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We sought to assess if a state-wide lockdown implemented due to COVID-19 was associated with increased odds of being a potentially avoidable transfer (PAT).We conducted a retrospective observational analysis using hospital administrative data of interfacility ED-to-ED transfers to a single, quaternary care adult ED after "Safer at Home" orders were issued March 23rd, 2020 in [Blinded for submission]. Using the PAT classification to identify transfers rapidly discharged from the ED or hospital and may not require in-person care, we used a multivariable logistic regression model to examine the association of the lockdown order with odds of a transfer being a PAT. We compared the period January 1, 2018 to March 23, 2020 with March 24, 2020 to September 30, 2020, adjusting for seasonality, patient, and situational factors.There were 20,978 ED-to-ED transfers from during this period that were eligible and 4806 (23%) that met PAT criteria. While the first month post-lockdown saw a decrease in PATs (28%), this was not sustained. In the multivariable model there was a significant seasonal effect; May through September had the highest number of transfers as well as PATs. After adjusting for seasonality, the lockdown was not associated with PATs (adjusted odds ratio [aOR] 0.99, 95% CI 0.2, 5.2) and PATs decreased over time.We did not find an effect of the COVID-19 lockdown on PATs though there was a considerable seasonal effect and an overall downward trend in PATs over time.

Background US emergency department (ED) visits for burns and factors associated with inter-facility transfer are unknown and described in this manuscript. Methods We conducted a retrospective analysis of burn-related injuries from 2009–2014 using the Nationwide Emergency Department Sample (NEDS), the largest sample of all-payer datasets. We included all ED visits by adults with a burn related ICD-9 code and used a weighted multivariable logistic regression model to predict transfer adjusting for covariates. Results Between 2009–2014, 3,047,701 (0.4%) ED visits were for burn related injuries. A total of 108,583 (3.6%) burn visits resulted in inter-facility transfers occurred during the study period, representing approximately 18,097 inter-facility transfers per year. Burns with greater than 10% total body surface area (TBSA) resulted in a 10-fold increase in the probability of transfer, compared to burn visits with less than 10% TBSA burns. In the multivariable model, male sex (adjusted odds ratio [aOR] 2.4, 95% CI 2.3–2.6) was associated with increased odds of transfer. Older adults were more likely to be transferred compared to all other age groups. Odds of transfer were increased for Medicare and self-pay patients (vs. private pay) but there was a significant interaction of sex and payer and the effect of insurance varied by sex. Conclusions In a national sample of ED visits, burn visits were more than twice as likely to have an inter-facility transfer compared to the general ED patient population. Substantial sex differences exist in U.S. EDs that impact the location of care for patients with burn injuries and warrants further investigation.

Background: Fluid and vasopressor management in septic shock remains controversial. In this randomized controlled trial, we evaluated the efficacy of dynamic measures (stroke volume change during passive leg raise) to guide resuscitation and improve patient outcome. Research Question: Will resuscitation guided by dynamic assessments of fluid responsiveness in patients with septic shock improve patient outcomes? Study Design and Methods: Prospective, multicenter, randomized clinical trial at 13 hospitals in the United States and United Kingdom. Patients presented to Emergency Rooms with sepsis associated hypotension and anticipated Intensive Care Unit (ICU) admission. Intervention arm patients were assessed for fluid responsiveness before clinically driven fluid bolus or increase in vasopressors. The protocol included reassessment and therapy as indicated by the PLR result. The control arm received Usual Care. Primary clinical outcome was positive fluid balance at 72 hours or ICU discharge, whichever occurred first. Results: In modified-ITT (mITT) analysis including 83 Intervention and 41 Usual Care eligible patients, fluid balance at 72 hours or ICU discharge was significantly lower (-1.37L favoring Intervention arm, 0.65 ± 2.85L Intervention arm vs. 2.02 ± 3.44L Usual Care arm, p=0.021. Fewer patients required renal replacement therapy (5.1% vs 17.5%, p=0.04) or mechanical ventilation (17.7% vs 34.1%, p=0.04) in the Intervention arm compared to Usual Care. In the allrandomized Intent to Treat (ITT) population (102 Intervention, 48 Usual Care) there were no significant differences in safety signals. Interpretation: Physiologically informed fluid and vasopressor resuscitation using passive leg raise-induced stroke volume change to guide management of septic shock is safe and demonstrated lower net fluid balance and reductions in the risk of renal and respiratory failure. Dynamic assessments to guide fluid administration may improve outcomes for septic shock patients compared with Usual Care. Trial Registration clinicaltrials.gov identifier: NCT02837731

Introduction Emergency department (ED) providers and clinicians find that feedback on acute stroke patients is rewarding, valuable to professional development, and helpful for practice improvement. However, feedback is rarely provided, particularly for patients with stroke. Here we describe the implementation of an electronic stroke outcome reporting tool for providing feedback to ED providers. Methods We sought to evaluate the implementation of an electronic stroke outcome reporting tool at 3 Nashville hospitals. ED staff and providers voluntarily enrolled to receive de-identified reports of clinical (e.g., survival) and operational (e.g., timeliness) outcomes of patients with acute ischemic stroke and were offered free continuing education (CE) credits for following up on patients. We evaluated the implementation of this system through a descriptive evaluation of the feasibility, use of the system and CE, and perceived usefulness of the reports. Results We enrolled 232 ED providers, including 107 (46%) nurses and 57 (25%) attending physicians and transmitted 55 stroke outcome reports. Reports took 30–60 min to compile and were viewed by a mean of 2.6 (SD 1.5) registered providers; 97.1% found the reports useful and 36.2% reported likelihood to change practice. Continuing education credits were initiated or claimed by 22 providers. Conclusions An electronic stroke outcome reporting tool was used and liked by ED staff and providers but the time to compile the reports is the major challenge to scalability. Future research should address the effectiveness of this reporting tool as a source of provider education and its impact on clinical and operational outcomes.

Background Septic shock therapies that shorten the time to physiologic and clinical recovery may result in financial savings. However, the financial implications of improving these nonmortal outcomes are not well characterized. Therefore, we quantified hospital charges associated with four outcomes: ICU length of stay, duration of invasive mechanical ventilation, duration of vasopressor use, and new renal replacement therapy. Methods This was an observational study using administrative data from a large academic hospital in the United States. The analysis included adults treated with vasopressors for septic shock in a medical ICU. Linear regression modeling with ordinary least square was used to estimate the incremental hospital charges associated with 1 day of ICU length of stay, 1 day of mechanical ventilation, 1 day of vasopressor use, and new renal replacement therapy. Results The study population included 587 adults with septic shock, including 180 (30.7%) who died in the hospital. The median charge for a septic shock hospitalization was $98,583 (interquartile range [IQR], $61,177-$136,672). Decreases in ICU length of stay, mechanical ventilation duration, and vasopressor duration of 1 day were associated with charge reductions of $15,670 (IQR, $15,023-$16,317), $15,284 (IQR, $13,566-$17,002), and $17,947 (IQR, $16,344-$19,549), respectively. Avoidance of new renal replacement therapy was associated with a charge reduction of $36,051 (IQR, $22,353-$49,750). Conclusions Septic shock therapies that reduce the duration of organ support and ICU care have the potential to lead to substantial financial savings.

Background Interfacility transfers between emergency department (EDs) are common and at times unnecessary. We sought to examine the role of health insurance status with potentially avoidable transfers. Methods We conducted a retrospective observational analysis using hospital electronic administrative data of all interfacility ED‐to‐ED transfers to a single, quaternary care adult ED in 2018. We defined a potentially avoidable transfer as an ED‐to‐ED transfer in which the patient did not receive a procedure from a specialist at the receiving hospital and was discharged from the ED or the receiving hospital within 24 hours of arrival. We constructed a multivariable logistic regression model to examine whether insurance status was associated with potentially avoidable transfers among all ED‐to‐ED transfers adjusting for patient demographics, severity, mode of arrival, clinical condition, and rurality. Results Among 7508 transfers, 1862 (25%) were potentially avoidable and were more likely to be uninsured (20% vs 9%). In the multivariable analysis, among ED‐to‐ED transfers for adults aged 18–64 years old who were uninsured (vs any insurance) were significantly more likely to be potentially avoidable (adjusted odds ratio [aOR] 2.1 [1.7, 2.4]) and there is a significant interaction with age. Potentially avoidable transfers increased with younger age, male sex, black (vs white), small rural classification (vs urban), and arrival by ground ambulance (vs flight). Conclusions Potentially avoidable transfers comprised 1 in 4 transfers. Patients who lack insurance were more than twice as likely to be classified as potentially avoidable even after evaluating for confounders and interactions. This effect was most pronounced among younger patients. Further research is needed to explore why uninsured patients are disproportionately more likely to experience potentially avoidable transfers.

