Search

Objective: Our objective was to assess the reported driving patterns of older emergency department (ED) drivers and the factors that might lead them to enroll in a safe driving program.Methods: We conducted a prospective, cross-sectional survey of a convenience sample of ED patients 65-years-old and up regarding their driving patterns, behaviors and willingness to enroll in a safe driving program.Results: We surveyed 138 patients. Most (73%) reported driving within the last year, and 88% of these believe they could not manage without driving. Eleven percent of ED older drivers have been in a motor vehicle crash (MVC) in the past year (95% CI 6-20%), compared to 2.5% of all seniors. Our survey findings suggest that 88% of older ED drivers avoid at least some high-risk driving situations and 65% are unwilling to enroll in a safe driver program unless it lowers their automobile insurance rates. At the same time, most older ED drivers underestimate their risk of being involved in (75%) or dying from (74%) a MVC.Conclusion: Overall, there are a significant number of older people for whom driving remains a vital yet risky daily function. Most of these drivers have little interest in information regarding safe driving programs while in the ED. Those willing to learn about such programs would prefer to take home the information regarding the program rather than have any staff member discuss it while in the ED. [West J Emerg Med. 2011;12(1):51-55.]

Objective: Severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) emerged as a global pandemic in early 2020 with rapidly evolving approaches to diagnosing the clinical illness called coronavirus disease (COVID‐19). The primary objective of this scoping review is to synthesize current research of the diagnostic accuracy of history, physical examination, routine laboratory tests, real‐time reverse transcription–polymerase chain reaction (rRT‐PCR), immunology tests, and computed tomography (CT) for the emergency department (ED) diagnosis of COVID‐19. Secondary objectives included a synopsis of diagnostic biases likely with current COVID‐19 research as well as corresponding implications of false‐negative and false‐positive results for clinicians and investigators. Methods: A Preferred Reporting Items for Systematic Reviews and Meta‐Analyses–Scoping Review (PRISMA‐ScR)–adherent synthesis of COVID‐19 diagnostic accuracy through May 5, 2020, was conducted. The search strategy was designed by a medical librarian and included studies indexed by PubMed and Embase since January 2020. Results: A total of 1,907 citations were screened for relevance. Patients without COVID‐19 are rarely reported, so specificity and likelihood ratios were generally unavailable. Fever is the most common finding, while hyposmia and hypogeusia appear useful to rule in COVID‐19. Cough is not consistently present. Lymphopenia is the mostly commonly reported laboratory abnormality and occurs in over 50% of COVID‐19 patients. rRT‐PCR is currently considered the COVID‐19 criterion standard for most diagnostic studies, but a single test sensitivity ranges from 60% to 78%. Multiple reasons for false‐negatives rRT‐PCR exist, including sample site tested and disease stage during which sample was obtained. CT may increase COVID‐19 sensitivity in conjunction with rRT‐PCR, but guidelines for imaging patients most likely to benefit are emerging. IgM and IgG serology levels are undetectable in the first week of COVID‐19, but sensitivity (range = 82% to 100%) and specificity (range = 87% to 100%) are promising. Whether detectable COVID‐19 antibodies correspond to immunity remains unanswered. Current studies do not adhere to accepted diagnostic accuracy reporting standards and likely report significantly biased results if the same tests were to be applied to general ED populations with suspected COVID‐19. Conclusions: With the exception of fever and disorders of smell/taste, history and physical examination findings are unhelpful to distinguish COVID‐19 from other infectious conditions that mimic SARS‐CoV‐2 like influenza. Routine laboratory tests are also nondiagnostic, although lymphopenia is a common finding and other abnormalities may predict severe disease. Although rRT‐PCR is the current criterion standard, more inclusive consensus‐based criteria will likely emerge because of the high false‐negative rate of PCR tests. The role of serology and CT in ED assessments remains undefined. [ABSTRACT FROM AUTHOR]

The article offers information on a study which analysis frequency of abnormal and critical laboratory results in older patients presenting to the emergency department with syncope. Topics include information on guidelines on the evaluation of syncope that recommend targeted laboratory testing based on history; independence between categorical variables with chisquare or Fisher's exact test; and nonnormal laboratory values and identified critical laboratory values in one in 25 patients.

