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The American journal of emergency medicine
Centrum Philadelphia]
The American journal of emergency medicine

Centrum Philadelphia]

0735-6757

The American journal of emergency medicine/Journal The American journal of emergency medicine
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    Avoidable emergency department visits for rabies vaccination

    Swan J.T.Iso T.Yuan F.Rizk E....
    7页
    查看更多>>摘要：? 2022 Elsevier Inc.Background: Administering subsequent doses of rabies vaccine is not a medical emergency and does not require access to emergency department (ED) services. This study reviewed ED visits for rabies postexposure prophylaxis (PEP) to identify avoidable ED visits for subsequent rabies vaccination. Methods: This retrospective study included patients who received human rabies immune globulin (HRIG) or rabies vaccine at 15 EDs of a multi-hospital health system from 2016 to 2018. All ED visits were classified as initial or non-initial healthcare visits after animal exposure. Emergency department visits for non-initial healthcare were classified as necessary (HRIG administration, worsening symptoms, other emergent conditions, or vaccination during a natural disaster) or avoidable (rabies vaccination only). Results: This study included 145 patients with 203 ED visits (113 initial and 90 non-initial healthcare visits). Avoidable ED visits were identified for 19% (28 of 145) of patients and 66% (59 of 90) of ED visits for non-initial healthcare. Contributing factors for avoidable ED visits were suboptimal ED discharge instructions to return to the ED for vaccination (n = 20 visits) and patients' inability to coordinate outpatient follow-up (n = 17 visits). Patients with previous avoidable ED visits had a 73% probability for unnecessarily returning to the ED for vaccination. The average number of avoidable ED visits observed per patient was 0.41 (95% CI = 0.25 to 0.56). Since the Centers for Disease Control and Prevention reports that 30,000 to 60,000 Americans initiates rabies PEP each year, we estimate that 7500 to 33,600 avoidable ED visits occur for rabies vaccination in the US each year. Conclusions: One of 5 patients who received rabies PEP in the ED had avoidable ED visits for subsequent rabies vaccination. This study highlights systemic lack of coordination following ED discharge and barriers to accessing rabies vaccine.
      原文链接:
    • NSTL
    • Elsevier

    Reduced mortality and faster treatment in sepsis seen at freestanding vs. hospital-based emergency departments

    Griffin G.Smalley C.M.Fertel B.S.Mo K....
    4页
    查看更多>>摘要：? 2022 Elsevier Inc.Introduction: Freestanding Emergency Departments (FEDs) have grown in number and understanding their impact on the healthcare system is important. Sepsis causes significant morbidity and mortality and identifying how FEDs impact sepsis morbidity and mortality has not been studied. The objective of this study was to determine if there is a difference in in-hospital mortality for sepsis patients who present initially to FEDs compared to a hospital-based ED. Methods: This was a retrospective cohort of adult patients seen at a hospital-based ED or one of three FEDs within a large hospital system from 1/1/2018–10/31/2020. We included those who were diagnosed with sepsis, severe sepsis or septic shock and evaluated ED throughput measures, in-hospital mortality, and hospital length of stay. Categorical variables are presented as frequencies and percentages. Continuous variables are presented as mean and standard deviations or median and quartiles depending on distribution. Multiple logistic regression was fit to compare in-hospital mortality rates between the two groups. Variables controlled for included Charlson Comorbidity Index, race, gender, insurance, and sepsis severity. Wilcoxon rank sum tests were used to compare the time metrics. Results: There were 1955 patients included in the study. Mean age of participants was 61.9 at the FEDs vs 63.7 at the HBED. Majority of the participants were white; 88.2% at the FED vs. 77.3% at the HBED; and male 49.0% at the FED vs. 51.1% at the HBED. Most patients had Medicare; 45.4% at the FED vs. 58.3% at the HBED. In-patient mortality rate was significantly lower for patients that presented to FEDs compared to HBED (95%CI 0.13–0.46) adjusted odds ratio 0.24. Time to IV fluids, time to lactate, time to blood cultures, time to ED disposition, ED LOS, time to arrival on the inpatient unit were all significantly lower for FEDs vs HBED (p < 0.05). Conclusion: Patients presenting to FEDs for sepsis, severe sepsis and septic shock had lower inpatient mortality, quicker treatment times, and were transferred and admitted to the hospital faster than patients seen at a HBED.
      原文链接:
    • NSTL
    • Elsevier

