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Background and Objectives: Intubation for acute stroke is common in the United States, with few established guidelines., Methods: This is a retrospective observational study of acute stroke admissions from 2011 to 2018 among fee-for-service Medicare beneficiaries aged 65-100 years. Patient demographics and chronic conditions as well as hospital characteristics were identified. We identified patient intubation, stroke subtype (ischemic vs intracerebral hemorrhage), and thrombectomy. Factors associated with intubation were identified by a linear probability model with intubation as the outcome and patient characteristics, stroke subtype, and thrombectomy as predictors, adjusting for within-hospital correlation. We compared hospital characteristics between adjusted intubation rate quartiles. We specified a linear probability model with 30-day mortality as the patient-level outcome and hospital intubation rate quartile as the categorical predictor, again adjusting for patient characteristics. We specified an analogous model for quartiles of hospital referral regions., Results: There were 800,467 stroke hospitalizations at 3,581 hospitals. Among 2,588 hospitals with 25 or more stroke hospitalizations, the median intubation rate was 4.8%, while a quarter had intubation rates below 2.4% and 10% had rates above 12.5%. Ischemic strokes had a 21% lower adjusted intubation risk than intracerebral hemorrhages (risk difference [RD] -21.1%, 95% CI -21.3% to -20.9%; p < 0.001), whereas thrombectomy was associated with a 19.2% higher adjusted risk (95% CI RD 18.8%-19.6%; p < 0.001). Women and older patients had lower intubation rates. Large, urban hospitals and academic medical centers were overrepresented in the top quartile of hospital adjusted intubation rates. Even after adjusting for available characteristics, intubated patients had a 44% higher mortality risk than non-intubated patients ( p < 0.001). Hospitals in the highest intubation quartile had higher adjusted 30-day mortality (19.3%) than hospitals in the lowest quartile (16.7%), a finding that was similar when restricting to major teaching hospitals (22.3% vs 18.1% in the 4th vs 1st quartiles, respectively). There was no association between market quartile of intubation and patient 30-day mortality., Discussion: Intubation for acute stroke varied by patient and hospital characteristics. Hospitals with higher adjusted rates of intubation had higher patient-level 30-day mortality, but much of the difference may be due to unmeasured patient severity given that no such association was observed for health care markets.

Background and Objectives: Current understanding based on older studies is that pc-BPPV is far more common than hc-BPPV. Such studies are limited by small sample sizes, and often the supine roll test for hc-BPPV is not performed. To better estimate the prevalence of hc-BPPV, we studied a large cross-section of patients with VOG-diagnosed BPPV., Methods: Using a cross-sectional study of patients with BPPV, we investigated patients referred to NeuroEquilibrium specialty clinics throughout India between January 1, 2021, and December 31, 2021. All patients were evaluated with video oculography (VOG) during positional tests, and all diagnoses were confirmed by a neurotologist and neurologist., Results: Of 3,975 patients with VOG-confirmed and specialist-diagnosed BPPV (median age, 51 years; 56 . 6% women), pc-BPPV accounted for 1,901 (47 . 8%), hc-BPPV was seen in 1,842 (46 . 3%), and anterior canal BPPV was found in 28 (0 . 7%) patients., Discussion: This study found that hc-BPPV is far more common than previously reported. It is important to perform the supine roll test in addition to the Dix-Hallpike in all patients suspected with BPPV. Better training to diagnose patients with BPPV and to accurately recognize the nystagmus pattern of hc-BPPV should be a priority., Competing Interests: The authors report no relevant disclosures. Full disclosure form information provided by the authors is available with the full text of this article at Neurology.org/cp., (© 2023 American Academy of Neurology.)

