Stable Emergency Department Patients Research Articles

Right Ventricular “Bubble Time” to Identify Patients With Right Ventricular Dysfunction

ObjectiveWe propose a novel method of evaluating right ventricular (RV) dysfunction in the emergency department (ED) using RV “bubble time” – the duration of time bubbles from a saline flush are visualized in the RV on echocardiography. The objective was to identify the optimal cutoff value for RV bubble time that differentiates patients with RV dysfunction and report on its diagnostic test characteristics. MethodsThis prospective diagnostic accuracy study enrolled a convenience sample of hemodynamically stable ED patients. A sonographer administered a 10-milliliter saline flush into patient’s intravenous catheter, performed a bedside echocardiogram, and measured RV bubble time. Subsequently, the patient underwent a comprehensive cardiologist-interpreted echocardiogram with 36 hours, which served as the gold standard. Patients with RV strain or enlargement on the latter echocardiogram were considered to have RV dysfunction. Bubble time was evaluated by a second provider, blinded to the initial results, who reviewed the ultrasound clips. The primary outcome measure was the optimal cutoff value of RV bubble time that identifies patients with and without RV dysfunction. ResultsOf 196 patients, median age was 67 and half were female, with 69 (35.2%) having RV dysfunction. Median RV bubble time among patients with RV dysfunction was 62 seconds (interquartile range (IQR): 52, 93) compared with 21 seconds (IQR: 12, 32) among patients without (p<0.0001). The optimal cutoff value of RV bubble time for identifying patients with RV dysfunction was ≥40 seconds, with a sensitivity of 0.97 (95% CI: 0.93, 1.00) and specificity of 0.87 (95% CI: 0.82, 0.93). ConclusionIn ED patients, an RV bubble time of ≥40 seconds had high sensitivity in identifying patients with RV dysfunction, while an RV bubble time of <40 seconds had good specificity in identifying patients without RV dysfunction. These findings warrant further investigation in undifferentiated patient population and by emergency physicians without advanced ultrasound training.

Efficacy and tolerability of oral morphine versus oxycodone/acetaminophen for analgesia in the emergency department.

Oxycodone/acetaminophen is one of the most commonly prescribed medications for pain management in the emergency department (ED) despite its high abuse liability. Our objective was to determine whether oral immediate-release morphine is as effective and well tolerated as oral oxycodone/acetaminophen for pain relief in stable ED patients. This is a prospective comparative study in which stable adult patients with acute painful conditions who had either oral morphine (15 or 30 mg) or oxycodone/acetaminophen (5/325 mg or 10/650 mg) ordered for them at the discretion of a triage physician were recruited. This study took place in an urban, academic ED from 2016 to 2019. Seventy-three percent of the subjects were between the ages of 18 and 59, 57 percent were female, and 85 percent were African American. Most presented with abdominal, extremity, or back pain. Patient characteristics were similar between treatment groups. Of the 364 enrolled patients, 182 were given oral morphine and 182 were given oxycodone/acetaminophen at the discretion of the triage provider. They were asked to rate their pain score prior to receiving analgesia and at 60 and 90 minutes after administration. We examined pain scores, adverse effects, overall satisfaction, willingness to accept the same treatment again, and the need for additional analgesia. There was no difference in satisfaction reported by patients who received morphine versus oxycodone/acetaminophen: 15.9 percent vs 16.5 percent were very satisfied, 31.9 percent vs 26.4 percent were somewhat satisfied, and 23.6 percent vs 22.5 percent were not satisfied, p = 0.56. Secondary outcomes also showed no significant difference: net change in pain score -2 vs -2 at 60 and 90 minutes, p = 0.91 and p = 0.72, respectively; adverse effects 20.9 percent vs 19.2 percent, p = 0.69; need for further analgesia 9.3 percent vs 7.1 percent, p = 0.44; willingness to accept analgesic again 73.1 percent vs 78.6 percent, p = 0.22. Oral morphine is a feasible alternative to oxycodone/acetaminophen for analgesia in the ED.

