The latest medical research on Emergency Medicine
The research magnet gathers the latest research from around the web, based on your specialty area. Below you will find a sample of some of the most recent articles from reputable medical journals about emergency medicine gathered by our medical AI research bot.
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Affecting emergency department oxycodone discharge prescribing: An educational intervention.EMA - Emergency Medicine Australasia
To describe the impact of an educational intervention for ED prescribers on discharge oxycodone prescribing both for the number of oxycodone prescriptions per 1000 discharged patients, and the number of tablets per prescription. Secondary outcomes included the quality of general practitioner communication.
An interrupted time series assessment was conducted in the ED of a tertiary referral hospital to establish the pre-intervention, peri-intervention and post-intervention prescribing profile of ED medical practitioners. Prescriber numbers were used to obtain drug data for all oxycodone-containing prescriptions from the Queensland Health Medicines Regulation and Quality Unit database. The intervention included education sessions, a staff information email, posters within the ED, and a patient brochure. It was conducted with relevant nurses, pharmacists and prescribing doctors.
In the pre-intervention period, 656/17 371 (38 per 1000) discharged patients were prescribed oxycodone, compared to 180/5938 (30 per 1000) during the intervention, and 602/20 505 (29 per 1000) post-intervention. This equated to a decrease of 8 per 1000 (95% CI 5-12 per 1000) and a 22% (95% CI 13-31%) relative prescribing reduction. The mean total number of tablets of oxycodone per prescription decreased from 16.7 (SD 16.5) pre-intervention, to 12.7 (SD 6.0) peri-intervention, to 10.7 (SD 5.2) post-intervention. After the intervention, there was an increase in discharge communications to general practitioners by 15.4% (95% CI 9.7-21.1%).
An ED prescriber-targeted intervention reduced overall prescribing of oxycodone and improved communication at discharge. The prescribing intervention is one strategy that may be used by ED medical staff to improve patient safety and opioid stewardship in Australia.
Homeless status documentation at a metropolitan hospital emergency department.EMA - Emergency Medicine Australasia
This study compared the prevalence of homelessness in consecutive patients presenting to a metropolitan hospital ED measured via a prospective housing screen with the prevalence of homelessness determined via retrospective audit of hospital data. Factors that altered the odds of patients being homeless and service outcomes that differed were examined for screened patients.
All patients presenting to the ED during a 7 day period in 2017 were invited to complete a housing screen. A retrospective audit of all ED presentations during the same period also occurred. Demographic (e.g. age, gender), clinical (e.g. reason for presentation, ED presentation history) and arrival mode (e.g. time, how arrived) predictors of homeless status were examined alongside care outcomes (e.g. ED length of stay, admission and 28 day re-presentation).
Of 1208 presenting patients, 504 were prospectively screened and 7.9% were homeless. This compared with 0.8% of ED presentations coded as homeless in the Victorian Emergency Minimum Dataset and 2.3% of the 704 non-screened patients identified as homeless using Victorian Emergency Minimum Dataset Usual Accommodation alongside primary diagnosis and registration address. Within the screened sample, homeless patients were more likely to be male, arrive by emergency ambulance/with police, have a psychosocial diagnosis, and be frequent presenters. Re-presentation within 28 days occurred for 43% of homeless and 15% of not-homeless patients.
Hospital ED administrative data substantially under-recognises the prevalence of homelessness in presenting patients. Standardised use of brief housing screens could improve identification of and provision of support to this often highly vulnerable population.
Attitudes and beliefs of Australian emergency department clinicians on antimicrobial stewardship in the emergency department: A qualitative study.EMA - Emergency Medicine Australasia
To explore the attitudes and beliefs of Australian ED clinicians towards antimicrobial stewardship in the ED.
Semi-structured one-to-one interviews were conducted with ED clinicians between March and October 2015. Participants were identified via purposive and snowball sampling. Questionnaires were developed using the literature. Interviews were audio-recorded, transcribed and analysed using thematic analysis via the framework approach. Two researchers coded independently, with one using QSR International's NVivo 10 software and the other manually. Emergent themes were identified and classified.
