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Objective Cardiogenic shock is a critical emergency for which ventricular support devices (VSDs), such as the Impella (AbioMed Inc, Danvers, MA), are placed. Many referring facilities cannot provide cardiac intensive care. This requires a regional approach to the care of patients with VSD. Critical care transport to the regional center is needed and requires specialty trained personnel. As the need for specialty trained personnel increases, appropriate utilization of the personnel needs to be considered. This study illustrates the effective transport and successful management of Impella patients in the transport environment by a downsized specialty trained critical care team. Methods A retrospective chart review explored critical care transports of patients with Impella devices over a 73-month period. Our goal was to show that with training, protocols, and guidelines a downsized critical care team can effectively transport these high-risk, low-frequency patients. Results Forty-seven VSD transports occurred within 13,823 transports during the study period. Twenty-seven included an Impella device only. Thirteen were completed by a downsized team. One hundred percent of the transport resulted in the patient having perfusing rhythms and blood pressures at the receiving facility. Conclusion VSDs can be successfully transported between hospitals with small specialty trained critical care transport teams using air or ground assets.

Study objective This study aimed to develop and validate 2 machine learning models that use historical and current-visit patient data from electronic health records to predict the probability of patient admission to either an inpatient unit or ICU at each hour (up to 24 hours) of an emergency department (ED) encounter. The secondary goal was to provide a framework for the operational implementation of these machine learning models. Methods Data were curated from 468,167 adult patient encounters in 3 EDs (1 academic and 2 community-based EDs) of a large academic health system from August 1, 2015, to October 31, 2018. The models were validated using encounter data from January 1, 2019, to December 31, 2019. An operational user dashboard was developed, and the models were run on real-time encounter data. Results For the intermediate admission model, the area under the receiver operating characteristic curve was 0.873 and the area under the precision-recall curve was 0.636. For the ICU admission model, the area under the receiver operating characteristic curve was 0.951 and the area under the precision-recall curve was 0.461. The models had similar performance in both the academic- and community-based settings as well as across the 2019 and real-time encounter data. Conclusion Machine learning models were developed to accurately make predictions regarding the probability of inpatient or ICU admission throughout the entire duration of a patient’s encounter in ED and not just at the time of triage. These models remained accurate for a patient cohort beyond the time period of the initial training data and were integrated to run on live electronic health record data, with similar performance.

Author(s): Schmutz, Kaitlyn; McGaig, Gaea; Theiling, B. Jason | Abstract: Case Presentation: Approximately 94% of patients with Hirschsprung’s disease (HD) are diagnosed before the age of five. In our case, a young adult with years of constipation presented to the emergency department with significant abdominal distention. He was ultimately diagnosed with HD, which was identified using computed tomography (CT).Discussion: In HD, we find defects in gastric motility due to improper gut colonization. Without childhood recognition, HD often leads to chronic constipation and failure to thrive in adulthood. CT is a key step in identifying this rare adult diagnosis that should be considered in all patients with a history of chronic constipation.

The modified Sgarbossa criteria were proposed in a derivation study to be superior to the original criteria for diagnosing acute coronary occlusion (ACO) in left bundle branch block (LBBB). The new rule replaces the third criterion (5 mm of excessively discordant ST elevation [STE]) with a proportion (at least 1 mm STE and STE/S wave ≤-0.25). We sought to validate the modified criteria.This retrospective case-control study was performed by chart review in 2 tertiary care center emergency departments (EDs) and 1 regional referral center. A billing database was used at 1 site to identify all ED patients with LBBB and ischemic symptoms between May 2009 and June 2012. In addition, all 3 sites identified LBBB ACO patients who underwent emergent catheterization. We measured QRS amplitude and J-point deviation in all leads, blinded to outcomes. Acute coronary occlusion was determined by angiographic findings and cardiac biomarker levels, which were collected blinded to electrocardiograms. Diagnostic statistics of each rule were calculated and compared using McNemar's test.Our consecutive cohort search identified 258 patients: 9 had ACO, and 249 were controls. Among the 3 sites, an additional 36 cases of ACO were identified, for a total of 45 ACO cases and 249 controls. The modified criteria were significantly more sensitive than the original weighted criteria (80% vs 49%, P.001) and unweighted criteria (80% vs 56%, P.001). Specificity of the modified criteria was not statistically different from the original weighted criteria (99% vs 100%, P = .5) but was significantly greater than the original unweighted criteria (99% vs 94%, P = .004).The modified Sgarbossa criteria were superior to the original criteria for identifying ACO in LBBB.

Author(s): Hocker, Michael B.; Gerardo, Charles J.; Theiling, B. Jason; Villani, John; Donohoe, Rebecca; Sandesara, Hirsh; Limkakeng, Alexander T. | Abstract: Introduction: Triage systems play a vital role in emergency department (ED) operations and can determine how well a given ED serves its local population. We sought to describe ED utilization patterns for different triage levels using the National Hospital Ambulatory Medical Care Survey (NHAMCS) database. Methods: We conducted a multi-year secondary analysis of the NHAMCS database from 2009-2011. National visit estimates were made using standard methods in Analytics Software and Solutions (SAS, Cary, NC). We compared patients in the mid-urgency range in regard to ED lengths of stay, hospital admission rates, and numbers of tests and procedures in comparison to lower or higher acuity levels. Results: We analyzed 100,962 emergency visits (representing 402,211,907 emergency visits nationwide). In 2011, patients classified as triage levels 1-3 had a higher number of diagnoses (5.5, 5.6 and 4.2, respectively) when compared to those classified as levels 4 and 5 (1.61 and 1.25). This group also underwent a higher number of procedures (1.0, 0.8 and 0.7, versus 0.4 and 0.4), had a higher ED length of stay (220, 280 and 237, vs. 157 and 135), and admission rates (32.2%, 32.3% and 15.5%, vs. 3.1% and 3.6%). Conclusion: Patients classified as mid-level (3) triage urgency require more resources and have higher indicators of acuity as those in triage levels 4 and 5. These patients’ indicators are more similar to those classified as triage levels 1 and 2.