Advantage of Vital Sign Monitoring Using a Wireless Wearable Device for Predicting Septic Shock in Febrile Patients in the Emergency Department: A Machine Learning-Based Analysis.

Intermittent manual measurement of vital signs may not rapidly predict sepsis development in febrile patients admitted to the emergency department (ED). We aimed to evaluate the predictive performance of a wireless monitoring device that continuously measures heart rate (HR) and respiratory rate (RR) and a machine learning analysis in febrile but stable patients in the ED. We analysed 468 patients (age, ≥18 years; training set, n = 277; validation set, n = 93; test set, n = 98) having fever (temperature >38 °C) and admitted to the isolation care unit of the ED. The AUROC of the fragmented model with device data was 0.858 (95% confidence interval [CI], 0.809–0.908), and that with manual data was 0.841 (95% CI, 0.789–0.893). The AUROC of the accumulated model with device data was 0.861 (95% CI, 0.811–0.910), and that with manual data was 0.853 (95% CI, 0.803–0.903). Fragmented and accumulated models with device data detected clinical deterioration in febrile patients at risk of septic shock 9 h and 5 h 30 min earlier, respectively, than those with manual data. Continuous vital sign monitoring using a wearable device could accurately predict clinical deterioration and reduce the time to recognise potential clinical deterioration in stable ED patients with fever.

Exploring the attitudes & practices of shared decision-making for CT scan use in emergency department patients with abdominal pain

BackgroundShared decision-making (SDM) has been studied in the emergency department (ED) in relation to hospital admissions but not for CT scan utilization. CT scans are a common imaging modality with high accuracy that emit considerable ionizing radiation. This study has three aims: to measure provider and patient preference for SDM; to evaluate patient involvement in the decision to order a CT scan; and to determine the association between patient involvement and CT utilization. MethodsIn this prospective study, stable ED patients with abdominal pain with CT imaging as a likely diagnostic tool, were screened and consented. The Control Preferences Scale assessed patient and provider baseline decision-making preference. Using the OPTION-5 tool, providers were assessed in each encounter for the extent to which they engaged patients in discussions. The association between the Control Preferences Scale, the OPTION-5 score and ultimate CT utilization was evaluated. ResultsTwenty-nine encounters were observed. CT was considered in 70% (n = 20) of encounters and ordered in 55% (n = 16). 62% of patients and 59% of providers reported that they prefer “shared responsibility” when making treatment decisions. In >80% of encounters, provider's showed no or minimal effort when discussing whether to perform a CT scan. Provider or patient preference was not associated with patient involvement. Patient involvement was not associated with CT utilization. ConclusionsHigh rates of provider and patient preference to use SDM for treatment plans were reported but providers were rarely observed engaging patients with abdominal pain in the decision to order a CT scan.

Normal Saline Solution and Lactated Ringer’s Solution Have a Similar Effect on Quality of Recovery: A Randomized Controlled Trial

The purpose of this study is to test the hypothesis that balanced crystalloids improve quality of recovery more than normal saline solution (0.9% sodium chloride) in stable emergency department (ED) patients. Secondary outcomes measured differences in health care use. A single-site, participant- and evaluator-blinded, 2-arm parallel allocation (1:1), comparative effectiveness, randomized controlled trial allocated adults receiving intravenous fluids in the ED before discharge to receive 2 L of lactated Ringer's solution or normal saline solution. The primary outcome was symptom scores measured by the validated Quality of Recovery-40 instrument (scores 40 to 200) 24 hours after enrollment. Secondary outcomes included subsequent health care use and medication compliance. Participants (N=157) were enrolled and follow-up was analyzed for 94 (follow-up rate of 60%) with intention-to-treat methodology. There was no difference in postenrollment Quality of Recovery-40 scores between normal saline solution and lactated Ringer's solution groups (mean difference 2.4; 95% confidence interval [CI] -6.8 to 11.6). Although preenrollment scores were higher in the lactated Ringer's solution group (mean difference 10.5; 95% CI 1.9 to 19.0), adjusting for presurvey imbalances did not change the primary outcome (adjusted difference -3.9; 95% CI -12.9 to 5.2). There were no differences in return to ED (mean difference 7.5%; 95% CI -8.7% to 23.8%), prescriptions filled (mean difference 22.2%; 95% CI -3.3% to 47.6%), or seeking care from another provider (mean difference -2.0%; 95% CI -19.9% to 15.9%) at 7 days. Normal saline solution and lactated Ringer's solution were associated with similar 24-hour recovery scores and 7-day health care use in stable ED patients. These results supplement those of recent trials by informing fluid choice for stable ED patients.

