Emergency Medicine Commons^™

From Evaluation To Elevation: Standardized Letter Of Evaluation Domains Tied To Future Emergency Medicine Chief Residents, Abagayle Bierowski, Zaid Tayyem, Casey Morrone, Carlos Rodriguez, Chaiya Laoteppitaks, Peter Tomaselli, Dimitrios Papanagnou, Xiao Chi Zhang

Department of Emergency Medicine Faculty Papers

INTRODUCTION: The Standardized Letter of Evaluation (SLOE) is a core component of emergency medicine (EM) residency applications, designed to assess clinical performance, professionalism, and leadership potential. While its utility in selecting residency candidates is well established, its association with future leadership roles, such as chief resident, remains unclear. Identifying early indicators of leadership potential could inform both recruitment and resident development efforts. In this study we aimed to evaluate whether medical students' SLOEs are associated with subsequent selection as chief residents, offering insight into the SLOE's potential to forecast future leadership within EM.

METHODS: We conducted a retrospective review of …

Mbiochemical Identification And Clinical Description Of Edetomidine Exposure In People Who Use Fentanyl In Philadelphia, Pa, Phil Durney, Jennifer L. Kahoud, Tareva Warrick-Stone, Maeve Montesi, Meg Carter, Sabrina Butt, Alberto Martinez Mencia, Louisa Omoregie, Monali Shah, Mariah Bloomfield, Nicholas Tomasko, Rebecca C. Jaffe, Allison Herens, Warren R. Korn, Karen Alexander, Douglas F. Stickle, Dennis Goodstein, Lara Weinstein, Kory S. London

Department of Emergency Medicine Faculty Papers

Medetomidine, a veterinary α2-adrenergic agonist, has recently emerged as an adulterant in the non-medical opioid supply, yet human exposure has remained poorly characterized. We conducted a pragmatic retrospective cohort analysis utilizing chart review and liquid chromatography-tandem mass spectrometry (LC-MS/MS) toxicology testing on available urine samples from patients presenting to two hospitals in Philadelphia, PA, who fit two clinical phenotypes, intoxication or withdrawal. Samples also underwent glucuronidase pre-treatment to assess impact on the yield of medetomidine and xylazine metabolite detection. Testing identified universal exposure to medetomidine (58/58 samples) via the 3-hydroxy-medetomidine (3-OH-M) metabolite, post glucuronidase treatment and variable xylazine exposure (40/58 …

Savings Associated With Bundled Payments For Outpatient Spine Surgery Among Medicare Beneficiaries, Austin S. Kilaru, Grace Y. Ng, Erkuan Wang, Erin Huang, Aidan P. Crowley, Jingsan Zhu, Joshua M. Liao, Said A. Ibrahim, Torrey Shirk, Deborah S. Cousins, Neil R. Malhotra, Amol S. Navathe

Department of Medicine Faculty Papers

IMPORTANCE: Few value-based payment programs have targeted outpatient surgery, although these procedures comprise most surgeries performed in hospitals. In 2018, the Centers for Medicare and Medicaid Services introduced Bundled Payments for Care Improvement Advanced (BPCI Advanced), the first episode-based payment model to include an outpatient surgical condition-spine surgery. It is not known whether bundled payments reduce spending or improve quality for outpatient surgery, despite plans to expand outpatient episodes in future models.

OBJECTIVE: To determine whether hospital participation in the first year of BPCI Advanced for outpatient and inpatient spine surgery (back and neck except spinal fusion procedures [BNESF]) was …

Delays To Antibiotics In The Emergency Department And Risk Of Mortality In Children With Sepsis., Roni D. Lane, Troy Richardson, Halden F. Scott, Raina M. Paul, Fran Balamuth, Matthew A. Eisenberg, Ruth Riggs, W Charles Huskins, Christopher M. Horvat, Grant E. Keeney, Leslie Hueschen, Justin M. Lockwood, Vishal Gunnala, Bryan P. Mckee, Nikhil Patankar, Venessa Lynn Pinto, Amanda M. Sebring, Matthew P. Sharron, Jennifer Treseler, Jennifer J. Wilkes, Jennifer K. Workman

Manuscripts, Articles, Book Chapters and Other Papers

IMPORTANCE: Pediatric consensus guidelines recommend antibiotic administration within 1 hour for septic shock and within 3 hours for sepsis without shock. Limited studies exist identifying a specific time past which delays in antibiotic administration are associated with worse outcomes.