Objectives:. Given finite ICU bed capacity, knowledge of ICU bed utilization during the coronavirus disease 2019 pandemic is critical to ensure future strategies for resource allocation and utilization. We sought to examine ICU census trends in relation to ICU bed capacity during the rapid increase in severe coronavirus disease 2019 cases early during the pandemic. Design:. Observational cohort study. Setting:. Thirteen geographically dispersed academic medical centers in the United States. Patients/Subjects:. We obtained daily ICU censuses from March 26 to June 30, 2020, as well as prepandemic ICU bed capacities. The primary outcome was daily census of ICU patients stratified by coronavirus disease 2019 and mechanical ventilation status in relation to ICU capacity. Interventions:. None. Measurements and Main Results:. Prepandemic overall ICU capacity ranged from 62 to 225 beds (median 109). During the study period, the median daily coronavirus disease 2019 ICU census per hospital ranged from 1 to 84 patients, and the daily ICU census exceeded overall ICU capacity for at least 1 day at five institutions. The number of critically ill patients exceeded ICU capacity for a median (interquartile range) of 17 (12–50) of 97 days at these five sites. All 13 institutions experienced decreases in their noncoronavirus disease ICU population, whereas local coronavirus disease 2019 cases increased. Coronavirus disease 2019 patients reached their greatest proportion of ICU capacity on April 12, 2020, when they accounted for 44% of ICU patients across all participating hospitals. Maximum ICU census ranged from 52% to 289% of overall ICU capacity, with three sites less than 80%, four sites 80–100%, five sites 100–128%, and one site 289%. Conclusions:. From March to June 2020, the coronavirus disease 2019 pandemic led to ICU censuses greater than ICU bed capacity at fives of 13 institutions evaluated. These findings demonstrate the short-term adaptability of U.S. healthcare institutions in redirecting limited resources to accommodate a public health emergency.

IntroductionMechanical ventilation of intensive care unit (ICU) patients universally involves titration of the fraction of inspired oxygen to maintain arterial oxygen saturation (SpO2). However, the optimal SpO2 target remains unknown.Methods and analysisThe Pragmatic Investigation of optimaL Oxygen Targets (PILOT) trial is a prospective, unblinded, pragmatic, cluster-crossover trial being conducted in the emergency department (ED) and medical ICU at Vanderbilt University Medical Center in Nashville, Tennessee, USA. PILOT compares use of a lower SpO2 target (target 90% and goal range: 88%–92%), an intermediate SpO2 target (target 94% and goal range: 92%–96%) and a higher SpO2 target (target 98% and goal range: 96%–100%). The study units are assigned to a single SpO2 target (cluster-level allocation) for each 2-month study block, and the assigned SpO2 target switches every 2 months in a randomly generated sequence (cluster-level crossover). The primary outcome is ventilator-free days (VFDs) to study day 28, defined as the number of days alive and free of invasive mechanical ventilation from the final receipt of invasive mechanical ventilation through 28 days after enrolment.Ethics and disseminationThe trial was approved by the Vanderbilt Institutional Review Board. The results will be submitted for publication in a peer-reviewed journal and presented at one or more scientific conferences.Trial registration numberThe trial protocol was registered with ClinicalTrials.gov on 25 May 2018 prior to initiation of patient enrolment (ClinicalTrials.gov identifier: NCT03537937).

Introduction Understanding patient factors associated with not being vaccinated is essential for successful implementation of influenza vaccination programs. Methods We enrolled adults hospitalized with severe acute respiratory illness at 10 United States (US) hospitals during the 2019–2020 influenza season. We interviewed patients to collect data about influenza vaccination, sociodemographic characteristics, and vaccine perceptions. Results Among 679 participants, 264 (38.9%) reported not receiving influenza vaccination. Among those not vaccinated, 135 (51.1%) reported choosing not to receive a vaccine because of perceived ineffectiveness (36.7%) or risk (14.4%) of influenza vaccination. Sociodemographic factors associated with not being vaccinated included no medical insurance (aOR = 6.42; 95% CI: 2.52–16.38) and being non-White or Hispanic (aOR = 1.54, 95% CI: 1.02–2.32). Conclusions Optimizing uptake of influenza vaccination in the US may be improved by educational programs regarding vaccine safety and effectiveness and enhancing vaccine access, particularly among non-White and Hispanic Americans and those without medical insurance.

Current diagnostics are insufficient for diagnosis and prognosis of acute infections and sepsis. Clinical decisions including prescription and timing of antibiotics, ordering of additional diagnostics and level-of-care decisions rely on understanding etiology and implications of a clinical presentation. Host mRNA signatures can differentiate infectious from noninfectious etiologies, bacterial from viral infections, and predict 30-day mortality. The 29-host-mRNA blood-based InSepTM test (Inflammatix, Burlingame, CA, formerly known as HostDxTM Sepsis) combines machine learning algorithms with a rapid point-of-care platform with less than 30 min turnaround time to enable rapid diagnosis of acute infections and sepsis, as well as prediction of disease severity. A scientific advisory panel including emergency medicine, infectious disease, intensive care and clinical pathology physicians discussed technical and clinical requirements in preparation of successful introduction of InSep into the market. Topics included intended use, patient populations of greatest need, patient journey and sample flow in the emergency department (ED) and beyond, clinical and biomarker-based decision algorithms, performance characteristics for clinical utility, assay and instrument requirements, and result readouts. The panel identified clear demand for a solution like InSep, requirements regarding test performance and interpretability, and a need for focused medical education due to the innovative but complex nature of the result readout. Innovative diagnostic solutions such as the InSep test could improve management of patients with suspected acute infections and sepsis in the ED, thereby lessening the overall burden of these conditions on patients and the healthcare system.

Endotracheal intubation (EI) is a potentially lifesaving but high-risk procedure in critically ill patients. While the ACGME mandates that trainees in pulmonary and critical care medicine (PCCM) achieve competence in this procedure, there is wide variation in EI training across the USA. One study suggests that 40% of the US PCCM trainees feel they would not be proficient in EI upon graduation. This article presents a review of the EI training literature; the recommendations of a national group of PCCM, anesthesiology, emergency medicine, and pediatric experts; and a call for further research, collaboration, and consensus guidelines.

Health care personnel (HCP) caring for patients with coronavirus disease 2019 (COVID-19) might be at high risk for contracting SARS-CoV-2, the virus that causes COVID-19. Understanding the prevalence of and factors associated with SARS-CoV-2 infection among frontline HCP who care for COVID-19 patients are important for protecting both HCP and their patients. During April 3-June 19, 2020, serum specimens were collected from a convenience sample of frontline HCP who worked with COVID-19 patients at 13 geographically diverse academic medical centers in the United States, and specimens were tested for antibodies to SARS-CoV-2. Participants were asked about potential symptoms of COVID-19 experienced since February 1, 2020, previous testing for acute SARS-CoV-2 infection, and their use of personal protective equipment (PPE) in the past week. Among 3,248 participants, 194 (6.0%) had positive test results for SARS-CoV-2 antibodies. Seroprevalence by hospital ranged from 0.8% to 31.2% (median = 3.6%). Among the 194 seropositive participants, 56 (29%) reported no symptoms since February 1, 2020, 86 (44%) did not believe that they previously had COVID-19, and 133 (69%) did not report a previous COVID-19 diagnosis. Seroprevalence was lower among personnel who reported always wearing a face covering (defined in this study as a surgical mask, N95 respirator, or powered air purifying respirator [PAPR]) while caring for patients (5.6%), compared with that among those who did not (9.0%) (p = 0.012). Consistent with persons in the general population with SARS-CoV-2 infection, many frontline HCP with SARS-CoV-2 infection might be asymptomatic or minimally symptomatic during infection, and infection might be unrecognized. Enhanced screening, including frequent testing of frontline HCP, and universal use of face coverings in hospitals are two strategies that could reduce SARS-CoV-2 transmission.

“Smoothing” is the phenomenon by which manually recorded vital signs are less likely to document values at the extremes compared to automated systems [1]. Intermittent manual recording of the peripheral oxygen saturation (SpO2) has the potential to inaccurately reflect patients’ true physiological states. Taenzer et al. observed that manually charted SpO2 values were, on average, 6.5 percentage points greater than SpO2 values collected by automated sampling [2]. Automated high-frequency SpO2 monitoring may more reliably quantify the incidence and severity of hypoxemia and hyperoxemia. Intensive Care Units (ICUs) have traditionally been more vigilant in preventing hypoxemia than hyperoxemia, and ICU patients frequently receive more supplemental oxygen than required to maintain normal values for SpO2 [3]. Hyperoxemia has been associated with worse patient outcomes in observational studies [4, 5], but randomized trials evaluating oxygen saturation targets for mechanically ventilated adults have reported conflicting results [6–9]. These trials have used intermittent recording of SpO2 by study personnel every 4 to 24 h to assess oxygenation. Automating data collection for SpO2 has the potential to facilitate the design, conduct, and analysis of pragmatic clinical trials examining SpO2 targets in mechanically ventilated ICU patients [10]. We developed a technique for automated extraction of large-volume data on SpO2 values for use in a randomized clinical trial. We aimed to quantify the completeness and density of SpO2 data among mechanically ventilated patients. We evaluated the reliability of automated extraction of SpO2 data from pulse oximetry using physician manual review of photoplethysmographic waveforms.