Background: Syncope is a common chief complaint among older adults in the Emergency Department (ED), and orthostatic vital signs are often a part of their evaluation. We assessed whether abnormal orthostatic vital signs in the ED are associated with composite 30-day serious outcomes in older adults presenting with syncope.Methods: We performed a secondary analysis of a prospective, observational study at 11 EDs in adults ≥ 60 years who presented with syncope or near syncope. We excluded patients lost to follow up. We used the standard definition of abnormal orthostatic vital signs or subjective symptoms of lightheadedness upon standing to define orthostasis. We determined the rate of composite 30-day serious outcomes, including those during the index ED visit, such as cardiac arrhythmias, myocardial infarction, cardiac intervention, new diagnosis of structural heart disease, stroke, pulmonary embolism, aortic dissection, subarachnoid hemorrhage, cardiopulmonary resuscitation, hemorrhage/anemia requiring transfusion, with major traumatic injury from fall, recurrent syncope, and death) between the groups with normal and abnormal orthostatic vital signs.Results: The study cohort included 1974 patients, of whom 51.2% were male and 725 patients (37.7%) had abnormal orthostatic vital signs. Comparing those with abnormal to those with normal orthostatic vital signs, we did not find a difference in composite 30-serious outcomes (111/725 (15.3%) vs 184/1249 (14.7%); unadjusted odds ratio, 1.05 [95%CI, 0.81-1.35], p = 0.73). After adjustment for gender, coronary artery disease, congestive heart failure (CHF), history of arrhythmia, dyspnea, hypotension, any abnormal ECG, physician risk assessment, medication classes and disposition, there was no association with composite 30-serious outcomes (adjusted odds ratio, 0.82 [95%CI, 0.62-1.09], p = 0.18).Conclusions: In a cohort of older adult patients presenting with syncope who were able to have orthostatic vital signs evaluated, abnormal orthostatic vital signs did not independently predict composite 30-day serious outcomes. [ABSTRACT FROM AUTHOR]

Almost 20% of patients with syncope will experience another event. It is unknown whether recurrent syncope is a marker for a higher or lower risk etiology of syncope. The goal of this study is to determine whether older adults with recurrent syncope have a higher likelihood of 30-day serious clinical events than patients experiencing their first episode.Methods: This study is a pre-specified secondary analysis of a multicenter prospective, observational study conducted at 11 emergency departments in the US. Adults 60 years or older who presented with syncope or near syncope were enrolled. The primary outcome was occurrence of 30-day serious outcome. The secondary outcome was 30-day serious cardiac arrhythmia. In multivariate analysis, we assessed whether prior syncope was an independent predictor of 30-day serious events.Results: The study cohort included 3580 patients: 1281 (35.8%) had prior syncope and 2299 (64.2%) were presenting with first episode of syncope. 498 (13.9%) patients had 1 prior episode while 771 (21.5%) had >1 prior episode. Those with recurrent syncope were more likely to have congestive heart failure, coronary artery disease, previous diagnosis of arrhythmia, and an abnormal ECG. Overall, 657 (18.4%) of the cohort had a serious outcome by 30 days after index ED visit. In multivariate analysis, we found no significant difference in risk of events (adjusted odds ratio 1.09; 95% confidence interval 0.90-1.31; p = 0.387).Conclusion: In older adults with syncope, a prior history of syncope within the year does not increase the risk for serious 30-day events. [ABSTRACT FROM AUTHOR]