OBJECTIVE: To determine a time point for antibiotic administration that is associated with increased risk of mortality among pediatric patients with sepsis.

DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study used data from 51 US children's hospitals in the Improving Pediatric Sepsis Outcomes collaborative. Participants included patients aged 29 days to less than 18 years with sepsis recognized within 1 hour …

Delays To Antibiotics In The Emergency Department And Risk Of Mortality In Children With Sepsis, Roni D Lane, Troy Richardson, Halden F Scott, Raina M Paul, Fran Balamuth, Matthew A Eisenberg, Ruth Riggs, W Charles Huskins, Christopher M Horvat, Grant E Keeney, Leslie A Hueschen, Justin M Lockwood, Vishal Gunnala, Bryan P Mckee, Nikhil Patankar, Venessa Lynn Pinto, Amanda M Sebring, Matthew P Sharron, Jennifer Treseler, Jennifer J Wilkes, Jennifer K Workman

Faculty, Staff and Students Publications

IMPORTANCE: Pediatric consensus guidelines recommend antibiotic administration within 1 hour for septic shock and within 3 hours for sepsis without shock. Limited studies exist identifying a specific time past which delays in antibiotic administration are associated with worse outcomes.

OBJECTIVE: To determine a time point for antibiotic administration that is associated with increased risk of mortality among pediatric patients with sepsis.

DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study used data from 51 US children's hospitals in the Improving Pediatric Sepsis Outcomes collaborative. Participants included patients aged 29 days to less than 18 years with sepsis recognized within 1 hour …

Development Of A Follow-Up Measure To Ensure Complete Screening For Colorectal Cancer, Elizabeth L Ciemins, Jeff T Mohl, Carlos A Moreno, Francis Colangelo, Robert A Smith, Mary Barton

Faculty, Staff and Student Publications

IMPORTANCE: The current quality performance measure for colorectal cancer (CRC) screening is limited to initial screening. Despite low rates, there is no measure for appropriate follow-up with colonoscopy after receipt of an abnormal result of a stool-based screening test (SBT) for CRC. A quality performance measure is needed.

OBJECTIVE: To develop and test a quality performance measure for follow-up colonoscopy within 6 months of an abnormal result of an SBT for CRC.

DESIGN, SETTING, AND PARTICIPANTS: This retrospective quality improvement study examined data from January 1, 2016, to December 31, 2020, with 2018 plus 6 months of follow-up as the …

Association Between Emergency Medical Service Agency Volume And Mortality In Trauma Patients, David S Silver, Jason L Sperry, Jamison Beiriger, Liling Lu, Francis X Guyette, Stephen Wisniewski, Ernest E Moore, Martin Schreiber, Bellal Joseph, Chad T Wilson, Bryan Cotton, Daniel Ostermayer, Erin E Fox, Brian G Harbrecht, Mayur Patel, Joshua B Brown

Faculty, Staff and Student Publications

Objective: The aim of this study was to evaluate the association of annual trauma patient volume on outcomes for emergency medical services (EMS) agencies.

Background: Regionalization of trauma care saves lives. The underlying concept driving this is a volume-outcome relationship. EMS are the entry point to the trauma system, yet it is unknown if a volume-outcome relationship exists for EMS.

Methods: A retrospective analysis of prospective cohort including 8 trauma centers and 20 EMS air medical and metropolitan ground transport agencies. Patients 18 to 90 years old with injury severity scores ≥9 transported from the scene were included. Patient and …

A Case Report: A Patient Rescued By Va-Ecmo After Cardiac Arrest Triggered By Trigeminocardiac Reflex After Nasal Surgery, Xu Zhang, Bin Sun, Chen Pac-Soo, Daqing Ma, Liwei Wang

Faculty, Staff and Student Publications

Rationale:

Cardiac arrest (CA) caused by trigeminocardiac reflex (TCR) after endoscopic nasal surgery is rare. Hence, when a patient suffers from TCR induced CA in the recovery room, most doctors may not be able to find the cause in a short time, and standard cardiopulmonary resuscitation and resuscitation measures may not be effective. Providing circulatory assistance through venous-arterial extracorporeal membrane oxygenation (VA-ECMO) can help healthcare providers gain time to identify the etiology and initiate symptom-specific treatment.