Background Studies suggest that using balanced crystalloids (lactated Ringer’s solution or Plasma-Lyte A) rather than saline (0.9% sodium chloride) may improve outcomes for patients with sepsis in the ED and ICU. Research Question What is the relative impact on sepsis outcomes of fluid composition during early resuscitation in the ED vs after ICU admission? Study Design and Methods We performed a secondary analysis of the Isotonic Solutions and Major Adverse Renal Events Trial (SMART) data set, examining medical ICU patients with a diagnosis of sepsis (n = 1,641). SMART was a cluster-crossover trial comparing balanced crystalloids vs saline among critically ill adults. During the first 7 months of SMART, fluid choice was controlled only in the ICU (“ICU-only period”). In the final 15 months, fluid choice was coordinated between the ED and ICU (“ED and ICU period”). We performed logistic regression modeling for 30-day in-hospital mortality with an interaction term between randomized group (balanced crystalloids vs saline) and study period (ICU-only period vs ED and ICU period). Results Three hundred and sixty-seven patients with sepsis were enrolled during the ICU-only period and 1,274 were enrolled during the ED and ICU period. Thirty-day in-hospital mortality occurred in 47 of 142 patients (33.1%) in the balanced crystalloid group vs 74 of 225 patients (32.9%) in the saline group during the ICU-only period (OR, 1.14; 95% CI, 0.70-1.88) and in 170 of 682 patients (24.9%) in the balanced crystalloid group vs 181 of 592 patients (30.6%) in the saline group in the ED and ICU period (OR, 0.68; 95% CI, 0.52-0.89) (P value for interaction, .07), consistent with a beneficial effect of balanced crystalloid primarily in the ED and ICU period. Interpretation Among patients with sepsis, the effect of balanced crystalloids vs saline on mortality was greater among patients for whom fluid choice was controlled starting in the ED compared with starting in the ICU.

OBJECTIVES With the rise of opioid use in the United States, the increasing demand for treatment for opioid use disorders presents both a challenge and an opportunity to develop new care pathways for emergency department (ED) patients seeking opioid detoxification. We set out to improve the care of patients presenting to our ED seeking opioid detoxification by implementing a standardized management pathway and to measure the effects of this intervention. METHODS We conducted a before-after study of the effects of an opioid detoxification management pathway on ED length of stay (EDLOS), use of resources (social worker consultation, laboratory tests obtained), and return visits to the same ED within 30 days of discharge. All data were collected retrospectively by review of the electronic health record. RESULTS Ultimately, 107 patients presented to the ED that met criteria, 52 in the intervention period and 55 in the preintervention period. Median EDLOS in the intervention period was 152 (interquartile range [IQR] = 93-237) minutes compared to 312 (IQR = 187-468) minutes in the preintervention period (p

Introduction A triage cardiology program, in which cardiologists provide consultation to the Emergency Department (ED), may safely reduce admissions. For patients with chest pain, the HEART Pathway may obviate the need for cardiology involvement, unless there is a difference between ED and cardiology assessments. Therefore, in a cohort concurrently evaluated by both specialties, we analyzed discordance between ED and cardiology HEART scores. Methods We performed a single-center, cross-sectional, retrospective study of adults presenting to the ED with chest pain who had a documented bedside evaluation by a triage cardiologist. Separate ED and cardiology HEART scores were computed based on documentation by the respective physicians. Discrepancies in HEART score between ED physicians and cardiologists were quantified using Cohen κ coefficient. Results Thirty-three patients underwent concurrent ED physician and cardiologist evaluation. Twenty-three patients (70%) had discordant HEART scores ( κ = 0.13; 95% confidence interval, −0.02 to 0.32). Discrepancies in the description of patients' chest pain were the most common source of discordance and were present in more than 50% of cases. HEART scores calculated by ED physicians tended to overestimate the scores calculated by cardiologists. When categorized into low-risk or high-risk by the HEART Pathway, more than 25% of patients were classified as high risk by the ED physician, but low risk by the cardiologist. Conclusion There is substantial discordance in HEART scores between ED physicians and cardiologists. A triage cardiology system may help refine risk stratification of patients presenting to the ED with chest pain, even when the HEART Pathway tool is used.

IntroductionFollowing extubation from invasive mechanical ventilation, nearly one in seven critically ill adults requires reintubation. Reintubation is independently associated with increased mortality. Postextubation respiratory support (non-invasive ventilation or high-flow nasal cannula applied at the time of extubation) has been reported in small-to-moderate-sized trials to reduce reintubation rates among hypercapnic patients, high-risk patients without hypercapnia and low-risk patients without hypercapnia. It is unknown whether protocolised provision of postextubation respiratory support to every patient undergoing extubation would reduce the overall reintubation rate, compared with usual care.Methods and analysisThe Protocolized Post-Extubation Respiratory Support (PROPER) trial is a pragmatic, cluster cross-over trial being conducted between 1 October 2017 and 31 March 2019 in the medical intensive care unit of Vanderbilt University Medical Center. PROPER compares usual care versus protocolized post-extubation respiratory support (a respiratory therapist-driven protocol that advises the provision of non-invasive ventilation or high-flow nasal cannula based on patient characteristics). For the duration of the trial, the unit is divided into two clusters. One cluster receives protocolised support and the other receives usual care. Each cluster crosses over between treatment group assignments every 3 months. All adults undergoing extubation from invasive mechanical ventilation are enrolled except those who received less than 12 hours of mechanical ventilation, have ‘Do Not Intubate’ orders, or have been previously reintubated during the hospitalisation. The anticipated enrolment is approximately 630 patients. The primary outcome is reintubation within 96 hours of extubation.Ethics and disseminationThe trial was approved by the Vanderbilt Institutional Review Board. The results will be submitted for publication in a peer-reviewed journal and presented at one or more scientific conferences.Trial registration numberNCT03288311.

Author(s): Evans, Christopher S.; Self, Wesley; Ginde, Adit A.; Chandrasekhar, Rameela; Ely, E. Wesley; Han, Jin H. | Abstract: Introduction: Approximately 16% of acutely ill older adults develop new, long-term cognitive impairment (LTCI), many of whom initially seek care in the emergency department (ED). Currently, no effective interventions exist to prevent LTCI after an acute illness. Identifying early and modifiable risk factors for LTCI is the first step toward effective therapy. We hypothesized that Vitamin D deficiency at ED presentation was associated with LTCI in older adults.Methods: This was an observational analysis of a prospective cohort study that enrolled ED patients ≥ 65 years old who were admitted to the hospital for an acute illness. All patients were enrolled within four hours of ED presentation. Serum Vitamin D was measured at enrollment and Vitamin D deficiency was defined as serum concentrations l20 mg/dL. We measured pre-illness and six-month cognition using the short form Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE), which ranges from 1 to 5 (severe cognitive impairment). Multiple linear regression was performed to determine whether Vitamin D deficiency was associated with poorer six-month cognition adjusted for pre-illness IQCODE and other confounders. We incorporated a two-factor interaction into the regression model to determine whether the relationship between Vitamin D deficiency and six-month cognition was modified by pre-illness cognition.Results: We included a total of 134 older ED patients; the median (interquartile range [IQR]) age was 74 (69, 81) years old, 61 (46%) were female, and 14 (10%) were nonwhite race. The median (IQR) vitamin D level at enrollment was 25 (18, 33) milligrams per deciliter and 41 (31%) of enrolled patients met criteria for vitamin D deficiency. Seventy-seven patients survived and had a six-month IQCODE. In patients with intact pre-illness cognition (IQCODE of 3.13), Vitamin D deficiency was significantly associated with worsening six-month cognition (β-coefficient: 0.43, 95% CI, 0.07 to 0.78, p = 0.02) after adjusting for pre-illness IQCODE and other confounders. Among patients with pre-illness dementia (IQCODE of 4.31), no association with Vitamin D deficiency was observed (β-coefficient: -0.1;, 95% CI, [-0.50-0.27], p = 0.56).Conclusion: Vitamin D deficiency was associated with poorer six-month cognition in acutely ill older adult ED patients who were cognitively intact at baseline. Future studies should determine whether early Vitamin D repletion in the ED improves cognitive outcomes in acutely ill older patients.

