Structured Chart Review Research Articles

Electroencephalography-Guided Minimisation of Anaesthetic Administration to Prevent Post-Operative Delirium: A Randomised, Pragmatic Trial

Background: Intraoperative electroencephalogram suppression, suggesting excessive general anaesthesia, predicts postoperative delirium. The primary purpose of this trial was to assess the effectiveness of electroencephalography-guided minimisation of anaesthetic administration and electroencephalogram suppression to prevent postoperative delirium in older adults. Methods: The Electroencephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes [ENGAGES] study enrolled adults older than 60 undergoing major surgery under general anaesthesia at Barnes-Jewish Hospital in Saint Louis. Using a computer-generated randomisation sequence we randomly assigned patients in blocks of 20 in four strata (cardiac or non-cardiac surgery; positive or negative recent fall history) to electroencephalography-guided or usual anaesthetic care. Participants and investigators were blinded to group assignment. Delirium was assessed for 5 postoperative days, using structured chart review and daily Confusion Assessment Method. We analysed by intention-to-treat and assessed adverse events. Findings: Between Jan 16, 2015 and May 7, 2018, 39144 patients were screened, and 1232 patients were randomly assigned, with 614 in the electroencephalography-guided and 618 in the usual care group. Compared with usual care, the guided group had a 14% median decrease in volatile anaesthetic administration, and a 46% reduction in the median [interquartile range] intraoperative time with electroencephalogram suppression (7 [1 to 23] vs 13 [2 to 58] minutes, p<0·001). However, there was no significant difference between groups in delirium incidence: 157/604 in the guided compared with 140/609 in the usual care group (26·0% vs 23·0%; absolute difference 3·0%, 95% CI -2·0 to 8·0, P=0·224). No patients reported intraoperative awareness, but patient movement occurred in 22·3% of patients in the guided and 15·4% in the usual care group (absolute difference 6·9%, 95% CI 2·6 to 11·3, P=0·002). Duration of hypotension and overall occurrence of serious adverse events were similar in the groups. Interpretation: Electroencephalography-guidance of anaesthesia with the aim of minimising suppression and anaesthetic administration is unlikely to prevent postoperative delirium, and might instead promote undesirable patient movement during surgery. Trial Registry Number: The trial is registered with clinicaltrials.gov, number NCT02241655. Funding: This study was funded by a National Institutes of Health grant to support pragmatic trials ((1 UH2 HL125141, 5 UH3 AG050312). This study was also funded by the National Institutes of Health NIDUS Grant (NIA R24AG054259) and the Dr Seymour and Rose T. Brown Endowed Chair at Washington University. Declaration of Interests: The authors have no conflicts of interest to report. Ethical Approval Statement: The ethics committee at Washington University School of Medicine approved the study, and all patients provided written informed consent.

Arrest etiology among patients resuscitated from cardiac arrest

IntroductionCardiac arrest etiology is often assigned according to the Utstein template, which differentiates medical (formerly “presumed cardiac”) from other causes. These categories are poorly defined, contain within them many clinically distinct etiologies, and are rarely based on diagnostic testing. Optimal clinical care and research require more rigorous characterization of arrest etiology. MethodsWe developed a novel system to classify arrest etiology using a structured chart review of consecutive patients treated at a single center after in- or out-of-hospital cardiac arrest over four years. Two reviewers independently reviewed a random subset of 20% of cases to calculate inter-rater reliability. We used X2 and Kruskal-Wallis tests to compare baseline clinical characteristics and outcomes across etiologies. ResultsWe identified 14 principal arrest etiologies, and developed objective diagnostic criteria for each. Inter-rater reliability was high (kappa = 0.80). Median age of 986 included patients was 60 years, 43% were female and 71% arrested out-of-hospital. The most common etiology was respiratory failure (148 (15%)). A minority (255 (26%)) arrested due to cardiac causes. Only nine (1%) underwent a diagnostic workup that was unrevealing of etiology. Rates of awakening and survival to hospital discharge both differed across arrest etiologies, with survival ranging from 6% to 60% (both P < 0.001), and rates of favorable outcome ranging from 0% to 40% (P < 0.001). Timing and mechanism of death (e.g. multisystem organ failure or brain death) also differed significantly across etiologies. ConclusionsArrest etiology was identifiable in the majority cases via systematic chart review. “Cardiac” etiologies may be less common than previously thought. Substantial clinical heterogeneity exists across etiologies, suggesting previous classification systems may be insufficient.

