Academic emergency medicine : official journal of the Society for Academic Emergency Medicine
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Observational Study
PREDICTing mortality in the emergency department: external validation and derivation of a clinical prediction tool.
The Choosing Wisely campaign has called for better engagement of palliative and hospice care services for patients in the emergency department (ED). PREDICT is a clinical prediction tool that was derived in an Australian ED cohort. It assesses a patient's risk of mortality at 1 year to select those who would benefit from advanced care planning. Such goals-of-care discussion can improve patients' ability to communicate what they want out of their healthcare and, in cases of end of life, potentially reduce the number of futile interventions. Using a cutoff of 13 points, PREDICT had a reported 95.3% specificity and 53.9% sensitivity for 1-year mortality. We externally validated PREDICT and derived a simpler modified PREDICT tool to systematically identify high-risk patients eligible for goals-of-care discussions and palliative care consultation in the ED. ⋯ PREDICT is an easy tool to administer to be able to identify patients who are at high risk of 1-year mortality and who could benefit from AHDs, goals-of-care discussion, and when appropriate in the context of an end-of-life setting, palliative medicine consultation. External validation of PREDICT was successful in our population. We simplified PREDICT and derived a new tool, the modified PREDICT minus ICU tool, without significantly altering the sensitivity, specificity, and AUC for death at 1 year. The next steps include external validation of the newly derived rule and prospective implementation.
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Multicenter Study Comparative Study Observational Study
Emergency Physicians Are Able to Detect Right Ventricular Dilation with Good Agreement Compared to Cardiology.
Focused cardiac ultrasound (FOCUS) is a useful tool in evaluating patients presenting to the emergency department (ED) with acute dyspnea. Prior work has shown that right ventricular (RV) dilation is associated with repeat hospitalizations and shorter life expectancy. Traditionally, RV assessment has been evaluated by cardiologist-interpreted comprehensive echocardiography. The primary goal of this study was to determine the inter-rater reliability between emergency physicians (EPs) and a cardiologist for determining RV dilation on FOCUS performed on ED patients with acute dyspnea. ⋯ Emergency physician sonographers are able to detect RV dilation with good agreement when compared to cardiology. These results support the wider use of EP-performed FOCUS to evaluate for RV dilation in ED patients with dyspnea.
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Multicenter Study
Individual and Neighborhood Characteristics of Children Seeking Emergency Department Care for Firearm Injuries Within the PECARN Network.
The objective was to describe the characteristics of children seeking emergency care for firearm injuries within the PECARN network and assess the influence of both individual and neighborhood factors on firearm-related injury risk. ⋯ Among children receiving ED treatment within the PECARN network, there are distinct demographic and neighborhood factors associated with firearm injuries. Among younger children (<10 years old), unintentional injuries predominate, while assault-type injuries were most common among older adolescents. Overall, among this PECARN patient population, male adolescents living in neighborhoods characterized by high levels of concentrated disadvantage had an elevated risk for firearm injury. Public health efforts should focus on developing and implementing initiatives addressing risk factors at both the individual and the community level, including ED-based interventions to reduce the risk for firearm injuries among high-risk pediatric populations.
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Review Meta Analysis
Intravenous versus Non-Intravenous Benzodiazepines for the Abortion of Seizures: A Systematic Review and Meta-analysis of Randomized Controlled Trials.
The acquisition of intravenous (IV) access in the actively convulsing patient is difficult. This often delays the administration of the IV benzodiazepine (BDZ) necessary for seizure cessation. Delays in seizure cessation are associated with increased pharmacoresistance, increased risk of neuronal injury, worse patient outcomes, and increased morbidity. ⋯ Non-IV BDZ, compared to IV BDZ, terminate seizures faster and have a superior efficacy and side effect profile. Higher-quality studies and further evaluation in different age groups are warranted.
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Multicenter Study
Embedded Clinical Decision Support in Electronic Health Record Decreases Use of High Cost Imaging in the Emergency Department: EmbED study.
The objective was to evaluate the impact of evidence-based clinical decision support tools integrated directly into provider workflow in the electronic health record on utilization of computed tomography (CT) brain, C-spine, and pulmonary embolism (PE). ⋯ Embedded clinical decision support is associated with decreased overall utilization of high-cost imaging, especially among higher utilizers. It also affected low utilizers, increasing their usage consistent with improved adherence to guidelines, but this effect did not offset the overall decreased utilization for CT brain or CT C-spine. Thus, integrating clinical decision support into the provider workflow promotes usage of validated tools across providers, which can standardize the delivery of care and improve compliance with evidence-based guidelines.