    Real world utilization of Dalbavancin at a rural community emergency department

    Dolan A.Kuge E.Bremmer E.Dietrich T....
    4页
    查看更多>>摘要：? 2022 Elsevier Inc.Introduction: Acute bacterial skin and skin structure infections (ABSSI) are frequently encountered in the emergency department and compromise more than 700,000 hospital admissions annually. Dalbavancin is a single dose long acting semi-synthetic lipogylcopepitde antibiotic with coverage against gram-positive organisms including methicillin resistant Staphylococcus aureus. Recent data from large tertiary care centers have shown a decrease in hospital admissions and repeat emergency department visits for ABSSI's but little data is available for those who practice in a rural community setting. The primary objective of this study was to describe the use of dalbavancin at a single rural emergency department. Methods: A retrospective cohort study of all adult patients who received dalbavancin between 2019 and 2021 while in the emergency department was completed. Abstracted data included patient demographics, infection location by body region, emergency department return visits, hospital admissions, and length of stay. Analysis was conducted using descriptive statistics, the Mann-Whitney test for continuous data, and the chi-squared analysis for nominal data. Results: A total of 125 patients were included in the final analysis with 35.2% being female. The median age of those treated with dalbavancin was 54 years (42.0–64.0) and the most common infection site was the lower extremities. A total of 35 patients re-presented to the emergency department following treatment with dalbavancin within 30 days and 16 were admitted to the hospital. Of those who re-presented to the emergency department, the median age was 56 (40.0–66.0) and the median re-presentation was 9 days (3–17) after dalbavancin administration. A total of 16 patients (12.8%) were subsequently admitted to the hospital with a median length of stay of 5.5 days (3.0–8.0). 30-day readmission rates were 23.9% in those who had an abnormal WBC count at initial presentation, 26.1% for those with congestive heart failure, 20.3% for those with hypertension, and 26.0% in those who had diabetes mellitus. Conclusion: Following the administration of dalbavancin for ABSSI at a rural emergency department, few patients are subsequently admitted within the following 30 days. To further decrease this number and alleviate the burden on emergency departments and hospitals, local treatment algorithms should be developed to minimize the risk of representation and hospitalization following administration.
      原文链接:
    • NSTL
    • Elsevier

    Association of hypoxic ischemic brain injury on early CT after out of hospital cardiac arrest with neurologic outcome

    Mulder M.Moore J.Evans D.Hall J....
    6页
    查看更多>>摘要：? 2022 Elsevier Inc.Aim: This study aimed to describe the prevalence of hypoxic-ischemic brain injury (HIBI) on head CT (HCT) obtained within two hours of return of spontaneous circulation (ROSC) care in the Emergency Department following out-of-hospital cardiac arrest (OHCA) and evaluate the association between early HIBI and neurologic outcome. Methods: Retrospective single center observational study of post-OHCA patients between 2009 and 2017. Two cohorts were analyzed: those who underwent non-contrast HCT within two hours of ROSC and all others who survived to ICU admission. HIBI was defined as the presence of cerebral edema and/or abnormal gray-white matter differentiation in the HCT interpretation by a neuroradiologist. The primary outcomes were the prevalence of HIBI on early HCT and the magnitude of the association between HIBI and survival with good neurologic outcome using multivariable logistic regression. Results: Following OHCA, 333 of 520 patients (64%) underwent HCT within two hours of ROSC and HIBI was present in 96 of 333 patients (29%). Of the early HCT cohort, those with HIBI had a significantly lower hospital survival (2%) and favorable neurologic outcome (1%). In those without HIBI on imaging, 88 of 237 patients (37%) had a favorable outcome. After adjustment for confounding variables, HIBI on early HCT was independently associated with a decreased likelihood of good neurologic outcome (aOR 0.015, 95% CI 0.002–0.12). Conclusion: HIBI was present on 29% of HCTs obtained within 2 h of ROSC in the patients selected for early imaging by emergency physicians and was strongly and inversely associated with survival with a good neurologic outcome.
      原文链接:
    • NSTL
    • Elsevier

    Phenobarbital and/or benzodiazepines for recurrent alcohol withdrawal: A self-controlled, retrospective cohort study