Twenty-two clinicians (eight doctors, eight nurses and six pharmacists) from seven institutions participated. Participants were aware and concerned about antimicrobial resistance. Clinicians were divided based on their opinion on whether antimicrobials are prescribed appropriately and judiciously in the ED, with many perceiving prescribing to be inappropriate. Prior knowledge of the term 'Antimicrobial Stewardship' was demonstrated by doctors and pharmacists, with a relative lack of awareness by nurses. Four main themes were identified as both barriers and facilitators to antimicrobial stewardship in the ED: individual healthcare provider, resource, organisational and cultural. Uncertainty of diagnosis, time and resource pressures, reliance on previous experience and lack of access to expert opinion were perceived barriers. To facilitate appropriate prescribing, clinicians emphasised the need for routine education and feedback, adequate staffing, robust guidelines, senior medical clinician advocacy and multidisciplinary support.
Australian ED clinicians were aware of antimicrobial resistance. Many perceive injudicious antimicrobial use as problematic. Consideration of ED clinicians' perceived barriers and facilitators might enhance implementation of antimicrobial stewardship programmes in EDs.
Subdissociative Dose Ketamine Is Effective for Treating Acute Exacerbations of Chronic Pain.Academic Emergency Medicine
Sub-dissociative dose ketamine (SDDK) is used to treat acute pain. We sought to determine if SDDK is effective in relieving acute exacerbations of chronic pain.
Randomized double-blind placebo-controlled trial conducted May 2017-June 2018 at a public teaching hospital (ClinicalTrials. gov#NCT02920528). Primary endpoint was a 20 mm decrease on a 100 mm Visual Analog Scale (VAS) at 60 minutes. Power analysis using three groups (ketamine 0.5 mg/kg, 0.25 mg/kg, or placebo infused over 20 minutes) estimated 96 subjects were needed for 90% power. Inclusion: age >18 years, chronic pain >3 months, acute exacerbation (VAS ≥70 mm). Pain, agitation, and sedation were assessed by VAS at baseline and 20, 40, 60 min after initiation of study drug. Telephone follow-up at 24-48 hr used a 10-point Likert pain scale.
106 subjects were recruited, 3 excluded for baseline pain <70mm. After randomization, 35 received 0.5 mg/kg, 36 received 0.25 mg/kg, and 35 received placebo. Three subjects receiving 0.5 mg/kg withdrew during the infusion due to adverse effects, and 1 subject in each group had incomplete data, leaving 97 for analysis. Initial pain scores (91.9 ±8.9 mm), age (46.5±12.6 years), gender distribution and types of pain reported were similar. Primary endpoint analysis found 25/30 (83%) improved with 0.5 mg/kg, 28/35 (80%) with 0.25 mg/kg, and 13/32 (41%) with placebo (p=0.001). More adverse effects occurred in the ketamine groups with one subject in the 0.25 mg/kg group requiring a restraint code for agitation. 89% of subjects were contacted at 24-48 hr and no difference in pain level was detected between groups.
Ketamine infusions at both 0.5 mg/kg and 0.25 mg/kg over 20 minutes were effective in treating acute exacerbations of chronic pain but resulted in more adverse effects compared to placebo. Ketamine did not demonstrate longer term pain control over the next 24-48 hr. This article is protected by copyright. All rights reserved.
A comparison of scoring systems for predicting short- and long-term survival after trauma in older adults.Academic Emergency Medicine
Early identification of geriatric patients at high risk for mortality is important to guide clinical care, medical decision-making, palliative discussions, quality assurance, and research. We sought to identify injured older adults at highest risk for 30-day mortality using an empirically derived scoring system from available data, and to compare it with current prognostic scoring systems.
This was a retrospective cohort study of injured adults ≥ 65 years transported by 44 emergency medical services (EMS) agencies to 49 emergency departments in Oregon and Washington from 1/1/2011 through 12/31/2011, with follow-up through 12/31/2012. We matched data from EMS, to Medicare, inpatient, trauma registries, and vital statistics. Using a primary outcome of 30-day mortality, we empirically derived a new risk score using binary recursive partitioning and compared it to the Charlson comorbidity index (CCI); modified frailty index (MFI); geriatric trauma outcome score (GTOS); GTOS II; and injury severity score (ISS).