Background and Objectives: The IDSA has published guidelines for the treatment of urinary tract infections, recommending limiting treatment to symptomatic patients and pregnant females. Our objective is to elucidate current practice patterns among emergency physicians (EPs) in treating positive urine cultures in various clinical situations., Methods: This study employed a cross-sectional design utilizing a questionnaire addressing nine common scenarios encountered by EPs in the follow-up of a positive urine culture. The questionnaire was conducted using RedCap and distributed via email to current and former physicians and residents across our hospital network. Demographic information included years of training and practice setting. For each of nine clinical scenarios, Physicians were asked if they would treat with antibiotics. Results were then analyzed by tabulating percentage of responses and 95% confidence intervals., Results: Of 120 respondents, 40.8% worked in academic centers with emergency medicine residencies, 37.5% in large community hospitals, and 20.67% in small community hospitals. Responses came from 14 residents, 33 attendings < 5 years out of training, 23 attendings 5-9 years out of training, 37 attendings 10-20 years out of training, and 13 attendings > 20 beyond training. Asymptomatic young women were treated by 34.2% (95% CI 25.91-43.46%) while asymptomatic elderly women were treated by 50% (95% CI 40.79-59.21%) of EPs. All EPs (95% CI 96.13-100%) chose to treat a symptomatic male and 99.2% (95% CI 94.77-99.96%) chose to treat an asymptomatic pregnant female. Elderly females after a fall were treated by 63.3% (95% CI 54-71.8%) of EPs while elderly males with confusion and a fall were treated by 96.7% (95% CI 91.18-98.93%). Asymptomatic males with a chronic Foley catheter were treated by 28.2% (95% CI 20.67-37.4%) of EPs and 46.7% (95%CI 37.59-55.97%) would treat an asymptomatic middle-aged female with diabetes. Finally, 92.5% (95% CI 85.85-96.3%) of EPs chose to treat an asymptomatic kidney transplant patient., Conclusion: EPs in varied training stages and practice settings have significant practice variation in the treatment of positive urine cultures, particularly in the geriatric population, often prescribing antibiotics to patients where clear, specific and data-driven IDSA guidelines suggest treatment is unnecessary and potentially harmful., (© 2022. The Author(s), under exclusive licence to Società Italiana di Medicina Interna (SIMI).)

Root cause analysis is often suggested as a means of conducting quality assurance, but few physicians are familiar with the actual process. We describe a detailed approach to conducting root cause analysis, with an illustrative case to explain the technique. By studying how root cause analysis is applied to the case of a missed epidural abscess, the reader will see how the process reveals systems improvements that reduce the risk that such a miss will happen again. Following this process will be helpful in using root cause analysis to fix not just individuals' issues but also but systemwide quality assurance issues to improve patient care., (Copyright © 2020 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Background and Purpose: Total spine MRIs are requested by the emergency department when focused imaging can not be ordered on the basis of history or clinical findings. However, their efficacy is not known. We assessed the following: 1) major radiologic and clinical outcomes of total spine MR imaging performed by the emergency department, and 2) whether the presence of a high-risk clinical profile and/or neurologic findings impacts the clinical outcomes., Materials and Methods: Total spine MRIs requested by the emergency department during a 28-month period were evaluated for major radiologic (cord compression, cauda equina compression, and other significant findings) and major clinical outcomes (hospital admission during the visit followed by an operation, radiation therapy, or intravenous antibiotics or steroids). Associations between a high-risk clinical profile (cancer, infection, coagulopathy) and/or the presence of neurologic findings and outcomes were assessed., Results: After we excluded trauma or nondiagnostic studies, 321/2047 (15.7%) MRIs ordered during study period were total spine MR imaging; 117/321 (36.4%) had major radiologic and 60/321 (18.6%) had major clinical outcomes (34/60 in <24 hours); and 58/117(49.6%) with major radiologic outcome were treated compared with 2/205 (1.0%) without (OR = 99, P  < .001). The presence of both a high-risk clinical profile and neurologic findings concurrently in a patient (142/321) increased the likelihood of major clinical outcomes during the same visit (OR = 3.1, P  < .001) and in <24-hours (OR = 2.6, P  = .01) compared with those with either a high-risk clinical profile or neurologic findings alone (179/321)., Conclusions: Total spine MR imaging ordered by our emergency department has a high radiologic and significant clinical yield. When a high-risk clinical profile and neurologic findings are both present in a patient, they should be prioritized for emergent total spine MR imaging, given the increased likelihood of clinical impact., (© 2020 by American Journal of Neuroradiology.)

