Pandemic phase-related racial and ethnic disparities in COVID-19 positivity and outcomes among patients presenting to emergency departments during the first two pandemic waves in the USA

BACKGROUND

In many countries including the USA, the UK and Canada, the impact of COVID-19 on people of colour has been disproportionately high but examination of disparities in patients presenting to ED has been limited. We assessed racial and ethnic differences in COVID-19 positivity and outcomes in patients presenting to EDs in the USA, and the effect of the phase of the pandemic on these outcomes.

METHODS

This is a retrospective cohort study of adult patients tested for COVID-19 during, or 14 days prior to, the index ED visit in 2020. Data were obtained from the National Registry of Suspected COVID-19 in Emergency Care network which has data from 155 EDs across 27 US states. Hierarchical models were used to account for clustering by hospital. The outcomes included COVID-19 diagnosis, hospitalisation at index visit, subsequent hospitalisation within 30 days and 30-day mortality. We further stratified the analysis by time period (early phase: March-June 2020; late phase: July-September 2020).

RESULTS

Of the 26 111 adult patients, 38% were non-Hispanic White (NHW), 29% Black, 20% Hispanic/Latino, 3% Asian and 10% all others; half were female. The median age was 56 years (IQR 40-69), and 53% were diagnosed with COVID-19; of those, 59% were hospitalised at index visit. Of those discharged from ED, 47% had a subsequent hospitalisation in 30 days. Hispanic/Latino patients had twice (adjusted OR (aOR) 2.3; 95% CI 1.8 to 3.0) the odds of COVID-19 diagnosis than NHW patients, after adjusting for age, sex and comorbidities. Black, Asian and other minority groups also had higher odds of being diagnosed (compared with NHW patients). On stratification, this association was observed in both phases for Hispanic/Latino patients. Hispanic/Latino patients had lower odds of hospitalisation at index visit, but when stratified, this effect was only observed in early phase. Subsequent hospitalisation was more likely in Asian patients (aOR 3.1; 95% CI 1.1 to 8.7) in comparison with NHW patients. Subsequent ED visit was more likely in Blacks and Hispanic/Latino patients in late phase.

CONCLUSION

We found significant differences in ED outcomes that are not explained by comorbidity burden. The gap decreased but persisted during the later phase in 2020.

Application of motor learning theory to teach the head impulse test to emergency medicine resident physicians

Objectives

The objective was to develop an innovative method of training emergency medicine (EM) resident physicians to perform the head impulse test (HIT) component of the HINTS (head impulse test, nystagmus, test of skew) examination using video-oculography (VOG) device feedback.

Methods

Using principles from motor learning theory and Ericsson's framework for expertise, we developed a training innovation utilizing VOG device feedback to teach the degree (10°-20°) and velocity (>100°/s) of head turn required for the HIT. We assessed the technical ability of participants to perform the HIT using the VOG device, without feedback, to count the number of successful HITs out of 20 attempts before, immediately after, and 2 weeks after the training innovation. Participants rated their confidence on a 1 to 5 Likert scale before and 2 weeks after training.

Results

Most participants (11 of 14, 78%) were unable to perform even one successful HIT in 20 attempts before training despite brief verbal and visual instruction regarding the head turn parameters. However, most participants achieved more than one success, in fact, all with at least five successes, immediately after training (13 of 14, 93%) and again 2 weeks after training (nine of 11, 82%). The median (interquartile range) number of successful HITs was 0 (0, mean 0.79) during baseline testing, 7.5 (5.8) immediately after training, and 10 (8.0) 2 weeks after training (p < 0.01, Kruskal-Wallis). The median confidence rating increased from 1.5 (1) before baseline testing to 3 (1.5) after follow-up testing (p = 0.02, Mann-Whitney U).

Conclusions

Prior to motor training, most participants failed to properly perform the HIT. Feedback training with VOG devices may facilitate development of the skills required to properly perform the HIT. Further study is needed to assess the ability to train the interpretive aspect of the HIT and other components of the HINTS examination.

Database derived from an electronic medical record-based surveillance network of US emergency department patients with acute respiratory illness

BACKGROUND

For surveillance of episodic illness, the emergency department (ED) represents one of the largest interfaces for generalizable data about segments of the US public experiencing a need for unscheduled care. This protocol manuscript describes the development and operation of a national network linking symptom, clinical, laboratory and disposition data that provides a public database dedicated to the surveillance of acute respiratory infections (ARIs) in EDs.

METHODS

The Respiratory Virus Laboratory Emergency Department Network Surveillance (RESP-LENS) network includes 26 academic investigators, from 24 sites, with 91 hospitals, and the Centers for Disease Control and Prevention (CDC) to survey viral infections. All data originate from electronic medical records (EMRs) accessed by structured query language (SQL) coding. Each Tuesday, data are imported into the standard data form for ARI visits that occurred the prior week (termed the index file); outcomes at 30 days and ED volume are also recorded. Up to 325 data fields can be populated for each case. Data are transferred from sites into an encrypted Google Cloud Platform, then programmatically checked for compliance, parsed, and aggregated into a central database housed on a second cloud platform prior to transfer to CDC.

RESULTS

As of August, 2023, the network has reported data on over 870,000 ARI cases selected from approximately 5.2 million ED encounters. Post-contracting challenges to network execution have included local shifts in testing policies and platforms, delays in ICD-10 coding to detect ARI cases, and site-level personnel turnover. The network is addressing these challenges and is poised to begin streaming weekly data for dissemination.