Objectives: An estimated 1.2 million annual emergency department (ED) visits for syncope/near syncope occur in the United States. Cardiac biomarkers are frequently obtained during the ED evaluation, but the prognostic value of index high‐sensitivity troponin (hscTnT) and natriuretic peptide (NT‐proBNP) are unclear. The objective of this study was to determine if hscTnT and NT‐proBNP drawn in the ED are independently associated with 30‐day death/serious cardiac outcomes in adult patients presenting with syncope. Methods: A prespecified secondary analysis of a prospective, observational trial enrolling participants ≥ age 60 presenting with syncope, at 11 United States hospitals, was conducted between April 2013 and September 2016. Exclusions included seizure, stroke, transient ischemic attack, trauma, intoxication, hypoglycemia, persistent confusion, mechanical/electrical invention, prior enrollment, or predicted poor follow‐up. Within 3 hours of consent, hscTnT and NT‐proBNP were collected and later analyzed centrally using Roche Elecsys Gen 5 STAT and 2010 Cobas, respectively. Primary outcome was combined 30‐day all‐cause mortality and serious cardiac events. Adjusting for illness severity, using multivariate logistic regression analysis, variations between primary outcome and biomarkers were estimated, adjusting absolute risk associated with ranges of biomarkers using Bayesian Markov Chain Monte Carlo methods. Results: The cohort included 3,392 patients; 367 (10.8%) experienced the primary outcome. Adjusted absolute risk for the primary outcome increased with hscTnT and NT‐proBNP levels. HscTnT levels ≤ 5 ng/L were associated with a 4% (95% confidence interval [CI] = 3%–5%) outcome risk, and hscTnT > 50 ng/L, a 29% (95% CI = 26%–33%) risk. NT‐proBNP levels ≤ 125 ng/L were associated with a 4% (95% CI = 4%–5%) risk, and NT‐proBNP > 2,000 ng/L a 29% (95% CI = 25%–32%) risk. Likelihood ratios and predictive values demonstrated similar results. Sensitivity analyses excluding ED index serious outcomes demonstrated similar findings. Conclusions: hscTnT and NT‐proBNP are independent predictors of 30‐day death and serious outcomes in older ED patients presenting with syncope. [ABSTRACT FROM AUTHOR]

Background: Syncope is a common chief complaint in the ED, and the electrocardiogram (ECG) is a routine diagnostic tool in the evaluation of syncope. We assessed whether increasingly prolonged QTc intervals are associated with composite 30-day serious outcomes in older adults presenting to the ED with syncope.Methods: This is a secondary analysis of a prospective, observational study at 11 EDs in adults 60 years or older who presented with syncope or near syncope. We excluded patients presenting without an ECG, measurement of QTc, non-sinus rhythm, bundle branch block or those without 30-day follow-up. We categorized QTc cutoffs into values of <451; 451-470; 471-500, and >500 ms. We determined the rate of composite 30-day serious outcomes including ED serious outcomes and 30-day arrhythmias not identified in ED.Results: The study cohort included 2609 patients. There were 1678 patients (64.3%) that had QTc intervals <451 ms; 544 (20.8%) were 451-470 ms; 302 (11.6%) were 471-500 ms, and 85 (3.3%) had intervals >500 ms. Composite 30-day serious outcomes was associated with increasingly prolonged QTc intervals (13.0%, 15.3%, 18.2%, 22.4%, p = 0.01), but this association did not persist in multivariate analysis.Conclusions: In a cohort of older patients presenting with syncope, increased QTc interval was a marker of but was not independently predictive of composite 30-day serious outcomes. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: Syncope and near‐syncope are common in patients with dementia and a leading cause of emergency department (ED) evaluation and subsequent hospitalization. The objective of this study was to describe the clinical trajectory and short‐term outcomes of patients who presented to the ED with syncope or near‐syncope and were assessed by their ED provider to have dementia. Methods: This multisite prospective cohort study included patients 60 years of age or older who presented to the ED with syncope or near‐syncope between 2013 and 2016. We analyzed a subcohort of 279 patients who were identified by the treating ED provider to have baseline dementia. We collected comprehensive patient‐level, utilization, and outcomes data through interviews, provider surveys, and chart abstraction. Outcome measures included serious conditions related to syncope and death. Results: Overall, 221 patients (79%) were hospitalized with a median length of stay of 2.1 days. A total of 46 patients (16%) were diagnosed with a serious condition in the ED. Of the 179 hospitalized patients who did not have a serious condition identified in the ED, 14 (7.8%) were subsequently diagnosed with a serious condition during the hospitalization, and an additional 12 patients (6.7%) were diagnosed postdischarge within 30 days of the index ED visit. There were seven deaths (2.5%) overall, none of which were cardiac‐related. No patients who were discharged from the ED died or had a serious condition in the subsequent 30 days. Conclusions: Patients with perceived dementia who presented to the ED with syncope or near‐syncope were frequently hospitalized. The diagnosis of a serious condition was uncommon if not identified during the initial ED assessment. Given the known iatrogenic risks of hospitalization for patients with dementia, future investigation of the impact of goals of care discussions on reducing potentially preventable, futile, or unwanted hospitalizations while improving goal‐concordant care is warranted. [ABSTRACT FROM AUTHOR]