Helpful Only When Elevated: Initial Serum Lactate in Stable Emergency Department Patients with Sepsis Is Specific, but Not Sensitive for Future Deterioration

BackgroundEarly emergency department (ED) identification of septic patients at risk of deterioration is critical. Lactate is associated with 28-day mortality in admitted patients, but little evidence exists on its use in predicting short-term deterioration. ObjectiveOur aim was to determine the role of initial serum lactate for prediction of short-term deterioration in stable ED patients with suspected sepsis. MethodsWe conducted a prospective cohort study of adult ED sepsis patients. Venous lactate was obtained within 2 h of ED arrival. Main outcome was subsequent deterioration (defined as any of the following: death, intensive care admission > 24 h, intubation, vasoactive medications for > 1 h, or noninvasive positive pressure ventilation for > 1 h) within 72 h. Patients meeting any endpoint within 1 h of arrival were excluded. ResultsNine hundred and eighty-five patients were enrolled, of whom 84 (8.5%) met the primary outcome of deterioration. Initial lactate ≥ 4.0 mmol/L had a specificity of 97% (95% confidence interval [CI] 94–100%), but a sensitivity of 27% (95% CI 18–37%) for predicting deterioration, with positive and negative likelihood ratios of 10.7 (95% CI 6.3–18.3) and 0.8 (95% CI 0.7–0.9), respectively. A lower threshold of lactate (≥2.0 mmol/L) had a sensitivity of 67% (95% CI 55–76%) and specificity of 66% (95% CI 63–69%), with corresponding positive and negative likelihood ratios of 2.0 (95% CI 1.7–2.3) and 0.5 (95% CI 0.4–0.7). ConclusionsHigh ED lactate is predictive of subsequent deterioration from sepsis within 72 h, and may be useful in determining disposition, but low lactate is not effective in screening stable patients at risk of deterioration.

Safety and Efficacy of the “Easy Internal Jugular (IJ)”: An Approach to Difficult Intravenous Access

BackgroundThe easy internal jugular (Easy IJ) technique involves placement of a single-lumen catheter in the internal jugular vein using ultrasound guidance. This technique is used in patients who do not have suitable peripheral or external jugular venous access. The efficacy and safety of this procedure are unknown. ObjectiveWe aimed to estimate efficacy and safety parameters for the Easy IJ when used in emergency department (ED) settings. MethodsWe conducted a prospective study of the Easy IJ in stable ED patients with severe intravenous access difficulty. The study was conducted simultaneously at two academic EDs and a community university-affiliated ED. Patients were selected for failure of alternative access, hemodynamic stability, and ability to increase the IJ diameter with the Valsalva maneuver. Emergency physicians prepped the skin and inserted an 18-gauge, 4.8-cm catheter using a limited sterile technique. We collected the following data: patient body mass index, age, procedure time, pain score, initial success, loss of patency, occurrence of pneumothorax, infection, or arterial puncture. ResultsWe recorded 83 attempts in 74 patients, with a median age of 44 years and a median body mass index of 27 kg/m2. The initial success rate was 88%, with a mean procedure time of 4.4 min (95% confidence interval 3.8–4.9). The average pain score was 3.9 out of 10 (95% confidence interval 3.4–4.5). Ten of 73 successful lines (14%) lost patency. There were no cases of pneumothorax, arterial puncture, or line infection. ConclusionThe Easy IJ was inserted successfully in 88% of cases, with a mean time of 4.4 min. Loss of patency, the only complication, occurred in 14% of cases.