CONCLUSIONS

The RESP-LENS network provides a weekly updated database that is a public health resource to survey the epidemiology, viral causes, and outcomes of ED patients with acute respiratory infections.

Diagnostic management of acute pulmonary embolism: a prediction model based on a patient data meta-analysis

AIMS

Risk stratification is used for decisions regarding need for imaging in patients with clinically suspected acute pulmonary embolism (PE). The aim was to develop a clinical prediction model that provides an individualized, accurate probability estimate for the presence of acute PE in patients with suspected disease based on readily available clinical items and D-dimer concentrations.

METHODS AND RESULTS

An individual patient data meta-analysis was performed based on sixteen cross-sectional or prospective studies with data from 28 305 adult patients with clinically suspected PE from various clinical settings, including primary care, emergency care, hospitalized and nursing home patients. A multilevel logistic regression model was built and validated including ten a priori defined objective candidate predictors to predict objectively confirmed PE at baseline or venous thromboembolism (VTE) during follow-up of 30 to 90 days. Multiple imputation was used for missing data. Backward elimination was performed with a P-value <0.10. Discrimination (c-statistic with 95% confidence intervals [CI] and prediction intervals [PI]) and calibration (outcome:expected [O:E] ratio and calibration plot) were evaluated based on internal-external cross-validation. The accuracy of the model was subsequently compared with algorithms based on the Wells score and D-dimer testing. The final model included age (in years), sex, previous VTE, recent surgery or immobilization, haemoptysis, cancer, clinical signs of deep vein thrombosis, inpatient status, D-dimer (in µg/L), and an interaction term between age and D-dimer. The pooled c-statistic was 0.87 (95% CI, 0.85-0.89; 95% PI, 0.77-0.93) and overall calibration was very good (pooled O:E ratio, 0.99; 95% CI, 0.87-1.14; 95% PI, 0.55-1.79). The model slightly overestimated VTE probability in the lower range of estimated probabilities. Discrimination of the current model in the validation data sets was better than that of the Wells score combined with a D-dimer threshold based on age (c-statistic 0.73; 95% CI, 0.70-0.75) or structured clinical pretest probability (c-statistic 0.79; 95% CI, 0.76-0.81).

CONCLUSION

The present model provides an absolute, individualized probability of PE presence in a broad population of patients with suspected PE, with very good discrimination and calibration. Its clinical utility needs to be evaluated in a prospective management or impact study.

REGISTRATION

PROSPERO ID 89366.

ChatGPT and conversational artificial intelligence: Friend, foe, or future of research?

Artificial intelligence (AI) and machine learning are increasingly utilized across healthcare. More recently, there has been a rise in the use AI within research, particularly through novel conversational AI platforms, such as ChatGPT. In this Controversies paper, we discuss the advantages, limitations, and future directions for ChatGPT and other forms of conversational AI in research and scholarly dissemination.

Bedside exclusion of pulmonary embolism in children without radiation (BEEPER): a national study of the Pediatric Emergency Care Applied Research Network-Study protocol

Background

The Pulmonary Embolism Rule Out Criteria (PERC) Peds rule, derived from the PERC rule, was derived to estimate a low pretest probability for pulmonary embolism (PE) in children but has not been prospectively validated.

Objective

The objective of this study was to present a protocol for an ongoing multicenter prospective observational study that evaluates the diagnostic accuracy of the PERC-Peds rule.

Methods

This protocol is identified by the acronym, BEdside Exclusion of Pulmonary Embolism without Radiation in children. The study aims were designed to prospectively validate, or if necessary, refine, the accuracy of PERC-Peds and D-dimer in excluding PE among children with clinical suspicion or testing for PE. Multiple ancillary studies will examine clinical characteristics and epidemiology of the participants. Children aged 4 through 17 years were being enrolled at 21 sites through the Pediatric Emergency Care Applied Research Network (PECARN). Patients taking anticoagulant therapy are excluded. PERC-Peds criteria data, clinical gestalt, and demographic information are collected in real time. The criterion standard outcome is image-confirmed venous thromboembolism within 45 days, determined from independent expert adjudication. We assessed interrater reliability of the PERC-Peds, frequency of PERC-Peds use in routine clinical care, and descriptive characteristics of missed eligible and missed patients with PE.

Results

Enrollment is currently 60% complete with an anticipated data lock in 2025.

Conclusions

This prospective multicenter observational study will not only test whether a set of simple criteria can safely exclude PE without need for imaging but also provide a resource to fill a critical knowledge gap about clinical characteristics of children with suspected and diagnosed PE.

An adaptive clinical trial design to identify the target dose of tenecteplase for treatment of acute pulmonary embolism

BACKGROUND/AIMS

Fibrinolytic therapy with tenecteplase has been proposed for patients with pulmonary embolism but the optimal dose is unknown. Higher-than-necessary dosing is likely to cause excess bleeding. We designed an adaptive clinical trial to identify the minimum and assumed safest dose of tenecteplase that maintains efficacy.

METHODS

We propose a Bayesian adaptive, placebo-controlled, group-sequential dose-finding trial using response-adaptive randomization to preferentially allocate subjects to the most promising doses, dual analyses strategies (continuous and dichotomized) using a gatekeeping approach to maximize clinical impact, and interim stopping rules to efficiently address competing trial objectives. The operating characteristics of the proposed design were evaluated using Monte Carlo simulation across multiple hypothetical efficacy scenarios.

