Academic emergency medicine : official journal of the Society for Academic Emergency Medicine
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Randomized Controlled Trial
Mobile crisis team intervention to enhance linkage of discharged suicidal emergency department patients to outpatient psychiatric services: a randomized controlled trial.
Many suicidal patients treated and released from emergency departments (ED) fail to follow through with subsequent outpatient psychiatric appointments, often presenting back for repeat ED services. Thus, the authors sought to determine whether a mobile crisis team (MCT) intervention would be more effective than standard referral to a hospital-based clinic as a means of establishing near-term clinical contact after ED discharge. This objective was based on the premise that increased attendance at the first outpatient mental health appointment would initiate an ongoing treatment course, with subsequent differential improvements in psychiatric symptoms and functioning for patients successfully linked to care. ⋯ Community-based mobile outreach was a highly effective method of contacting suicidal patients who were discharged from the ED. However, establishing initial postdischarge contact in the community versus the clinic did not prove more effective at enhancing symptomatic or functional outcomes, nor did successful linkage with outpatient psychiatric care. Overall, participants showed some improvement shortly after ED discharge regardless of outpatient clinical contact, but nonetheless remained significantly symptomatic and at risk for repeated ED presentations.
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Although many high-quality migraine clinical trials have been performed in the emergency department (ED) setting, almost as many different primary outcome measures have been used, making data aggregation and meta-analysis difficult. The authors assessed commonly used migraine trial outcomes in two ways. First, the authors examined the association of each commonly used outcome versus the following patient-centered variable: the research subject's wish, when asked 24 hours after investigational medication administration, to receive the same medication the next time they presented to an ED with migraine ("would take again"). This variable was chosen as the criterion standard because it provides a simple, dichotomous, clinically sensible outcome, which allows migraineurs to factor important intangibles of efficacy and adverse effects of treatment into an overall assessment of care. The second part of the analysis assessed how sensitive to true efficacy each outcome measure was by calculating sample size requirements based on results observed in previously conducted clinical trials. ⋯ "Would take again" was associated with all migraine outcome measures we examined. No individual outcome was more closely associated with "would take again" than any other. Even the best-performing alternate outcome misclassified more than 20% of subjects. However, sample sizes based on "would take again" tended to be larger than other outcome measures. On the basis of these findings and this outcome measure's inherent patient-centered focus, "would take again," included as a secondary outcome in all ED migraine trials, is proposed.
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Heart fatty acid-binding protein (h-FABP) and ischemia-modified albumin (IMA) have recently been evaluated, but to the best of our knowledge, no study has reported an analysis of these two markers for the detection of early myocardial infarction and myocardial ischemia in a large cohort of consecutive patients presenting to an emergency department (ED). This study evaluates the diagnostic accuracy and the clinical utility of h-FABP and IMA for non-ST-segment elevation acute coronary syndrome (ACS) diagnosis in the first hour of management in an ED. ⋯ In this study on a large cohort of patients admitted to an ED for chest pain, IMA and h-FABP did not provide valuable information for ACS diagnosis.
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Prior research has demonstrated that rigid cervical collars cause an increase in intracranial pressure (ICP). The mechanism for this effect is unclear and one proposed mechanism involves obstruction of venous outflow in the neck. Ultrasound (US) allows assessment of internal jugular vein dimensions and may yield information regarding the mechanism for the increase in ICP seen with rigid collar application. ⋯ Internal jugular vein cross-sectional area increases after application of a rigid cervical collar. This supports the hypothesis that venous obstruction in the neck may contribute to the increase in ICP seen after rigid collar application.
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Repetitive practice with feedback in residency training is essential in the development of procedural competency. Lightly embalmed cadaver laboratories provide excellent simulation models for a variety of procedures, but to the best of our knowledge, none describe a central venous access model that includes the key psychomotor feedback elements for the procedure, namely intravascular contents that allow for determination of correct needle position by either ultrasonographic imaging and/or aspiration or vascular contents. ⋯ For the key psychomotor elements of central venous access, the lightly embalmed cadaver with intravascular water-soluble gel infusion provided a procedural model that closely simulated clinicians' experience with patients.