Variability of renal colic management and outcomes in two Canadian cities

Some centres favour early intervention for ureteral colic while others prefer trial of spontaneous passage, and relative outcomes are poorly described. Calgary and Vancouver have similar populations and physician expertise, but differing approaches to ureteral colic. We studied 60-day hospitalization and intervention rates for patients having a first emergency department (ED) visit for ureteral colic in these diverse systems. We used administrative data and structured chart review to study all Vancouver and Calgary patients with an index visit for ureteral colic during 2014. Patient demographics, arrival characteristics and triage category were captured from ED information systems, while ED visits and admissions were captured from linked regional hospital databases. Laboratory results were obtained from electronic health records and stone characteristics were abstracted from diagnostic imaging reports. Our primary outcome was hospitalization or urological intervention from 0 to 60 days. Secondary outcomes included ED revisits, readmissions and rescue interventions. Time to event analysis was conducted and Cox Proportional Hazards modelling was performed to adjust for covariate imbalance. We studied 3283 patients with CT-defined stones. Patient and stone characteristics were similar for the cities. Hospitalization or intervention occurred in 60.9% of Calgary patients and 31.3% of Vancouver patients (p<0.001). Calgary patients had higher index intervention rates (52.1% v. 7.5%), and experienced more ED revisits and hospital readmissions during follow-up. The data suggest that outcome events were associated with overtreatment of small stones in one city and undertreatment of large stones in the other. An early interventional approach was associated with higher ED revisit, hospitalization and intervention rates. If these events are markers of patient disability, then a less interventional approach to small stones and earlier definitive management of large stones may reduce system utilization and improve outcomes for patients with acute ureteral colic.

Safety of bolus-dose phenylephrine for hypotensive emergency department patients

IntroductionBolus-dose phenylephrine (BDPE) is routinely used to treat hypotension in the operating room. BDPE's fast onset of action and ability to be administered peripherally have prompted calls for its use in the Emergency Department (ED). There are few published data on the safety of BDPE use in the ED. Primary concerns include BDPE's potential to cause dangerous hypertension or reflex bradycardia. We hypothesize that BDPE is a safe short-term vasopressor choice for hypotensive ED patients. MethodsWe conducted a structured chart review for all patients who received BDPE from preloaded syringes over 42months. We defined an adverse event (AE) as sBP>180, dBP>110, or HR<50 within 30min of receiving BDPE. We defined a serious adverse event (SAE) as an AE with pharmacologic intervention to correct vital sign abnormality. We also compared mean arterial pressure (MAP), sBP, and dBP pre/post BDPE administration to assess effectiveness. We used a two-sample t-test to assess for differences between the mean delta MAP after low versus high-dose BDPE. ResultsWe identified 181 cases of ED use. 147 cases had complete pre/post vital signs. We identified 5 AEs and no SAEs. Three patients developed sBP>180mmHg. The patients suffered no apparent harm. No patients had dBP>110. Two patients developed bradycardia post-drug. In both cases, MAP improved despite bradycardia. ConclusionsBDPE does not appear to cause reflex bradycardia or hypertension requiring intervention among hypotensive ED patients. The apparent safety of BDPE should be confirmed in prospective trials.

High dose insulin for beta-blocker and calcium channel-blocker poisoning

Background/objectivesHigh dose insulin (HDI) is a standard therapy for beta-blocker (BB) and calcium channel-blocker (CCB) poisoning, however human case experience is rare. Our poison center routinely recommends HDI for shock from BBs or CCBs started at 1U/kg/h and titrated to 10U/kg/h. The study objective was to describe clinical characteristics and adverse events associated with HDI. MethodsThis was a structured chart review of patients receiving HDI for BB or CCB poisoning with HDI defined as insulin infusion of ≥0.5U/kg/h. ResultsIn total 199 patients met final inclusion criteria. Median age was 48years (range 14–89); 50% were male. Eighty-eight patients (44%) were poisoned by BBs, 66 (33%) by CCBs, and 45 (23%) by both. Median nadir pulse was 54 beats/min (range 12–121); median nadir systolic blood pressure was 70mmHg (range, 30–167). Forty-one patients (21%) experienced cardiac arrest; 31 (16%) died. Median insulin bolus was 1U/kg (range, 0.5–10). Median starting insulin infusion was 1U/kg/h (range 0.22–10); median peak infusion was 8U/kg/h (range 0.5–18). Hypokalemia occurred in 29% of patients. Hypoglycemia occurred in 31% of patients; 50% (29/50) experienced hypoglycemia when dextrose infusion concentration ≤10%, and 30% (31/105) experienced hypoglycemia when dextrose infusion concentration ≥20%. ConclusionsHDI, initiated by emergency physicians in consultation with a poison center, was feasible and safe in this large series. Metabolic abnormalities were common, highlighting the need for close monitoring. Hypoglycemia was more common when less concentrated dextrose maintenance infusions were utilized.