    Staidle A.Geier C.
    4页
    查看更多>>摘要：? 2022Background: While there is ample data supporting the use of barbiturates and benzodiazepines (BZDs) for the treatment of alcohol withdrawal, there is a paucity of information on treating recurrent withdrawal among high healthcare utilizing patients. The purpose of this study was to assess the efficacy and safety of phenobarbital (PB), with or without adjuvant BZDs, for treatment of acute alcohol withdrawal in the emergency department (ED) in patients with high rates of recurrent withdrawal. Methods: This non-matched, self-controlled, retrospective cohort study evaluated patients seen in the ED of an urban trauma center and safety-net teaching hospital between July 1st, 2018, and July 31st, 2019. Patients treated for alcohol withdrawal were included if they had at least one visit where they received intravenous PB with or without BZDs, then during a separate encounter received BZD only. Each encounter was then assigned to a treatment group based on administration of PB only, BZD only, or the combination of PB and BZD. The primary outcomes were admission to hospital or discharge and return to the ED for any reason within 48 h of disposition. Results: A total of 137 unique patients were included, with 642 encounters composed of 245 PB only, 293 BZD only, and 104 combination visitations. No significant difference was found between the PB, BZD, or combination treatment groups for rates of admission (36.7%, 38.9%, and 46.1% respectively) or for return within 48 h (17.1%, 15.0%, and 13.5%). There was a significantly longer ED length of stay for the combination group (8.6 h) compared to either the PB or BZD only groups (6.4 and 7.0 h, respectively, p < 0.05) but not between the monotherapy groups. There were significantly higher rates of ICU admission and hypotension when PB and BZDs were used together (8.6% and 15.4%) versus either agent alone (PB 2.9% and 5.7%, BZD 3.8% and 4.5%, p < 0.05). Conclusion: Among patients with multiple visits presenting with alcohol withdrawal, treatment with PB, BZDs, or both did not result in significantly different rates of admission or readmission within 48 h. Receiving a combination of PB and BZDs was associated with significantly longer ED length of stay, more ICU care, and increased incidence of hypotension as compared to either PB or a BZD alone.
      原文链接:
    • NSTL
    • Elsevier

    Higher frequency of new chest tumor diagnoses in emergency department due to the COVID-19 pandemic

    Krzyzaniak K.Sieminski M.
    2页
      原文链接:
    • NSTL
    • Elsevier

    Disposition, outcomes, and lengths of stay due to bupropion overdose at a tertiary care center with a medical toxicology service

    McCabe D.J.Radke J.B.Wilson B.Z.
    5页
    查看更多>>摘要：? 2022 Elsevier Inc.Introduction: Bupropion is an antidepressant with unique mechanisms of action leading to a narrow therapeutic window. Parallel to increasing indications, there is an increasing number of overdoses and fatalities attributable to bupropion overdose. Due to the serious effects of a bupropion overdose including arrhythmias and early or delayed seizures, these patients necessitate prolonged monitoring with high levels of medical care. In the setting of a tertiary care center with a medical toxicology consult service, our institution is heavily relied upon to manage these patients. This study was performed to provide clarity on the resources used, lengths-of-stay, and treatments provided for these patients. Methods: All patients at a tertiary care center with an oral bupropion overdose and a medical toxicology consult less than 24 h after the ingestion were included between July 15, 2017 and October 14, 2021. Chart review was performed to determine lengths-of-stay, the unit of disposition, treatments provided, and outcomes. Results: A total of 73 cases were identified with 36 bupropion-only ingestions. Most cases were transferred from outside facilities, developed seizures, had QRS prolongation; and almost a third required intubation. The vast majority were admitted to an ICU and received GABA-A agonists. A median of 1.47 days per case was spent in the ED or ICU. There was an average of 41.9 ED or ICU bed-days per year and 68.5 non-psychiatric bed-days per year occupied by a patient after a bupropion overdose at a single center. Conclusions: Bupropion overdose necessitates high resource utilization which we believe will increase with the expanding indications for its use.
      原文链接:
    • NSTL
    • Elsevier

    Should COVID-19 symptoms be used to cohort patients in the emergency department? A retrospective analysis

    Bijur P.E.Friedman B.W.Baron S.W.Ramasahayam A....
    5页
    查看更多>>摘要：? 2022 Elsevier Inc.Objective: To determine how cohorting patients based on presenting complaints affects risk of nosocomial infection in crowded Emergency Departments (EDs) under conditions of high and low prevalence of COVID-19. Methods: This was a retrospective analysis of presenting complaints and PCR tests collected during the COVID-19 epidemic from 4 EDs from a large hospital system in Bronx County, NY, from May 1, 2020 to April 30, 2021. Sensitivity, specificity, positive and negative predictive value (PPV, NPV) were calculated for a symptom screen based on the CDC list of COVID-19 symptoms: fever/chills, shortness of breath/dyspnea, cough, muscle or body ache, fatigue, headache, loss of taste or smell, sore throat, nasal congestion/runny nose, nausea, vomiting, and diarrhea. PPV was calculated for varying values of prevalence. Results: There were 80,078 visits with PCR tests. The sensitivity of the symptom screen was 64.7% (95% CI: 63.6, 65.8), specificity 65.4% (65.1, 65.8). PPV was 16.8% (16.5, 17.0) and NPV was 94.5% (94.4, 94.7) when the observed prevalence of COVID-19 in the ED over the year was 9.7%. The PPV of fever/chills, cough, body and muscle aches and nasal congestion/runny nose were each approximately 25% across the year, while diarrhea, nausea, vomiting and headache were less predictive, (PPV 4.7%–9.6%) The combinations of fever/chills, cough, muscle/body aches, and shortness of breath had PPVs of 40–50%. The PPV of the screen varied from 3.7% (3.6, 3.8) at 2% prevalence of COVID-19 to 44.3% (44.0, 44.7) at 30% prevalence. Conclusion: The proportion of patients with a chief complaint of COVID-19 symptoms and confirmed COVID-19 infection was exceeded by the proportion without actual infection. This was true when prevalence in the ED was as high as 30%. Cohorting of patients based on the CDC's list of COVID-19 symptoms will expose many patients who do not have COVID-19 to risk of nosocomially acquired COVID-19. EDs should not use the CDC list of COVID-19 symptoms as the only strategy to minimize exposure.
      原文链接:
    • NSTL
    • Elsevier

