Academic emergency medicine : official journal of the Society for Academic Emergency Medicine
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Review Meta Analysis
Effectiveness of Educational Interventions to Increase Primary Care Follow-up for Adults Seen in the Emergency Department for Acute Asthma: A Systematic Review and Meta-analysis.
Patients with asthma commonly present to emergency departments (ED) with exacerbations. Asthma guidelines recommend close follow-up with a primary care provider (PCP) after ED discharge; however, this linkage is often delayed or absent. The objective of this study was to assess whether ED-directed educational interventions improve office follow-up with PCPs after ED discharge for acute asthma. ⋯ ED-directed educational interventions targeting either patients or providers increase the chance of having office follow-up visits with PCPs after asthma exacerbations. Their impact on health-related outcomes (e.g., relapse and admissions) remains unclear.
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Randomized Controlled Trial
Adherence to an Accelerated Diagnostic Protocol for Chest Pain: Secondary Analysis of the HEART Pathway Randomized Trial.
Accelerated diagnostic protocols (ADPs), such as the HEART Pathway, are gaining popularity in emergency departments (EDs) as tools used to risk stratify patients with acute chest pain. However, provider nonadherence may threaten the safety and effectiveness of ADPs. The objective of this study was to determine the frequency and impact of ADP nonadherence. ⋯ Real-time use of the HEART Pathway resulted in a nonadherence rate of 20%, mostly due to overtesting. None of these patients had MACE within 30 days. Nonadherence decreased the discharge rate, attenuating the HEART Pathway's impact on health care use.
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Observational Study
Intravenous Ondansetron and the QT Interval in Adult Emergency Department Patients: An Observational Study.
Ondansetron is known to cause QT interval prolongation, but this effect and clinical significance has not been prospectively studied in adult emergency department (ED) patients. The primary objective was to determine the mean maximal corrected QT interval (QTc) prolongation after intravenous (IV) administration of 4 mg of ondansetron. The secondary objective was to report any serious adverse cardiac electrical events. ⋯ While QTc prolongation does occur in adult ED patients receiving IV ondansetron, the clinical impact is questionable.
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Changes in health care delivery and graduate medical education have important consequences for the workforce in pediatric emergency medicine (PEM). This study compared career preparation and potential attrition of the PEM workforce with the prior assessment from 1998. ⋯ While satisfaction with fellowship preparation for professional activities in PEM is improving, gaps remain in training in nonclinical skills. Symptoms of burnout are prevalent, and there is likely to be substantial attrition of PEM providers in the near future.
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Traditionally, in both pediatric and adult trauma patients, management of hemorrhage and shock has included early rapid intravenous fluid (IVF) replacement at the scene or during transport to a definitive care facility. Because prehospital resuscitation can be considered as a lifesaving intervention, severely injured patients are more likely to receive IVF. Observational studies not adequately adjusting for this confounding by indication (indication bias) while evaluating the impact of prehospital IVF on mortality in clinically heterogeneous patient populations are likely to find an increased mortality associated with the use of prehospital IVF, an association that may be spurious even after traditional multivariable risk adjustment. Propensity scores can be used to mitigate the impact of this selection bias on the estimated effect. The authors hypothesized that the effect of IVF on mortality will differ based on whether propensity scores (based on a set of prehospital indications for IVF) are adjusted for in a multivariable outcome model. ⋯ Propensity-adjusted survival analysis suggests that the observed increased risk in mortality associated with use of prehospital IVF replacement may be a spurious association resulting from inadequate control of confounding by indication inherent in observational studies. In the absence of patient subgroup-specific results from well-controlled studies, IVF resuscitation should not be a reason to delay patient transport to a definitive care facility. Randomized trials evaluating the effect of prehospital fluids are warranted in the pediatric trauma population, as such studies have shown clinical significance in the adult trauma population.