Incidence, risk factors, and clinical implications of post-operative delirium in lung transplant recipients

Delirium significantly affects post-operative outcomes, but the incidence, risk factors, and long-term impact of delirium in lung transplant recipients have not been well studied. We analyzed 155 lung transplant recipients enrolled in the Lung Transplant Outcomes Group (LTOG) cohort at a single center. We determined delirium incidence by structured chart review, identified risk factors for delirium, determined whether plasma concentrations of 2 cerebral injury markers (neuron-specific enolase [NSE] and glial fibrillary acidic protein [GFAP]) were associated with delirium, and determined the association of post-operative delirium with 1-year survival. Fifty-seven (36.8%) patients developed post-operative delirium. Independent risk factors for delirium included pre-transplant benzodiazepine prescription (relative risk [RR] 1.82; 95% confidence interval [CI] 1.08 to 3.07; p = 0.025), total ischemic time (RR 1.10 per 30-minute increase; 95% CI 1.01 to 1.21; p = 0.027), duration of time with intra-operative mean arterial pressure <60 mm Hg (RR 1.07 per 15-minute increase; 95% CI 1.00 to 1.14; p = 0.041), and Grade 3 primary graft dysfunction (RR 2.13; 95% CI 1.27 to 3.58; p = 0.004). Ninety-one (58.7%) patients had plasma available at 24 hours. Plasma GFAP was inconsistently detected, whereas NSE was universally detectable, with higher NSE concentrations associated with delirium (risk difference 15.1% comparing 75th and 25th percentiles; 95% CI 2.5 to 27.7; p = 0.026). One-year mortality appeared higher among delirious patients, 12.3% compared with 7.1%, but the difference was not significant (p = 0.28). Post-operative delirium is common in lung transplant recipients, and several potentially modifiable risk factors deserve further study to determine their associated mechanisms and predictive values.

Abstract TP301: Primary Language Predicts Outcomes in Acute Ischemic Stroke

Introduction: Intravenous (IV) thrombolysis with tissue plasminogen activator (tPA) is the only FDA approved medical therapy for acute ischemic stroke. There is a paucity of data regarding the effect of primary language on outcomes in stroke patients. The aim of this study was to determine if primary language impacts outcomes of acute stroke patients receiving IV thrombolysis. Methods: This is a retrospective study of patients with acute ischemic stroke who received IV tPA at our institution from January 1, 2013 to December 31, 2016. Subjects were divided by primary language based on structured chart review. Subgroups for Non-English speakers were Spanish, Vietnamese, and Other language. Outcomes were modified Rankin scale (mRS) at discharge, favorable outcome (mRS score 0-2) at discharge, mortality at hospital discharge, and length of stay (LOS). Statistical analysis of data was done with unpaired t test and ANOVA multi-variant analysis as appropriate. Results: During the study period, 190 patients received IV tPA for acute stroke. Among them, 120 primarily spoke English, 35 Spanish, 22 Vietnamese, and 13 Other languages. Favorable outcome at discharge was highest in Vietnamese group at 50%, followed by English (48%), Spanish (40%), and Other language group (7.7%). English and Vietnamese groups scored nearly two points better on average mRS at discharge than the Other language group. The mortality rate was highest in the Other language group at 15.4%, followed by English (9.2%), Vietnamese (4.5%), and then Spanish group (2.9%). English speaking patients had shorter mean LOS (4.2 days versus 5.2 days; 95% CI 0.068-2.02) compared to Non-English speaking patients. Average LOS for the Other language group was one week longer than other groups. The Other language group was also least likely to be discharged home (7.7%) compared to English (34.5%), Spanish (42.9%) and Vietnamese (50.0%) groups. Conclusions: This study demonstrated an outcome advantage for tPA patients whose primary language is more frequent (English, Spanish, and Vietnamese) at a multi-ethnic regional hospital. Patients whose primary language was uncommon (Other language) had higher mortality rate, longer LOS, and were less likely to be discharged home than frequent language groups.