There were 4,849 patients, of whom 234 (4.8%) died within 30 days and 1,040 (21.5%) died within 1 year. The derived score, the Geriatric Trauma Risk Indicator (GTRI) (emergent airway or CCI ≥2), had 87.2% sensitivity (95% CI 83.0-91.5%) and 30.6%% specificity (95% CI 29.3-31.9%) for 30-day mortality (AUROC 0.589, 95% CI: 0.566-0.611). AUROC values for other scoring systems ranged from 0.592 to 0.678. When the sensitivity for each existing score was held at 90%, specificity values ranged from 7.5% (ISS) to 30.6% (GTRI).
Older, injured, adults transported by EMS to a large variety of trauma and non-trauma hospitals were more likely to die within 30 days if they required emergent airway management or have a higher comorbidity burden. When compared to other risk measures and holding sensitivity constant near 90%, the GTRI had higher specificity, despite a lower AUROC. Using GTOS II or the GTRI may better identify high-risk older adults than traditional scores, such as ISS, but identification of an ideal prognostic tool remains elusive. This article is protected by copyright. All rights reserved.
Depression in Emergency Department Patients and Association with Healthcare Utilization.Academic Emergency Medicine
Depression is one of the most common illnesses in the U.S., with increased prevalence among people with lower socioeconomic status and chronic mental illness who often seek care in the Emergency Department (ED). We sought to estimate the rate and severity of major depressive disorder (MDD) in a non-psychiatric emergency department (ED) population and its association with subsequent ED visits and hospitalizations.
This prospective cohort study enrolled a convenience sample of English-speaking adults presenting to an urban academic medical center ED without psychiatric complaints between January 1, 2015 and September 21, 2015. Patients completed a computerized adaptive depression diagnostic screen (CAD-MDD) and dimensional depression severity measurement test (CAT-DI) via tablet computer. Primary outcomes included number of ED visits and hospitalizations assessed from index visit until January 1, 2016. Negative binomial regression modeling was performed to assess associations between depression, depression severity, clinical covariates, and utilization outcomes.
Of 999 enrolled patients, 27% screened positive for MDD. The presence of MDD conveyed a 61% increase in the rate of ED visits (IRR=1.61, 95% CI: 1.27-2.03) and a 49% increase in the rate of hospitalizations (IRR=1.49, 95% CI: 1.06-2.09). For each 10% increase in MDD severity, there was a 10% increase in the relative rate of subsequent ED visits (incident rate ratio, IRR=1.10, 95% CI: 1.04-1.16) and hospitalizations (IRR=1.10, 95% CI: 1.02-1.18). Across the range of the severity scale there was over a 2.5-fold increase in the rate of ED visits and hospitalization rates.
Rates of depression were high among a convenience sample of English-speaking adult ED patients presenting with non-psychiatric complaints and independently associated with increased risk of subsequent ED utilization and hospitalization. Standardized assessment tools that provide rapid, accurate and precise classification of MDD severity have the potential to play an important role in identifying ED patients in need of urgent psychiatric resource referral. This article is protected by copyright. All rights reserved.
Comments on Manuscript AEMJ-18-765.R1: Civil monetary penalties resulting from violations of EMTALA involving psychiatric emergencies, 2002-2018.Academic Emergency Medicine
The authors' stated objective is to describe characteristics of EMTALA civil monetary penalties (CMPs) levied by the Office of Inspector General (O...
Psychiatric Outcomes of Patients with Severe Agitation Following Administration of Prehospital Ketamine.Academic Emergency Medicine
Ketamine is an emerging drug used in the management of undifferentiated, severe agitation in the prehospital setting. However, prior work has indicated that ketamine may exacerbate psychotic symptoms in patients with schizophrenia. The objective of this study was to describe psychiatric outcomes in patients who receive prehospital ketamine for severe agitation.
This is a retrospective cohort study, conducted at two tertiary academic medical centers, utilizing chart review of patients requiring prehospital sedation for severe agitation from 01/01/2014 - 06/30/2016. Patients received either intramuscular (IM) vs IV ketamine or IM vs IV benzodiazepine. The primary outcome was psychiatric inpatient admission with secondary outcomes including ED psychiatric evaluation and non-psychiatric inpatient admission. Generalized estimating equations and Fisher's exact tests were used to compare cohorts.
