Final Emergency Department Diagnosis Research Articles

Change in Care Transition Practice for Patients With Nonspecific Chest Pain After Emergency Department Evaluation 2006 to 2012.

From 2005 to 2010 health care financing shifts in the United States may have affected care transition practices for emergency department (ED) patients with nonspecific chest pain (CP) after ED evaluation. Despite being less acutely ill than those with myocardial infarction, these patients' management can be challenging. The risk of missing acute coronary syndrome is considerable enough to often warrant admission. Diagnostic advances and reimbursement limitations on the use of inpatient admission are encouraging the use of alternative ED care transition practices. In the setting of these health care changes, we hypothesized that there is a decline in inpatient admission rates for patients with nonspecific CP after ED evaluation. We retrospectively used the Nationwide ED Sample to quantify total and annual inpatient hospital admission rates from 2006 to 2012 for patients with a final ED diagnosis of nonspecific CP. We assessed the change in admission rates over time and stratified by facility characteristics including safety-net hospital status, U.S. geographic region, urban/teaching status, trauma-level designation, and hospital funding status. The admission rate for all patients with a final ED diagnosis of nonspecific CP declined from 19.2% in 2006 to 11.3% in 2012. Variability across regions was observed, while metropolitan teaching hospitals and trauma centers reflected lower admission rates. There was a 41.1% decline in inpatient hospital admission for patients with nonspecific CP after ED evaluation. This reduction is temporally associated with national policy changes affecting reimbursement for inpatient admissions.

19 Collaborative Application of Guidelines Changes Imaging Utilization and Impacts Length of Stay in Acute Renal Colic

Applying guidelines to the management of acute renal colic in the emergency department (ED) provides an opportunity to improve resource utilization and clinical care for this patient population. We engaged in a collaborative effort across specialties within our academic institution to influence practice patterns in the ED through the formation of diagnostic and treatment algorithms that incorporated guidelines from multiple specialty societies and Choosing Wisely statements. We sought to investigate the changes in imaging utilization and ED length of stay (LOS) before and after the employment of these efforts. We conducted a before and after study following introduction of a renal colic order set and evaluation algorithm (Figure 1). A retrospective chart review was completed of patients diagnosed with nephrolithiasis in the ED at a single academic institution. Two reviewers were utilized to identify renal colic patients by searching final ED diagnosis. Individual patient encounters were subsequently analyzed for rates of imaging utilization and ED LOS. The pre-intervention and post-intervention cohorts included 456 and 174 patients respectively. The utilization of imaging and ED LOS are summarized in Table 1. There was a statistically significant decrease from 57% to 44% in CT utilization after the intervention. The average ED LOS for patients receiving bedside ultrasound was 199 minutes (95% CI 182 to 216 minutes), while average ED LOS for patients receiving CT imaging was 336 minutes (95% CI 316 to 356 minutes). Overall ED LOS for the pre-intervention cohort was 291 minutes (95% CI 277 to 305 minutes), while overall ED LOS for the post-intervention cohort was 269 minutes (95% CI 250 to 288 minutes). Our collaborative educational initiative and employment of evidence-based algorithms impacted imaging utilization in our ED patients with nephrolithiasis. The CT utilization rate was reduced in a statistically significant manner. Patients who had bedside US performed had a significantly decreased LOS, as compared with those receiving CT. The average overall ED LOS was lower in the post-protocol group, though this reduction did not reach statistical significance. Further study will involve the evaluation of impacts in clinical outcomes, as well as predictive factors for downstream urological intervention.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