Changing costs of metastatic non small cell lung cancer in the Netherlands

ObjectivesThe primary objective of this study was to identify the total intramural cost of illness of metastatic non-small cell lung cancer (NSCLC) in the Netherlands between 2006–2012. Secondary objective was to identify whether changes in cost patterns of metastatic NSCLC have occurred over the last years. MethodsPatients diagnosed with metastatic NSCLC between 1-1-2006 and 31-12-2012, who had follow-up to death or the date of data cut-off and no trial participation were included. A structured chart review was performed using a case report form. Data collection started after diagnosis of metastatic NSCLC and ended at death or April first, 2015. Data regarding outpatient visits, clinical attendance, oncolytic drug use, imaging, lab tests, radiotherapy and surgery were collected. ResultsSixty-seven patients were included with a median age of 67 years. The median follow-up was 234days. On average patients had 28 outpatient visits and 11 inpatient days. Oncolytic drugs were administered to 76% of the patients. Mean per patient expenditures amounted up to €17,463, with oncolytic drugs (€6,390) as the main cost driver. In comparison with the time-period of 2003–2005 total per patient per year expenses decreased by 44%. The contribution to total yearly costs of oncolytic drugs increased from 18% to 35%, while costs for inpatient stay decreased from 52% to 28% of total expenditures. ConclusionOutcomes in this study demonstrate that average treatment costs for metastatic NSCLC in the Netherlands Cancer Institute amount to €17,463. Compared to a prior study the average cost for metastatic NSCLC over time in the Netherlands has decreased. A shift of main cost drivers seems to have occurred from inpatient stay, to oncolytic drugs as main contributor. The shift towards treatment cost might become more visible with the introduction of immunotherapy. These results mark the importance of up-to-date cost of illness studies.

Association of antiplatelet therapy with patient outcomes after out-of-hospital cardiac arrest

BackgroundCessation of blood flow during out-of-hospital cardiac arrest (OHCA) results in microvascular thrombosis, protracted hypoperfusion after return of spontaneous circulation and damage to vital organs. We tested the hypothesis that pre-arrest antiplatelet and anticoagulant medication use would be associated with less post-arrest organ dysfunction and better outcomes. MethodsWe included OHCA patients treated from January 2005 to October 2014 at a single academic medical center. We combined our prospective OHCA registry of clinical and demographic data with a structured chart review to abstract home antiplatelet and anticoagulant medications. We fit unadjusted and adjusted regression models to test the association of antiplatelet and anticoagulant medication use with early post-arrest illness severity, survival and functionally favorable recovery. ResultsOf 1054 subjects, 295 (28%) were prescribed an antiplatelet agent and 147 (14%) were prescribed an anticoagulant prior to arrest. In adjusted models, antiplatelet agents were associated with lower post-arrest illness severity (adjusted OR 0.50 95% CI 0.33–0.77), greater odds of survival to discharge (adjusted OR 1.74 95% CI 1.08–2.80) and greater odds favorable functional outcome (adjusted OR 2.11 95% CI 1.17–3.79). By contrast, anticoagulation via any agent was not associated with illness severity, survival to discharge or favorable outcome. ConclusionPreventing intra-arrest and post-arrest microvascular thrombosis via antiplatelet agents could represent a novel therapeutic target to improve outcomes after OHCA.

Risperidone in the Emergency Setting is Associated with More Hypotension in Elderly Patients

BackgroundExpert consensus panels have recommended risperidone as first-line treatment for agitation of psychiatric origin. However, there are few if any studies on this medication in the emergency setting. ObjectivesTo assess the hemodynamic effects of risperidone in an emergency department (ED) setting, stratified by age. MethodsThis is a structured chart review of all patients who received oral risperidone over a 6-year period in an ED setting, excluding patients who received this medication as a prescription refill. Vital signs were analyzed for this subset prior to and after medication administration, and changes in vital signs were stratified by age. ResultsThe median dose of risperidone was less in patients aged > 65 years. However, the median drop in systolic blood pressure was larger in this age group compared with younger patients. ConclusionsClinicians tend to be more cautious with dosing of risperidone to geriatric patients in the ED. Despite this, decreases in systolic blood pressure are larger and more frequent in this age group. When possible, clinicians should consider or attempt nonpharmacologic methods of agitation treatment prior to administering medications such as risperidone to elderly patients.

Outcomes Following Possible Undiagnosed Aneurysmal Subarachnoid Hemorrhage: AContemporary Analysis.