RESULTS

Simulation demonstrated response-adaptive randomization can preferentially allocate subjects to doses which appear to be performing well based on interim data. Interim decision-making, including the interim evaluation of both analysis strategies with gatekeeping, allows the trial to continue enrollment when success with the dichotomized analysis strategy appears sufficiently likely and to stop enrollment and declare superiority based on the continuous analysis strategy when there is little chance of ultimately declaring superiority with the dichotomized analysis.

CONCLUSION

The proposed design allows evaluation of a greater number of dose levels than would be possible with a non-adaptive design and avoids the need to choose either the continuous or the dichotomized analysis strategy for the primary endpoint.

Increased Body Mass Index and Metabolic Syndrome Are Associated with Poor Outcomes in SARS-CoV-2-Positive Emergency Department Patients

Background

Increased body mass index (BMI) and metabolic syndrome (MetS) have been associated with adverse outcomes in viral syndromes. We sought to examine associations of increased BMI and MetS on several clinical outcomes in patients tested for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

Methods

The registry of suspected COVID-19 in emergency care (RECOVER) is an observational study of SARS-CoV-2-tested patients (n=27,051) across 155 United States emergency departments (EDs). We used multivariable logistic regression to test for associations of several predictor variables with various clinical outcomes.

Results

We found that a BMI ≥30 kg/m² increased odds of SARS-CoV-2 test positivity (odds ratio [OR], 1.30; 95% confidence interval [CI], 1.23–1.38), while MetS reduced odds of testing positive for SARS-CoV-2 (OR, 0.76; 95% CI, 0.71–0.82). Adjusted multivariable analysis found that MetS was significantly associated with the need for admission (OR, 2.11; 95% CI, 1.89–2.37), intensive care unit (ICU) care (OR, 1.58; 95% CI, 1.40–1.78), intubation (OR, 1.46; 95% CI, 1.28–1.66), mortality (OR, 1.29; 95% CI, 1.13–1.48), and venous thromboembolism (OR, 1.51; 95% CI, 1.07–2.13) in SARS-CoV-2-positive patients. Similarly, BMI ≥40 kg/m² was significantly associated with ICU care (OR, 1.97; 95% CI, 1.65–2.35), intubation (OR, 2.69; 95% CI, 2.22–3.26), and mortality (OR, 1.50; 95% CI, 1.22–1.84).

Conclusion

In this large nationwide sample of ED patients, we report a significant association of both high BMI and composite MetS with poor outcomes in SARS-CoV-2-positive patients. Findings suggest that composite MetS profile may be a more universal predictor of adverse disease outcomes, while the impact of BMI is more heavily modulated by SARS-CoV-2 status.

Venous Thromboembolism During Pregnancy and the Postpartum Period: Risk Factors, Diagnostic Testing, and Treatment

Importance

The risk of venous thromboembolism (VTE) increases during pregnancy and the postpartum period. Deep vein thrombosis is the most common VTE during pregnancy, but pulmonary embolism is typically of greater concern as it contributes to far higher morbidity and mortality. Diagnosis and treatment of VTE during pregnancy differ substantially from the general nonpregnant population.

Objective

This review describes the epidemiology, risk factors, clinical presentation, diagnosis, and treatment of VTE during pregnancy and the postpartum period.

Evidence Acquisition

First, we reviewed the VTE guidelines from professional societies in obstetrics, cardiology, hematology, emergency medicine, pulmonology, and critical care. Second, we examined references from these documents and used PubMed to identify recent articles that cited the guidelines. Finally, we searched PubMed and Google Scholar for articles published since 2018 that included terms for pregnancy and the epidemiology, risk factors, diagnostic imaging, or treatment of VTE.

Results

Venous thromboembolism risk increases throughout pregnancy and peaks shortly after delivery. More than half of pregnancy-related VTE are associated with thrombophilia; other major risks include cesarean delivery, postpartum infection, and the combination of obesity with immobilization. Most VTE can be treated with low molecular weight heparin, but cases of limb- or life-threatening VTE require consideration of thrombolysis and other reperfusion therapies.

Conclusions and Relevance

Venous thromboembolism is far more frequent in antepartum and postpartum women than age-matched controls, and clinical suspicion for VTE in this population should incorporate pregnancy-specific risks. Treatment of limb- or life-threatening antepartum or postpartum VTE requires multispecialty coordination to optimize maternal and fetal outcomes.

Age-related differences in symptoms in older emergency department patients with COVID-19: Prevalence and outcomes in a multicenter cohort

BACKGROUND

Older adults represent a disproportionate share of severe COVID-19 presentations and fatalities, but we have limited understanding of the differences in presentation by age and the association between less typical emergency department (ED) presentations and clinical outcomes.

METHODS

This retrospective cohort study used the RECOVER Network registry, a research collaboration of 86 EDs in 27 U.S. states. We focused on encounters with a positive nasopharyngeal swab for SARS-CoV-2, and described their demographics, clinical presentation, and outcomes. Sequential multivariable logistic regressions examined the strength of association between age cohort and outcomes.