IntroductionIntubation-related complications are less frequent when intubation is successful on the first attempt. The rate of first attempt success in the emergency department (ED) and intensive care unit (ICU) is typically less than 90%. The bougie, a semirigid introducer that can be placed into the trachea to facilitate a Seldinger-like technique of tracheal intubation and is typically reserved for difficult or failed intubations, might improve first attempt success. Evidence supporting its use, however, is from a single academic ED with frequent bougie use. Validation of these findings is needed before widespread implementation.Methods and analysisThe BOugie or stylet in patients Undergoing Intubation Emergently trial is a prospective, multicentre, non-blinded randomised trial being conducted in six EDs and six ICUs in the USA. The trial plans to enrol 1106 critically ill adults undergoing orotracheal intubation. Eligible patients are randomised 1:1 for the use of a bougie or use of an endotracheal tube with stylet for the first intubation attempt. The primary outcome is successful intubation on the first attempt. The secondary outcome is severe hypoxaemia, defined as an oxygen saturation less than 80% between induction until 2 min after completion of intubation. Enrolment began on 29 April 2019 and is expected to be completed in 2021.Ethics and disseminationThe trial protocol was approved with waiver of informed consent by the Central Institutional Review Board at Vanderbilt University Medical Center or the local institutional review board at an enrolling site. The results will be submitted for publication in a peer-reviewed journal and presented at scientific conferences.Trial registration numberClinicalTrials.gov Registry (NCT03928925).

Importance Up to 20% of patients who present to the emergency department (ED) with acute heart failure (AHF) are discharged without hospitalization. Compared with rates in hospitalized patients, readmission and mortality are worse for ED patients. Objective To assess the impact of a self-care intervention on 90-day outcomes in patients with AHF who are discharged from the ED. Design, Setting, and Participants Get With the Guidelines in Emergency Department Patients With Heart Failure was an unblinded, parallel-group, multicenter randomized trial. Patients were randomized 1:1 to usual care vs a tailored self-care intervention. Patients with AHF discharged after ED-based management at 15 geographically diverse EDs were included. The trial was conducted from October 28, 2015, to September 5, 2019. Interventions Home visit within 7 days of discharge and twice-monthly telephone-based self-care coaching for 3 months. Main Outcomes and Measures The primary outcome was a global rank of cardiovascular death, HF-related events (unscheduled clinic visit due to HF, ED revisit, or hospitalization), and changes in the Kansas City Cardiomyopathy Questionnaire-12 (KCCQ-12) summary score (SS) at 90 days. Key secondary outcomes included the global rank outcome at 30 days and changes in the KCCQ-12 SS score at 30 and 90 days. Intention-to-treat analysis was performed for the primary, secondary, and safety outcomes. Per-protocol analysis was conducted including patients who completed a home visit and had scheduled outpatient follow-up in the intervention arm. Results Owing to slow enrollment, 479 of a planned 700 patients were randomized: 235 to the intervention arm and 244 to the usual care arm. The median age was 63.0 years (interquartile range, 54.7-70.2), 302 patients (63%) were African American, 305 patients (64%) were men, and 178 patients (37%) had a previous ejection fraction greater than 50%. There was no significant difference in the primary outcome between patients in the intervention vs usual care arm (hazard ratio [HR], 0.89; 95% CI, 0.73-1.10;P = .28). At day 30, patients in the intervention arm had significantly better global rank (HR, 0.80; 95% CI, 0.64-0.99;P = .04) and a 5.5-point higher KCCQ-12 SS (95% CI, 1.3-9.7;P = .01), while at day 90, the KCCQ-12 SS was 2.7 points higher (95% CI, −1.9 to 7.2;P = .25). Conclusions and Relevance The self-care intervention did not improve the primary global rank outcome at 90 days in this trial. However, benefit was observed in the global rank and KCCQ-12 SS at 30 days, suggesting that an early benefit of a tailored self-care program initiated at an ED visit for AHF was not sustained through 90 days. Trial Registration ClinicalTrials.gov Identifier:NCT02519283

Objective Ultrasound-guided intravenous catheter (USGIV) insertion is increasingly being used for administration of intravenous (IV) contrast for computed tomography (CT) scans. The goal of this investigation was to evaluate the risk of contrast extravasation among patients receiving contrast through USGIV catheters. Methods A retrospective observational study of adult patients who underwent a contrast-enhanced CT scan at a tertiary care emergency department during a recent 64-month period was conducted. The unadjusted prevalence of contrast extravasation was compared between patients with an USGIV and those with a standard peripheral IV inserted without ultrasound. Then, a two-stage sampling design was used to select a subset of the population for a multivariable logistic regression model evaluating USGIVs as a risk factor for extravasation while adjusting for potential confounders. Results In total, 40,143 patients underwent a contrasted CT scan, including 364 (0.9%) who had contrast administered through an USGIV. Unadjusted prevalence of extravasation was 3.6% for contrast administration through USGIVs and 0.3% for standard IVs (relative risk = 13.9, 95% confidence interval [CI] = 7.9 to 24.6). After potential confounders were adjusted for, CT contrast administered through USGIVs was associated with extravasation (adjusted odds ratio = 8.6, 95% CI = 4.6 to 16.2). No patients required surgical management for contrast extravasation; one patient in the standard IV group was admitted for observation due to extravasation. Conclusions Patients who received contrast for a CT scan through an USGIV had a higher risk of extravasation than those who received contrast through a standard peripheral IV. Clinicians should consider this extravasation risk when weighing the risks and benefits of a contrast-enhanced CT scan in a patient with USGIV vascular access.

Objectives Given the sparse evidence for selection of first-line therapy for acute atrial fibrillation (AF) based on clinical factors alone, incorporation of genotype data may improve the effectiveness of treatment algorithms and advance the understanding of interpatient heterogeneity. We tested whether candidate nucleotide polymorphisms (SNPs) related to AF physiologic responses are associated with ventricular rate control after intravenous diltiazem in the emergency department (ED). Methods We conducted an analysis within a prospective observational cohort of ED patients with acute symptomatic AF, ventricular rate > 110 beats per minute within the first 2 hours, initially treated with intravenous diltiazem, and who had DNA available for analysis. We evaluated 24 candidate SNPs that were grouped into 3 categories based on their phenotype response (atrioventricular nodal [AVN] conduction, resting heart rate, disease susceptibility) and calculated 3 genetic scores for each patient. Our primary outcome was maximum heart rate reduction within 4 hours of diltiazem administration. Multivariable regression was used to identify associations with the outcome while adjusting for age, sex, baseline heart rate, and diltiazem dose. Results Of the 142 patients, 127 had complete data for the primary outcome. None of the genetic scores for AVN conduction, resting heart rate, or AF susceptibility showed a significant association with maximal heart rate response. Conclusion Using a candidate SNP approach, screening for genetic variants associated with AVN conduction, resting heart rate, or AF susceptibility failed to provide significant data for predicting successful rate control response to intravenous diltiazem for treating acute AF in the ED.

The objective was to evaluate the prognostic performance of a new biomarker, plasma bioactive adrenomedullin (bio-ADM), for short-term clinical outcomes in acute heart failure.A multicenter prospective cohort study of adult emergency department (ED) patients suspected of having acute heart failure was conducted to evaluate the association between plasma bio-ADM concentration and clinical outcomes. The primary outcome was a composite of the following within 30 days: death, cardiac arrest with resuscitation, respiratory failure, emergency dialysis, acute coronary syndrome, hospitalization5 days, and repeat ED visit or hospitalization. Prognostic accuracy was evaluated with a nonparametric receiver operating characteristic curve. In addition, a multivariable logistic regression model was constructed to assess the additive prognostic performance of bio-ADM while adjusting for other biomarkers routinely used clinically, including B-type natriuretic peptide, cardiac troponin I, creatinine, and sodium concentration.Two hundred forty-six patients were enrolled, including 85 (34.6%) patients with the primary outcome. Plasma bio-ADM concentrations were higher among patients who experienced the primary outcome (median, 80.5 pg/mL; interquartile range [IQR], 53.7-151.5 pg/mL) compared with those who did not (median, 54.4 pg/mL; IQR, 43.4-78.4 pg/mL) (P.01). Area under the receiver operating characteristic curve was 0.70 (95% confidence interval, 0.63-0.75). After adjusting for the other biomarkers, plasma bio-ADM remained a strong predictor of the primary outcome (adjusted odds ratio per IQR change, 2.68; 95% confidence interval, 1.60-4.51).Bioactive adrenomedullin concentrations at the time of ED evaluation for acute heart failure were predictive of clinically important 30-day outcomes, suggesting that bio-ADM is a promising prognostic marker for further study.