Background: There is no common understanding of how needs of emergency department (ED) frequent users differ from other patients. This study sought to examine how to best serve this population. Examinations of why ED frequent users present to the ED, what barriers to care exist, and what service offerings may help these patients achieve an optimal level of health were conducted.Methods: We performed a prospective study of frequent ED users in an adult only, level 1 trauma center with approximately 90,000 visits per year. Frequent ED users were defined as those who make four or more ED visits in a 12 month period. Participants were administered a piloted structured interview by a trained researcher querying demographics, ED usage, perceived barriers to care, and potential aids to maintaining health.Results: Of 1,523 screened patients, 297 were identified as frequent ED users. One hundred frequent ED users were enrolled. The mean age was 48 years (95% CI 45-51). The majority of subjects were female (64%, 64/100, 95% CI 55-73%), white (61%, 60/98, 95% CI 52-71%) and insured by Medicaid (55%, 47/86, 95% CI 44-65%) or Medicare (23%, 20/86, 95% CI 14-32%). Subjects had a median of 6 ED visits, and 2 inpatient admissions in the past 12 months at this hospital. Most frequent ED users (61%, 59/96, 95% CI 52-71%) stated the primary reason for their visit was that they felt that their health problem could only be treated in an ED. Transportation presented as a major barrier to few patients (7%, 7/95, 95% CI 3-14%). Subjects stated that "after-hours options, besides the ED for minor health issues" (63%, 60/95, 95% CI 53-73%) and having "a nurse to work with you one-on-one to help manage health care needs" (53%, 50/95, 95% CI 43-63%) would be most helpful in achieving optimal health.Conclusion: This study characterized ED frequent users and identified several opportunities to better serve this population. By understanding barriers to care from the patient perspective, health systems can potentially address unmet needs that prevent wellness in this population. [ABSTRACT FROM AUTHOR]

Loss to follow-up of enrolled patients (a.k.a. attrition) is a major threat to study validity and power. Minimizing attrition can be challenging even under ideal research conditions, including the presence of adequate funding, experienced study personnel, and a refined research infrastructure. Emergency care research is shifting toward enrollment through multisite networks, but there have been limited descriptions of approaches to minimize attrition for these multicenter emergency care studies. This concept paper describes a stepwise approach to minimize attrition, using a case example of a multisite emergency department prospective cohort of over 3,000 patients that has achieved a 30-day direct phone follow-up attrition rate of <3%. The seven areas of approach to minimize attrition in this study focused on patient selection, baseline contact data collection, patient incentives, patient tracking, central phone banks, local enrollment site assistance, and continuous performance monitoring. Appropriate study design, including consideration of these methods to reduce attrition, will be time well spent and may improve study validity. [ABSTRACT FROM AUTHOR]

Objectives 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. Methods We conducted a cross-sectional study at 11 EDs in adults 60 years of age or older who presented with unexplained syncope or near syncope. We excluded patients with a presumptive cause of syncope (e.g., seizure) or if they were unable or unwilling to follow-up. Evaluations of the patient's past medical history and current medication use were completed by treating provider and trained research associate pairs. Evaluations of the patient's physical examination and ECG interpretation were completed by attending/resident, attending/advanced practice provider, or attending/attending pairs. All evaluations were blinded to the responses from the other rater. We calculated the percent agreement and kappa statistic for binary variables. Inter-rater agreement was considered acceptable if the kappa statistic was 0.6 or higher. Results We obtained paired observations from 255 patients; mean (± SD) age was 73 (±9) years, 137 (54%) were male, and 204 (80%) were admitted to the hospital. Acceptable agreement was achieved in 18 of the 21 (86%) past medical history and current medication findings, none of the 10 physical examination variables, and three of the 13 (23%) ECG interpretation variables. There was moderate agreement (Spearman correlation coefficient, r = 0.40) between clinicians on the patient's probability of 30-day death or serious cardiac outcome, although as the probability increased, there was less agreement. Conclusions 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. [ABSTRACT FROM AUTHOR]