Existing literature suggests that patients with aneurysmal subarachnoid hemorrhage (aSAH) and "sentinel" aSAH symptoms prompting healthcare evaluations prior to aSAH diagnosis are at increased risk of unfavorable neurologic outcomes and death. Accordingly, these encounters have been presumed to be unrecognized opportunities to diagnose aSAH and the worse outcomes representative of the added risks of delayed diagnoses. We sought to reinvestigate this paradigm among a contemporary cohort of patients with aSAH. A case-control cohort was retrospectively assembled among patients diagnosed with aSAH between January 1, 2007 and June 30, 2013 within an integrated healthcare delivery system. Patients with a discrete clinical evaluation for headache or neck pain within 14 days prior to formal aSAH diagnosis were identified as cases, and the remaining patients served as controls. Modified Rankin Scale scores at 90 days and 1 year were determined by structured chart review. Multivariable logistic regression controlling for age, sex, ethnicity, presence of intracerebral or intraventricular hemorrhage at diagnosis, and aneurysm size was used to compare adjusted outcomes. Sensitivity analyses were performed using varying definitions of favorable neurologic outcomes, a restricted control subgroup of patients with normal mental status at hospital admission, inclusion of additional cases that were diagnosed outside of the integrated health system, and exclusion of patients without evidence of subarachnoid blood on initial noncontrast cranial computed tomography (CT) at the diagnostic encounter (i.e. "CT-negative" SAH). A total of 450 patients with aSAH were identified, 46 (10%) of whom had clinical evaluations for possible aSAH-related symptoms in the 14 days preceding formal diagnosis (cases). In contrast to prior reports, no differences were observed among cases compared to control patients in adjusted odds of death or unfavorable neurologic status at 90 days (0.35, 95% confidence interval [CI]= 0.11-1.15; 0.59, 95% CI= 0.22-1.60, respectively) or at 1 year (0.58, 95% CI= 0.19-1.73; 0.52, 95% CI= 0.18-1.51, respectively). Likewise, neither restricting the analysis to a control subgroup of patients with normal mental status at hospital admission, varying the dichotomous definition of unfavorable neurologic outcome, inclusion of cases diagnosed outside the integrated health system, or exclusion of patients with CT-negative SAH resulted in significant adjusted outcome differences. In a contemporary cohort of patients with aSAH, we observed no statistically significant increase in the adjusted odds of death or unfavorable neurologic outcomes among patients with clinical evaluations for possible aSAH-related symptoms in the 14 days preceding formal diagnosis of aSAH. While these findings cannot exclude a smaller risk difference than previously reported, they can help refine decision analyses and testing threshold determinations for patients with possible aSAH.

The Use, Safety, and Efficacy of Olanzapine in a Level I Pediatric Trauma Center Emergency Department Over a 10-Year Period.

Olanzapine is a second-generation antipsychotic increasingly used in emergency medicine for many indications. Literature on its use in children is sparse. Our objectives were to describe the use, safety, and efficacy of olanzapine in pediatric emergency patients. A structured chart review was performed of patients 18 years old or younger receiving olanzapine from 2007 to 2016 in the emergency department of a pediatric level I trauma center. A total of 285 children received olanzapine. Mean age was 16.4 years (range, 9-18 years); 121 were male (42.8%). Primary indications for olanzapine included agitation (n = 166, 58.3%), headache (n = 58, 20.4%), nausea/vomiting/abdominal pain (n = 37, 12.5%), unspecified pain (n = 20, 7%), and other (n = 4, 1.4%). Route of olanzapine administration was intramuscular (n = 160, 56%; median dose, 10 mg; range, 2.5-20), intravenous (n = 101, 36%; median dose, 5 mg; range, 1.25-5), and oral (n = 24, 8%; median dose, 10 mg; range, 5-10). For agitated patients, 28 (17%) received another sedative within 1 hour. For headache patients, 5 (8.6%) received another analgesic. For gastrointestinal complaints, 5 patients (13.5%) received another analgesic/antiemetic. Adverse respiratory events were hypoxia (pulse oximetry reading, in percentage, <92%; n = 7, 2.4%), supplemental oxygen placement (n = 9, 3.2%), and intubation (n = 2, 0.7%). No patient died or had a dysrhythmia. One patient experienced dystonia. Olanzapine seems safe when used for a variety of conditions in pediatric emergency patients. It may be effective for acute agitation, primary headache, and gastrointestinal complaints.

Protocol for an observational study of delirium in the post-anaesthesia care unit (PACU) as a potential predictor of subsequent postoperative delirium

IntroductionPostoperative delirium can be a serious consequence of major surgery, associated with longer hospital stays, readmission, cognitive and functional deterioration and mortality. Delirium is an acute, reversible disorder characterised by...