RESULTS

Of 4536 encounters, median patient age was 55 years, 49% were women, and 34% were non-Hispanic Black persons. Cough was the most common presenting complaint across age groups (18-64, 65-74, and 75+): 71%, 67%, and 59%, respectively (p < 0.001). Neurological symptoms, particularly altered mental status, were more common in older adults (2%, 11%, 26%; p < 0.001). Patients 75+ had the greatest odds of ED index visit admission of all age groups (adjusted odds ratio [aOR] 6.66; 95% CI 5.23-8.56), 30-day hospitalization (aOR 7.44; 95% CI 5.63-9.99), and severe COVID-19 (aOR 4.26; 95% CI 3.45-5.27). Compared to individuals with alternate presentations and adjusting for age, patients with typical symptoms (fever, cough and/or shortness of breath) had similar odds of ED index visit admission (aOR 1.01; 95% CI 0.81-1.24), potentially higher odds of 30-day hospitalization (aOR 1.23; 95% CI 1.00-1.53), and greater odds of severe COVID-19 (aOR 1.46; 95% CI 1.12-1.90).

CONCLUSIONS

Older patients with COVID-19 are more likely to have presentations without the most common symptoms. However, alternate presentations of COVID-19 in older ED patients are not associated with greater odds of mechanical ventilation and/or death. Our data highlights the importance of a liberal COVID-19 testing strategy among older ED patients to facilitate accurate diagnoses and timely treatment and prophylaxis.

SARS-CoV-2 Positivity in Ambulatory Symptomatic Patients Is Not Associated With Increased Venous or Arterial Thrombotic Events in the Subsequent 30 Days

BACKGROUND

COVID-19 has been associated with increased risk of thromboembolism in critically ill patients.

OBJECTIVE

We sought to examine the association of SARS-CoV-2 test positivity and subsequent acute vascular thrombosis, including venous thromboembolism (VTE) or arterial thrombosis (AT), in a large nationwide registry of emergency department (ED) patients tested with a nucleic acid test for suspected SARS-CoV-2.

METHODS

The RECOVER (Registry of Potential COVID-19 in Emergency Care) registry includes 155 EDs across the United States. We performed a retrospective cohort study to produce odds ratios (ORs) for COVID-19-positive vs. COVID-19-negative status as a predictor of 30-day VTE or AT, adjusting for age, sex, active cancer, intubation, hospital length of stay, and intensive care unit (ICU) care.

RESULTS

Comparing 14,056 COVID-19-positive patients with 12,995 COVID-19-negative patients, the overall 30-day prevalence of VTE events was 1.4% vs. 1.3%, respectively (p = 0.44, χ²). Multivariable analysis identified that testing positive for SARS-CoV-2 status was negatively associated with both VTE (OR 0.76; 95% confidence interval [CI] 0.61-0.94) and AT (OR 0.51; 95% CI 0.32-0.80), whereas intubation, ICU care, and age 50 years or older were positively associated with both VTE and AT.

CONCLUSIONS

In contrast to other reports, results from this large, hetereogenous national sample of ED patients tested for SARS-CoV-2, showed no association between vascular thrombosis and COVID-19 test positivity.

Assessing quality of life after pulmonary embolism: Comparing results from the PEmb-QoL with semistructured interviews

Background

The Pulmonary Embolism Quality of Life questionnaire (PEmb‐QoL) assesses quality of life (QoL) in patients with previous pulmonary embolism (PE).

Objective

Our aim was to assess the agreement between the PEmb‐QoL and interviews and to explore other QoL concerns in patients diagnosed with PE.

Methods

This mixed‐method study included interviews with 21 patients about QoL after PE, followed by the PEmb‐QoL questionnaire. In interviews, patients were asked about their lived experiences and impact of PE. Our analysis identified the frequency and severity of decreased QoL in qualitative interviews and compared with the PEmb‐QoL score. Excerpts that described the effect of PE on QoL in interview transcripts were transcoded to match the answers corresponding to the 1 to 6 numeric values for each question from the PEmb‐QoL using a predetermined matrix (eg, “constant” and “daily” = all of the time = value 1) and directly compared with responses on the PEmb‐QoL in the areas of emotional complaints and activities of daily living/social limitations.

Results

Interviews showed more functional impairment than predicted by PEmb‐QoL. For fear of recurrence, 86% of participants had disagreements between PEmb‐QoL scores and transcoded interview scores. We found 42% disagreement between reported descriptions of the inability to do or enjoy hobbies in interviews and the PEmb‐QoL score.

Conclusion

Patient interviews showed discordances compared with a validated psychometric tool. To capture a more detailed and accurate picture of the effect of PE on QoL, providers and researchers should consider the addition of qualitative methods to assess outcomes.

Acceptability of Exercise in Urban Emergency Department Patients With Metabolic Syndrome, Including a Subset With Venous Thromboembolism

Metabolic syndrome (MetS) afflicts more than one-third of US adults. In venous thromboembolism (VTE), MetS increases the risk of recurrence and severity of the post-pulmonary embolism syndrome, disproportionately affecting persons of color in urban settings. Exercise can positively modulate components of MetS. Our objective was to survey a sample of urban emergency department (ED) patients with MetS on their exercise habits and interest in increasing activity levels and to compare ± VTE patients. This survey study consisted of: (1) International Physical Activity Questionnaire, and (2) Likert scale gauging interest in increasing activity levels. Any adult ED patient with a composite MetS profile was included. We surveyed 247 patients with an average age of 59 years and 57% reported Black race. Only 9% met recommendations for vigorous exercise and 28% for moderate activity, with no significant difference in the 18% with prior VTE. Fifty-seven percent responded positively regarding motivation in increasing activity. This survey presents novel data supporting the need and feasibility of an interventional study examining exercise as an adjuvant therapy in patients with MetS and VTE.