Objectives The objective was to examine the relationship between laboratory testing (including test volume and turnaround time [ TAT]) and emergency department ( ED) length of stay ( LOS), using linked patient-level data from four hospitals across 4 years. Methods This was a retrospective, multisite cohort study of patients presenting to any one of four EDs in New South Wales, Australia, during a 2-month period (August and September) in 2008, 2009, 2010, and 2011. Data from ED information systems were linked to laboratory test data. A cross-classified random-effect modeling approach was applied to identify factors affecting ED LOS, taking into account the correlation between patients' presentations at the same hospital and/or in the same calendar year. Number of test order episodes (tests ordered at one point in time during the ED stay) and TAT (time from laboratory order receipt to result available) were examined. Results As the number of test order episodes increased, so did the duration of patient ED LOS (p < 0.0001). For every five additional tests ordered per test order episode, the median ED LOS increased by 10 minutes (2.9%, p < 0.0001); each 30-minute increase in TAT was, on average, associated with a 5.1% (17 minutes; p < 0.0001) increase in ED LOS, after adjustment for other factors. Patients presenting to the ED at night (7 p.m. to 7 a.m.) had longer stays than those presenting during the daytime, although the median TATs at nights were shorter than those during the daytime. Conclusions Laboratory testing has a direct effect on patients' LOS in ED. Laboratory TAT, number of testing episodes, and test volume influence ED LOS. Targeted increases of ED resources and staffing after-hours may also contribute to reductions in ED LOS. [ABSTRACT FROM AUTHOR]

Objectives A significant proportion of geriatric patients experience suboptimal outcomes following episodes of emergency department ( ED) care. Risk stratification screening instruments exist to distinguish vulnerable subsets, but their prognostic accuracy varies. This systematic review quantifies the prognostic accuracy of individual risk factors and ED-validated screening instruments to distinguish patients more or less likely to experience short-term adverse outcomes like unanticipated ED returns, hospital readmissions, functional decline, or death. Methods A medical librarian and two emergency physicians conducted a medical literature search of PubMed, EMBASE, SCOPUS, CENTRAL, and ClinicalTrials.gov using numerous combinations of search terms, including emergency medical services, risk stratification, geriatric, and multiple related Me SH terms in hundreds of combinations. Two authors hand-searched relevant specialty society research abstracts. Two physicians independently reviewed all abstracts and used the revised Quality Assessment of Diagnostic Accuracy Studies instrument to assess individual study quality. When two or more qualitatively similar studies were identified, meta-analysis was conducted using Meta-DiSc software. Primary outcomes were sensitivity, specificity, positive likelihood ratio ( LR+), and negative likelihood ratio ( LR-) for predictors of adverse outcomes at 1 to 12 months after the ED encounters. A hypothetical test-treatment threshold analysis was constructed based on the meta-analytic summary estimate of prognostic accuracy for one outcome. Results A total of 7,940 unique citations were identified yielding 34 studies for inclusion in this systematic review. Studies were significantly heterogeneous in terms of country, outcomes assessed, and the timing of post- ED outcome assessments. All studies occurred in ED settings and none used published clinical decision rule derivation methodology. Individual risk factors assessed included dementia, delirium, age, dependency, malnutrition, pressure sore risk, and self-rated health. None of these risk factors significantly increased the risk of adverse outcome ( LR+ range = 0.78 to 2.84). The absence of dependency reduces the risk of 1-year mortality ( LR- = 0.27) and nursing home placement ( LR- = 0.27). Five constructs of frailty were evaluated, but none increased or decreased the risk of adverse outcome. Three instruments were evaluated in the meta-analysis: Identification of Seniors at Risk, Triage Risk Screening Tool, and Variables Indicative of Placement Risk. None of these instruments significantly increased ( LR+ range for various outcomes = 0.98 to 1.40) or decreased ( LR- range = 0.53 to 1.11) the risk of adverse outcomes. The test threshold for 3-month functional decline based on the most accurate instrument was 42%, and the treatment threshold was 61%. Conclusions Risk stratification of geriatric adults following ED care is limited by the lack of pragmatic, accurate, and reliable instruments. Although absence of dependency reduces the risk of 1-year mortality, no individual risk factor, frailty construct, or risk assessment instrument accurately predicts risk of adverse outcomes in older ED patients. Existing instruments designed to risk stratify older ED patients do not accurately distinguish high- or low-risk subsets. Clinicians, educators, and policy-makers should not use these instruments as valid predictors of post- ED adverse outcomes. Future research to derive and validate feasible ED instruments to distinguish vulnerable elders should employ published decision instrument methods and examine the contributions of alternative variables, such as health literacy and dementia, which often remain clinically occult. [ABSTRACT FROM AUTHOR]