Abstract TP257: Thrombolytic Treatment and Complications in Stroke Mimics

Background: Patients with symptoms that simulate Acute Ischemic Stroke (AIS), but are ultimately determined to have another diagnosis are referred to as Stroke Mimics (SM). SM are reported to be 1.4% to 30% of Emergency Department (ED) cases, and reducing door-to-needle time (DTN) has been associated with increased treatment of SM (from 6.7% to 30%). The risk of tPA in SM patients is unclear. We are challenged with the conflicting goals of timely administration of therapy and mitigating unnecessary risk. We successfully reduced DTN and were interested to see if that effected SM. Objectives: To evaluate the impact of DTN on diagnostic accuracy in patients receiving tPA in the ED; and to determine the associated complication rate in patients with AIS compared to SM. Methods: We performed a retrospective cohort study of patients receiving tPA for suspected AIS between 2013-2015. Patients were identified through our Stroke registry and confirmed by pharmacy audit of tPA orders. We performed a structured chart review and provide a descriptive analysis of variables. Results: In our study period, 97 patients were treated with tPA for the presumptive diagnosis of AIS, 90 (92.8%) had a final diagnosis of AIS, while 7 (7.2%) were SM. The only complications of treatment with tPA reported were in the AIS group, 4 (15%) and 1 (4.2%) in 2013/2014 repectively. There were no complications reported in either group in 2015. This reduction in complications was achieved while reducing the DTN to less than 45 min in 50% of patients and less than 60 min in 75% of patients. Conclusion: While doubling the number of patients treated, we reduced the DTN and the complication rate in AIS patients. Contrary to prior studies, we found a decrease in the number of SM treated. None of the SM patients had a complication. The reduction in DTN and SM over time suggests that our screening of tPA candidates is appropriate.

Prospective Prehospital Evaluation of the Cincinnati Stroke Triage Assessment Tool

Background and Purpose: A simple, easily adoptable scale with good performance characteristics is needed for EMS providers to appropriately triage suspected stroke patients to comprehensive stroke centers (CSC). Many existing tools are complex, require substantial training, or have not been prospectively validated in the prehospital setting. We describe the feasibility and effectiveness of prehospital implementation of our previously retrospectively derived and validated Cincinnati Stroke Triage Assessment Tool (C-STAT) to identify subjects with severe stroke (NIHSS ≥15) among all prehospital patients with clinical suspicion of stroke/TIA. Secondarily, we evaluated the tool's ability to identify subjects with NIHSS ≥10, large vessel occlusion (LVO), or needing services available only at a CSC. Methods: Without formalized training, Cincinnati Fire Department providers performed standard stroke screening (“face, arm, speech, time;” FAST) and C-STAT as part of their assessment of suspected stroke/TIA patients. Outcomes for patients brought to the region's only CSC or assessed by the regional stroke team were determined through structured chart review by a stroke team nurse. C-STAT test characteristics for each outcome were calculated with 95% confidence intervals. Results: Complete prehospital and outcome data were available for 58 FAST-positive subjects among 158 subjects with prehospital suspicion for stroke/TIA. Subjects were excluded if FAST was negative (n = 22), FAST or C-STAT was incompletely documented (n = 24), if the patient was taken to a non-CSC and did not receive a stroke team consult (n = 48), or if outcome data were missing (n = 6). C-STAT sensitivity and specificity for each outcome were: NIHSS ≥ 15, 77% (95% CI 46–95) and 84% (95% CI 69–93); NIHSS ≥10, 64% (95% CI 41–83) and 91% (95% CI 76–98); LVO, 71% (95% CI 29–96) and 70% (95% CI 55–83); overall CSC need 57% (95% CI 34–78) and 79% (95% CI 61–91). Conclusion: In this pilot prospective evaluation performed in the prehospital setting by EMS providers without formalized training, C-STAT is comparable to other published tools in test characteristics and may inform appropriate CSC triage beyond LVO ascertainment alone.

Emergency Department Management of Patients With Febrile Neutropenia: Guideline Concordant or Overly Aggressive?