Safety and Efficiency of Diagnostic Strategies for Ruling Out Pulmonary Embolism in Clinically Relevant Patient Subgroups : A Systematic Review and Individual-Patient Data Meta-analysis

BACKGROUND

How diagnostic strategies for suspected pulmonary embolism (PE) perform in relevant patient subgroups defined by sex, age, cancer, and previous venous thromboembolism (VTE) is unknown.

PURPOSE

To evaluate the safety and efficiency of the Wells and revised Geneva scores combined with fixed and adapted D-dimer thresholds, as well as the YEARS algorithm, for ruling out acute PE in these subgroups.

DATA SOURCES

MEDLINE from 1 January 1995 until 1 January 2021.

STUDY SELECTION

16 studies assessing at least 1 diagnostic strategy.

DATA EXTRACTION

Individual-patient data from 20 553 patients.

DATA SYNTHESIS

Safety was defined as the diagnostic failure rate (the predicted 3-month VTE incidence after exclusion of PE without imaging at baseline). Efficiency was defined as the proportion of individuals classified by the strategy as "PE considered excluded" without imaging tests. Across all strategies, efficiency was highest in patients younger than 40 years (47% to 68%) and lowest in patients aged 80 years or older (6.0% to 23%) or patients with cancer (9.6% to 26%). However, efficiency improved considerably in these subgroups when pretest probability-dependent D-dimer thresholds were applied. Predicted failure rates were highest for strategies with adapted D-dimer thresholds, with failure rates varying between 2% and 4% in the predefined patient subgroups.

LIMITATIONS

Between-study differences in scoring predictor items and D-dimer assays, as well as the presence of differential verification bias, in particular for classifying fatal events and subsegmental PE cases, all of which may have led to an overestimation of the predicted failure rates of adapted D-dimer thresholds.

CONCLUSION

Overall, all strategies showed acceptable safety, with pretest probability-dependent D-dimer thresholds having not only the highest efficiency but also the highest predicted failure rate. From an efficiency perspective, this individual-patient data meta-analysis supports application of adapted D-dimer thresholds.

PRIMARY FUNDING SOURCE

Dutch Research Council. (PROSPERO: CRD42018089366).

Ruling out pulmonary embolism across different healthcare settings: A systematic review and individual patient data meta-analysis

BACKGROUND

The challenging clinical dilemma of detecting pulmonary embolism (PE) in suspected patients is encountered in a variety of healthcare settings. We hypothesized that the optimal diagnostic approach to detect these patients in terms of safety and efficiency depends on underlying PE prevalence, case mix, and physician experience, overall reflected by the type of setting where patients are initially assessed. The objective of this study was to assess the capability of ruling out PE by available diagnostic strategies across all possible settings.

METHODS AND FINDINGS

We performed a literature search (MEDLINE) followed by an individual patient data (IPD) meta-analysis (MA; 23 studies), including patients from self-referral emergency care (n = 12,612), primary healthcare clinics (n = 3,174), referred secondary care (n = 17,052), and hospitalized or nursing home patients (n = 2,410). Multilevel logistic regression was performed to evaluate diagnostic performance of the Wells and revised Geneva rules, both using fixed and adapted D-dimer thresholds to age or pretest probability (PTP), for the YEARS algorithm and for the Pulmonary Embolism Rule-out Criteria (PERC). All strategies were tested separately in each healthcare setting. Following studies done in this field, the primary diagnostic metrices estimated from the models were the "failure rate" of each strategy-i.e., the proportion of missed PE among patients categorized as "PE excluded" and "efficiency"-defined as the proportion of patients categorized as "PE excluded" among all patients. In self-referral emergency care, the PERC algorithm excludes PE in 21% of suspected patients at a failure rate of 1.12% (95% confidence interval [CI] 0.74 to 1.70), whereas this increases to 6.01% (4.09 to 8.75) in referred patients to secondary care at an efficiency of 10%. In patients from primary healthcare and those referred to secondary care, strategies adjusting D-dimer to PTP are the most efficient (range: 43% to 62%) at a failure rate ranging between 0.25% and 3.06%, with higher failure rates observed in patients referred to secondary care. For this latter setting, strategies adjusting D-dimer to age are associated with a lower failure rate ranging between 0.65% and 0.81%, yet are also less efficient (range: 33% and 35%). For all strategies, failure rates are highest in hospitalized or nursing home patients, ranging between 1.68% and 5.13%, at an efficiency ranging between 15% and 30%. The main limitation of the primary analyses was that the diagnostic performance of each strategy was compared in different sets of studies since the availability of items used in each diagnostic strategy differed across included studies; however, sensitivity analyses suggested that the findings were robust.

CONCLUSIONS

The capability of safely and efficiently ruling out PE of available diagnostic strategies differs for different healthcare settings. The findings of this IPD MA help in determining the optimum diagnostic strategies for ruling out PE per healthcare setting, balancing the trade-off between failure rate and efficiency of each strategy.