Patient concerns:

We report a rare case of CA after endoscopic nasal surgery treated with VA-ECMO.

Diagnoses:

We excluded myocardial infarction, pulmonary embolism, allergies, …

Performance Of Six Clinical Physiological Scoring Systems In Predicting In-Hospital Mortality In Elderly And Very Elderly Patients With Acute Upper Gastrointestinal Bleeding In Emergency Department, Po-Han Wu, Shang-Kai Hung, Chien-An Ko, Chia-Peng Chang, Cheng-Ting Hsiao, Jui-Yuan Chung, Hao-Wei Kou, Wan-Hsuan Chen, Chiao-Hsuan Hsieh, Kai-Hsiang Ku, Kai-Hsiang Wu

Faculty, Staff and Student Publications

Background and Objectives: The aim of this study is to compare the performance of six clinical physiological-based scores, including the pre-endoscopy Rockall score, shock index (SI), age shock index (age SI), Rapid Acute Physiology Score (RAPS), Rapid Emergency Medicine Score (REMS), and Modified Early Warning Score (MEWS), in predicting in-hospital mortality in elderly and very elderly patients in the emergency department (ED) with acute upper gastrointestinal bleeding (AUGIB). Materials and Methods: Patients older than 65 years who visited the ED with a clinical diagnosis of AUGIB were enrolled prospectively from July 2016 to July 2021. The six scores were calculated …

Mortality And Major Adverse Cardiovascular Events In Hospitalized Patients With Atrial Fibrillation With Covid-19, Lucas Wang, Lawrence Hoang, Kristopher Aten, Mujahed Abualfoul, Victor Canela, Sri Prathivada, Michael Vu, Yi Zhao, Manavjot Sidhu

Faculty, Staff and Student Publications

COVID-19 results in increased incidence of cardiac arrhythmias, including atrial fibrillation (AF). However, little is known about the combined effect of AF and COVID-19 on patient outcomes. This study aimed to determine if AF, specifically new-onset AF (NOAF), is associated with increased risk of mortality and major adverse cardiovascular events (MACEs) in hospitalized patients with COVID-19. This multicenter retrospective analysis identified 2,732 patients with COVID-19 admitted between March and December 2020. Data points were manually reviewed in the patients' electronic health records. Multivariate logistic regression was used to assess if AF was associated with death or MACE. Patients with AF …

Risk Factors For Ebola Virus Persistence In Semen Of Survivors In Liberia, Jonathan Dyal, Aaron Kofman, Jomah Z Kollie, John Fankhauser, Romeo Orone, Moses J Soka, Uriah Glaybo, Armah Kiawu, Edna Freeman, Giovanni Giah, Henry D Tony, Mylene Faikai, Mary Jawara, Kuku Kamara, Samuel Kamara, Benjamin Flowers, Mohammed L Kromah, Rodel Desamu-Thorpe, James Graziano, Shelley Brown, Maria E Morales-Betoulle, Deborah L Cannon, Kaihong Su, Susanne L Linderman, Mateusz Plucinski, Eric Rogier, Richard S Bradbury, W Evan Secor, Katherine E Bowden, Christi Phillips, Mary N Carrington, Yeon-Hwa Park, Maureen P Martin, Maria Del Pilar Aguinaga, Robert Mushi, Dana L Haberling, Elizabeth D Ervin, John D Klena, Moses Massaquoi, Tolbert Nyenswah, Stuart T Nichol, David E Chiriboga, Desmond E Williams, Steven H Hinrichs, Rafi Ahmed, Benjamin T Vonhm, Pierre E Rollin, Lawrence J Purpura, Mary J Choi

Faculty, Staff and Student Publications

BACKGROUND: Long-term persistence of Ebola virus (EBOV) in immunologically privileged sites has been implicated in recent outbreaks of Ebola virus disease (EVD) in Guinea and the Democratic Republic of Congo. This study was designed to understand how the acute course of EVD, convalescence, and host immune and genetic factors may play a role in prolonged viral persistence in semen.