Background: Many patients with acute intracerebral hemorrhages (ICHs) undergo endotracheal intubation with subsequent mechanical ventilation (MV) for "airway protection" with the intent to prevent aspiration, pneumonias, and its related mortality. Conversely, these procedures may independently promote pneumonia, laryngeal trauma, dysphagia, and adversely affect patient outcomes. The net benefit of intubation and MV in this patient cohort has not been systematically investigated., Methods: We conducted a large single-center observational cohort study to examine the independent association between endotracheal intubation and MV, hospital-acquired pneumonia (HAP), and in-hospital mortality (HM) in patients with ICH. All consecutive patients admitted with a primary diagnosis of a spontaneous ICH to a tertiary care hospital in Boston, Massachusetts, from June 2000 through January 2014, who were ≥18 years of age and hospitalized for ≥2 days were eligible for inclusion. Patients with pneumonia on admission, or those having brain or lung neoplasms were excluded. Our exposure of interest was endotracheal intubation and MV during hospitalization; our primary outcomes were incidence of HAP and HM, ascertained using International Classification of Diseases-9 and administrative discharge disposition codes, respectively, in patients who underwent endotracheal intubation and MV versus those who did not. Multivariable logistic regression was used to control for confounders., Results: Of the 2,386 hospital admissions screened, 1,384 patients fulfilled study criteria and were included in the final analysis. A total of 507 (36.6%) patients were intubated. Overall 133 (26.23%) patients in the intubated group developed HAP versus 41 (4.67%) patients in the non-intubated group (p < 0.0001); 195 (38.5%) intubated patients died during hospitalization compared to 48 (5.5%) non-intubated patients (p < 0.0001). After confounder adjustments, OR for HAP and HM, were 4.23 (95% CI 2.48-7.22; p < 0.0001) and 4.32 (95% CI 2.5-7.49; p < 0.0001) with c-statistics of 0.79 and 0.89, in the intubated versus non-intubated patients, respectively., Conclusion: In this large hospital-based cohort of patients presenting with an acute spontaneous ICH, endotracheal intubation and MV were associated with increased odds of HAP and HM. These findings urge further examination of the practice of intubation in prospective studies., (© 2018 S. Karger AG, Basel.)

Background: Chart review has been the mainstay of medical quality assurance practices since its introduction more than a century ago. The validity of chart review, however, has been vitiated by a lack of methodological rigor., Objectives: By measuring the degree of interrater agreement among a 13-member review board of emergency physicians, we sought to validate the reliability of a chart review-based quality assurance process using computerized screening based on explicit case parameters., Methods: All patients presenting to an urban, tertiary care academic medical center emergency department (annual volume of 57,000 patients) between November 2012 and November 2013 were screened electronically. Cases were programmatically flagged for review according to explicit criteria: return within 72hours, procedural evaluation, floor-to-ICU transfer within 24hours of admission, death within 24hours of admission, physician complaints, and patient complaints. Each case was reviewed independently by a 13-member emergency department quality assurance committee all of whom were board certified in emergency medicine and trained in the use of the tool. None of the reviewers were involved in the care of the specific patients reviewed by them. Reviewers used a previously validated 8-point Likert scale to rate the (1) coordination of patient care, (2) presence and severity of adverse events, (3) degree of medical error, and (4) quality of medical judgment. Agreement among reviewers was assessed with the intraclass correlation coefficient (ICC) for each parameter., Results: Agreement and the degree of significance for each parameter were as follows: coordination of patient care (ICC=0.67; P<.001), presence and severity of adverse events (ICC=0.52; P=.001), degree of medical error (ICC=0.72; P<.001), and quality of medical judgment (ICC=0.67; P<.001)., Conclusion: Agreement in the chart review process can be achieved among physician-reviewers. The degree of agreement attainable is comparable to or superior to that of similar studies reported to date. These results highlight the potential for the use of computerized screening, explicit criteria, and training of expert reviewers to improve the reliability and validity of chart review-based quality assurance., (Copyright © 2016. Published by Elsevier Inc.)