The Infectious Diseases Society of America and the American Society of Clinical Oncology recommend risk stratification of patients with febrile neutropenia (FN) and discharge with oral antibiotics for low-risk patients. We studied guideline concordance and clinical outcomes of FN management in our emergency department (ED). Our urban, tertiary care teaching hospital provides all emergency and inpatient services to a large comprehensive cancer center. We performed a structured chart review of all FN patients seen in our ED from January 2010 to December 2014. Using electronic medical records, we identified all visits by patients with fever and an absolute neutrophil countof <1000 cells/mm3 and then included only patients without a clear source of infection. Following national guidelines, we classified patients as low or high risk and assessed guideline concordance in disposition and parenteral versus oral antibiotic therapy by risk category as our main outcome measure. Of 173 qualifying visits, we classified 44 (25%) as low risk and 129 (75%) as high risk. Management was guideline concordant in 121 (70%, 95% confidence interval [CI]= 63% to 77%). Management was guideline discordant in 43 (98%, 95% CI= 88% to 100%) of low-risk patients versus 9 (7%, 95% CI= 3% to 13%) of high-risk patients (relative risk [RR]= 14, 95% CI= 7.5 to 26). Of 52 guideline-discordant cases, 36 (83%, 95% CI= 72% to 93%) involved low-risk cases with treatment that was more aggressive than recommended. Guideline concordance was low among low-risk patients, with management tending to be more aggressive than recommended. Unless data emerge that undermine the guidelines, we believe that many of these hospitalizations and parenteral antibiotic regimens can be avoided, decreasing the risks associated with hospitalization, while improving antibiotic stewardship and patient comfort.

Use of Oral Anticoagulant Therapy in Older Adults with Atrial Fibrillation After Acute Ischemic Stroke.

To explore barriers to anticoagulation in older adults with atrial fibrillation (AF) at high risk of stroke and to identify opportunities for interventions that might increase use of oral anticoagulants (OACs). Retrospective cohort study. Two large community-based AF cohorts. Individuals with ischemic stroke surviving hospitalization (N = 1,405, mean age 79). Using structured chart review, reasons for nonuse of OAC were identified, and 1-year poststroke survival was assessed. Logistic regression was used to identify correlates of OAC nonuse. Median CHA2 DS2 -VASc score was 5, yet 44% of participants were not prescribed an OAC at discharge. The most-frequent (nonmutually exclusive) physician reasons for not prescribing OAC included fall risk (26.7%), poor prognosis (19.3%), bleeding history (17.1%), participant or family refusal (14.9%), older age (11.0%), and dementia (9.4%). Older age (odds ratio (OR) = 8.96, 95% confidence interval (CI) = 5.01-16.04 for aged ≥85 vs <65) and disability (OR = 12.58, 95% CI = 5.82-27.21 for severe vs no deficit) were the most-important independent predictors of nonuse of OACs. By 1 year, 42.5% of those not receiving an OAC at discharge had died, versus 19.1% of those receiving an OAC (P < .001), far higher than recurrent stroke rates. Despite very high stroke risk, more than 40% of participants were not discharged with an OAC. Dominant reasons included fall risk, poor prognosis, older age, and dementia. These individuals' high 1-year mortality rate confirmed their high level of comorbidity. To improve anticoagulation decisions and outcomes in this population, future research should focus on strategies to mitigate fall risk, improve assessment of risks and benefits of anticoagulation in individuals with AF, and determine whether newer anticoagulants are safer in complex elderly and frail individuals.

Reducing the incidence of hospital-associated venous thromboembolism within a network of academic hospitals: Findings from five University of California medical centers.

Almost 700 patients suffered from hospital-associated venous thromboembolism (HA-VTE) across 5 University of California hospitals in calendar year 2011. Optimize venous thromboembolism (VTE) prophylaxis (VTEP) in adult medical/surgical inpatients and reduce HA-VTE by at least 20% within 3 years. Prospective, unblinded, open-intervention study with historical controls. Five independent but cooperating academic hospitals. All adult medical and surgical inpatients with stays ≥3 days. The baseline year was 2011, 2012 to 2014 were intervention years, and year 2014 was the mature comparison period. VTEP adequacy was assessed with structured chart review of 45 patients per month at each site via random selection beginning partway through the study. HA-VTE was identified by discharge coding, capturing patients readmitted within 30 days of prior VTE-free admit and VTE occurring during index admission. Cases were stratified medical versus surgical and cancer or noncancer. Interventions included structured order sets with "3-bucket" risk-assessment, measure-vention, techniques to improve reliable administration of VTEP, and education. Adequate prophylaxis reached 89% by early 2014. The rate of HA-VTE fell from 0.90% in 2011 to 0.69% in 2014 (24% relative risk [RR] reduction; RR: 0.76, 95% confidence interval: 0.68-0.852), equivalent to averting 81 pulmonary emboli and 89 deep venous thrombi. VTE rates were highest in cancer and surgical patients. Hospital systems can reduce HA-VTE by implementing a bundle of active interventions including structured VTEP orders with embedded risk assessment and measure-vention. Journal of Hospital Medicine 2016;11:S22-S28. © 2016 Society of Hospital Medicine.