Hypertension is a common chronic condition, but the burden of emergency department (ED) visits due to hypertension and associated patient and hospital characteristics are not well described. The goals of this study were to (1) establish the burden of hypertension-related ED visits, estimated by the total number, proportion of adult visits, and population-based rate, (2) evaluate for change over time, and (3) identify associated patient and hospital characteristics. The Nationwide Emergency Department Sample from 2006 to 2012 was used to identify hypertension-related ED visits (International Classification of Diseases, Ninth Revision, Clinical Modification codes 401 to 405, inclusive, and 437.2), and this was linked to US Census Bureau July population estimates to determine population-based rates for each study year. Negative binomial regression was performed to determine whether rates of hypertension-related ED visits changed over time. A total of 165,946,807 hypertension-related ED visits occurred during the 7-year study period (23.6% of all adult ED visits), and hypertension was the primary diagnosis for 6,399,088 (0.9% of all adult ED visits). The estimated yearly incidence rate increased 5.2% per year (incident rate ratio, 1.052; 95% confidence interval, 1.044 to 1.061; p

Key Points Question Does using a balanced crystalloid solution instead of saline for fluid therapy in adults with diabetic ketoacidosis (DKA) lead to faster resolution of DKA? Findings In this subgroup analysis of 172 adults with DKA from 2 large cluster randomized clinical trials comparing balanced crystalloids and saline, the median time to DKA resolution was 13.0 hours with balanced crystalloids and 16.9 hours with saline, a significant difference. Meaning These findings suggest that balanced crystalloid therapy leads to faster resolution of DKA than saline and may be the preferred isotonic fluid solution for acute management of DKA., This subgroup analysis of 2 cluster randomized clinical trials examines adults presenting to the emergency department with diabetic ketoacidosis and determines how long it takes to reach resolution by treating with balanced crystalloids vs saline., Importance Saline (0.9% sodium chloride), the fluid most commonly used to treat diabetic ketoacidosis (DKA), can cause hyperchloremic metabolic acidosis. Balanced crystalloids, an alternative class of fluids for volume expansion, do not cause acidosis and, therefore, may lead to faster resolution of DKA than saline. Objective To compare the clinical effects of balanced crystalloids with the clinical effects of saline for the acute treatment of adults with DKA. Design, Setting, and Participants This study was a subgroup analysis of adults with DKA in 2 previously reported companion trials—Saline Against Lactated Ringer’s or Plasma-Lyte in the Emergency Department (SALT-ED) and the Isotonic Solutions and Major Adverse Renal Events Trial (SMART). These trials, conducted between January 2016 and March 2017 in an academic medical center in the US, were pragmatic, multiple-crossover, cluster, randomized clinical trials comparing balanced crystalloids vs saline in emergency department (ED) and intensive care unit (ICU) patients. This study included adults who presented to the ED with DKA, defined as a clinical diagnosis of DKA, plasma glucose greater than 250 mg/dL, plasma bicarbonate less than or equal to 18 mmol/L, and anion gap greater than 10 mmol/L. Data analysis was performed from January to April 2020. Interventions Balanced crystalloids (clinician’s choice of Ringer lactate solution or Plasma-Lyte A solution) vs saline for fluid administration in the ED and ICU according to the same cluster-randomized multiple-crossover schedule. Main Outcomes and Measures The primary outcome was time between ED presentation and DKA resolution, as defined by American Diabetes Association criteria. The secondary outcome was time between initiation and discontinuation of continuous insulin infusion. Results Among 172 adults included in this secondary analysis of cluster trials, 94 were assigned to balanced crystalloids and 78 to saline. The median (interquartile range [IQR]) age was 29 (24-45) years, and 90 (52.3%) were women. The median (IQR) volume of isotonic fluid administered in the ED and ICU was 4478 (3000-6372) mL. Cumulative incidence analysis revealed shorter time to DKA resolution in the balanced crystalloids group (median time to resolution: 13.0 hours; IQR: 9.5-18.8 hours) than the saline group (median: 16.9 hours; IQR: 11.9-34.5 hours) (adjusted hazard ratio [aHR] = 1.68; 95% CI, 1.18-2.38; P = .004). Cumulative incidence analysis also revealed shorter time to insulin infusion discontinuation in the balanced crystalloids group (median: 9.8 hours; IQR: 5.1-17.0 hours) than the saline group (median: 13.4 hours; IQR: 11.0-17.9 hours) (aHR = 1.45; 95% CI, 1.03-2.03; P = .03). Conclusions and Relevance In this secondary analysis of 2 cluster randomized clinical trials, compared with saline, treatment with balanced crystalloids resulted in more rapid resolution of DKA, suggesting that balanced crystalloids may be preferred over saline for acute management of adults with DKA. Trial Registration ClinicalTrials.gov Identifiers: NCT02614040; NCT02444988

Background Adults hospitalized with community-acquired pneumonia (CAP) are at high risk for short-term mortality. However, it is unclear whether improvements in in-hospital pneumonia care could substantially lower this risk. We extensively reviewed all in-hospital deaths in a large prospective CAP study to assess the cause of each death and assess the extent of potentially preventable mortality. Methods We enrolled adults hospitalized with CAP at five tertiary-care hospitals in the United States. Five physician investigators reviewed the medical record and study database for each patient who died to identify the cause of death, the contribution of CAP to death, and any preventable factors potentially contributing to death. Results Among 2,320 enrolled patients, 52 (2.2%) died during initial hospitalization. Among these 52 patients, 33 (63.4%) were ≥ 65 years old, and 32 (61.5%) had ≥ two chronic comorbidities. CAP was judged to be the direct cause of death in 27 patients (51.9%). Ten patients (19.2%) had do-not-resuscitate orders prior to admission. Four patients were identified in whom a lapse in quality of care potentially contributed to death; preexisting end-of-life limitations were present in two of these patients. Two patients seeking full medical care experienced a lapse in in-hospital quality of pneumonia care that potentially contributed to death. Conclusions In this study of adults with CAP at tertiary-care hospitals with a low mortality rate, most in-hospital deaths did not appear to be preventable with improvements in in-hospital pneumonia care. Preexisting end-of-life limitations in care, advanced age, and high comorbidity burden were common among those who died.

Prompt intravenous fluid therapy is a fundamental treatment for patients with septic shock. However, the optimal approach for administering intravenous fluid in septic shock resuscitation is unknown. Two competing strategies are emerging—a liberal fluids approach consisting of a larger volume of initial fluid [50 – 75 ml/kg (4–6 liters in an 80 kg adult) over the first 6 hours] and later use of vasopressors, versus a restrictive fluids approach consisting of a smaller volume of initial fluid [≤30 ml/kg (≤2–3 liters)] with earlier reliance on vasopressor infusions to maintain blood pressure and perfusion. Early fluid therapy may enhance or maintain tissue perfusion by increasing venous return and cardiac output. However, fluid administration may also have deleterious effects by causing edema within vital organs, leading to organ dysfunction and impairment of oxygen delivery. Conversely, a restrictive fluids approach primarily relies on vasopressors to reverse hypotension and maintain perfusion while limiting the administration of fluid. Both strategies have some evidence to support their use, but lack robust data to confirm the benefit of one strategy over the other, creating clinical and scientific equipoise. As part of the National Heart, Lung and Blood Institute (NHLBI) Prevention and Early Treatment of Acute Lung Injury (PETAL) Network, we designed a randomized clinical trial to compare the liberal and restrictive fluids strategies—the Crystalloid Liberal Or Vasopressor Early Resuscitation in Sepsis (CLOVERS) trial. The purpose of this manuscript is to review the current literature on approaches to early fluid resuscitation in adults with septic shock and outline the rationale for the upcoming trial.

Objectives Studies suggest that inflammatory, autonomic, and coagulation alterations associated with cancer may increase incident atrial fibrillation (AF). New-onset AF is associated with increased mortality in other nonneoplastic disease processes. We investigated the association of active cancer with 30-day mortality in emergency department (ED) patients with new-onset AF. Methods We conducted an analysis within an observational cohort study at a tertiary care hospital that included ED patients with new-onset AF. The exposure variable was presence of active cancer. We defined active cancer as the patient received chemotherapy, radiotherapy, or recent cancer-related surgery within 90 days of the ED visit. The primary outcome was 30-day mortality. Logistic regression was used to analyze the association between cancer status and 30-day mortality adjusting for patient age and sex. Results During the 5.5-year study period, 420 patients with new-onset AF were included in our cohort, including 37 (8.8%) with active cancer. Patients with active cancer had no clinically relevant differences in their hemodynamic stability. Among the 37 patients with active cancer, 9 (24%) died within 30 days. Of the 383 patients without active cancer, 11 (3%) died within 30 days. After adjusting for age and sex, active cancer was an independent predictor of 30-day mortality, with an adjusted odds ratio of 10.8 (95% confidence interval, 3.8-31.1). Conclusions Among ED patients with new-onset AF, active cancer appears to be associated with 11-fold increased odds of 30-day mortality; new-onset AF may represent progressive organ dysfunction leading to an increased risk of short-term mortality in patients with cancer.