METHODS: A cohort of 131 male EVD survivors in Liberia were enrolled in a case-case study. "Early clearers" were defined as those with 2 consecutive negative EBOV semen test results by real-time reverse-transcription polymerase chain reaction (rRT-PCR) ≥2 weeks apart within …

Multisite Evaluation Of Prediction Models For Emergency Department Crowding Before And During The Covid-19 Pandemic, Ari J Smith, Brian W Patterson, Michael S Pulia, John Mayer, Rebecca J Schwei, Radha Nagarajan, Frank Liao, Manish N Shah, Justin J Boutilier

Faculty, Staff and Student Publications

OBJECTIVE: To develop a machine learning framework to forecast emergency department (ED) crowding and to evaluate model performance under spatial and temporal data drift.

MATERIALS AND METHODS: We obtained 4 datasets, identified by the location: 1-large academic hospital and 2-rural hospital, and time period: pre-coronavirus disease (COVID) (January 1, 2019-February 1, 2020) and COVID-era (May 15, 2020-February 1, 2021). Our primary target was a binary outcome that is equal to 1 if the number of patients with acute respiratory illness that were ED boarding for more than 4 h was above a prescribed historical percentile. We trained a random forest …

Hyperkalemia And Electrocardiogram Manifestations In End-Stage Renal Disease, Zubaid Rafique, Bryan Hoang, Heba Mesbah, Ryan Pappal, Frank W Peacock, Raul Juarez-Vela, Lukasz Szarpak, Dick C Kuo

Faculty, Staff and Students Publications

Hyperkalemia is one of the more common acute life-threatening metabolic emergencies. The aim of our study is to determine the correlation and accuracy of abnormal ECG parameters as a function of serum potassium concentration in the end-stage renal disease (ESRD) population. We performed a retrospective chart review of emergency department patients presenting with ESRD and receiving emergent hemodialysis treatment. A total of 96 patients, each with five independent ED visits, provided 480 sets of ECGs and electrolytes. Of these, four ECGs were excluded for inability to interpret, leaving a total of 476 patient encounters that met all inclusion criteria. Linear …

Association Of Renin Angiotensin Aldosterone System Inhibitors And Outcomes Of Hospitalized Patients With Covid-19, Neha Gupta, Lisa Settle, Brent R Brown, Donna L Armaignac, Michael Baram, Nicholas E Perkins, Margit Kaufman, Roman R Melamed, Amy B Christie, Valerie C Danesh, Joshua L Denson, Sreekanth R Cheruku, Karen Boman, Vikas Bansal, Vishakha K Kumar, Allan J Walkey, Juan P Domecq, Rahul Kashyap, Christopher E Aston

Faculty, Staff and Student Publications

OBJECTIVES: To determine the association of prior use of renin-angiotensin-aldosterone system inhibitors (RAASIs) with mortality and outcomes in hospitalized patients with COVID-19.

DESIGN: Retrospective observational study.

SETTING: Multicenter, international COVID-19 registry.

SUBJECTS: Adult hospitalized COVID-19 patients on antihypertensive agents (AHAs) prior to admission, admitted from March 31, 2020, to March 10, 2021.

INTERVENTIONS: None.

MEASUREMENTS AND MAIN RESULTS: Data were compared between three groups: patients on RAASIs only, other AHAs only, and those on both medications. Multivariable logistic and linear regressions were performed after controlling for prehospitalization characteristics to estimate the effect of RAASIs on mortality and other outcomes during …

Impact Of Risk-Based Sexually Transmitted Infection Screening In The Emergency Department, Fahd A Ahmad, Kayleigh Fischer, Hongjie Gu, Thomas C Bailey, Donna B Jeffe, Christopher R Carpenter, Philip R O Payne

Faculty, Staff and Student Publications

OBJECTIVES: Sexually transmitted infections (STIs), including chlamydia, gonorrhea, and human immunodeficiency virus (HIV) pose a significant health burden in adolescents. Many adolescents receiving care in the emergency department (ED) are in need of testing, regardless of their chief complaint. Our objective was to determine whether an electronic, risk-based STI screening program in our ED was associated with an increase in STI testing among at-risk adolescents.