MP27: Costs of emergency syncope care in Canada

Introduction: Syncope is a common emergency department (ED) presentation and constitutes 1% of all ED visits, approximately 160,000 visits annually across Canada. Lack of standardized syncope care has economic and cost implications. Currently, emergency medical services (EMS) is over utilized, variations in ED management exist and a substantial proportion (46.5%) are hospitalized for cardiac monitoring. Our previous studies have proposed ways to reduce health care utilization through development of EMS clinical decision tool, ED risk scores and remote cardiac monitoring. We sought to: 1) Estimate costs associated with syncope care in the pre-hospital, ED and inpatient settings; and 2) Determine potential cost savings if the proposed alternate strategies were adopted. Methods: A prospective cohort study was conducted in five Canadian EDs from 2010-2014. We enrolled adult (≥16 years) syncope patients and excluded those with prolonged loss of consciousness, mental status changes, seizure, significant trauma, or alcohol/illicit drug abuse. Demographics, medical history, mode of arrival, EMS time points, reasons for hospitalization, ED and inpatient length of stay, final ED diagnosis and any serious adverse event within 30 days of index visit were collected. Descriptive and inferential statistics were used. Results: Out of 4,064 patients enrolled, 67.3% were transported to the ED by EMS and the average cost per event was $262.78 (range at study sites: $156.43-$553.03). The average cost per ED visit was $267.98 (range: $174.66-$374.95). 12.9% of the patients were admitted and the average of cost per admission was $9,886.15 (range: $9,715.23-$10,277.98). Syncope is associated with an estimated total annual cost of $257 million. In Canada, we estimate that diverting low-risk patients will save $5 million in the pre-hospital setting and $15 million in the ED annually, and implementing a remote cardiac monitoring strategy will save $50 million annually. Conclusion: It is estimated that the proposed strategies will save $70 million annually. This is likely an underestimation as cost savings due to reduction in investigations related to diversion of ED patients, reduction in ED length of stay and hospitalization are unaccounted. Adoption of similar strategies will likely lead to significantly higher cost savings in countries with higher resource utilization for syncope management.

Predicting Early Rapid Response Team Activation in Patients Admitted From the Emergency Department: The PeRRT Score

Rapid response teams (RRTs) respond to signs of deterioration to avoid morbidity and mortality. Early RRT activation (eRRT) in patients admitted from the emergency department (ED) is associated with significantly increased mortality. Predicting these events may represent an opportunity to identify patients who would benefit from further resuscitation, aid disposition decision-making, or improve communication between ED and inpatient providers. We aimed to create a clinical prediction instrument to quantify the risk of eRRT. We performed an observational cohort study of patients admitted to a non-intensive care unit (ICU) setting who triggered eRRT from January 2009 to December of 2012 compared to those who did not trigger eRRT. Age, sex, ED vital sign measurements, and final ED diagnosis by ICD-9 code were evaluated in a multivariable logistic regression model. The performance of prediction models was assessed using discrimination summarized by area under a receiver operating curve (AUC) and calibration with the Hosmer and Lemeshow goodness-of-fit test. The final model was used to create a simplified scoring system. The eRRT group consisted of 474 patients who were compared to 2,575 patients in the reference group. Age and sex did not add significant discrimination to the model and were eliminated from the simplified, final model. This model, which included vital signs and diagnosis category, was found to have an AUC of 0.754 (95% confidence interval [CI] = 0.730 to 0.778) and was used to create a simplified scoring system. The odds ratio for the association of a 1-unit increase in risk score with eRRT was 1.37 (95% CI = 1.32 to 1.41; p < 0.001). When internally validated, the score was found to have an AUC of 0.759 (95% CI = 0.735 to 0.753). Calculated scores ranged from -3 to 18, which corresponded to predicted probabilities of eRRT ranging from 5.1% to 72.2%. In summary, the PeRRT score is a simple tool that can be referenced by emergency providers at the bedside to quantify the risk of early RRT activation and potential deterioration, helping to answer the question, "How likely is my patient to trigger an RRT activation in the next twelve hours?" Given that patients who trigger eRRT have an elevated risk of morbidity and mortality, higher scores should result in resuscitative intervention, further observation in the ED, consideration of ICU admission, or direct enhanced communication between ED and inpatient providers. A prospective multicenter study is required to further validate this instrument.

A Multicenter Evaluation of the Impact of Sex on Abdominal and Fracture Pain Care.