Objectives Endotracheal intubation of trauma patients is a vital and high-risk procedure in the emergency department (ED). The hypothesis was that implementation of a standardized, preprocedural checklist would improve the safety of this procedure. Methods A preprocedural intubation checklist was developed and then implemented in a prospective pre-/postinterventional study in an academic trauma center ED. The proportions of trauma patients older than 16 years who experienced intubation-related complications during the 6 months before checklist implementation and 6 months after implementation were compared. Intubation-related complications included oxygen desaturation, emesis, esophageal intubation, hypotension, and cardiac arrest. Additional outcomes included time from paralysis to intubation and adherence to safety process measures. Results During the study, 141 trauma patients were intubated, including 76 in the prechecklist period and 65 in the postchecklist period. A lower proportion of patients experienced intubation-related complications in the postchecklist period (1.5%) than the prechecklist period (9.2%), representing a 7.7% (95% confidence interval = 0.5% to 14.8%) absolute risk reduction. Paralysis-to-intubation time was also lower in the postchecklist period (median = 82 seconds, interquartile range [IQR] = 68 to 101 seconds) compared to the prechecklist period (median = 94 seconds, IQR = 78 to 115 seconds; p = 0.02). Adherence to safety process measures also improved, with all safety measures performed in 69.2% in the postchecklist period compared to 17.1% before the checklist (p

The incidence and longitudinal trends of patients with ST-elevation myocardial infarction (STEMI) presenting to United States (US) emergency departments (EDs) are currently unknown. Efforts to use effective treatments for cardiovascular disease may decrease ED STEMI presentation. We conducted a descriptive epidemiological analysis of STEMI visits to EDs from 2006 to 2011 using the Nationwide ED Sample, the largest source of US ED data, to determine the incidence of patients with STEMIs presenting to the US EDs. We included adult ED visits with an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis of STEMI and calculated incidence rates for STEMI ED visits using US census population data. Incidence calculations were stratified by age group, geographic region, and year. From 2006 to 2011, there was a mean of 258,106 STEMIs presenting to EDs per year, decreasing from 300,466 in 2006 to 227,343 in 2011. Incidence of ED STEMI visits per 10,000 adults decreased from 10.1 (95% confidence interval [CI] 9.8 to 10.8) in 2006 to 7.3 (95% CI 6.8 to 7.8) in 2011. The Midwest had the highest rate of ED STEMIs at 10.0 (95% CI 9.2 to 10.8) and the West had the lowest with 6.6 (95% CI 6.1 to 7.0). The incidence of STEMI decreased for all age groups during the study period. In conclusion, we report the first national estimates of STEMI presentation to US EDs, which demonstrate decreasing incidence across all age groups and all geographic regions from 2006 to 2011. A decreasing STEMI incidence may affect the quality and timeliness of STEMI care. Continued national STEMI surveillance is needed to guide healthcare resource allocation.

Study objective The Third International Consensus Definitions Task Force (SEP-3) proposed revised criteria defining sepsis and septic shock. We seek to evaluate the performance of the SEP-3 definitions for prediction of inhospital mortality in an emergency department (ED) population and compare the performance of the SEP-3 definitions to that of the previous definitions. Methods This was a secondary analysis of 3 prospectively collected, observational cohorts of infected ED subjects aged 18 years or older. The primary outcome was all-cause inhospital mortality. In accordance with the SEP-3 definitions, we calculated test characteristics of sepsis (quick Sequential Organ Failure Assessment [qSOFA] score ≥2) and septic shock (vasopressor dependence plus lactate level >2.0 mmol/L) for mortality and compared them to the original 1992 consensus definitions. Results We identified 7,754 ED patients with suspected infection overall; 117 had no documented mental status evaluation, leaving 7,637 patients included in the analysis. The mortality rate for the overall population was 4.4% (95% confidence interval [CI] 3.9% to 4.9%). The mortality rate for patients with qSOFA score greater than or equal to 2 was 14.2% (95% CI 12.2% to 16.2%), with a sensitivity of 52% (95% CI 46% to 57%) and specificity of 86% (95% CI 85% to 87%) to predict mortality. The original systemic inflammatory response syndrome–based 1992 consensus sepsis definition had a 6.8% (95% CI 6.0% to 7.7%) mortality rate, sensitivity of 83% (95% CI 79% to 87%), and specificity of 50% (95% CI 49% to 51%). The SEP-3 septic shock mortality was 23% (95% CI 16% to 30%), with a sensitivity of 12% (95% CI 11% to 13%) and specificity of 98.4% (95% CI 98.1% to 98.7%). The original 1992 septic shock definition had a 22% (95% CI 17% to 27%) mortality rate, sensitivity of 23% (95% CI 18% to 28%), and specificity of 96.6% (95% CI 96.2% to 97.0%). Conclusion Both the new SEP-3 and original sepsis definitions stratify ED patients at risk for mortality, albeit with differing performances. In terms of mortality prediction, the SEP-3 definitions had improved specificity, but at the cost of sensitivity. Use of either approach requires a clearly intended target: more sensitivity versus specificity.

Objectives The goal of this study was to examine 2006 to 2010 emergency department (ED) admission rates, hospital procedures, lengths of stay, and costs for acute heart failure (AHF). Background Patients with AHF are often admitted and are associated with high readmissions and cost. Methods We utilized Nationwide Emergency Department Sample AHF data from 2006 to 2010 to describe admission proportion, hospital length of stay (LOS), and ED charges as a surrogate for resource utilization. Results were compared across U.S. regions, patient insurance status, and hospital characteristics. Results There were 958,167 mean yearly ED visits for AHF in the United States. Fifty-one percent of the patients were female, and the median age was 75.1 years (interquartile range [IQR]: 62.5 to 83.7 years). Overall, 83.7% (95% confidence interval: 83.1% to 84.2%) were admitted; the median LOS was 3.4 days (IQR: 1.9 to 5.8 days). Comparing 2006 with 2010, there was a small decrease in median LOS (0.09 days), but the proportion admitted did not change. Odds of admission, adjusting for age, sex, hospital characteristic (academic and safety net status), and insurance (Medicare, Medicaid, private, self-pay/no charge) were highest in the Northeast. Median ED charges were $1,075 (IQR: $679 to $1,665) in 2006 and $1,558 (IQR: $1,018 to $2,335) in 2010. Patients without insurance were more likely to be discharged from the ED, but when admitted, were more likely to receive a major diagnostic or therapeutic procedure. Conclusions A very high proportion of ED patients with AHF are admitted nationally, with significant variation in disposition and procedural decisions based on region of the country and type of insurance, even after adjusting for potential confounding.

Objectives Blood culture contamination is a common and preventable problem in the emergency department (ED). In a previous single-center study, changing the process of ED blood culture collection from the traditional “clean,” nonsterile procedure to a fully sterile procedure with standardized use of sterile gloves, large-volume chlorhexidine skin antisepsis, and fenestrated sterile drapes resulted in a substantial reduction in contamination. The objective of the current study was to evaluate the effectiveness of this sterile blood culture collection process for reducing blood culture contamination in two community hospital EDs. Methods The authors implemented the sterile blood culture collection process in the ED of two hospitals, including Hospital A, which historically had a contamination rate of approximately 5%, and Hospital B, with a 2.5% historical contamination rate. With an interrupted times-series design and segmented regression analysis to adjust for secular trends and autocorrelation, the monthly percentages of cultures contaminated at each hospital during an intervention period (sterile technique) were compared to a 10-month baseline period immediately preceding implementation (clean technique). At Hospital A, the full sterile blood culture collection process was used throughout the 16-month intervention period. At Hospital B, user feedback indicated poor adherence to the process due to difficulty implementing the fenestrated drape component; therefore, the process was simplified to the modified sterile collection process, in which the fenestrated drape component was dropped and sterile gloves and large-volume skin antisepsis were emphasized. Hence, at Hospital B, two intervention periods were compared to the baseline period: the 8-month intervention period 1 (full sterile process) and the subsequent 8-month intervention period 2 (modified sterile process). Results At Hospital A, during the baseline period, 165 of 3,417 (4.83%) cultures were contaminated, while 142 of 5,238 (2.71%) were contaminated during the intervention period (p