Modulation of soluble guanylate cyclase ameliorates pulmonary hypertension in a rat model of chronic thromboembolic pulmonary hypertension by stimulating angiogenesis

Acute pulmonary embolism (PE) does not always resolve after treatment and can progress to chronic thromboembolic disease (CTED) or the more severe chronic thromboembolic pulmonary hypertension (CTEPH). The mechanisms surrounding the likelihood of PE resolution or progress to CTED/CTEPH remain largely unknown. We have developed a rat model of CTEPH that closely resembles the human disease in terms of hemodynamics and cardiac manifestations. Embolization of rats with polystyrene microspheres followed by suppression of angiogenesis with the inhibitor of vascular endothelial growth factor receptor 2 (VEGF-R2) SU5416 results in transient, acute pulmonary hypertension that progresses into chronic PE with PH with sustained right ventricular systolic pressures exceeding 70 mmHg (chronic pulmonary embolism [CPE] model). This model is similar to the widely utilized hypoxia/SU5416 model with the exception that the "first hit" is PE. Rats with CPE have impaired right heart function characterized by reduced VO2 Max, reduced cardiac output, and increased Fulton index. None of these metrics are adversely affected by PE alone. Contrast-mediated CT imaging of lungs from rats with PE minus SU5416 show large increases in pulmonary vascular volume, presumably due to an angiogenic response to acute PE/PH. Co-treatment with SU5416 suppresses angiogenesis and produces the CTEPH-like phenotype. We report here that treatment of CPE rats with agonists for soluble guanylate cyclase, a source of cGMP which is in turn a signal for angiogenesis, markedly increases angiogenesis in lungs, and ameliorates the cardiac deficiencies in the CPE model. These results have implications for future development of therapies for human CTEPH.

Communication at diagnosis of venous thromboembolism: Lasting impact of verbal and nonverbal provider communication on patients

BACKGROUND

Establishing trust and effective communication can be challenging in the emergency department, where a prior relationship between patient and provider is lacking and decisions have to be made rapidly. Venous thromboembolism (VTE) represents an emergent condition that requires immediate decision making.

OBJECTIVE

The aim of this paper was to document the experiences, perceptions, and the overall impact of health care provider communication on patients during the diagnosis of VTE in the emergency department.

METHODS

This was a qualitative method study using semistructured interviews to increase understanding of the patient experience during the diagnosis of VTE and impact of the health care provider communication on subsequent patient perceptions.

RESULTS

A total of 24 interviews were conducted. Content analysis revealed that certain aspects of health care providers' communication-namely, word choice, incomplete information, imbalance between fear over reassurance and nonverbal behavior-used to deliver and explain VTE diagnosis, treatment, and prognosis increases patients' fears.

CONCLUSION

These interviews elucidate areas for improvement of communication in the emergency care setting for acute VTE.

D-dimer Thresholds to Exclude Pulmonary Embolism among COVID-19 Patients in the Emergency Department: Derivation with Independent Validation

Objective

To derive and validate a D-dimer cutoff for ruling out pulmonary embolism (PE) in COVID-19 patients presenting to the emergency department (ED).

Methods

A retrospective cohort study was performed in an integrated healthcare system including 22 adult ED's between March 1, 2020, and January 31, 2021. Results were validated among patients enrolled in the RECOVER Registry, representing data from 154 ED's from 26 US states. Consecutive ED patients with laboratory confirmed COVID-19, a D-dimer performed within 48 h of ED arrival, and with objectively confirmed PE were compared to those without PE. After identifying a D-dimer threshold at which the 95% confidence lower bound of the negative predictive value for PE was higher than 98% in the derivation cohort, it was validated using RECOVER registry data.

Results

Among 3978 patients with a D-dimer result, 3583 with confirmed COVID-19 infection were included in the derivation cohort. Overall, PE incidence was 4.1% and a D-dimer cutoff of <2 μ/mL (2000 ng/mL) was associated with a NPV of 98.5% (95% CI = 98.0%−98.9%). In the validation cohort of 13,091 patients with a D-dimer, 7748 had confirmed COVID-19 infection, and the PE incidence was 1.14%. A D-dimer cutoff of <2 μ/mL was associated with a NPV of 99.5% (95% CI = 99.3%−99.7%).

Conclusion

A D-dimer cutoff of <2 μ/ml was associated with a high negative predictive value for PE among patients with COVID-19. However, the resultant sensitivity for PE result at that threshold without pre-test probability assessment would be considered clinically unsafe.

Association between baseline use of angiotensin converting enzyme inhibitors and angiotensin receptor blockers and death among patients tested for COVID-19

Angiotensin converting enzyme inhibitor (ACEI) and angiotensin receptor blocker (ARB) drugs may modify risk associated with SARS-CoV-2. Therefore, we assessed whether baseline therapy with ACEI or ARB (ACEI/ARB) was associated with lower mortality, respiratory failure (non-invasive ventilation or intubation) and renal failure (new renal replacement therapy) in SARS-CoV-2-positive patients. This retrospective registry-based observational cohort study used data from a national database of Emergency Department (ED) patients tested for SARS-CoV-2. Symptomatic ED patients were accrued from January-October 2020, across 197 hospitals in the USA. Multivariable analysis using logistic regression evaluated endpoints among SARS-CoV-2-positive cases, focusing on ACEI/ARB and adjusting for covariates. Model performance was evaluated using the c statistic for discrimination, and Cox plotting for calibration. 13,859 (99.9%) patients had known mortality status, of whom 2,045 (14.8%) died. Respiratory failure occurred in 2,485/13,880 (17.9%) and renal failure in 548/13,813 (4.0%) patients with available data. ACEI/ARB status was associated with a 25% decrease in mortality odds (OR 0.75, 95% CI 0.59-0.94, p = .011, c = .82). ACEI/ARB was not significantly associated with respiratory failure (OR 0.89, 95% CI 0.78-1.06, p = .206) or renal failure (OR 0.75, 95% CI 0.55-1.04, p = .083). Adjusting for covariates, baseline ACEI/ARB was associated with 25% lower mortality in SARS-CoV-2-positive patients. The potential mechanism for ACEI/ARB mortality modification requires further exploration. This article is protected by copyright. All rights reserved.

