BackgroundThe decision to obtain a computed tomography CT scan in the emergency department (ED) is complex, including a consideration of the risk posed by the test itself weighed against the importance of obtaining the result. In patients with limited access to primary care follow up the consequences of not making a diagnosis may be greater than for patients with ready access to primary care, impacting diagnostic reasoning. We set out to determine if there is an association between CT utilization in the ED and patient access to primary care.MethodsWe performed a cross-sectional study of all ED visits in which a CT scan was obtained between 2003 and 2012 at an academic, tertiary-care center. Data were abstracted from the electronic medical record and administrative databases and included type of CT obtained, demographics, comorbidities, and access to a local primary care provider (PCP). CT utilization rates were determined per 1000 patients.ResultsA total of 595,895 ED visits, including 98,001 visits in which a CT was obtained (16.4%) were included. Patients with an assigned PCP accounted for 55% of all visits. Overall, CT use per 1000 ED visits increased from 142.0 in 2003 to 169.2 in 2012 (p < 0.001), while the number of annual ED visits remained stable. CT use per 1000 ED visits increased from 169.4 to 205.8 over the 10-year period for patients without a PCP and from 118.9 to 142.0 for patients with a PCP. Patients without a PCP were more likely to have a CT performed compared to those with a PCP (OR 1.57, 95%CI 1.54 to 1.58; p < 0.001). After adjusting for age, gender, year of visit and number of comorbidities, patients without a PCP were more likely to have a CT performed (OR 1.20, 95% CI 1.18 to 1.21, p < 0.001).ConclusionsThe overall rate of CT utilization in the ED increased over the past 10 years. CT utilization was significantly higher among patients without a PCP. Increased availability of primary care, particularly for follow-up from the ED, could reduce CT utilization and therefore decrease costs, ED lengths of stay, and radiation exposure.

IntroductionRapid-response teams (RRTs) are interdisciplinary groups created to rapidly assess and treat patients with unexpected clinical deterioration marked by decline in vital signs. Traditionally emergency department (ED) disposition is partially based on the patients’ vital signs (VS) at the time of hospital admission. We aimed to identify which patients will have RRT activation within 12 hours of admission based on their ED VS, and if their outcomes differed.MethodsWe conducted a case-control study of patients presenting from January 2009 to December 2012 to a tertiary ED who subsequently had RRT activations within 12 hours of admission (early RRT activations). The medical records of patients 18 years and older admitted to a non-intensive care unit (ICU) setting were reviewed to obtain VS at the time of ED arrival and departure, age, gender and diagnoses. Controls were matched 1:1 on age, gender, and diagnosis. We evaluated VS using cut points (lowest 10%, middle 80% and highest 10%) based on the distribution of VS for all patients. Our study adheres to the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines for reporting observational studies.ResultsA total of 948 patients were included (474 cases and 474 controls). Patients who had RRT activations were more likely to be tachycardic (odds ratio [OR] 2.02, 95% CI [1.25–3.27]), tachypneic (OR 2.92, 95% CI [1.73–4.92]), and had lower oxygen saturations (OR 2.25, 95% CI [1.42–3.56]) upon arrival to the ED. Patients who had RRT activations were more likely to be tachycardic at the time of disposition from the ED (OR 2.76, 95% CI [1.65–4.60]), more likely to have extremes of systolic blood pressure (BP) (OR 1.72, 95% CI [1.08–2.72] for low BP and OR 1.82, 95% CI [1.19–2.80] for high BP), higher respiratory rate (OR 4.15, 95% CI [2.44–7.07]) and lower oxygen saturation (OR 2.29, 95% CI [1.43–3.67]). Early RRT activation was associated with increased healthcare utilization and worse outcomes including increased rates of ICU admission within 72 hours (OR 38.49, 95%CI [19.03–77.87]), invasive interventions (OR 5.49, 95%CI [3.82–7.89]), mortality at 72 hours (OR 4.24, 95%CI [1.60–11.24]), and mortality at one month (OR 4.02, 95%CI [2.44–6.62]).ConclusionAfter matching for age, gender and ED diagnosis, we found that patients with an abnormal heart rate, respiratory rate or oxygen saturation at the time of ED arrival or departure are more likely to trigger RRT activation within 12 hours of admission. Early RRT activation was associated with higher mortality at 72 hours and one month, increased rates of invasive intervention and ICU admission. Determining risk factors of early RRT activation is of clinical, operational, and financial importance, as improved medical decision-making regarding disposition would maximize allocation of resources while potentially limiting morbidity and mortality.