METHODS: We conducted a retrospective cohort analysis of patient outcomes in our pediatric ED after integrating an Audio-enhanced Computer-Assisted Self-Interview (ACASI) as standard of care. It obtained a focused sexual history and generated STI testing …

Impact Of Covid19 On Maxillofacial Fractures In The Province Of L’Aquila, Abruzzo, Italy Review Of 296 Patients Treated With Statistical Comparison Of The Two-Year Pre-Covid19 And Covid19, Filippo Giovannetti, Ettore Lupi, Danilo Di Giorgio, Secondo Scarsella, Antonio Oliva, Desiderio Di Fabio, Paolo Prata, Giada Petricca, Valentino Valentini

Faculty, Staff and Student Publications

The aim of this study was to understand the impact of the COVID-19 pandemic on the epidemiology of maxillofacial trauma in a regional trauma center in L'Aquila, Abruzzo, Italy, during the first wave of the pandemic and comparted it to an equivalent period from 2015 to 2018. The authorshave retrospectively analyzed personal data, site of trauma, etiology, and mechanism of injury. Statistical analysis has been carried out utilizing IBM SPSS Statistics software (IBM Corp., Armonk, NY) and significance was accepted for P values of 0.05) as opposed to the etiology in which the road traffic accidents decreased in favor of …

Emergency Department Antimicrobial Use In A Low-Resource Setting: Results From A Retrospective Observational Study At A Referral Hospital In Liberia, Sojung Yi, Anu Ramachandran, Lane Epps, Alex Mayah, Taylor W Burkholder, Michael Senyu Jaung, Ahson Haider, Paul Whesseh, John Shakpeh, Kayla Enriquez, Corey Bills

Faculty, Staff and Students Publications

OBJECTIVE: Data on antimicrobial use in low-income and middle-income countries (LMICs) remain limited. In Liberia, the absence of local data impedes surveillance and may lead to suboptimal treatment, injudicious use and resistance against antimicrobials. This study aims to examine antimicrobial prescribing patterns for patients in the emergency department (ED) of a large Liberian public hospital. Secondarily, this prescribing was compared with WHO prescribing indicators.

DESIGN: Retrospective observational study.

SETTING: An adult ED of a large public hospital in Monrovia, Liberia.

PARTICIPANTS: A total of 1082 adult patients (>18 years of age) were recorded in the ED, from 1 January …

Multidisciplinary Care For Refractory Pediatric Functional Abdominal Pain Decreases Emergency And Inpatient Utilization, Andrew S Chu, Laura Torres, Grace Kao, Caroyl Gilbert, Evelyn Caro Monico, Bruno P Chumpitazi

Faculty, Staff and Students Publications

Children with refractory functional abdominal pain (FAP) experience functional disability and may utilize emergency department (ED) and/or inpatient services. Whether multidisciplinary programs which help care for children with refractory FAP affect acute healthcare utilization is unknown. A retrospective chart review of children initially evaluated by the outpatient Multidisciplinary Abdominal Pain Program (MAPP) from October 2016 to May 2019 was completed. Patient characteristics and number of ED visits and hospitalizations for abdominal pain in the year prior to versus year after MAPP evaluation were captured. Thirty-eight children (ages 9-17 years [median 13 years]) were included. The median number of ED visits/patient/year …

Validation Of An Electronic Trigger To Measure Missed Diagnosis Of Stroke In Emergency Departments, Viralkumar Vaghani, Li Wei, Umair Mushtaq, Dean F Sittig, Andrea Bradford, Hardeep Singh

Faculty, Staff and Students Publications

OBJECTIVE: Diagnostic errors are major contributors to preventable patient harm. We validated the use of an electronic health record (EHR)-based trigger (e-trigger) to measure missed opportunities in stroke diagnosis in emergency departments (EDs).

METHODS: Using two frameworks, the Safer Dx Trigger Tools Framework and the Symptom-disease Pair Analysis of Diagnostic Error Framework, we applied a symptom-disease pair-based e-trigger to identify patients hospitalized for stroke who, in the preceding 30 days, were discharged from the ED with benign headache or dizziness diagnoses. The algorithm was applied to Veteran Affairs National Corporate Data Warehouse on patients seen between 1/1/2016 and 12/31/2017. Trained …

Characteristics And Outcomes Of In-Hospital Cardiac Arrest In Covid-19 A Systematic Review And Meta-Analysis, Lukasz Szarpak, Magdalena Borkowska, Frank W Peacock, Zubaid Rafique, Aleksandra Gasecka, Jacek Smereka, Katarzyna Pytkowska, Marta Jachowicz, Lukasz Iskrzycki, Natasza Gilis-Malinowska, Milosz J Jaguszewski

Faculty, Staff and Students Publications

BACKGROUND: The purpose herein, was to perform a systematic review of interventional outcome studies in patients with in-hospital cardiac arrest before and during the coronavirus disease 2019 (COVID-19) pandemic period.