Previous studies examining sex-based disparities in emergency department (ED) pain care have been limited to a single pain condition, a single study site, and lack rigorous control for confounders. A multicenter evaluation of the effect of sex on abdominal pain (AP) and fracture pain (FP) care outcomes. A retrospective cohort review of ED visits at 5 US hospitals in January, April, July, and October 2009. A total of 6931 patients with a final ED diagnosis of FP (n=1682) or AP (n=5249) were included. The primary predictor was sex. The primary outcome was time to analgesic administration. Secondary outcomes included time to medication order, and the likelihood of receiving an analgesic and change in pain scores 360 minutes after triage: Multivariable models, clustered by study site, were conducted to adjust for race, age, comorbidities, initial pain score, ED crowding, and triage acuity. On adjusted analyses, compared with men, women with AP waited longer for analgesic administration [AP women: 112 (65-187) minutes, men: 96 (52-167) minutes, P<0.001] and ordering [women: 84 (41-160) minutes, men: 71 (32-137) minutes, P<0.001], whereas women with FP did not (Administration: P=0.360; Order: P=0.133). Compared with men, women with AP were less likely to receive analgesics in the first 90 minutes (OR=0.766; 95% CI, 0.670-0.875; P<0.001), whereas women with FP were not (P=0.357). In this multicenter study, we found that women experienced delays in analgesic administration for AP, but not for FP. Future research and interventions to decrease sex disparities in pain care should take type of pain into account.

Validation of a decision rule for selective TSH screening in atrial fibrillation.

IntroductionAtrial fibrillation (AF) is the most common cardiac dysrhythmia. Current guidelines recommend obtaining thyroid-stimulating hormone (TSH) levels in all patients presenting with AF. Our aim was to investigate the utility of TSH levels for emergency department (ED) patients with a final diagnosis of AF while externally validating and potentially refining a clinical decision rule that recommends obtaining TSH levels only in patients with previous stroke, hypertension, or thyroid disease.MethodsWe conducted a retrospective, cross-sectional study of consecutive patients who presented to an ED from January 2011 to March 2014 with a final ED diagnosis of AF. Charts were reviewed for historical features and TSH level. We assessed the sensitivity and specificity of the previously derived clinical decision rule.ResultsOf the 1,964 patients who were eligible, 1,458 (74%) had a TSH level available for analysis. The overall prevalence of a low TSH (<0.3μIU/mL) was 2% (n=36). Elevated TSH levels (>5μIU/mL) were identified in 11% (n=159). The clinical decision rule had a sensitivity of 88.9% (95% CI [73.0–96.4]) and a specificity of 27.5% (95% CI [25.2–29.9]) for identifying a low TSH. When analyzed for its ability to identify any abnormal TSH values (high or low TSH), the sensitivity and specificity were 74.4% (95% CI [67.5–80.2]) and 27.3% (95% CI [24.9–29.9]), respectively.ConclusionLow TSH in patients presenting to the ED with a final diagnosis of AF is rare (2%). The sensitivity of a clinical decision rule including a history of thyroid disease, hypertension, or stroke for identifying low TSH levels in patients presenting to the ED with a final diagnosis of atrial fibrillation was lower than originally reported (88.9% vs. 93%). When elevated TSH levels were included as an outcome, the sensitivity was reduced to 74.4%. We recommend that emergency medicine providers not routinely order TSH levels for all patients with a primary diagnosis of AF. Instead, these investigations can be limited to patients with new onset AF or those with a history of thyroid disease with no known TSH level within three months.

Hemodynamic Effects of Nitroglycerin Ointment in Emergency Department Patients

BackgroundNitroglycerin ointment is commonly used in the treatment of emergency department (ED) patients with suspected acute heart failure (AHF) or suspected acute coronary syndrome (ACS), but its hemodynamic effects in this population are not well described. ObjectiveOur objective was to assess the effect of nitroglycerin ointment on mean arterial pressure (MAP) and systemic vascular resistance (SVR) in ED patients receiving nitroglycerin. We hypothesized that nitroglycerin ointment would result in a reduction of MAP and SVR in the acute treatment of patients. MethodsWe conducted a prospective, observational pilot study in a convenience sample of adult patients from a single ED who were treated with nitroglycerin ointment. Impedance cardiography was used to measure MAP, SVR, cardiac output (CO), stroke volume (SV), and thoracic fluid content (TFC) at baseline and at 30, 60, and 120 min after application of nitroglycerin ointment. Mixed effects regression models with random slope and random intercept were used to analyze changes in hemodynamic parameters from baseline to 30, 60, and 120 min after adjusting for age, sex, and final ED diagnosis of AHF. ResultsSixty-four subjects with mean age of 55 years (interquartile range, 48–67 years) were enrolled; 59% were male. In the adjusted analysis, MAP and TFC decreased after application of nitroglycerin ointment (p = 0.001 and p = 0.043, respectively). Cardiac index, CO, SVR, and SV showed no change (p = 0.113, p = 0.085, p = 0.570, and p = 0.076, respectively) over time. ConclusionsAmong ED patients who are treated with nitroglycerin ointment, MAP and TFC decrease over time. However, other hemodynamic parameters do not change after application of nitroglycerin ointment in these patients.