During the study period, 141 patient encounters met inclusion with 59 (42%) receiving prehospital ketamine. There were no statistically significant differences between the ketamine and benzodiazepine cohorts for psychiatric inpatient admission (6.8% vs. 2.4%; difference: 4.3%; 95% CI: -2% to 12%, p=0.23) or ED psychiatric evaluation (8.6% vs. 15%; difference: -6.8%; 95% CI: -18% to 5%, p=0.23). Patients with schizophrenia who received ketamine did not require psychiatric inpatient admission (17% vs 10%; difference: 6.7%; CI (-46% to 79%, p=0.63) or ED psychiatric evaluation (17% vs 50%; difference: -33%; 95% CI: -100% to 33%, p=0.55) significantly more than those who received benzodiazepines, though the subgroup was small (n=16). While there was no significant difference in non-psychiatric admission rate between the ketamine and benzodiazepine cohorts (35% vs. 51%, p=0.082), non-psychiatric admissions in the benzodiazepine cohort were largely driven by intubation (63% vs. 3.8%; difference: 59%; 95% CI: 38% to 79%, p<0.001).
Administration of prehospital ketamine for severe agitation was not associated with an increase in rate of psychiatric evaluation in the emergency department or psychiatric inpatient admission when compared with benzodiazepine treatment, regardless of the patient's psychiatric history. This article is protected by copyright. All rights reserved.
One hundred and counting: Centenarian use of emergency departments in New South Wales.EMA - Emergency Medicine Australasia
To study ED utilisation by people aged 100 years and over with a focus on patient demographics, reasons for presentation and patient flow factors.
This is a retrospective descriptive analysis of linked ED Data Collection Registry for presentations to New South Wales (NSW) EDs over a 5 year period. Patients were included if they presented to an ED and were aged 100 years and over at the time of presentation. Demographics, triage category, presenting problem, ED length of stay, disposition and ED re-presentation were determined for this age group.
A total of 4033 presentations to 115 NSW EDs during 2010-2014 were analysed. We found that 78% of the patients were females and 76% still living at home. This group were the second most common age group to present to ED, after the 90-99 year age group, with 87% arriving via ambulance. Most presentations were triaged as a category 3 or 4, with the most common presenting problem being because of injury (28.5%) followed by respiratory disease (11.4%) and cardiovascular disease (10.0%). Overall, 64% required hospital admission and the average length of stay for all patients was 5.7 h.
Centenarians ED presentations are increasing over time with injuries as the most common reason for presentation. Most patients have prolonged ED length of stay and many require hospital admission. Early streaming of these patients through specialised geriatric assessment units may be more appropriate to reduce the demand on EDs and improve patient care. Models that facilitate rapid access to supported living arrangements and improved advanced care planning may be more realistic for many centenarians and different models of care need to be considered for this age group.
Effective triage in the Pacific region: The development and implementation of the Solomon Islands Triage Scale.EMA - Emergency Medicine Australasia
The ED at the National Referral Hospital in Honiara, Solomon Islands, receives approximately 50 000 patients per year. A 2014 review of ED functioning identified deficiencies in triage processes. Placement of Australian volunteer advisors provided an opportunity to develop and implement a purpose-designed triage system.
Action research methodology and the 'plan, act, observe, reflect' cycle was employed, leading to the development of a three-tier triage system based on the South African Triage Scale. ED patient flow and data management processes were simultaneously updated, and staff were trained in the new system. After a pilot period, the Solomon Islands Triage Scale was implemented in August 2017. Evaluation after 3 months of operation included predictive validity (using admission and case fatality rates as surrogate markers of urgency) and reliability (based on inter-rater agreement at retrospective chart review by an independent nurse).
In the period 1 August to 31 October, there were 10 905 presentations, of which 97.1% were allocated a triage category (1% category 1, 21.3% category 2 and the remainder category 3). Admission rates correlated closely with triage category (P < 0.01). The case fatality rate was 22.1% for category 1 patients, 0.09% for category 2 and 0.01% for category 3 (P < 0.01). An audit of 96 records conducted in October 2017 revealed 88.4% agreement for triage category allocation.
