency department (ED) with altered mental status (AMS) as compared to other common chief complaints. METHODS: Observational cohort study of adult patients (age ≥ 40) who presented to an academic ED over a 1-year period with five pre-specified complaints at ED triage: AMS, generalized weakness, chest pain, abdominal pain, and headache. Primary outcomes included 7- and 30-day mortality. Hazard ratios (HR) were calculated with 95% confidence intervals (CI) using Cox proportional hazards models adjusted for age, acuity level, and comorbidities. RESULTS: A total of 9,850 ED visits were included for analysis from which 101 (1.0%) and 295 (3.0%) died within 7 and 30 days, respectively. Among 683 AMS visits, the 7-day mortality rate was 3.2%. Mortality was lower for all other chief complaints, including generalized weakness (17/1170, 1.5%), abdominal pain (32/3609, 0.9%), chest pain (26/3548, 0.7%), and headache (4/840, 0.5%). After adjusting for key confounders, patients presenting with AMS had a significantly higher risk of death within 7 days of ED arrival than patients presenting with chest pain (HR 3.72, 95% CI 2.05 to 6.76, p

STUDY OBJECTIVE: To derive a risk score that uses variables available early during the ED encounter to identify high-risk geriatric patients who may benefit from delirium screening. METHODS: This was an observational study of older adults age ≥ 75 years who presented to an academic ED and who were screened for delirium during their ED visit. Variable selection from candidate predictors was performed through a LASSO-penalized logistic regression. A risk score was derived from the final prediction model, and predictive accuracy characteristics were calculated with 95% confidence intervals (CIs). RESULTS: From the 967 eligible ED visits, delirium was detected in 107 (11.1%). The area under the curve for the REcognizing DElirium in Emergency Medicine (REDEEM) score was 0.901 (95% CI 0.864 to 0.938). The REEDEM risk score included 10 different variables (7 based on triage information and 3 obtained during early history taking) with a score ranging from −3 to 66. Using an optimal cutoff of ≥ 11, we found a sensitivity of 84.1% (90 of 107 ED delirium patients, 95% CI 75.5% to 90.2%) and a specificity of 86.6% (745 of 860 non-ED delirium patients, 95% CI 84.1% to 88.8%). A lower cutoff of ≥ 5 was found to minimize false negatives with an improved sensitivity at 91.6% (98 of 107 ED delirium patients, 95% CI 84.2% to 95.8%). CONCLUSION: A risk stratification score was derived with the potential to augment delirium recognition in geriatric ED patients. This has the potential to assist on delirium targeted screening of high-risk patients in the ED. Validation of REDEEM, however, is needed prior to implementation.

We conducted a systematic review and meta-analysis to identify risk factors for delirium in geriatric patients in the emergency department and to identify emergency department (ED)-based modifiable risk factors for developing delirium during hospitalization. We searched evidence based medicine reviews, EMBASE, MEDLINE, Scopus, and Web of Science for observational studies from the time of their inception to July 2020. We included studies that evaluated potential risk factors for either prevalent or incident delirium among older adults (age ≥ 60 years) presenting to the ED. When appropriate, we meta-analyzed estimates for risk factors using a random-effects model. The certainty of evidence was evaluated using the grading of recommendations assessment, development and evaluation approach. The study's protocol was registered in PROSPERO (CDR42020175261). A total of 4,513 citations were reviewed, and 34 studies met the criteria for inclusion: 27 evaluating risk factors for ED delirium (13,412 patients) and 7 evaluating ED-based risk factors for developing delirium during hospitalization (2,238 patients). The prevalence of ED delirium ranged from 7% to 35%. Four factors had strong associations with ED delirium and were graded as high-certainty evidence, including nursing home residence (4 studies; odds ratio [OR], 3.45; 95% confidence interval [CI], 2.17 to 5.48), cognitive impairment (7 studies; OR, 4.46; 95% CI, 3.38 to 5.89), hearing impairment (3 studies, OR, 2.57; 95% CI, 1.03 to 6.41), and a history of stroke (3 studies; OR, 3.20; 95% CI, 1.17 to 8.75). The rate of developing delirium during hospitalization ranged from 11% to 27%. A length of stay of more than 10 hours in ED was associated with a higher risk of delirium (1 study; OR, 2.23; 95% CI, 1.13 to 4.41). One study reported that severe pain, rather than the use of opioids, was associated with the development of delirium. These findings can be used to prioritize delirium screening in the ED and develop novel ED delirium risk scores or prevention interventions.

To describe the emergency department (ED) triage of anaphylaxis patients based on the Emergency Severity Index (ESI), assess the association between ESI triage level and ED epinephrine administration, and determine characteristics associated with lower acuity triage ESI assignment (levels 3 and 4).We conducted a cohort study of adult and pediatric anaphylaxis patients between September 2010 and September 2018 at an academic ED. Patient characteristics and management were compared between Emergency Severity Index (ESI) triage level 1 or 2 versus levels 3 or 4 using logistic regression analysis. We adhered to STROBE reporting guidelines.A total of 1090 patient visits were included. There were 26 (2%), 515 (47%), 489 (45%), and 60 (6%) visits that were assigned an ESI triage level of 1, 2, 3, and 4, respectively. Epinephrine was administered in the ED to 53% of patients triaged ESI level 1 or 2 and to 40% of patients triaged ESI level 3 or 4. Patients who were assigned a lower acuity ESI level of 3 or 4 had a longer median time from ED arrival to epinephrine administration compared to those with a higher acuity ESI level of 1 or 2 (28 min compared to 13 min, p .001). A lower acuity ESI level was more likely to be assigned to visits with a chief concern of hives, rash, or pruritus (OR 2.33 [95% CI, 1.20-4.53]) and less likely to be assigned to visits among adults (OR, 0.43 [0.31-0.60]), patients who received epinephrine from emergency medical services (OR 0.56 [0.38-0.82]), presented with posterior pharyngeal or uvular angioedema (OR, 0.56 [0.38-0.82]), hypoxemia (OR, 0.34 [0.18-0.64]), or increased heart (OR 0.83 [0.73-0.95]) or respiratory (OR 0.70 [0.60-0.82]) rates.Patients triaged to lower acuity ESI levels experienced delays in ED epinephrine administration. Adult and pediatric patients with skin-related chief concerns were more likely to be to be assigned lower acuity ESI levels. Further studies are needed to identify interventions that will improve ED anaphylaxis triage.