Management of patients with non-traumatic hypotension presenting at emergency department Muhimbili national hospital

Hypotension is associated with high morbidity and mortality among emergency department (ED) patients. The diagnostic workup and management may vary greatly based on suspected aetiology and regional burden of disease. Little is known about ED diagnostic evaluation, treatment, and discharge diagnoses of patients with non-traumatic hypotension in sub-Saharan Africa. This study aims to characterize the diagnostic test utilization, treatment, and final ED diagnosis for patients presenting to the Muhimbili ED with non-traumatic hypotension. A prospective descriptive cohort study was carried out from April to November 2012 at Muhimbili ED. Adult 65 patients with non-traumatic hypotension were enrolled. Data collected included history, physical examination findings, diagnostic testing, and final ED diagnosis. Follow-up data included hospital length of stay, discharge diagnosis, and 24-h and in-hospital mortality. 53 of 65 patients (88%) were referred from other hospitals, and 12 (18%) were self-referred. Mean SBP at arrival was 84 mmHg. 54 (83%) patients had ECGs done, of which 32 (59%) were abnormal. Bedside Ultrasound done in all 65, with 45 (69%) abnormal. 15(23%) received X-rays, abnormal in 11(73%). All patients underwent laboratory work up. Only 20 (38%) of the 53 referred patients received fluids prior to arrival. In the ED 63 patients (97%) received fluids. Mean SBP after intervention was 91 mmHg (median 90 mmHg). The mean hospital stay was 2 days in those who died and 4 days for those who survived to discharge. In 78%, the ED diagnosis matched hospital discharge diagnosis. Overall mortality in this study was 26% (17) patients, with 7 (48%) of these deaths occurring in the first 24 h . The most common diagnostic tests performed in the ED were Ultrasound, ECG, plain X-Rays and bedside bloods. There was a high overall mortality in these patients with almost half within the first 24 h.

Magnitude of d-dimer matters for diagnosing pulmonary embolus

ObjectiveThe objective of this study is to determine whether the magnitude of the d-dimer correlates with a higher likelihood of pulmonary embolus (PE). MethodsWe performed an electronic chart review at our academic, tertiary care center, annual emergency department (ED) census greater than 100000. All patients with a chest computed tomographic (CT) scan with intravenous contrast and an elevated d-dimer level obtained in the ED between January 2001 and July 2008 were identified. Specific, predetermined, predefined data elements including sex, age, d-dimer level, and final ED diagnosis were recorded by a hypothesis-blinded extractor using a preformatted data form. d-dimer level less than 0.58 μg/mL constitutes the normal laboratory reference range for our turbidometric d-dimer assay. Data were analyzed using standard statistical methods, and a linear regression analysis was performed for correlation analysis of d-dimer and diagnosis of PE. ResultsWe identified 544 subjects who had both a chest CT scan performed and an elevated d-dimer level obtained in the ED. Fifty-eight subjects (10.7%; mean d-dimer, 4.9 μg/mL) were diagnosed with PE, and 486 (89.3%; mean d-dimer, 2.0) did not have a PE. The percentages of PE diagnoses for d-dimers in the ranges 0.58 to 1.0, 1.0 to 2.0, 2.0 to 5.0, 5.0 to 20.0, and greater than 20.0 (n = 11) were 3.6%, 8.0%, 16.2%, 35.3%, and 45.5%, respectively. The positive predictive value of PE for d-dimer level cutoffs of greater than 0.58, greater than 1.0, greater than 2.0, greater than 5.0, and greater than 20.0 was 10.7%, 14.6%, 22.2%, 37.8%, and 45.5%, respectively. Increasing d-dimer values were strongly correlated with the presence of PE (odds ratio, 1.1685 per stratum; P < .001). ConclusionIncreasing magnitude of d-dimer correlates with increasing likelihood of PE diagnosed by CT angiography.