METHODS: A meta-analysis was performed of publications meeting the following PICOS criteria: (1) participants, patients > 18 years of age with cardiac arrest due to any causes; (2) intervention, cardiac arrest in COVID-19 period; (3) comparison, cardiac arrest in pre-COVID-19 period; (4) outcomes, detailed information for survival; (5) study design, randomized controlled trials, quasi-randomized or observational studies comparing cardiac arrest in COVID-19 and pre-COVID-19 period for their effects in patients with …

Redefining Cardiac Biomarkers In Predicting Mortality Of Inpatients With Covid-19, Juan-Juan Qin, Xu Cheng, Feng Zhou, Fang Lei, Gauri Akolkar, Jingjing Cai, Xiao-Jing Zhang, Alice Blet, Jing Xie, Peng Zhang, Ye-Mao Liu, Zizhen Huang, Ling-Ping Zhao, Lijin Lin, Meng Xia, Ming-Ming Chen, Xiaohui Song, Liangjie Bai, Ze Chen, Xingyuan Zhang, Da Xiang, Jing Chen, Qingbo Xu, Xin-Liang Ma, Rhian M Touyz, Chen Gao, Haitao Wang, Liming Liu, Weiming Mao, Pengcheng Luo, Youqin Yan, Ping Ye, Manhua Chen, Guohua Chen, Lihua Zhu, Zhi-Gang She, Xiaodong Huang, Yufeng Yuan, Bing-Hong Zhang, Yibin Wang, Peter P Liu, Hongliang Li

Department of Emergency Medicine Faculty Papers

The prognostic power of circulating cardiac biomarkers, their utility, and pattern of release in coronavirus disease 2019 (COVID-19) patients have not been clearly defined. In this multicentered retrospective study, we enrolled 3219 patients with diagnosed COVID-19 admitted to 9 hospitals from December 31, 2019 to March 4, 2020, to estimate the associations and prognostic power of circulating cardiac injury markers with the poor outcomes of COVID-19. In the mixed-effects Cox model, after adjusting for age, sex, and comorbidities, the adjusted hazard ratio of 28-day mortality for hs-cTnI (high-sensitivity cardiac troponin I) was 7.12 ([95% CI, 4.60-11.03] P<0.001), (NT-pro)BNP (N-terminal pro-B-type natriuretic peptide or brain natriuretic peptide) was 5.11 ([95% CI, 3.50-7.47] P<0.001), CK (creatine phosphokinase)-MB was 4.86 ([95% CI, 3.33-7.09] P<0.001), MYO (myoglobin) was 4.50 ([95% CI, 3.18-6.36] P<0.001), and CK was 3.56 ([95% CI, 2.53-5.02] P<0.001). The cutoffs of those cardiac biomarkers for effective prognosis of 28-day mortality of COVID-19 were found to be much lower than for regular heart disease at about 19%-50% of the currently recommended thresholds. Patients with elevated cardiac injury markers above the newly established cutoffs were associated with significantly increased risk of COVID-19 death. In conclusion, cardiac biomarker elevations are significantly associated with 28-day death in patients with COVID-19. The prognostic cutoff values of these biomarkers might be much lower than the current reference standards. These findings can assist in better management of COVID-19 patients to improve outcomes. Importantly, the newly established cutoff levels of COVID-19-associated cardiac biomarkers may serve as useful criteria for the future prospective studies and clinical trials.

Simulation-Based Mastery Learning Compared To Standard Education For Discussing Diagnostic Uncertainty With Patients In The Emergency Department: A Randomized Controlled Trial., Danielle M. Mccarthy, Rhea E. Powell, Kenzie A. Cameron, David H. Salzman, Dimitrios Papanagnou, Amanda Doty, Benjamin E. Leiby, Katherine Piserchia, Matthew R. Klein, Xiao C. Zhang, William C. Mcgaghie, Kristin L. Rising

Department of Pharmacology and Experimental Therapeutics Faculty Papers

BACKGROUND: Diagnostic uncertainty occurs frequently in emergency medical care, with more than one-third of patients leaving the emergency department (ED) without a clear diagnosis. Despite this frequency, ED providers are not adequately trained on how to discuss diagnostic uncertainty with these patients, who often leave the ED confused and concerned. To address this training need, we developed the Uncertainty Communication Education Module (UCEM) to teach physicians how to discuss diagnostic uncertainty. The purpose of the study is to evaluate the effectiveness of the UCEM in improving physician communications.