Abstract 18471: A Teachable Moment: Clinically Stable Emergency Department Patients and Their Companions are Willing to Learn Compression-only Cardiopulmonary Resuscitation

Introduction: Bystander CPR is uncommonly performed in out of hospital cardiac arrest patients transported to our Emergency Department (ED). ED visits are brief and complex, but represent a valuable opportunity to teach CPR to members of our community. Our objective was to determine what percentage of ED patients and their companions are willing to learn compression-only CPR. Hypothesis: The majority of ED patients and their companions are willing to learn compression-only CPR. Methods: A convenience sample of clinically stable adults age 18-70 from two urban, academic EDs with socioeconomically diverse patient populations was recruited. Patients in hallways and non-english speakers were excluded. Subjects were asked to complete a pre-video survey to assess baseline knowledge and willingness to perform CPR, watch a 60-second previously validated CPR instructional video, and then complete a post-training CPR survey. Consenting patients were asked if they thought their ED visit was related to their heart. All study subjects were categorized as: 1. patient or companion, and 2. cardiovascular or non-cardiovascular complaint. Subjects who did not consent were asked to share reasons for not participating. Data were entered into a REDCap database. Results: Between 1/1/15 to 6/7/15, 281 patients and their companions were approached about study participation. Mean age was 47, 66% female, 68% African American, and 69% had a college education. 73 believed their visit was related to their heart. 70% were patients, and the remainder were their companions. Overall, 229 (82%) were willing to learn compression-only CPR. 51 of 52 shared reasons for not participating. Reasons included: not feeling well (29%), already CPR trained (16%), and not interested (16%). Patients who thought their ED visit was related to their heart and their companions were equally likely to participate than those who did not (80% vs 83%). Conclusion: In two diverse, academic EDs, 82% of medically stable adult patients and their companions were willing to learn compression-only CPR.

Safety and efficiency of outpatient versus emergency department-based coronary CT angiography for evaluation of patients with potential ischemic chest pain

BackgroundWhile coronary CT angiography (coronary CTA) may be comparable to standard care in diagnosing acute coronary syndrome (ACS) in emergency department (ED) chest pain patients, it has traditionally been obtained prior to ED discharge and a strategy of delayed outpatient coronary CTA following an ED visit has not been evaluated. ObjectiveTo investigate the safety of discharging stable ED patients and obtaining outpatient CCTA. MethodsAt two urban Canadian EDs, patients up to 65 years with chest pain but no findings indicating presence of ACS were further evaluated depending upon time of presentation: (1) ED-based coronary CTA during normal working hours, (2) or outpatient coronary CTA within 72 hours at other times. All data were collected prospectively. The primary outcome was the proportion of patients who had an outpatient coronary CTA ordered and had a predefined major adverse cardiac event (MACE) between ED discharge and outpatient CT; secondary outcome was the ED length of stay in both groups. ResultsFrom July 1, 2012 to June 30, 2014, we enrolled 521 consecutive patients: 350 with outpatient CT and 171 with ED-based CT. Demographics and risk factors were similar in both cohorts. No outpatient CT patients had a MACE prior to coronary CTA. (0.0%, 95% CI 0 to 0.9%) The median length of stay for ED-based evaluation was 6.6 hours (interquartile range 5.4 to 8.3 hours) while the outpatient group had a median length of stay of 7.0 hours (IQR 6.0 to 9.8 hours, n.s.). ConclusionsIn ED chest pain patients with a low risk of ACS, performing coronary CTA as an outpatient may be a safe strategy.

Does computed tomographic scan affect diagnosis and management of patients with suspected renal colic?

