Academic emergency medicine : official journal of the Society for Academic Emergency Medicine
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Clinical prediction models for risk stratification of older adults with syncope or near syncope may improve resource utilization and management. Predictors considered for inclusion into such models must be reliable. Our primary objective was to evaluate the inter-rater agreement of historical, physical examination, and electrocardiogram (ECG) findings in older adults undergoing emergency department (ED) evaluation for syncope or near syncope. Our secondary objective was to assess the level of agreement between clinicians on the patient's overall risk for death or serious cardiac outcomes. ⋯ Acceptable agreement between raters was more commonly achieved with historical rather than physical examination or ECG interpretation variables. Clinicians had moderate agreement in assessing the patient's overall risk for a serious outcome at 30 days. Future development of clinical prediction models in older adults with syncope should account for variability of assessments between raters and consider the use of objective clinical variables.
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Multicenter Study
The use of very low concentrations of high sensitivity troponin T to rule out acute myocardial infarction using a single blood test.
Recent single-center and retrospective studies suggest that acute myocardial infarction (AMI) could be immediately excluded without serial sampling in patients with initial high-sensitivity cardiac troponin T (hs-cTnT) levels below the limit of detection (LoD) of the assay and no electrocardiogram (ECG) ischemia. ⋯ In the absence of ECG ischemia, the detection of very low concentrations of hs-cTnT at admission seems to allow rapid, safe exclusion of AMI in one-third of patients without serial sampling. This could be used alongside careful clinical assessment to help reduce unnecessary hospital admissions.
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Coronary computerized tomography angiography (CCTA) is a rapidly emerging technology for the evaluation of chest pain in the emergency department (ED). We assessed trends in CCTA use and compared downstream healthcare utilization between CCTA and cardiac stress testing modalities. ⋯ CCTA use increased fourfold during the study period and was associated with higher rates of PCI, CABG, repeat noninvasive testing, hospitalization, and return ED visits. The authors have no relevant financial information or potential conflicts to disclose.
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In-hospital factors contribute more to delayed diagnosis of childhood arterial ischemic stroke (AIS) than prehospital factors. We aimed to explore process and patient factors associated with type of and timing to neuroimaging in childhood AIS in the emergency department (ED). ⋯ Strategies to improve rapid diagnosis of pediatric stroke should include shared regional hospital networks protocols to optimize local imaging strategies and where possible rapid transfer to the tertiary center. Future priorities should include development of pediatric ED physician decision support tools to differentiate stroke from mimics and the development and implementation of rapid ED imaging stroke protocols to improve access to confirmatory MRI scanning.
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The opioid abuse and overdose epidemic in the United States has led to the need for new practice policies to guide clinicians. We describe implementation of opioid-related policies in emergency departments (EDs) in New England to gauge progress and determine where further work is needed. ⋯ The implementation of opioid-related policies varies among New England EDs. The presence of policies recommending use of screening tools and prescribing naloxone for at-risk patients was low, whereas those regarding utilization of the PDMP and referral of patients with opioid abuse to recovery resources were more common. These data provide important benchmarks for future evaluations and recommendations.