METHODS: The trial is a multicenter, two-arm randomized controlled trial designed to …

Myocardial Dysfunction After Out-Of-Hospital Cardiac Arrest: Predictors And Prognostic Implications., Yuan Yao, Nicholas James Johnson, Sarah Muirhead Perman, Vimal Ramjee, Anne Victoria Grossestreuer, David Foster Gaieski

Department of Emergency Medicine Faculty Papers

We aim to determine the incidence of early myocardial dysfunction after out-of-hospital cardiac arrest, risk factors associated with its development, and association with outcome. A retrospective chart review was performed among consecutive out-of-hospital cardiac arrest (OHCA) patients who underwent echocardiography within 24 h of return of spontaneous circulation at three urban teaching hospitals. Our primary outcome is early myocardial dysfunction, defined as a left ventricular ejection fraction < 40% on initial echocardiogram. We also determine risk factors associated with myocardial dysfunction using multivariate analysis, and examine its association with survival and neurologic outcome. A total of 190 patients achieved ROSC and underwent echocardiography within 24 h. Of these, 83 (44%) patients had myocardial dysfunction. A total of 37 (45%) patients with myocardial dysfunction survived to discharge, 39% with intact neurologic status. History of congestive heart failure (OR 6.21; 95% CI 2.54-15.19), male gender (OR 2.27; 95% CI 1.08-4.78), witnessed arrest (OR 4.20; 95% CI 1.78-9.93), more than three doses of epinephrine (OR 6.10; 95% CI 1.12-33.14), more than four defibrillations (OR 4.7; 95% CI 1.35-16.43), longer duration of resuscitation (OR 1.06; 95% CI 1.01-1.10), and therapeutic hypothermia (OR 3.93; 95% CI 1.32-11.75) were associated with myocardial dysfunction. Cardiopulmonary resuscitation immediately initiated by healthcare personnel was associated with lower odds of myocardial dysfunction (OR 0.40; 95% CI 0.17-0.97). There was no association between early myocardial dysfunction and mortality or neurological outcome. Nearly half of OHCA patients have myocardial dysfunction. A number of clinical factors are associated with myocardial dysfunction, and may aid providers in anticipating which patients need early diagnostic evaluation and specific treatments. Early myocardial dysfunction is not associated with neurologically intact survival.

Validation Of An Icd Code For Accurately Identifying Emergency Department Patients Who Suffer An Out-Of-Hospital Cardiac Arrest., Shelby K. Shelton, Steve B. Chukwulebe, David F. Gaieski, Benjamin S. Abella, Brendan G. Carr, Sarah M. Perman

Department of Emergency Medicine Faculty Papers

AIM: International classification of disease (ICD-9) code 427.5 (cardiac arrest) is utilized to identify cohorts of patients who suffer out-of-hospital cardiac arrest (OHCA), though the use of ICD codes for this purpose has never been formally validated. We sought to validate the utility of ICD-9 code 427.5 by identifying patients admitted from the emergency department (ED) after OHCA.

METHODS: Adult visits to a single ED between January 2007 and July 2012 were retrospectively examined and a keyword search of the electronic medical record (EMR) was used to identify patients. Cardiac arrest was confirmed; and ICD-9 information and location of return …

A Novel Approach To Addressing An Unintended Consequence Of Direct To Room: The Delay Of Initial Vital Signs., J. Basile, E. Youssef, B. Cambria, J. Chacko, K. Treval, B. Hahn, B. Ardolic

Journal Articles

Introduction: The concept of "direct to room" (DTR) and "immediate bedding" has been described in the literature as a mechanism to improve front-end, emergency department (ED) processing. The process allows for an expedited clinician-patient encounter. An unintended consequence of DTR was a time delay in obtaining the initial set of vital signs upon patient arrival.

Methods: This retrospective cohort study was conducted at a single, academic, tertiary-care facility with an annual census of 94,000 patient visits. Inclusion criteria were all patients who entered the ED from 11/1/15 to 5/1/16 and between the hours of 7 am to 11 pm. During …

Indoor Tobacco Legislation Is Associated With Fewer Emergency Department Visits For Asthma Exacerbation In Children., Christina E. Ciaccio, Tami Gurley-Calvez, Theresa I. Shireman

Manuscripts, Articles, Book Chapters and Other Papers

BACKGROUND: During the past 3 decades, numerous cities and states have adopted laws that ban smoking in public indoor spaces. The rationale for these policies has been to protect nonsmokers from the adverse health effects of secondhand smoke.