BackgroundPatients with renal colic commonly present to the emergency department (ED) and are usually treated with analgesics, antiemetics and hydration. Computed tomographic (CT) scan is commonly utilized in evaluating patients with suspected renal colic. ObjectivesWe compared diagnosis and treatment plans before and after CT in patients with suspected renal colic with the aim to evaluate how often changes in diagnosis, treatment and disposition are made. MethodsIn this prospective observational study, we enrolled a convenience sample of clinically Stable ED patients older than 17 with suspected renal colic for whom CT was planned. Exclusion criteria were: chronic kidney disease, urinary tract infection, recent CT and history of previous kidney stone. Pre-CT and Post-CT surveys were completed by the treating provider. ResultsThe discharge diagnosis was renal colic in 62 of 93 enrolled patients (67%). Urinalysis showed blood in 52 of these patients (84%). CT confirmed obstructing kidney or bladder stone in 50 patients. There were five cases of alternative diagnoses noted on CT scan. After CT scan, 7 patients had changes in disposition. Sixteen providers felt that CT would not change management. In these cases, CT offered no alternative diagnosis and didn't change disposition. ConclusionCT scan didn't change management when providers did not expect it would. This indicates that providers who are confident with the diagnosis of renal colic should consider forgoing a CT scan. CT scan did occasionally find important alternative diagnoses and should be utilized when providers are considering other concerning pathology.

Feasibility of a computer-assisted alcohol SBIRT program in an urban emergency department: patient and research staff perspectives

ObjectivesThe study objective was to assess the feasibility of a computerized alcohol-screening interview (CASI) program to identify at-risk alcohol users among adult emergency department (ED) patients. The study aimed to evaluate the feasibility of implementing a computerized screening, brief intervention, and referral to treatment (SBIRT) program within a busy urban ED setting, to report on accurate deployment of alcohol screening results, and to assess comprehension and satisfaction with CASI from both patient and research staff perspectives.MethodsResearch assistants (RAs) screened a convenience sample of medically stable ED patients. The RAs brought CASI to patients’ bedsides, and patients entered their own alcohol consumption data. The CASI intervention consisted of an alcohol use screening identification test, a personalized normative feedback profile, NIAAA low-risk drinking educational materials, and treatment referrals (when indicated).ResultsFive hundred seventeen patients were enrolled. The median age of participants was 37 years (range, 21-85 years); 37% were men, 62% were Hispanic, 7% were Caucasian, 30% were African American, and 2% were multiracial. Eighty percent reported regular use of computers at home. Eighty percent of patients approached consented to participate, and 99% of those who started CASI were able to complete it. Two percent of interviews were interrupted for medical tests and procedures, however, no patients required breaks from using CASI for not feeling well. The CASI program accurately provided alcohol risk education to patients 100% of the time. Thirty-two percent of patients in the sample screened positive for at-risk drinking. Sixty percent of patients reported that CASI increased their knowledge of safe drinking limits, 39% reported some likeliness to change their alcohol use, and 28% reported some intention to consult a health care professional about their alcohol use as a result of their screening results. Ninety-three percent reported CASI was easy to use, 93% felt comfortable receiving alcohol education via computer, and 89% liked using CASI. Ninety percent of patients correctly identified their alcohol risk level after participating in CASI. With regard to research staff experience, RAs needed to provide standby assistance to patients during <1% of CASI administrations and needed to troubleshoot computer issues in 4% of interviews. The RAs distributed the correct alcohol risk normative profiles to patients 97% of the time and provided patients with treatment referrals when indicated 81% of the time. The RAs rated patients as “not bothered at all” by using CASI 94% of the time.ConclusionsThis study demonstrates that an ED-based computerized alcohol screening program is both acceptable to patients and effective in educating patients about their alcohol risk level. Additionally, this study demonstrates that few logistical problems related to using computers for these interventions were experienced by research staff: in most cases, staff accurately deployed alcohol risk education to patients, and in all cases, the computer provided accurate education to patients. Computer-assisted SBIRT may represent a significant time-saving measure, allowing EDs to reach larger numbers of patients for alcohol intervention without causing undue clinical burden or interruptions to clinical care. Future studies with follow-up are needed to replicate these results and assess drinking reductions post-intervention.