Predicting 30-day return hospital admissions in patients with COVID-19 discharged from the emergency department: A national retrospective cohort study

OBJECTIVES

Identification of patients with coronavirus disease 2019 (COVID-19) at risk for deterioration after discharge from the emergency department (ED) remains a clinical challenge. Our objective was to develop a prediction model that identifies patients with COVID-19 at risk for return and hospital admission within 30 days of ED discharge.

METHODS

We performed a retrospective cohort study of discharged adult ED patients (n = 7529) with SARS-CoV-2 infection from 116 unique hospitals contributing to the National Registry of Suspected COVID-19 in Emergency Care. The primary outcome was return hospital admission within 30 days. Models were developed using classification and regression tree (CART), gradient boosted machine (GBM), random forest (RF), and least absolute shrinkage and selection (LASSO) approaches.

RESULTS

Among patients with COVID-19 discharged from the ED on their index encounter, 571 (7.6%) returned for hospital admission within 30 days. The machine-learning (ML) models (GBM, RF, and LASSO) performed similarly. The RF model yielded a test area under the receiver operating characteristic curve of 0.74 (95% confidence interval [CI], 0.71-0.78), with a sensitivity of 0.46 (95% CI, 0.39-0.54) and a specificity of 0.84 (95% CI, 0.82-0.85). Predictive variables, including lowest oxygen saturation, temperature, or history of hypertension, diabetes, hyperlipidemia, or obesity, were common to all ML models.

CONCLUSIONS

A predictive model identifying adult ED patients with COVID-19 at risk for return for return hospital admission within 30 days is feasible. Ensemble/boot-strapped classification methods (eg, GBM, RF, and LASSO) outperform the single-tree CART method. Future efforts may focus on the application of ML models in the hospital setting to optimize the allocation of follow-up resources.

Multicenter Study of Outcomes Among Persons With HIV Who Presented to US Emergency Departments With Suspected SARS-CoV-2

BACKGROUND

There is a need to characterize patients with HIV with suspected severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

SETTING

Multicenter registry of patients from 116 emergency departments in 27 US states.

METHODS

Planned secondary analysis of patients with suspected SARS-CoV-2, with (n = 415) and without (n = 25,306) HIV. Descriptive statistics were used to compare patient information and clinical characteristics by SARS-CoV-2 and HIV status. Unadjusted and multivariable models were used to explore factors associated with death, intubation, and hospital length of stay. Kaplan-Meier curves were used to estimate survival by SARS-CoV-2 and HIV infection status.

RESULTS

Patients with both SARS-CoV-2 and HIV and patients with SARS-CoV-2 but without HIV had similar admission rates (62.7% versus 58.6%, P = 0.24), hospitalization characteristics [eg, rates of admission to the intensive care unit from the emergency department (5.0% versus 6.3%, P = 0.45) and intubation (10% versus 13.3%, P = 0.17)], and rates of death (13.9% versus 15.1%, P = 0.65). They also had a similar cumulative risk of death (log-rank P = 0.72). However, patients with both HIV and SARS-CoV-2 infections compared with patients with HIV but without SAR-CoV-2 had worsened outcomes, including increased mortality (13.9% versus 5.1%, P < 0.01, log-rank P < 0.0001) and their deaths occurred sooner (median 11.5 versus 34 days, P < 0.01).

CONCLUSIONS

Among emergency department patients with HIV, clinical outcomes associated with SARS-CoV-2 infection are not worse when compared with patients without HIV, but SARS-CoV-2 infection increased the risk of death in patients with HIV.

Viral Coinfection is Associated with Improved Outcomes in Emergency Department Patients with SARS-CoV-2

Introduction

Coinfection with severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) and another virus may influence the clinical trajectory of emergency department (ED) patients. However, little empirical data exists on the clinical outcomes of coinfection with SARS-CoV-2

Methods

In this retrospective cohort analysis, we included adults presenting to the ED with confirmed, symptomatic coronavirus 2019 who also underwent testing for additional viral pathogens within 24 hours. To investigate the association between coinfection status with each of the outcomes, we performed logistic regression.

Results

Of 6,913 ED patients, 5.7% had coinfection. Coinfected individuals were less likely to experience index visit or 30-day hospitalization (odds ratio [OR] 0.57; 95% confidence interval [CI], 0.36–0.90 and OR 0.39; 95% CI, 0.25–0.62, respectively).

Conclusion

Coinfection is relatively uncommon in symptomatic ED patients with SARS-CoV-2 and the clinical short- and long-term outcomes are more favorable in coinfected individuals.

AEM special issue on (in)equity in emergency medicine

The year of 2020 was a momentous one for the United States. A confluence of purposely-designed systems' outcomes and deep histories of schism converged with a viral mutation to force the topic of (in)justice to re-enter mainstream conversation. Not since the Civil Rights Movement has the matter of (in)equity been in the homes of so many U.S. families and the (virtual) offices of so many workplaces. The disproportionate deaths of Indigenous, Black, Asian, and Latinx peoples in relation to Whites is long-known in communities of color and is well documented in public health.

