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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]

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]

Background Patient satisfaction impacts emergency medicine in multiple ways, including patient−physician rapport, patient compliance with medical recommendations, and individual physician and hospital reimbursement issues. Objective The objective of this study was to assess the differences, if any, in satisfaction scores among patients treated in regular treatment rooms vs. those treated in hallway treatment areas. Methods A cross-sectional survey study of conveniently sampled participants from both regular treatment rooms and hallway treatment areas in an urban, adult community teaching emergency department (ED) was performed confidentially, measuring overall satisfaction, as well as satisfaction with regard to treatment location only, medical care only, and their willingness to return to or recommend the ED in the future based on their experience. Each of these four outcomes was measured on a 100-mm visual analog scale. Results Overall satisfaction scores were 8 mm lower for those patients treated in hallway treatment areas, and there was a 20-mm difference with regard to location only. After controlling for apparent baseline differences between the groups, a 7.6-mm difference for overall satisfaction remained. Conclusions Despite differences between patients placed in regular treatment rooms vs. hallway treatment areas, overall satisfaction levels are lower for those patients treated in hallway treatment areas. This difference is likely attributable primarily to their hallway location, and stakeholders should therefore take appropriate steps to address such discrepancies. [ABSTRACT FROM AUTHOR]

BACKGROUND: The objectives of this study are to estimate the prevalence of weakness and fatigue visits in older emergency department (ED) patients, to compare demographics and resource use in these patients with those without these complaints, and to determine their ED diagnoses and disposition. METHODS: We performed a cross-sectional cohort analysis of ED visits in patients aged older than 65 years from the 2003 to 2007 National Hospital Ambulatory Medical Care Surveys. Weakness and fatigue visits had a reason for visit code of generalized weakness (1020.0) or tiredness and exhaustion (1015.0); the comparison cohort lacked these codes. Descriptive data are presented as totals, means, and proportions with 95% confidence intervals (CIs). Comparisons between cohorts used [chi](2) for proportions and the adjusted Wald test for means. RESULTS: There were an estimated 575 million ED visits, those aged 65 years and older made 14.7% (95% CI, 14.2-15.3) of visits. Overall, 6.0% (95% CI, 5.6-6.4) of these visits had weakness and fatigue; this was the fifth most common primary reason for visit. Weakness and fatigue visits increased with age. Weakness and fatigue visits had longer ED lengths of stay (300 vs 249 minutes, P < .001), more diagnostic tests (7.7 vs 5.0, P < .001), procedures (5.7 vs 4.7, P < .001), and hospital admissions (55% vs 35%, P < .001). The most common primary diagnoses for the weakness and fatigue cohort were 'other malaise and fatigue,' pneumonia, and urinary tract infection. CONCLUSION: Weakness and fatigue are common in older ED patients. These patients undergo more tests and procedures, and most are admitted. [ABSTRACT FROM AUTHOR]

Background: Self-administered epinephrine is the primary out-of-hospital treatment of anaphylaxis. Intramuscular injection of epinephrine results in higher peak plasma concentration than subcutaneous injection. With the prevalence of obesity, autoinjectors may not have an adequate needle length for intramuscular injection. Objectives: To measure muscle depth and evaluate predictors of autoinjector needle length inadequacy. Methods: We performed a prospective cross-sectional study of a convenience sample of low acuity emergency department patients aged 18 to 55 years. We recorded demographic data, measured thigh circumference, and calculated body mass index (BMI). Using ultrasound, we took depth-to-muscle measurements of the vastus lateralus in a standing position, with and without gentle pressure to simulate muscle compression that occurs with correct autoinjector use. We conducted univariate analyses using χ(2) and t tests with P ≤ .05 and 95% confidence intervals. We considered the patient a potential "failure" risk if his/her muscle depth exceeded 15.9 mm (longest available epinephrine autoinjectors needle). Results: We enrolled 120 subjects with a mean BMI of 29.2 kg/m(2). Thirty-one percent (31%) of our sample were found to be failure risks (36/116; confidence interval, 22.6%-39.5%). Women were 6.4 times more likely than men to be a failure risk (54.4% vs 5% for men failure rate; P < .001). Failures were more likely to be shorter, have a higher BMI, and have larger thigh circumference (P < .001). We did not find any statistical difference in muscle depth for race, age, or weight. Conclusion: The current epinephrine autoinjector needle length is inadequate for intramuscular injection, especially among women. [ABSTRACT FROM AUTHOR]

Abstract: Objective: This study was conducted to assess the ultrasound''s (US''s) ability to identify pertinent landmarks for lumbar puncture (LP) in patients of various body mass indices (BMIs) and establish spatial relationships of pertinent LP landmarks across BMIs. Methods: In this institutional review board–approved cross-sectional study, we calculated the BMIs of eligible patients and then categorized them as normal (BMI ≤24.9), overweight (BMI 24.9-30), or obese (BMI ≥30). We recorded the difficulty in palpating traditional LP landmarks. Identification and measurement of the spatial relationships of the sacrum; spinous processes of lumbar vertebrae L3, L4, and L5; ligamentum flavum; and the spinal canal by US was attempted. Results: Successful identification of pertinent structures (L4-L5 spinous processes and the spinal canal) occurred in 100% of patients with normal BMI, 95% of those who were overweight, and 74% of those who were obese (P = .011). Difficulty in palpating landmarks was noted in 5% of patients with normal BMI, 33% of those who were overweight, and 68% of those who were obese (P < .0001). In subjects with difficult-to-palpate landmarks, US identified pertinent structures in 16 of 21 (76%; 95% confidence interval, 53-92). The average distance from skin to ligamentum flavum was 44 mm in those with normal BMI, 51 mm in those who were overweight, and 64 mm in those who were obese (P < .00001); measurements between spinous processes did not vary by BMI. Overall, there was a moderate correlation (0.62) between BMI and the distance from skin to ligamentum flavum. Conclusion: The usefulness of US in identifying structures for LP is inversely related to BMI. Even with this limitation, US is still able to identify obese patients'' pertinent landmarks almost 75% of the time. In addition, US may be helpful in identifying pertinent structures for LP in those patients with difficult-to-palpate landmarks. In patients who were obese with structures not palpable by hand or identifiable by US, other modalities should be considered. [Copyright &y& Elsevier]

Abstract: This trial was conducted at 11 EDs to test the effectiveness of distributing fall prevention information to patients 65 years or older. Intervention patients were given 2 brochures and received a reminder call 2 weeks later. All patients were called at 1 month and asked if they made home safety modifications. Three hundred ninety-seven patients were enrolled (118 control, 279 intervention). Seventy-six percent had complete follow up interviews. Nine percent of control and 8% of intervention patients reported a home modification (95% confidence interval on difference, −8.1% to 5.5%). Patients who fell in the prior year had a 2.0 increased odds (95% confidence interval, 0.8-4.6) of making a home modification. The similar home modification rates in the 2 study groups suggest that even minimum discussion (eg, the informed consent procedure) may increase patients'' fall prevention activities. The stronger association in patients who fell suggests that a targeted program may have added benefit. [Copyright &y& Elsevier]

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]