Interrater reliability and parallel forms reliability of two noninvasive hemodynamic monitoring devices in clinically stable emergency department patients

To evaluate the interrater reliability and parallel forms reliability of transcutaneous Doppler ultrasonography (TCDU) and impedance cardiography (ICG) in clinically and hemodynamically stable emergency department patients. We enrolled 30 emergency department patients over a 2-day period. Patients had three consecutive simultaneously blinded measurements of stroke volume (SV) and heart rate (HR) recorded by TCDU (USCOM) and ICG (Cardiodynamics). Two physicians, with basic familiarity but no clinical experience with either device recorded three measurements of SV and HR on each device. Intraclass correlation coefficients (ICC), mixed linear models for repeated measures, and Bland-Altman plots were used to assess interrater reliability and nature of relationships between measures from the devices (parallel forms reliability). The ICC for TCDU was 0.96 for HR and 0.95 for SV, whereas the ICC for ICG was 0.93 for HR and 0.98 for SV. The device HR estimates were significantly related (P<0.0001 for all slopes) for all phases, but SV failed to reach significance following the first 50 trials [t(94.2)=2.72, P=0.0077]. Although HR estimates were within reasonable clinical tolerances (bias 0.5%, limits of agreement -15.4 to 16.4%) SV disagreement was concerning (bias 3.8%, limits of agreement -58 to 66%). Both TCDU and ICG have fair interrater reliability of SV independent of operator experience. A statistically significant relationship exists between the two devices but this does not produce predictable values in SV. Over time comparative results become less biased but remain limited by a great degree of variability.

34: Assessing Inter-Rater Reliability and Agreement Between Two Methods of Noninvasive Hemodynamic Monitoring in Clinically Stable Emergency Department Patients

Noninvasive hemodynamic monitoring is becoming more frequent. Transcutaneous doppler ultrasonagraphy (TCDU) and impedance cardiography (IC) are two technologies available for use in the emergency department setting. Limited studies have indicated some operator variability, particularly with novice users of TCDU. We sought to evaluate the inter-rater reliability of two devices based on these technologies and compare them in clinically and hemodynamically stable ED patients. We hypothesized a high inter-rater reliability for each device, as well as a high level of agreement between the devices.

Capillary Refill Time in Adults Has Poor Inter-Observer Agreement

ObjectivesCapillary refill time (CRT) has been taught as a rapid indicator of circulatory status but to be a useful clinical test, CRT needs to be reproducible when performed by another health care worker. No inter-rater agreement studies have been reported for adult patients. The aim of this study was to determine the inter-observer reliability of CRT in a sample of adult emergency department (ED) patients. Methods This prospective observational study included clinically stable ED patients with a variety of conditions from two community EDs. A doctor and a nurse each measured CRT by estimation to the nearest half-second using a standard method on each patient. They were blinded to each other's measurements. The primary outcome of interest was inter-rater agreement. Secondary outcome was agreement in classification as normal or abnormal according to accepted definitions. Data was analysed using bias plot analysis, correlation, absolute percent agreement and kappa analysis. Results Totally, 209 patients were enrolled; 51% were female and 86% were Caucasian. Median CRT was 2 seconds (95% CI 2–2.35 seconds). The mean difference between measurements by the different observers was 0 second, however the 95% limits of agreement were very wide (–1.7 to +1.9 seconds). Agreement was 70% for classification of ‘normal’ or ‘abnormal’ using the 2-second definition of normal, with a kappa of 0.38. Conclusion Interobserver agreement in measurement of CRT was poor in adult subjects with wide limits of agreement. This is a serious threat to the appropriateness of this test for use in clinical practice.