Background: Aneurysmal subarachnoid hemorrhage (SAH) is the most devastating form of hemorrhagic stroke. Primary predictors of mortality are based on initial clinical presentation. Initial serum lactic acid levels have been shown to predict mortality and disease severity. Initial serum lactate may be an objective predictor or mortality., Methods: Retrospective review of aneurysmal SAH in a large academic center over a 42-month period. Data collected included demographics, clinical data, serum, and clinical outcomes data. Epidemiologic data were collected at baseline, and patients were followed up through their inpatient stay. We compared data in the group of patients who were deceased (group A) vs survivors (group B)., Results: There were a total of 249 patients. Mortality was 21.5%. Mean age was the same for both groups: 57 years (group A) and 55 years (group B). Mean admission serum lactate level was 3.5 ± 2.5 (group A) and 2.2 ± 1.6 (group B; P <. 0001). The range was 0.01 to 14.7. Multivariable analysis controlling for Hunt and Hess grades showed lactic acid levels to be an independent predictor of mortality with a P value of .0018., Conclusions: In aneurysmal SAH, elevated serum lactate levels on admission may have a predictive role for mortality and represent a marker of disease severity. Currently, lactic acid levels are not ordered on all patients with SAH but perhaps should be part of the routine initial blood work and may serve as an additional prognostic marker., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: The incidence of errors and adverse events in emergency medicine is poorly characterized., Objective: The objective was to systematically determine the rates and types of errors and adverse events in an academic, tertiary care emergency department (ED)., Methods: Prospective data were collected on all patients presenting to a tertiary-care academic medical center ED with an annual census of 55,000 patients between January 2009 and November 2012. Cases of patients meeting predetermined criteria were systematically identified by an electronic medical record system. Criteria for review included patients who (1) returned to the ED within 72 hours and were admitted on their second visit, (2) were admitted from the ED to the floor and then transferred to the intensive care unit (ICU) within 24 hours, (3) expired within 24 hours of ED arrival, (4) required airway management, or (5) were referred to the QA committee as the result of complaints. Cases were randomly assigned to individual physicians not involved with the care. All cases were reviewed using a structured electronic tool that assessed the occurrence of error and adverse events. Institutional review board jurisdiction was waived by the Beth Israel Deaconess Medical Center IRB., Results: During the study period, 152,214 cases were screened and 2131 cases (1.4%) met prespecified criteria for review. The incidence of error in these cases was 9.5% (95% confidence interval [CI], 8.3%-10.8%), representing an overall incidence of 0.13% among all ED patients. In cases that involved error, 50.5% occurred among patients who returned to the ED within 72 hours; 17.3% occurred among floor-to-ICU transfers; 5.4% occurred among mortality cases; 2.0% occurred among airway cases; and 24.8% occurred among cases referred as the result of complaints. The incidence of adverse events in the reviewed cohort was 8.3% (CI, 7.2%-9.6%), representing an overall incidence of 0.11% among all ED patients. In cases that involved adverse events, 48.6% occurred among patients who returned to the ED within 72 hours; 16.4% occurred among floor-to-ICU transfers; 9.0% occurred among mortality cases; 1.1% occurred among airway cases; and 24.9% occurred among cases referred as the result of complaints., Conclusion: Although the overall incidence of error and adverse events in EDs is low, the likelihood of such events is markedly increased among patients who return to the ED within 72 hours, among patients who require floor-to-ICU transfer within 24 hours, and among those whose cases come to attention as the result of complaints., (Copyright © 2015. Published by Elsevier Inc.)

Transient ischemic attack represents a medical emergency and warns of an impending stroke in roughly one-third of patients who experience it. The risk of stroke is highest in the first 48 hours following a transient ischemic attack, and the initial evaluation in the emergency department is the best opportunity to identify those at highest risk of stroke recurrence. The focus should be on differentiating transient ischemic attack from stroke and common mimics. Accurate diagnosis is achieved by obtaining a history of abrupt onset of negative symptoms of ischemic origin fitting a vascular territory, accompanied by a normal examination and the absence of neuroimaging evidence of infarction. Transient ischemic attacks rarely last longer than 1 hour, and the classic 24-hour time-based definition is no longer relevant. Once the diagnosis has been made, clinical risk criteria may augment imaging findings to identify patients at highest and lowest risk of early recurrence. Early etiologic evaluation, including neurovascular and cardiac investigations, allows for catered secondary prevention strategies. Specialized transient ischemic attack clinics and emergency department observation units are safe and efficient alternatives to hospital admission for many transient ischemic attack patients.

Acute headache is a common chief complaint in the Emergency Department (ED), accounting for up to 4% of all ED visits. Migraine is a common, chronic, at times incapacitating disorder, characterized by attacks of severe headache, autonomic nervous system dysfunction, and in some patients, an aura characterized by various neurologic symptoms. It is the most common cause of severe, recurring headaches. Although most headaches in the ED are benign, one should be vigilant in searching for "red flags", which may represent dangerous conditions. In addition to properly identifying important secondary causes of headache, the goal of acute therapy is to provide rapid, complete, and sustained relief of pain and associated symptoms without generating significant adverse effects. In many patients, migraine responds well to simple treatment at the time of an attack. In patients with substantial disability, it is appropriate to prescribe a triptan early in the course of treatment, in keeping with a stratified approach to care.