Background FebriDx is a 10-minute disposable point-of-care test designed to identify clinically significant systemic host immune responses and aid in the differentiation of viral and bacterial respiratory infection by simultaneously detecting C-reactive protein (CRP) and myxovirus resistance protein A (MxA) from a fingerstick blood sample. Methods A prospective, multicenter, cross-sectional study of primarily adults with acute upper respiratory tract infections (URIs), with and without a confirmed fever at the time of enrollment, was performed to evaluate the diagnostic accuracy of FebriDx to identify clinically significant bacterial infection with host response and acute pathogenic viral infection. URI was defined as rhinosinusitis, pharyngitis, nonspecific URI, and bronchitis and the reference method consisted of an algorithm that included throat bacterial cell culture, respiratory PCR panels for viral and atypical pathogens, procalcitonin, white blood cell count, and bandemia. The algorithm also utilized the Centor criteria and allowed for physician over-ride. Results Among 220 patients enrolled, 100% reported fever ≥100.5 within the last 72 hours while 55% (121/220) had a confirmed fever at the time of enrollment. Of the total enrolled patients, 15% (34/220) were classified as bacterial, 56% (124/220) were classified as viral, and 28% (62/220) negative by the reference standard. Sample Size (n) Confirmation of Fever Diagnosis Sensitivit % and [95% CI] Specificity % and [95% CI] Positive Predictive Value (PPV)% and [95% CI] Negative Predictive Value (NPV)% and [95% CI] 220 Reported within last3 days Bacterial 85 (29/34) [69-95] 93 (183/196) [89-96] 69 (29/42 ) [56-79] 97 (183/188) [94-99] Viral 90 (111/124) [83-94] 76 (73/96) [66-84] 83 (111/134) [77-87] 85 (73/86) [77-90] 121 Exhibited on enrollment Bacterial 95 (19/20) [77-100] 94 (95/101) [88-98] 76 (19/25) [59-87] 99 95/96) [93-100] Viral 90 (72/80) [81-96] 78 (32/41) [62-89] 89 (72/81) [82-93] 80 (32/40) [67-89] Conclusion When comparing clinical accuracy of diagnostic tests, performance values should be determined in febrile patients. FebriDx’s 97–99% NPV may help to identify clinically significant bacterial URI’s and supports outpatient antibiotic decisions. Disclosures R. Sambursky, Rapid Pathogen Screening, Inc.: Board Member, Employee and Shareholder, Salary.

Background Few studies have quantified the risk of community-acquired pneumonia (CAP) among adults with co-morbidities. Combining data from the population-based, prospective Etiology of Pneumonia in the Community study (EPIC) and the nationwide health-related Behavioral Risk Factor Surveillance System (BRFSS) telephone-survey, we estimated the annual risk of hospitalization for CAP among adults with co-morbidities. Methods We identified adults hospitalized with radiographic and clinical CAP at hospitals in Chicago, IL and Nashville, TN from July 2010 to June 2012. Using 2011 BRFSS data, we estimated the prevalence of the population with selected co-morbidities (chronic lung disease [CLD], cardiovascular disease [CVD], chronic kidney disease [CKD], or diabetes) in the EPIC study catchment counties, as well as the population without co-morbidities. We estimated the incidence of hospitalized CAP, age-adjusted relative risk (RR) using Poisson regression, and population attributable fraction for each co-morbidity. Results Among 2,061 adult patients enrolled in EPIC, 1,428 (69%) had at least one selected co-morbidity, most commonly CLD (42%) and CVD (35%). Among the adult population in the EPIC catchment area, 17% had ≥1 selected co-morbidity. The overall incidence of hospitalized CAP was 24.8/10,000, 118.7/10,000 among adults with ≥1 co-morbidity, and 11.2/10,000 among adults without a co-morbidity. Compared with patients without co-morbidities, the incidence of hospitalization for CAP was higher among patients with CLD (aRR: 20.7 [95% confidence interval [CI]: 20.0–21.5]), CKD (aRR: 14.5 [CI: 13.8–15.1]), CVD (aRR: 14.0 [CI: 13.5–14.6]), and diabetes (aRR: 6.2 [CI: 5.9–6.4]). While CLD and CVD accounted for high proportions of the incidence of CAP hospitalizations in the study population, the contribution of the selected co-morbidities varied by age groups (figure). Conclusion There is an increased risk of hospitalization for CAP among adults with co-morbidities, particularly chronic lung and cardiovascular disease. As a large portion of CAP is attributable to these co-morbidities, targeted public health interventions, such as vaccination and risk communication, need to be reinforced among these high-risk groups. Disclosures All authors: No reported disclosures.

Survey data suggest that there is considerable international variation in the emergency department (ED) management of patients with atrial fibrillation (AF) (1–3). Hospitalization is common in the United States (2), where nearly 70% of ED visits for AF end in hospitalization (2,3); this has remained constant since 2000 (2,3). By comparison, in Canada’s most populous province

The emergency department (ED) is often where atrial fibrillation (AF) is first detected and acutely treated and affected patients dispositioned. We used the Nationwide Emergency Department Sample to estimate the percentage of visits resulting in hospitalization and investigate associations between patient and hospital characteristics with hospitalization at the national and regional levels. We conducted a cross-sectional study of adults with AF listed as the primary ED diagnosis in the 2007 to 2009 Nationwide Emergency Department Sample. We performed multivariate logistic regression analyses investigating the associations between prespecified patient and hospital characteristics with hospitalization. From 2007 to 2009, there were 1,320,123 weighted ED visits for AF, with 69% hospitalized nationally. Mean regional hospitalization proportions were: Northeast (74%), Midwest (68%), South (74%), and West (57%). The highest odds ratios for predicting hospitalization were heart failure (3.85, 95% confidence interval [CI] 3.66 to 4.02), chronic obstructive pulmonary disease (2.47, 95% CI 2.34 to 2.61), and coronary artery disease (1.65, 95% CI 1.58 to 1.73). After adjusting for age, privately insured (0.77, 95% CI 0.73 to 0.81) and self-pay (0.77 95% CI 0.66 to 0.90) patients had lower odds compared with Medicare recipients, whereas Medicaid (1.21, 95% CI 1.11 to 1.32) patients tended to have higher odds. Patients living in low-income zip codes (1.18, 95% CI 1.12 to 1.25) and patients treated at large metropolitan hospitals (1.75, 95% CI 1.59 to 1.93) had higher odds. In conclusion, our analysis showed considerable regional variation in the management of patients with AF in the ED and in associations between patient socioeconomic and hospital characteristics with ED disposition; adapting best practices from among these variations in management could reduce hospitalizations and health-care expenses.

Introduction: The purpose of this study was to test if intravenous (IV) fluids warmed to body temperature are associated with greater patient comfort than room temperature IV fluids in adult emergency department (ED) patients. Methods: This was a pilot double-blind, crossover, randomized controlled trial. Enrolled subjects sequentially received boluses of body temperature (36ºC) and room temperature (22 ºC) IV fluid, with the order of boluses randomized. Each subject’s level of discomfort was assessed prior to and after each bolus, using a 10 cm visual analog scale (Discomfort VAS), with higher scores indicating greater discomfort. We calculated the change in Discomfort VAS score associated with body temperature IV fluid (ΔVASbody) and room temperature IV fluid (ΔVASroom) by subtracting the score reported before the bolus from the score reported after that bolus. We compared changes in Discomfort VAS score with body temperature and room temperature IV fluid using the Wilcoxon matched-pairs signed-rank test. Results: Twenty-seven subjects were included. Treatment with body temperature IV fluid was associated with a significant decrease in discomfort (median ΔVASbody: -0.7 cm; interquartile range (IQR): -4.5 cm to +0.4 cm) compared to room temperature IV fluid (median ΔVASroom: +1.2 cm; interquartile range: -0.1 cm to + 3.6 cm) (P = 0.001). Conclusion: In this small trial of adult ED patients, infusing IV fluids warmed to body temperature was associated with improved comfort compared to standard, room temperature IV fluids. [West J Emerg Med. 2013;14(5):542–546.]