The Quality of Emergency Department Pain Care for Older Adult Patients

To determine whether there are differences in emergency department (ED) pain assessment and treatment for older and younger adults. Retrospective observational cohort. Urban, academic tertiary care ED during July and December 2005. Adult patients with conditions warranting ED pain care. Age, Charlson comorbidity score, number of prior medications, sex, race and ethnicity, triage severity, degree of pain, treating clinician, and final ED diagnosis. Pain care process measures were pain assessment and treatment and time of activities. One thousand thirty-one ED visits met inclusion criteria; 92% of these had a documented pain assessment. Of those reporting pain, 41% had follow-up pain assessments, and 59% received analgesic medication (58% of these as opioids, 24% as nonsteroidal anti-inflammatory drugs (NSAIDs)). In adjusted analyses, there were no differences according to age in pain assessment and receiving any analgesic. Older patients (65-84) were less likely than younger patients (18-64) to receive opioid analgesics for moderate to severe (odds ratio (OR) = 0.44, 95% confidence interval (CI) = 0.22-0.88) and were more likely to more likely to receive NSAIDs for mild pain (OR = 3.72, 95% CI = 0.97-14.24). Older adults had a lower reduction of initial to final recorded pain scores (P = .002). There appear to be differences in acute ED pain care for older and younger adults. Lower overall reduction of pain scores and less opioid use for the treatment of painful conditions in older patients highlight disparities of concern. Future studies should determine whether these differences represent inadequate ED pain care.

Headache patients in the emergency department of a Greek tertiary care hospital

The aim of this study was to record the demographic and epidemiological data on adult patients with headache who attend the emergency department (ED) and the diagnoses that made by the neurologists in the ED of a tertiary care hospital in metropolitan Thessaloniki (Greece). In an open prospective study, demographic and epidemiological data were collected on all patients who reported headache (as chief complaint or not) and presented to the ED of Papageorgiou Hospital between August 2007 and July 2008. Headache patients accounted for 1.3% of all ED patients and for 15.5% of patients primarily referred to the ED neurologist. Tension type headache was the most frequent diagnosis, followed by secondary headaches and migraine. The large number of patients without final ED diagnosis and ward admission for further evaluation sheds a light on the immense workload of Greek ED physicians. Furthermore, we found evidence for the misuse of Emergency Medical Services by chronic headache patients. These findings indicate shortcomings in the pre-hospital (primary care) management of headache patients in the Greek National Health System to an extent unreported so far.Electronic supplementary materialThe online version of this article (doi:10.1007/s10194-009-0178-3) contains supplementary material, which is available to authorized users.

Disconnect Between Charted Vestibular Diagnoses and Emergency Department Management Decisions: A Cross‐sectional Analysis From a Nationally Representative Sample

The most common vestibular disorders seen in the emergency department (ED) are benign paroxysmal positional vertigo (BPPV) and acute peripheral vestibulopathy (APV; i.e., vestibular neuritis or labyrinthitis). BPPV and APV are two very distinct disorders that have different clinical presentations that require different diagnostic and treatment strategies. BPPV can be diagnosed without imaging and is treated with canalith-repositioning maneuvers. APV sometimes requires neuroimaging by magnetic resonance imaging (MRI) to exclude posterior fossa stroke mimics and should be treated with vestibular sedatives and corticosteroids. We sought to determine if emergency physicians (EPs) apply best practices to diagnose and treat these common vestibular disorders. This was a cross-sectional study of ED visits from the National Hospital Ambulatory Medical Care Survey (NHAMCS). A weighted sample of U.S. ED visits (1993-2005) was used. Patients at least 16 years of age who were given a final ED diagnosis of BPPV (International Classification of Diseases, 9th Revision [ICD-9], 386.11) or APV (ICD-9 386.12 or 386.3x) comprised the study population. The frequency of imaging and drug therapy in those diagnosed as BPPV or APV versus controls was the main outcome measure. A total of 9,472 dizzy patient visits were sampled over 13 years (weighted estimate 33.6 million U.S. ED visits over that period). A weighted estimate of 2.5 million patients (7.4%) were given a vestibular diagnosis, mostly BPPV (weighted 0.2 million) or APV (weighted 1.9 million). Patients given BPPV (19%) and APV (19%) diagnoses were more likely to undergo imaging (all by computed tomography [CT]) than controls (7%; p < 0.001). Patients given BPPV (58%) and APV (70%) diagnoses were more likely to receive meclizine than controls (0.1%; p < 0.001). Corticosteroid administration was rarely documented (2% BPPV, 1% APV). Patients given a vestibular diagnosis in the ED may not be managed optimally. Patients given BPPV and APV diagnoses undergo imaging (predominantly CT) with equal frequency, suggesting overuse of CT (BPPV) and probably underuse of MRI (APV). Most patients diagnosed with BPPV are given meclizine, which is not indicated. Specific therapy for APV (corticosteroids) is probably underutilized. Educational initiatives and clinical guidelines merit consideration.