Solomon Islands Triage Scale is the first three-tier triage scale to be implemented in the Pacific region and appears to have adequate validity and reliability. The partnership between Australian volunteers and local clinicians is a positive example of capacity development and represents a model that could be implemented in other resource-limited settings.
Critical Review, Development and Testing of a Taxonomy for Adverse Events and Near Misses in the Emergency Department.Academic Emergency Medicine
An adverse event (AE) is a physical harm experienced by a patient due to health care, requiring intervention. Describing and categorizing AEs is important for quality and safety assessment and identifying areas for improvement. Safety science suggests that improvement efforts should focus on preventing and mitigating harm rather than on error, which is commonplace but infrequently leads to AEs. Most taxonomies fail to describe harm experienced by patients (e.g. hypoxia, hemorrhage, anaphylaxis), focusing instead on errors, and use categorizations that are too broad to be useful (e.g. "communication error"). We set out to create a patient-centered, ED-specific framework for describing adverse events and near misses in order to advance quality and safety in the acute care setting.
We performed a Critical Review of existing taxonomies of harm, evaluating their applicability to the ED. We identified and adopted a classification framework and developed a taxonomy using an iterative process categorizing approximately 600 previously identified adverse events and near misses. We reviewed this taxonomy with collaborators at four medical centers, receiving feedback and providing clarification. We then disseminated a set of representative scenarios for these safety experts to categorize independently using the taxonomy. We calculated interrater reliability and performance compared to our gold standard.
Our search identified candidate taxonomies for detailed review. We selected the Adventist Health Systems Adverse Event Taxonomy and modified this for use in the ED, adopting a framework of categories, subcategories and up to three modifiers to further describe events. On testing, overall reviewer agreement with the gold standard was 92% at the category level and 88% at the subcategory level. Three of the four raters concurred in 55/59 scenarios (93%) and all four concurred in 46/59 scenarios (78%). At the subcategory level, there was complete agreement in 40/59 (68%) scenarios and majority agreement in 55/59 instances (93%). Performance of individual raters ranged from very good (88%, 52/59) to near perfect (98%, 58/59) at the main category level.
We developed a taxonomy of adverse events and near-misses for the ED, modified from an existing framework. Testing of the tool with minimal training yielded high performance and good interrater reliability. This taxonomy can be adapted and modified by emergency departments seeking to enhance their quality and safety reviews, and characterize harm occurring in their EDs for quality improvement purposes. This article is protected by copyright. All rights reserved.
Emergency department non-invasive cardiac output study (EDNICO): a feasibility and repeatability study.Scandinavian Journal of
There is little published data investigating non-invasive cardiac output monitoring in the emergency department (ED). We assessed six non-invasive fluid responsiveness monitoring methods which measure cardiac output directly or indirectly for their feasibility and repeatability of measurements in the ED: (1) left ventricular outflow tract echocardiography derived velocity time integral, (2) common carotid artery blood flow, (3) suprasternal aortic Doppler, (4) bioreactance, (5) plethysmography with digital vascular unloading method, and (6) inferior vena cava collapsibility index.
This is a prospective observational study of non-invasive methods of assessing fluid responsiveness in the ED. Participants were non-ventilated ED adult patients requiring intravenous fluid resuscitation. Feasibility of each method was determined by the proportion of clinically interpretable measurements from the number of measurement attempts. Repeatability was determined by comparing the mean difference of two paired measurements in a fluid steady state (after participants received an intravenous fluid bolus).
76 patients were recruited in the study. A total of 207 fluid responsiveness measurement sets were analysed. Feasibility rates were 97.6% for bioreactance, 91.3% for vascular unloading method with plethysmography, 87.4% for common carotid artery blood flow, 84.1% for inferior vena cava collapsibility index, 78.7% for LVOT VTI, and 76.8% for suprasternal aortic Doppler. The feasibility rates difference between bioreactance and all other methods was statistically significant.
Our study shows that non-invasive fluid responsiveness monitoring in the emergency department may be feasible with selected methods. Higher repeatability of measurements were observed in non-ultrasound methods. These findings have implications for further studies specifically assessing the accuracy of such non-invasive cardiac output methods and their effect on patient outcome in the ED in fluid depleted states such as sepsis.