Objective To identify predictors of 30-day emergency department (ED) return visits in patients age 65–79 years and age ≥ 80 years. Methods This was a cohort study of older adults who presented to the ED over a 1-year period. A mixed-effects logistic regression model was used to identify predictors for returning to the ED within 30 days. We stratified the cohort into those aged 65–79 years and aged ≥80 years. Adjusted odds ratios (aORs) with 95% confidence intervals (CI) were reported. This study adhered to the STROBE reporting guidelines. Results A total of 21,460 ED visits representing 14,528 unique patients were included. The overall return rate was 15% (1998/13,300 visits) for age 65–79 years, and 16% (1306/8160 visits) for age ≥ 80 years. A history of congestive heart failure (CHF), dementia, or prior hospitalization within 2 years were associated with increased odds of returning in both age groups (for age 65–79: CHF aOR 1.36 [CI 1.16–1.59], dementia aOR 1.27 [CI 1.07–1.49], prior hospitalization aOR 1.36 [CI 1.19–1.56]; for age ≥ 80: CHF aOR 1.32 [CI 1.13–1.55], dementia aOR 1.22 [CI 1.04–1.42], and prior hospitalization aOR 1.27 [CI 1.09–1.47]). Being admitted from the ED was associated with decreased odds of returning to the ED within 30 days (aOR 0.72 [CI 0.64–0.80] for age 65–79 years and 0.72 [CI 0.63–0.82] for age ≥ 80). Conclusion Age alone was not an independent predictor of return visits. Prior hospitalization, dementia and CHF were predictors of 30-day ED return. The identification of predictors of return visits may help to optimize care transition in the ED.

Objective To compare resource utilization and mortality between older and younger adult patients with similar ED chief complaints and ESI triage levels. Methods This was an observational study of consecutive adult patients (age ≥ 40) who presented to an academic ED over a 1-year period with chest pain, abdominal pain, altered mental status, generalized weakness, or headache. Patients were categorized into 40–64, 65–79, and ≥ 80-year old groups. Mortality and utilization outcomes were compared between age groups through logistic regression models or Cox proportional hazards adjusting for ESI level and chief complaint. Odds ratios (OR) and hazard ratios (HR) were calculated with 95% confidence intervals (CI). Results A total of 9798 ED visits were included. As compared to younger adults (age 40–64), older adults, independently of ESI level and chief complaint, had higher ED laboratory use (OR 1.46 [CI 1.29, 1.66] for age 65–80; OR 1.33 [CI 1.15, 1.55] for age ≥ 80), ED radiology use (OR 1.40 [CI 1.26, 1.56]; OR 1.48 [CI 1.30, 1.69]), hospital admission (OR 1.56 [CI 1.42, 1.72]; OR 1.97 [CI 1.75, 2.21]), and ICU admission (OR 1.38 [CI 1.15, 1.65]; OR 1.23 [CI 0.99, 1.52]). Despite similar ESI and chief complaint, patients age 65–79 and ≥ 80 had higher 30-day mortality rates (HR 1.87 [CI 1.39 to 2.51] and 2.47 [CI 1.81 to 3.37], respectively). Conclusions Older adults with similar chief complaints and ESI levels than younger adults, have significantly higher ED resource use, hospitalization rates, and mortality.

BACKGROUND Emergency departments (ED) care for many patients who are chronically ill and nearing end of life. Simulation training offers an opportunity to teach physicians interpersonal skills required to manage end of life care. OBJECTIVE We hypothesized a simulation of an imminently dying patient utilizing the LIVE. DIE. REPEAT. (LDR) format would be perceived as an effective method to teach end-of-life communication and palliative care management skills. METHODS This was simulation training replicating the experience of caring for a critically ill patient in the ED. The scenario involved a patient with pancreatic cancer presenting with sepsis and respiratory distress and previously established goal of comfort care. LDR is a serious-game scheme in which learners are allowed infinite opportunities to progress through a single patient scenario. If learners successfully complete the predetermined critical actions, the game is paused and there is a debriefing to reinforce knowledge/skills before progressing to the next stage of the simulation. Conversely, if learners do not achieve critical actions, the game is over, and learners undergo debriefing before repeating the scenario. We used the Simulation Effectiveness Tool – Modified (SET-M) survey to evaluate perceived effectiveness in teaching end-of-life management. RESULTS The simulation was divided into four levels and learners were tasked with completing one critical action in each level. Eighty percent of residents completed SET-M survey and nearly 100% either strongly or somewhat agreed that the simulation improved their skills and confidence at the end of life. All residents felt debriefing contributed to learning and provided opportunities to self-reflect. Eighty eight percent strongly agreed they were more confident communicating with the patient and prioritizing care interventions which in the simulation were providing care that aligned with patient’s values. CONCLUSIONS This palliative simulation using LDR format was perceived by resident physicians to improve confidence in end-of-life communication and palliative care management.