Introduction. Despite attention directed at treatment times of ST-segment elevation myocardial infarctions (STEMIs), little is known about the types of STEMIs presenting to the emergency department (ED). Objective. The purpose of this study was to determine the relative frequencies and characteristics of emergency medical services (EMS) STEMIs compared with those in patients who present to the ED by walk-in. This information may be applied in EMS training, system planning, and public education. Methods. This was a query of a prospectively gathered database of all STEMIs in patients presenting to Summa Akron City Hospital ED in 2009 and 2010. We collected demographic information, chief complaint, mode and time of arrival, and STEMI pattern (anterior, lateral, inferior, or posterior). We excluded transfers and in-hospital STEMIs. We calculated means, percentages, significance, and 95% confidence intervals (CIs) ± 10%. Results. We analyzed data from 308 patients. Most patients (241/308, 78%, CI 73%-83%) arrived by EMS, were male (203/308, 66%, CI 60%-71%), and were white (286/308, 93%, CI 89%-96%). Patients arriving by EMS were older (average 63 years, range 35-95) than walk-in patients (average 57 years, range 24-92). Two percent (5/241, 2%, CI 1%-5%) of EMS STEMI patients were under 40 years of age, compared with 10% (7/67, 10%, CI 4%-20%) of walk-in patients (p = 0.0017). The most common chief complaint was chest pain (278/308, 90%, CI 86%-93%). Inferior STEMIs were most common (167/308, 54%, CI 49%-60%), followed by anterior (127/308, 41%, CI 48%-60%), lateral (8/308, 3%, CI 1%-5%), and posterior (6/308, 2%, CI 1%-4%). A day-of-the-week analysis showed that no specific day was most common for STEMI presentation. Forty percent (122/308, 40%, CI 34%-45%) of patients presented during open catheterization laboratory hours (Monday through Friday, 0730-1700 hours). There was no significant statistical difference between EMS and walk-in patients with regard to STEMI pattern or patient demographics. Conclusions. In this study, 95% (294/308) of all STEMIs were inferior or anterior infarctions, and these types of presentations should be stressed in EMS education. Most STEMI patients at this institution arrived by ambulance and during off-hours. Younger patients were more likely to walk in. We need further study, but we may have identified a target population for future interventions. Key words: emergency medical services; allied health personnel; electrocardiography; myocardial infarction; heart catheterization; STEMI [ABSTRACT FROM AUTHOR]

Several letters to the editor are presented in response to the article "Chronic Musculoskeletal Pain and the Occurrence of Falls in an Older Population," by S. G. Leveille and colleagues, published in the 2009 issue, including a view on the possible mechanism of the link between chronic pain and risk of falls, an explanation on vitamin D deficiency, and a response from the article's authors.