OBJECTIVE: To determine whether the implementation of indoor smoking legislation is associated with a decrease in emergency department visits for asthma in children.

METHODS: This retrospective analysis used a natural experiment to estimate the impact of clean indoor air legislation on the rate of emergency department admissions for asthma exacerbation in children. Data were obtained from the Pediatric Health Information System. A …

Inter-Rater Reliability Of Post-Arrest Cerebral Performance Category (Cpc) Scores., Anne V. Grossestreuer, Benjamin S. Abella, Kelsey R. Sheak, Marisa J. Cinousis, Sarah M. Perman, Marion Leary, Douglas J. Wiebe, David F. Gaieski

Department of Emergency Medicine Faculty Papers

PURPOSE: Cerebral Performance Category (CPC) scores are often an outcome measure for post-arrest neurologic function, collected worldwide to compare performance, evaluate therapies, and formulate recommendations. At most institutions, no formal training is offered in their determination, potentially leading to misclassification.

MATERIALS AND METHODS: We identified 171 patients at 2 hospitals between 5/10/2005 and 8/31/2012 with two CPC scores at hospital discharge recorded independently - in an in-house quality improvement database and as part of a national registry. Scores were abstracted retrospectively from the same electronic medical record by two separate non-clinical researchers. These scores were compared to assess inter-rater reliability …

The Association Between Hemoglobin Concentration And Neurologic Outcome After Cardiac Arrest., Nicholas J. Johnson, Babette Rosselot, Sarah M. Perman, Kalani Dodampahala, Munish Goyal, David F. Gaieski, Anne V. Grossestreuer

Department of Emergency Medicine Faculty Papers

PURPOSE: The purpose of the study is to determine the association between hemoglobin concentration (Hgb) and neurologic outcome in postarrest patients.

METHODS: We conducted a retrospective cohort study using the Penn Alliance for Therapeutic Hypothermia (PATH) cardiac arrest registry. Inclusion criteria were resuscitated cardiac arrest (inhospital or out of hospital) and an Hgb value recorded within 24 hours of return of spontaneous circulation. The primary outcome was favorable neurologic status at hospital discharge. Survival to hospital discharge was a secondary outcome.

RESULTS: There were 598 eligible patients from 21 hospitals. Patients with favorable neurologic outcome had significantly higher median Hgb …

Recurrent Violent Injury: Magnitude, Risk Factors, And Opportunities For Intervention From A Statewide Analysis., Elinore Kaufman, Kristin L. Rising, Md, Ms, Douglas J. Wiebe, David J. Ebler, Marie L. Crandall, M. Kit Delgado

Department of Emergency Medicine Faculty Papers

INTRODUCTION: Although preventing recurrent violent injury is an important component of a public health approach to interpersonal violence and a common focus of violence intervention programs, the true incidence of recurrent violent injury is unknown. Prior studies have reported recurrence rates from 0.8% to 44%, and risk factors for recurrence are not well established.

METHODS: We used a statewide, all-payer database to perform a retrospective cohort study of emergency department visits for injury due to interpersonal violence in Florida, following up patients injured in 2010 for recurrence through 2012. We assessed risk factors for recurrence with multivariable logistic regression and …

Urgent Care And Emergency Department Visits In The Pediatric Medicaid Population., Amanda Montalbano, Jonathan Rodean, Juhi Kangas, Brian R. Lee, Matt Hall

Manuscripts, Articles, Book Chapters and Other Papers

Background: Urgent care (UC) is one of the fastest growing venues of health care delivery. We compared clinical and cost attributes of pediatric UC and emergency department (ED) visits that did not result in admission.

Methods: Our study examined 5 925 568 ED and UC visits of children under 19 years old in the 2010 through 2012 Marketscan Medicaid Multi-State Database. Basic demographics, diagnoses, severity, and payments were compared. Between ED and UC visits, χ(2) tests were used for proportions and Wilcoxon rank-sum tests were used for continuous variables.

Results: The UC and ED had the same most common diagnoses. …