    Characterization of ophthalmic presentations to emergency departments in the United States: 2010–2018

    Kim S.Wang P.R.Lopez R.Valentim C....
    8页
    查看更多>>摘要：? 2022 Elsevier Inc.Background: Both traumatic and nontraumatic ocular issues often present to the emergency department. Understanding the epidemiology of ocular presentations to the emergency department not only informs current resource allocation, but also provides opportunities to evaluate the efficacy of prior healthcare access interventions. Purpose: To characterize emergency department utilization in the United States for ophthalmic encounters between 2010 and 2018. Methods: Cross-sectional analysis of the National Hospital Ambulatory Medical Care Survey database, a nationally representative sample of United States emergency department visits. 4284 deidentified emergency department patient encounters with an ICD-10 ophthalmic diagnosis from 2010 to 2018 were analyzed. The main outcome measures were the composition and characteristics of ophthalmic emergency department encounters over time. Main findings: 4284 ophthalmic visits were identified which represented an estimated 23.1 million visits (95% CI, 20.8 million—25.5 million). 31.6% (95% CI, 29.6—33.8) of ophthalmic visits were traumatic. Conjunctivitis was the most common non-traumatic diagnosis (32.8%, 95% CI, 30.7—35.0), while superficial injury of the cornea was the most common traumatic diagnosis (13.9%, 95% CI, 12.5—15.3). A greater proportion of emergency department visits involving the sclera and cornea were made by men (58.7%, 95% CI, 53.7%–63.6%; P = 0.02), whereas more women visited for visual disturbances (57.8%, 95% CI, 51.3%–64.4%; P = 0.01). Longitudinal trends of ophthalmic visits revealed an increase in public insurance payers in 2014, which corresponds to Medicaid expansion and implementation of mandated coverage for pediatric vision care. After stratification, this increase continued to be present in nontraumatic visits, but not traumatic ones. Conclusions: Ophthalmic emergency department visits in the United States between 2010 and 2018 were typically for non-traumatic eye issues. Diagnoses varied greatly by patient demographics, such as age and gender. Understanding these variations is valuable for preparing emergency departments for ocular presentations and providing guidance for future practice.
      原文链接:
    • NSTL
    • Elsevier

    Early initiation of norepinephrine in patients with septic shock: A propensity score-based analysis

    Xu F.Zhong R.Shi S.Zeng Y....
    10页
    查看更多>>摘要：? 2022 Elsevier Inc.Background: The use of vasopressors is vital in septic shock. However, the optimal timing of treatment remains unclear. Therefore, we aimed to explore the impact of early norepinephrine initiation on the survival of patients with septic shock. Methods: We selected 4253 patients from the Medical Information Mart for Intensive Care IV database between 2008 and 2019. The primary outcome was 28-day mortality. Propensity score matching (PSM) was applied to minimize between-group imbalances, and a restricted mean survival time was used to quantify the beneficial impact of early norepinephrine treatment on survival. Sensitivity analyses were conducted to test the robustness of the study results in multiple cohorts. Results: In the PSM cohort, 2862 patients were equally assigned to early (receiving norepinephrine within the first 3 h) and delayed (> 3 h) norepinephrine initiation groups. Patients in the early norepinephrine initiation group received significantly less fluid therapy (0 vs. 79 mL/kg), had lower 28-day mortality (30.0% vs. 37.8%), longer survival days (21.89 vs. 20.37 days), shorter duration of intensive care unit (4.9 vs. 7.2 days) and hospital stays (12.4 vs. 13.6 days), shorter duration of supportive norepinephrine and invasive mechanical ventilation, lower incidence of organ failure progression (64.4% vs. 79.2%) within 24 h after shock onset, and higher mean arterial pressure within 6 and 24 h after shock onset than patients in the delayed norepinephrine initiation group (p < 0.05). Conclusions: Norepinephrine initiation within the first 3 h, regardless of preload dependency, was associated with longer survival time and shorter duration of supportive norepinephrine and invasive mechanical ventilation and may delay or partially reverse rapid onset organ failure.
      原文链接:
    • NSTL
    • Elsevier