Objectives Pneumonia hospitalization rates are frequently reported as a measure of pneumonia disease burden in the United States. However, a detailed understanding of pneumonia burden in all health care settings, including the emergency department (ED), is essential for measuring the full effect of this disease on the population and planning and evaluating interventions to reduce pneumonia-related morbidity. The aim of this study was to quantify pneumonia-attributable ED visits in the United States among children and adults during the 3-year period July 2006 through June 2009. Methods Rates of pneumonia ED visits were calculated using the Nationwide Emergency Department Sample (NEDS), the largest source of U.S. ED data. Pneumonia ED visits were identified using International Classification of Diseases (ICD) codes within NEDS. A pneumonia ED visit was defined by a primary (first-listed) pneumonia discharge diagnosis or a secondary pneumonia diagnosis with an accompanying primary diagnosis of respiratory failure, shock, septicemia, a sign or symptom consistent with pneumonia, another acute respiratory infection, or an acute exacerbation of a chronic pulmonary disease. Population-based annual rates of pneumonia ED visits stratified by age group and geographic region from July 2006 through June 2009 were calculated. The percentages of pneumonia ED visits resulting in treat-and-release outpatient ED visits were also calculated within each age stratum. Results During the study period, 6,917,025 ED visits for pneumonia were identified, representing 2.2% of all U.S. ED visits. During the 3 study years, defined as July through June of 2006–2007, 2007–2008, and 2008–2009, pneumonia ED visit rates per 1,000 person-years were 7.4 (95% confidence interval [CI] = 7.0 to 7.8), 7.8 (95% CI = 7.3 to 8.2), and 7.6 (95% CI = 7.1 to 8.0), respectively. Annual rates were stable over the 3 years within each age group and geographic region. Overall, 39.3% of pneumonia ED visits, including 74.5% of pediatric and 28.1% of adult visits, were managed as treat-and-release outpatient visits. Conclusions Pneumonia accounts for 2.2% of ED visits in the United States and results in approximately seven to eight ED visits per 1000 persons per year. A substantial proportion of pneumonia cases diagnosed in the ED are managed in treat-and-release ED outpatient visits, highlighting that enumeration of ED visit rates provides important complementary information to hospitalization rates for the assessment of pneumonia burden. Resumen Tasa de Visitas al Servicio de Urgencias Debidas a Neumonia en Estados Unidos de Julio de 2006 a Junio de 2009 Objetivos Las tasas de hospitalizacion por neumonia frecuentemente se documentan como una medida de carga de enfermedad por neumonia en Estados Unidos (EEUU). Sin embargo, un conocimiento detallado de la carga de neumonia en todos los escenarios del sistema sanitario, incluyendo el servicio de urgencias (SU), es esencial para cuantificar el efecto global de esta enfermedad en la poblacion, y planificar y evaluar intervenciones para reducir la morbilidad relacionada con la neumonia. El objetivo de este estudio fue cuantificar las visitas al SU atribuibles a neumonia en EEUU entre los ninos y los adultos durante los tres anos del periodo comprendido entre julio de 2006 y junio de 2009. Metodologia Las tasas de visitas por neumonia al SU se calcularon mediante la Nationwide Emergency Department Sample (NEDS), la mayor fuente de datos de SU de EEUU. Las visitas por neumonia al SU se identificaron mediante los codigos de la International Classification of Diseases en la NEDS. Una visita por neumonia al SU se definio por un diagnostico principal (el primero enumerado) de neumonia al alta o un diagnostico secundario de neumonia acompanado de insuficiencia respiratoria, shock, septicemia, un signo o sintoma consistente con neumonia, infeccion respiratoria aguda o exacerbacion de una enfermedad pulmonar obstructiva cronica. Se calcularon las tasas anuales de visitas por neumonia al SU clasificadas por grupos de edad y region geografica de julio de 2006 a junio de 2009. Tambien se calcularon los porcentajes de visitas por neumonia que fueron tratadas y dadas de alta desde el propio SU en cada grupo de edad. Resultados Durante el periodo de estudio, se identificaron 6.917.025 de visitas por neumonia al SU, lo que supuso el 2,2% de todas las visitas al SU en EEUU. Durante los 3 anos del estudio, definidos como de julio a junio de 2006–2007, 2007–2008 y 2008–2009, las tasas de visitas por neumonia al SU por 1.000 personas-ano fueron 7,4 (intervalo de confianza [IC] 95% = 7,0 a 7,8), 7,8 (IC 95% = 7,3 a 8,2), y 7,6 (IC 95% = 7,1 a 8,0), respectivamente. Las tasas anuales se mantuvieron estables durante los tres anos en cada grupo de edad y region geografica. Del total, el 39,3% de las visitas por neumonia al SU, incluyendo un 74,5% de las visitas pediatricas y un 28,1% de las adultos, se trataron y dieron de alta desde el SU. Conclusiones La neumonia suma el 2,2% de las visitas al SU en EEUU y supone aproximadamente entre siete y ocho visitas al SU por cada 1000 personas y ano. Una proporcion sustancial de los casos de neumonia diagnosticados en el SU son tratados y dados de alta desde el propio SU. Destaca que el calculo de las tasas de visitas al SU proporciona una informacion complementaria importante a las tasas de ingreso para la valoracion de la carga de la neumonia.

Blood culture contamination is a common problem in the emergency department (ED) that leads to unnecessary patient morbidity and health care costs. The study objective was to develop and evaluate the effectiveness of a quality improvement (QI) intervention for reducing blood culture contamination in an ED.The authors developed a QI intervention to reduce blood culture contamination in the ED and then evaluated its effectiveness in a prospective interrupted times series study. The QI intervention involved changing the technique of blood culture specimen collection from the traditional clean procedure to a new sterile procedure, with standardized use of sterile gloves and a new materials kit containing a 2% chlorhexidine skin antisepsis device, a sterile fenestrated drape, a sterile needle, and a procedural checklist. The intervention was implemented in a university-affiliated ED and its effect on blood culture contamination evaluated by comparing the biweekly percentages of blood cultures contaminated during a 48-week baseline period (clean technique) and 48-week intervention period (sterile technique), using segmented regression analysis with adjustment for secular trends and first-order autocorrelation. The goal was to achieve and maintain a contamination rate below 3%.During the baseline period, 321 of 7,389 (4.3%) cultures were contaminated, compared to 111 of 6,590 (1.7%) during the intervention period (p0.001). In the segmented regression model, the intervention was associated with an immediate 2.9% (95% confidence interval [CI] = 2.2% to 3.2%) absolute reduction in contamination. The contamination rate was maintained below 3% during each biweekly interval throughout the intervention period.A QI assessment of ED blood culture contamination led to development of a targeted intervention to convert the process of blood culture collection from a clean to a fully sterile procedure. Implementation of this intervention led to an immediate and sustained reduction of contamination in an ED with a high baseline contamination rate.

Background— More than 25% of Medicare patients hospitalized for heart failure are readmitted within 30 days. The contributions of numeracy and health literacy to recidivism for patients with acute heart failure (AHF) are not known. Methods and Results— A cohort of patients with acute heart failure who presented to 4 emergency departments between January 2008 and September 2011. Research assistants administered subjective measures of numeracy and health literacy; 30-day follow-up was performed by phone interview. Recidivism was defined as any unplanned return to the emergency department or hospital within 30 days of the index emergency department visit for AHF. Multivariable logistic regression adjusting for patient age, sex, race, insurance status, hospital site, days eligible for recidivism, chronic kidney disease, abnormal hemoglobin, and low ejection fraction evaluated the relation between numeracy and health literacy with 30-day recidivism. Of the 709 patients included in the analysis, 390 (55%) had low numeracy skills and 258 (37%) had low literacy skills. Low numeracy was associated with increased odds of recidivism within 30 days (adjusted odds ratio, 1.41; 95% confidence interval, 1.00–1.98; P =0.048). For low health literacy, adjusted odds ratio of recidivism was 1.17 (95% confidence interval, 0.83–1.65; P =0.37). Conclusions— Low numeracy was associated with greater odds of 30-day recidivism. Further investigation is warranted to determine whether addressing numeracy and health literacy may reduce 30-day recidivism for patients with acute heart failure.

Purpose To determine the cost-effectiveness of implementing a point-of-care (POC) Lactate Program in the emergency department (ED) for patients with suspected sepsis to identify patients who can benefit from early resuscitation. Materials and methods We constructed a cost-effectiveness model to examine an ED with 30 000 patients annually. We evaluated a POC lactate program screening patients with suspected sepsis for an elevated lactate ≥4 mmol/L. Those with elevated lactate levels are resuscitated and their lactate clearance is evaluated by serial POC lactate measurements. The POC Lactate Program was compared with a Usual Care Strategy in which all patients with sepsis and an elevated lactate are admitted to the intensive care unit. Costs were estimated from the 2014 Medicare Inpatient and National Physician Fee schedules, and hospital and industry estimates. Results In the base-case, the POC Lactate Program cost $39.53/patient whereas the Usual Care Strategy cost $33.20/patient. The screened patients in the POC arm resulted in 1.07 quality-adjusted life years for an incremental cost-effectiveness ratio of $31 590 per quality-adjusted life year gained, well below accepted willingness-to-pay-thresholds. Conclusions Implementing a POC Lactate Program for screening ED patients with suspected sepsis is a cost-effective intervention to identify patients responsive to early resuscitation.