When is a Scarlet Letter Really a Red Badge of Courage?: The Paradox of Percentage of Pneumonia Patients Receiving Antibiotics Within 4 Hours in Accordance with JCAHO and CMS Core Measures

Effective October 2006, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Centers for Medicare and Medicaid Services (CMS) changed the inclusion criteria for identifying patients in the emergency department (ED) with community-acquired pneumonia who should receive antibiotics within 4 hours (PN-5b).1 The new criteria include both a final ED diagnosis of pneumonia (rather than an initial “working diagnosis”) and objective radiographic findings. These changes improve upon prior criteria that did not require objective data and presented emergency physicians the Hobson’s choice of administering antibiotics without sufficient evidence or being retrospectively criticized for failing to do so.

Quantifying the usefulness of CT in evaluating seniors with abdominal pain

Objectives (1) Determine if older patients with abdominal pain who receive emergency department (ED) abdominal CT have changes in diagnosis and/or disposition more often than similar patients without CT; (2) compare physician confidence in diagnosis and disposition for patients with versus without CT; (3) document factors that most influence physician's decision to order abdominal CT in this population. Methods ED patients 60 years of age or older, with acute non-traumatic abdominal pain were enrolled over a 6-week period. Physicians documented a preliminary and final ED diagnosis and disposition, along with pre- and post-evaluation confidence levels. Decision to order CT, along with clinical information most influencing that decision, was noted. Physician confidence levels and percent change in diagnosis and disposition were compared for patients with versus without CT. Results One hundred and twenty-six patients comprised study sample. Abdominal CT rate was 59% (95%CI, 50–67%). CT was associated with an increased change in diagnosis (46%; 95%CI, 4–58% versus 29%; 95%CI, 16–42%), but no change in disposition between patients with versus without CT. Preliminary diagnostic confidence was lower for EPs who ordered a CT than for those who did not ( p < 0.001). Patient history most influenced ordering CT, whereas prior lab/imaging results most influenced not ordering CT. Conclusion Patients with CT had a change in diagnosis more often than those without. Preliminary diagnostic confidence was lower in CT group. Percent change in disposition did not differ between groups. Physicians most often ordered CT based on history and did not order CT when other diagnostic evaluation supported a specific diagnosis.

Opioid analgesia for acute abdominal pain in the elderly: Is the diagnosis of gallbladder pathology hindered?