Background: Cerebral venous sinus thrombosis (CVST) is a rare but serious cause of neurologic impairment. Due to its relative rarity, there is limited research that describes the incidence and clinical features of CVST in the emergency department (ED)., Objectives: To describe the demographic, clinical, and historical characteristics of patients with CVST who were initially seen in the ED., Methods: This is a retrospective analysis of all patients presenting to three urban, tertiary care hospitals between January 2001 and December 2005 who were diagnosed with CVST. Patients were excluded if they were transferred from other hospitals, or admitted directly to the hospital without evaluation in the ED. We use one representative case to describe the presentation, evaluation, and treatment of CVST., Results: Seventeen patients met the inclusion criteria. Patients had a mean age of 42 years. Presenting complaints included headache (70%), focal neurologic complaints (numbness, weakness, aphasia) (29%), seizure (24%), and head injury (12%). Ninety-four percent of patients had a focal neurologic finding in the ED. A likely contributing cause of thrombosis was identified in all but one patient. More than half of the patients had been evaluated in the ED in the previous 60 days. Two patients died, both as a result of their thrombosis and resulting cerebral infarctions and edema. Of the patients who survived, 80% had a good functional outcome., Conclusions: CVST is rare, but it can have significant associated morbidity and mortality. Whereas the clinical outcome and functional outcomes of treated patients can vary, prompt recognition of the disease is important., (Copyright (c) 2010 Elsevier Inc. All rights reserved.)

Background: There is controversy regarding whether, and how frequently, other cranial nerve deficits accompany Bell's palsy. We sought to determine prospectively the presence of signs indicating an associated cranial neuropathy in patients with Bell's palsy., Methods: All subjects presenting to an emergency department with Bell's palsy over a 2-year period were evaluated. The study included 51 consecutive patients. One patient with Bell's palsy was not examined by a neurologist at the time of presentation and was excluded. The main outcome measure was presence of other cranial nerve deficits., Results: We identified 4 patients with additional cranial neuropathies (contralateral trigeminal [n=1], glossopharyngeal [n=2], and hypoglossal [n=1]). We also identified 13 patients with ipsilateral facial sensory loss, suggesting an ipsilateral trigeminal neuropathy; 3 patients with a contralateral facial palsy; and 3 patients with hearing impairment., Conclusion: This prospective study indicates that a small percentage (approximately 8%) of patients with otherwise typical Bell's palsy may harbor additional cranial neuropathies.

The purpose of our study is to demonstrate the value of CT in the emergency department (ED) for patients with non-traumatic abdominal pain. Between August 1998 and April 1999, 536 consecutive patients with non-traumatic abdominal pain were entered into our study. Using a computer order entry system, physicians were asked to identify: (a) their most likely diagnosis; (b) their level of certainty in their diagnosis; (c) if they thought CT would be normal or abnormal; (d) their treatment plan (prior to knowledge of the CT results); and (e) their role in deciding to order CT. This information was correlated with each patient's post-CT diagnosis and subsequent management. Pre- and post-CT diagnoses were concordant in 200 of 536 (37%) patients. The physicians' certainty in the accuracy of their pre-CT diagnosis was less than high in 88% of patients. Prior to CT, the management plan included hospital admission for 402 patients. Following CT, only 312 patients were actually admitted; thus, the net impact of performing CT was to obviate the need for hospital admission in 90 of 536 (17%) of patients with abdominal pain. Prior to CT, 67 of 536 (13%) of all patients would have undergone immediate surgery; however, following CT only 25 (5%) actually required immediate surgery. Among patients with the four most common pre-CT diagnoses (appendicitis, abscess, diverticulitis, and urinary tract stones) CT had the greatest impact on hospital admission and surgical management for patients with suspected appendicitis. For patients with suspected appendicitis, CT reduced the hospital admission rate in 28% (26 of 91) of patients and changed the surgical management in 40% (39 of 91) of patients. Our study demonstrates the advantage of performing abdominal CT in the ED for patients with non-traumatic abdominal pain.