Study Objective: Cardiac arrhythmia is a life-threatening condition in older adults who present to the emergency department (ED) with syncope. Previous work suggests the initial ED ECG can predict arrhythmia risk; however, specific ECG predictors have been variably specified. Our objective is to identify specific ECG abnormalities predictive of 30-day serious cardiac arrhythmias in older adults presenting to the ED with syncope.Methods: We conducted a prospective, observational study at 11 EDs in adults aged 60 years or older who presented with syncope or near syncope. We excluded patients with a serious cardiac arrhythmia diagnosed during the ED evaluation from the primary analysis. The outcome was occurrence of 30-day serous cardiac arrhythmia. The exposure variables were predefined ECG abnormalities. Independent predictors were identified through multivariate logistic regression. The sensitivities and specificities of any predefined ECG abnormality and any ECG abnormality identified on adjusted analysis to predict 30-day serious cardiac arrhythmia were also calculated.Results: After exclusion of 197 patients (5.5%; 95% confidence interval [CI] 4.7% to 6.2%) with serious cardiac arrhythmias in the ED, the study cohort included 3,416 patients. Of these, 104 patients (3.0%; 95% CI 2.5% to 3.7%) had a serious cardiac arrhythmia within 30 days from the index ED visit (median time to diagnosis 2 days [interquartile range 1 to 5 days]). The presence of nonsinus rhythm, multiple premature ventricular conductions, short PR interval, first-degree atrioventricular block, complete left bundle branch block, and Q wave/T wave/ST-segment abnormalities consistent with acute or chronic ischemia on the initial ED ECG increased the risk for a 30-day serious cardiac arrhythmia. This combination of ECG abnormalities had a similar sensitivity in predicting 30-day serious cardiac arrhythmia compared with any ECG abnormality (76.9% [95% CI 67.6% to 84.6%] versus 77.9% [95% CI 68.7% to 85.4%]) and was more specific (55.1% [95% CI 53.4% to 56.8%] versus 46.6% [95% CI 44.9% to 48.3%]).Conclusion: In older ED adults with syncope, approximately 3% receive a diagnosis of a serious cardiac arrhythmia not recognized on initial ED evaluation. The presence of specific abnormalities on the initial ED ECG increased the risk for 30-day serious cardiac arrhythmias. [ABSTRACT FROM AUTHOR]

Background: McKesson's InterQual criteria are widely used in hospitals to determine if patients should be classified as observation or inpatient status, but the accuracy of the criteria is unknown.Objective: We sought to determine whether InterQual criteria accurately predicted length of stay (LOS) in older patients with syncope.Methods: We conducted a secondary analysis of a cohort study of adults ≥60 years of age who had syncope. We calculated InterQual criteria and classified the patient as observation or inpatient status. Outcomes were whether LOS were less than or greater than 2 midnights.Results: We analyzed 2361 patients; 1227 (52.0%) patients were male and 1945 (82.8%) were white, with a mean age of 73.2 ± 9.0 years. The median LOS was 32.6 h (interquartile range 24.2-71.8). The sensitivity of InterQual criteria for LOS was 60.8% (95% confidence interval 57.9-63.6%) and the specificity was 47.8% (95% confidence interval 45.0-50.5%).Conclusions: In older adults with syncope, those who met InterQual criteria for inpatient status had longer LOS compared with those who did not; however, the accuracy of the criteria to predict length of stay over 2 days is poor, with a sensitivity of 60% and a specificity of 48%. Future research should identify criteria to improve LOS prediction. [ABSTRACT FROM AUTHOR]

Background: Frailty (defined as weakness, slowness, weight loss, exhaustion, and physical inactivity) is characterized by increased vulnerability to stressors. Frail older patients are at increased risk of Emergency Department (ED) visits, hospitalization, disability, and death. Objectives: Our aims were to determine the prevalence of frailty (and assess the feasibility of measuring frailty) in older ED patients. We also assessed the correlation of self-reported speed and weakness to measured values and the association between frailty and function. Methods: We performed a study of discharged ED patients aged ≥ 65 years. We used Fried’s frailty definition and a validated activities-of-daily-living (ADL) scale. We measured self-reported and objective weakness and slowness. Data were reported as means and proportions with 95% confidence interval (CI); associations were measured using 95% CI for the differences. Ninety patients provided a 95% CI of ± 10%. Results: The mean age of the 90 patients was 76 ± 6.4 SD years; 51% were male. Mean assessment time was 7.4 min (95% CI 6.9–7.9). Twenty percent of patients were frail (18/90, 95% CI 12–30%). Self-report was 18% sensitive and 90% specific for objective weakness; self-report was 42% sensitive and 86% specific for objective slowness. Frail and weak patients were more likely dependent in one or more ADLs (26% difference, 95% CI 1–51% and 20% difference, 95% CI 1–41%, respectively). Conclusions: Frailty is common in discharged older ED patients. Self-reported weakness and slowness are poor predictors of their objective counterparts. Frailty was associated with ADL dependence. These two domains may be reliable markers for elderly ED patients at high risk for adverse outcomes. [ABSTRACT FROM AUTHOR]