Background Adult, community-acquired pneumonia (CAP) guidelines from the Infectious Diseases Society of America (IDSA) and American Thoracic Society (ATS) include indications for urinary antigen tests (UATs) for Streptococcus pneumoniae (SP) and Legionella pneumophila (LP). These recommendations were based on expert opinions and have not been rigorously evaluated. Methods We used data from a multicenter, prospective, surveillance study of adults hospitalized with CAP to evaluate the sensitivity and specificity of the IDSA/ATS UAT indications for identifying patients who test positive. SP and LP UATs were completed on all included patients. Separate analyses were completed for SP and LP, using 2-by-2 contingency tables, comparing the IDSA/ATS indications (UAT recommended vs not recommended) and UAT results (positive vs negative). Additionally, logistic regression was used to evaluate the association of each individual criterion in the IDSA/ATS indications with positive UAT results. Results Among 1941 patients, UATs were positive for SP in 81 (4.2%) and for LP in 32 (1.6%). IDSA/ATS indications had 61% sensitivity (95% confidence interval [CI] 49–71%) and 39% specificity (95% CI 37–41%) for SP, and 63% sensitivity (95% CI 44–79%) and 35% specificity (95% CI 33–37%) for LP. No clinical characteristics were strongly associated with positive SP UATs, while features associated with positive LP UATs were hyponatremia, fever, diarrhea, and recent travel. Conclusions Recommended indications for SP and LP urinary antigen testing in the IDSA/ATS CAP guidelines have poor sensitivity and specificity for identifying patients with positive tests; future CAP guidelines should consider other strategies for determining which patients should undergo urinary antigen testing.

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.

BackgroundAtrial fibrillation (AF) is a common, growing, and costly medical condition. We aimed to evaluate the impact of a management algorithm for symptomatic AF that used an emergency department observation unit on hospital admission rates and patient outcomes.Methods and ResultsThis retrospective cohort study compared 563 patients who presented consecutively in the year after implementation of the algorithm, from July 2013 through June 2014 (intervention group), with 627 patients in a historical cohort (preintervention group) who presented consecutively from July 2011 through June 2012. All patients who consented to have their records used for chart review were included if they had a primary final emergency department diagnosis of AF. We observed no significant differences in age, sex, vital signs, body mass index, or CHADS2 (congestive heart failure, hypertension, age, diabetes mellitus, and prior stroke or transient ischemic attack) score between the preintervention and intervention groups. The rate of inpatient admission was significantly lower in the intervention group (from 45% to 36%; P<0.001). The groups were not significantly different with regard to rates of return emergency department visits (19% versus 17%; P=0.48), hospitalization (18% versus 16%; P=0.22), or adverse events (2% versus 2%; P=0.95) within 30 days. Emergency department observation unit admissions were 40% (P<0.001) less costly than inpatient hospital admissions of ≤1 day's duration.ConclusionsImplementation of an emergency department observation unit AF algorithm was associated with significantly decreased hospital admissions without increasing the rates of return emergency department visits, hospitalization, or adverse events within 30 days.

Traumatic abdominal wall hernias due to blunt abdominal trauma in pediatric patients can pose a diagnostic challenge because of spontaneous hernia reduction. Ultrasonography may be superior to computed tomography for this indication in some cases because of the ability to dynamically and repeatedly assess the area of injury. Herniation can be induced or exaggerated via Valsalva maneuvers, which can facilitate its detection during dynamic assessment. We present the case of a 3-year-old boy who sustained blunt abdominal trauma, with a resultant abdominal wall hernia that was diagnosed using point-of-care ultrasound imaging. This hernia was not visualized with computed tomography, and point-of-care ultrasonography expedited admission for operative repair.

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.

Implementation of an opioid detoxification management pathway reduced EDLOS, reduced utilization of resources, and increased the proportion of patients prescribed medications for symptom relief.