Study objectives: Inadequate treatment of acutely painful conditions is a widespread problem in emergency department (ED) settings. Recent literature has suggested that this problem is even more pronounced in elderly populations, where fear of side effects or masking underlying pathology may dissuade clinicians from properly treating pain. The assessment of undifferentiated abdominal pain in the elderly can be difficult, and some evidence exists demonstrating that classical physical examination findings such as the sonographic Murphy sign are unreliable in this population. This study sought to assess the effects of opioid analgesia on the ability of the sonographic Murphy sign to detect acute gallbladder disease (cholecystitis or cholelithiasis) in an elderly population. Methods: A retrospective, consecutive-sample study of 119 adult ED patients (in a Level I trauma center, ED census 70,000) receiving right upper quadrant ultrasonography in 2002 was undertaken. Age, sex, final diagnosis, and timing of opioid analgesia administration were documented. Logistic regression analysis with odds ratio (OR) and 95% confidence intervals (CIs) was used to compare patients older and younger than 65 years and who received opioid analgesia before ultrasonography with those who did not. Final ED or hospital diagnosis and 2-week follow-up was used as the criterion standard, and the negative predictive value of the sonographic Murphy sign for gallbladder disease was calculated. Results: The medical record review included 119 patients (73 female, mean age 49 years). Opioid analgesia was administered before ultrasonography in 25 patients (21%). Gallbladder disease was diagnosed in 43 patients (36%). Sonographic Murphy sign was positive in 30 patients (25%). There were 32 patients (27%) older than 65 years. Compared with younger adults, adults older than 65 years were no less likely to receive opioid analgesia (OR 1.07, 95% CI 0.40 to 2.88, P =.89). There was no association between age older than 65 years and the likelihood of a false negative sonographic Murphy sign (OR 1.74, 95% CI 0.62 to 4.93, P =.29). For patients older than 65 years, no association was found between receiving opioids and a false negative sonographic Murphy sign (OR 1.42, 95% CI 0.46 to 4.44, P =.55). Conclusion: This study found a high rate of inadequate analgesia for acute abdominal pain that is consistent with previous reports. No difference was found in the rate of opioid analgesia administration in the elderly subgroup, in contrast with studies demonstrating a bias against adequate analgesia in this population. In addition, ultrasonography and the sonographic Murphy sign were found to be no less accurate in the elderly, even when premedicated with opioid analgesia. This finding runs counter to limited evidence previously published and should be further investigated using a prospective model.

Decisions in chest pain: how often do they change after the initial evaluation?

Study objectives: We determine to what extent decisions in chest pain change from initial emergency department (ED) patient encounter to final ED diagnosis, disposition, and treatment. Methods: We designed a prospective, observational study of a convenience sample of chest pain patients triaged to the critical care area of an urban ED. Patients were excluded if they were diagnosed with ST-segment elevation myocardial in farction. Physician decisions about these patients were studied. The physicians involved in the study were attending emergency physicians and upper-level emergency medicine residents who staff 100% of cases with an attending emergency physician. Physicians were surveyed after initial patient evaluation. This initial evaluation was defined as initial medical history and physical examination and reading of the ECG. The survey elicited initial working diagnosis, treatment, and disposition. The treating physician was again surveyed after final ED decisions and disposition were made. The second survey elicited the same information as the first survey about decisions. The second survey also asked the treating physicians to cite the factors that led to changes in their decisions. The surveys were then compared, and decision changes were noted as upgrades or downgrades. Changes in decisions were correlated with cardiac marker results and physician-cited factors that led to those decision changes. Results: Of 83 physician/patient interactions studied, 20 (24%) had an upgrade in management, 24 (29%) a downgrade, and 39 (47%) had no change. Seventy-six patients had negative cardiac markers. Of the patients with negative markers, 14 (18%) had an upgrade, 24(32%) had a downgrade, and 37 (49%) had no change in decisions. The most common factor cited by the treating physician as affecting decisions was change in patient status (N=34, 41%). The second most common factor cited was cardiac marker results (N=30, 36%). From these 30 interactions, 4 had positive markers, all of which had an upgrade in management; 26 had negative markers. Of these 26, 6 were upgraded and 8 were downgraded; 12 had no change in management, even though the physician stated that the marker results affected their decisions. Finally, from these 30 interactions in which cardiac markers were cited as affecting decisions, 9 patients had negative markers and duration less than 6 hours. Follow-up was available for 81 of the 83 patients. No significant correlation between changes in decision and outcomes was found. Conclusion: Nearly 50% of chest pain management decisions did not change after the initial evaluation. Physicians may inappropriately rely on initial cardiac marker results in determining the etiology of a patient's chest pain.