Background: Clinical use of biomarkers requires the development of standardized assays and establishment of cutoffs. Urinary C-C motif chemokine ligand 14 (CCL14) has been validated to predict persistent severe AKI in critically ill patients with established AKI. We now report on the performance of standardized cutoffs using a clinical assay., Methods: A second aim of the multicenter RUBY Study was to establish two cutoffs for the prediction of persistent severe AKI (defined as KDIGO stage 3 AKI for at least 72 consecutive hours). Patients who received renal replacement therapy (RRT) or died before achieving 72 hours in stage 3 AKI were also considered to have reached the end point., Results: A cutoff value for urinary CCL14 of 1.3 ng/ml was determined to achieve high sensitivity (91%; 95% CI, 84% to 96%), and 13 ng/ml achieved high specificity (93%; 95% CI, 89% to 96%). The cutoff of 1.3 ng/ml identifies the majority (91%) of patients who developed persistent severe AKI with a negative predictive value of 92%. The cutoff at 13 ng/ml had a positive predictive value of 72% (with a negative predictive value of 75%). In multivariable adjusted analyses, a CCL14 concentration between 1.3 and 13 ng/ml had an adjusted odds ratio (aOR) of 3.82 (95% CI, 1.73 to 9.12; P =0.001) for the development of persistent severe AKI compared with those with a CCL14 ≤1.3 ng/ml, whereas a CCL14 >13 ng/ml had an aOR of 10.4 (95% CI, 3.89 to 29.9; P <0.001)., Conclusions: Using a clinical assay, these standardized cutoffs (1.3 and 13 ng/ml) allow for the identification of patients at high risk for the development of persistent severe AKI. These results have immediate utility in helping to guide AKI patient care and may facilitate future clinical trials. Clinical Trial registry name and registration number: Identification and Validation of Biomarkers of Acute Kidney Injury Recovery, NCT01868724., Competing Interests: L.S. Chawla reports current employment by Silver Creek Pharmaceuticals; ownership interest in Exthera Medical, Lowell Therapeutics, and Stavro Medical; and patents and inventions with George Washington University. S. Demirjian reports research funding from National Institute of Diabetes and Digestive and Kidney Diseases (UO1 DK129980-01); honoraria from Outset Medical; patents or royalties with Cleveland Clinic Innovation and the holder of US patent no. 10281455; and participating in a speakers’ bureau for Outset Medical. K.J. Gunnerson reports research funding from Spectral Medical. J.P. Kampf reports employment by Astute Medical, Inc. (a bioMérieux company) and ownership interest in bioMérieux. J.A. Kellum reports current employment by Spectral Medical; consultancy agreements with AM Pharma, Astellas, Astute Medical, Baxter, bioMérieux, Cytosorbents, Grifols, Klotho, Mallinckrodt, NxStage, PhotoPhage, Potrero, and RenalSense; ownership interest with J3RM, Klotho, Photophage, and Spectral Medical; research funding from Astellas, Astute Medical, Atox Bio, Baxter, bioMérieux, Bioporto, Cytosorbents, Grifols, and RenalSense; patents and inventions with Astute Medical, Cytosorbents, J3RM, Klotho, and Photophage; and is the editor of Critical Care Clinics of North America and on the editorial boards of Nephrology Dialysis Transplantation, Critical Care, Critical Care Medicine, and Blood Purification. J.L. Koyner reports consultancy for Astute Medical/bioMérieux, Baxter, Mallinckrodt, Novartis, and SeaStar; research funding from Astute Medical, Fresenius Medical, the National Institutes of Health, and Nxstage Medical; honoraria from Acute Disease Quality Initiative (ADQI), the American Society of Nephrology, CSCTR, and ISICEM; being listed on a patent for Pi GST to detect severe AKI following cardiac surgery with Argutus Medical; is on the editorial board of Clinical Journal of American Society of Nephrology (CJASN), American Journal of Nephrology, and Kidney360; is on the scientific advisory board for Guard Therapeutics, the NKF-National, and Novartis; and participated in a speakers’ bureau for NxStage Medical. T. Kwan reports current employment by Astute Medical, Inc. (a bioMérieux company). P. McPherson reports employment by Astute Medical, Inc. (a bioMérieux company) and ownership interest in bioMérieux. S.T. Wilber reports ownership interest in Merck & Co., Inc. All remaining authors have nothing to disclose., (Copyright © 2022 by the American Society of Nephrology.)