Time to Awakening Is Often Delayed in Patients Who Receive Targeted Temperature Management After Cardiac Arrest.

Post cardiac arrest, neuroprognostication remains a complex and clinically challenging issue for critical care providers. For this reason, our primary objective in this study was to determine the frequency of survival and favorable neurological outcomes in post-cardiac arrest patients with delayed time to awakening. To assess whether early withdrawal of care may adversely impact survival, we also sought to describe the time to withdrawal of care of non-surviving patients. We performed a retrospective study of patients resuscitated after cardiac arrest in two large academic community hospitals. We performed a structured chart review of patients treated with therapeutic hypothermia (TH) at one hospital from 2009 to 2015 and at a second hospital from 2013 to 2015. Demographics and Utstein style variables were recorded on all patients, as well as temporal variables to characterize the time interval from Return of Spontaneous Circulation (ROSC) to awakening as recorded by ICU nurses and defined as Glasgow Coma Scale (GCS) of >8. Descriptive data were also captured regarding time to withdrawal of care. We pre-hoc defined delayed awakening as >72 hours post ROSC or >72 hours post rewarming. Our primary outcome was survival to hospital discharge with a secondary outcome of a favorable cerebral performance category of 1 or 2. During this study period, 321 patients received TH, with 111 (34.6%) discharged alive and, of these, 67 (68.5%) experienced a good neurological outcome. Awakening more than 72 hours after return of circulation was common with 31 patients surviving to discharge. Of these, 16 of 31 (51.6%) were found to have a good neurological outcome on hospital discharge. Of the patients who died before discharge, 54 (29.5%) had care withdrawn less than 72 hours after ROSC. A delayed time to awakening is not infrequently associated with a good neurological outcome after TH in patients resuscitated from cardiac arrest.

Sex-related Differences in Emergency Department Renal Colic Management: Females Have Fewer Computed Tomography Scans but Similar Outcomes.

Sex-related differences occur in many areas of medicine. Emergency department (ED) studies have suggested differences in access to care, diagnostic imaging use, pain management, and intervention. We investigated sex-based differences in the care and outcomes for ED patients with acute renal colic. This was a multicenter population-based retrospective observational cohort study using administrative data and supplemented by structured chart review. All patients seen in Calgary Health Region EDs between January 1 and December 31, 2014, with an ED diagnosis of renal colic based on the following ICD-10 codes were eligible for inclusion: calculus of kidney (N200), calculus of ureter (N201), calculus of kidney with calculus of ureter (N202), hydronephrosis with renal and ureteral calculous obstruction (N132), unspecified renal colic (N23), and unspecified urinary calculus (N209). ED visit data and test results were accessed in the regional ED clinical database. Stone characteristics were captured from diagnostic imaging reports. Regional hospital databases were used to identify subsequent ED encounters, hospital admissions, and surgical procedures within 60days. Outcomes were stratified by sex. The primary outcome, intended as a marker of overall effectiveness of ED care, was the unscheduled 7-day ED revisit rate among patients who were discharged home after their index ED visit. Secondary outcomes included ED pain management as reflected by administration of narcotics or intravenous nonsteroidals, the performance of advanced imaging-either ultrasound (US) or computed tomography (CT), and the proportion of patients who required hospitalization or surgical intervention within 60days. From January 1 to December 31, 2014, a total of 3,104 eligible patients were studied: 1,111 women (35.8%) and 1,993 men (64.2%). Baseline characteristics, access times, analgesic use, and admission rates were similar in both groups. Men were more likely to have CT (68.9% vs. 58.5%, difference=10.4%, 95% confidence interval [CI]=6.8 to 14.0) while women were more likely to have US (20.8% vs. 9.6%, difference=11.2%, 95% CI=8.4 to 13.9). At 7days, 17.9% of women and 19.0% of men who were discharged after their index ED visit required an ED revisit (difference=1.1%, 95% CI=-2.8 to 4.9). Men were more likely to be hospitalized at 7days (9.8% vs. 6.5%, difference=3.3%, 95% CI=0.6 to 6.0). This study shows greater reliance on US in females but no other sex-specific differences in the management of ED patients with acute renal colic. Higher CT use in men was not associated with improved outcomes, and we found no important differences in access to care, diagnostic or treatment intensity, or revisit rates as a marker of care effectiveness.