Use of vasodilators in the emergency department treatment of acute decompensated heart failure patients

Background: Vasodilators are valuable in the treatment of acutely decompensated heart failure (adHF) although they are not consistently utilized in the emergency department (ED). Objective: To describe factors affecting ED vasodilator utilization and it's association with outcome. Methods: A retrospective analysis of a sample abstracted from all adHF patients presenting to a tertiary care medical center ED during 2004. Eligible patients had a final ED or inpatient diagnosis of adHF based on billing codes. Vasodilator usage was defined as receiving any nitroglycerin, or nesiritide, alone or in combination. Patient demographics were obtained from self-report or chart review. Electrocardiograms were interpreted by the treating physician for the presence or absence of an ischemic/infarction pattern (iECG). Adverse events were defined as death, recurrent myocardial infarction, or repeat hospitalization within 30 days. Univariate analysis was performed on the following variables to determine if there was an association with vasodilator usage: gender, age>70, past medical history of diabetes, hypertension, congestive heart failure, renal insufficiency, coronary artery disease, systolic blood pressure>160 mmHg, iECG, creatinine>2.5 mg/dl, BUN>60 mg/dl, normal initial troponin I level, and a radiologist's reading of pulmonary edema on chest radiography. Significant variables (p<0.05) were entered into a multivariate analysis. Results: There were 288 patients, with a mean age of 60.9 years (SD 14). Women comprised 48% (n=148) of the sample. Vasodilators were used in 153 (53%). Overall, there were 37(13%) adverse events, and 59 patients (21%) were discharged home. There was no difference in the use of vasodilators and adverse events (OR 1.7, 95% CI 0.6–2.5). The significant variables in the univariate analysis were creatinine, systolic blood pressure, iECG, and history of renal insufficiency. These were then entered into multivariate analysis. Only an iECG was an independent predictor of vasodilator use (OR 5.9, 95% CI 1.69–20.9). Conclusion: Only the presence of iECG identified patients more likely to receive vasodilators. However vasodilator use in the ED was not associated with an appreciable difference in adverse events. Larger studies may be warranted to determine vasodilator utilization affects outcomes.

How well does decision support software perform in the emergency department?

Objective: To determine how well general decision support systems perform given the data collected in an emergency department (ED).Methods: A convenience sample of 25 patients was selected from those patients...

Emergency care for posttonsillectomy and postadenoidectomy hemorrhage

There are an estimated 4,300 cases of postoperative hemorrhage after tonsillectomy in the United States each year. Most patients seek care in the Emergency Department for this potentially fatal condition. This study was performed to characterize the clinical presentation of patients seeking Emergency Department (ED) care for posttonsillectomy and postadenoidectomy hemorrhage (PTAH). In addition, the investigators attempted to describe the ED treatment for PTAH. A retrospective review of ED and inpatient medical records was executed for patients presenting to the ED with PTAH from June 1, 1983 to May 31, 1993. All patients presenting to the ED who received a final ED diagnosis of PTAH were included in the study. The setting included two community-based teaching hospitals that share a single emergency medicine residency. The combined ED census averaged 72,000 annual visits over the study period. The ED population included both children and adults. Neither hospital had an otolaryngology residency, nor was there 24 hour in-hospital otolaryngology staffing. Factors that were reviewed included patient age, gender, final disposition, presenting vital signs, time from the initial surgery to the time of bleeding, ED treatment, and the interaction with the on-call otolaryngologist. Subpopulations were defined primarily by age (child versus adult) and disposition (home versus hospital). χ 2 Analysis was used for most comparisons. When χ 2 analysis showed an association, the phi (Ф) coefficient was calculated to determine the strength of the association. When appropriate, means were compared using the Student's two-tailed t test. There were 106 visits involving 93 patients. There were 51 hospital admissions (48%), and 55 (52%) visits resulted in discharge to home. Of the 93 patients involved, 57 (61%) were children (≤17 years), accounting for 61 total visits; 36 (39%) were adults (≥18 years), accounting for 45 visits. Children with PTAH were more likely to be admitted than adults ( χ 2, P = .008; Ф test = 0.25) Procedures to stop PTAH were frequently performed in the ED, often by emergency medicine physicians; silver nitrate cautery was the most frequent. Adults were more likely to receive a minor hemostatic procedure, yet children were more likely to receive a blood transfusion initiated while in the ED or require surgery to achieve control of the bleeding.