Agricultural workers in meatpacking plants presenting to an emergency department with suspected COVID-19 infection are disproportionately Black and Hispanic

Objective

Facilities that process and package meat for consumer sale and consumption (meatpacking plants) were early sites of coronavirus disease 2019 (COVID‐19) outbreaks. The aim of this study was to characterize the association between meatpacking plant exposure and clinical outcomes among emergency department (ED) patients with COVID‐19 symptoms.

Methods

This was a retrospective cohort study of patients presenting to a single ED, from March 1 to May 31, 2020, who had: 1) symptoms consistent with COVID‐19 and 2) a COVID‐19 test performed. The primary outcome was COVID‐19 positivity, and secondary outcomes included hospital admission from the ED, ventilator use, intensive care unit (ICU) admission, hospital length of stay (LOS; <48 or ≥48 h), and mortality.

Results

Patients from meatpacking plants were more likely to be Black or Hispanic than the ED patients without this occupational exposure. Patients with a meatpacking plant exposure were more likely to test positive for COVID‐19 (adjusted relative risk [aRR] = 2.37, 95% confidence interval [CI] = 1.59 to 3.53) but had similar rates of hospital admission (aRR = 0.94, 95% CI = 0.82 to 1.07) and hospital LOS (aRR = 0.76, 95% CI = 0.45 to 1.23). There was no significant difference in ventilator use among patients with meatpacking and nonmeatpacking plant exposure (8.2% vs. 11.1%, p = 0.531), ICU admissions (4.1% vs. 12.0%, p = 0.094), and mortality (2.0% vs. 4.1%, p = 0.473).

Conclusions

Workers in meatpacking plants in Iowa had a higher rate of testing positive for COVID‐19 but were not more likely to be hospitalized for their illness. These patients were disproportionately Black and Hispanic.

The use of qualitative methods in venous thromboembolism research

INTRODUCTION

Qualitative research has been increasingly used in health care research to allow in-depth insights and understanding of patients' lived experiences for poorly understood phenomena. The psychological stress mechanisms underlying fear, dyspnea, and pain after venous thromboembolism (VTE) remain poorly understood. However, novice VTE researchers may not be familiar with the process of undertaking qualitative research.

OBJECTIVE

The aim of this article is to describe the planning, methodology and execution of qualitative methods, using the example of patients' lived experiences during and after the diagnosis of VTE. We discuss challenges and solutions in implementing qualitative research methods in health care research.

METHODS

Patients were recruited from the emergency department and clinic using in-person and phone contact. We used both in-person and video format to interview 24 patients. Interviews were guided by a set of questions to be explored but conducted to elucidate unique thoughts and opinions from patients.

RESULTS

For recruitment, "cold-calling" was found to be largely unsuccessful. Many patients have preexisting diagnoses of anxiety and depression. Video interviews were found to be at least as effective as in-person interviews. Interviews revealed unique post-VTE experiences from all participants, with a wide range of impact on quality of life. Themes that were most common included perceptions of physician communication, fear of recurrence, and concerns of death.

CONCLUSION

A qualitative research approach can reveal individual experiences and psychosocial impact in patients diagnosed with VTE, which allow the researchers to better comprehend the complexity of this phenomenon and its impact in health care.

Inter-rater reliability and prospective validation of a clinical prediction rule for SARS-CoV-2 infection

Objectives

Accurate estimation of the risk of SARS‐CoV‐2 infection based on bedside data alone has importance to emergency department (ED) operations and throughput. The 13‐item CORC (COVID [or coronavirus] Rule‐out Criteria) rule had good overall diagnostic accuracy in retrospective derivation and validation. The objective of this study was to prospectively test the inter‐rater reliability and diagnostic accuracy of the CORC score and rule (score ≤ 0 negative, > 0 positive) and compare the CORC rule performance with physician gestalt.

Methods

This noninterventional study was conducted at an urban academic ED from February 2021 to March 2021. Two practitioners were approached by research coordinators and asked to independently complete a form capturing the CORC criteria for their shared patient and their gestalt binary prediction of the SARS‐CoV‐2 test result and confidence (0%–100%). The criterion standard for SARS‐CoV‐2 was from reverse transcriptase polymerase chain reaction performed on a nasopharyngeal swab. The primary analysis was from weighted Cohen's kappa and likelihood ratios (LRs).

Results

For 928 patients, agreement between observers was good for the total CORC score, κ = 0.613 (95% confidence interval [CI] = 0.579–0.646), and for the CORC rule, κ = 0.644 (95% CI = 0.591–0.697). The agreement for clinician gestalt binary determination of SARs‐CoV‐2 status was κ = 0.534 (95% CI = 0.437–0.632) with median confidence of 76% (first–third quartile = 66–88.5). For 425 patients who had the criterion standard, a negative CORC rule (both observers scored CORC < 0), the sensitivity was 88%, and specificity was 51%, with a negative LR (LR−) of 0.24 (95% CI = 0.10–0.50). Among patients with a mean CORC score of >4, the prevalence of a positive SARS‐CoV‐2 test was 58% (95% CI = 28%–85%) and positive LR was 13.1 (95% CI = 4.5–37.2). Clinician gestalt demonstrated a sensitivity of 51% and specificity of 86% with a LR− of 0.57 (95% CI = 0.39–0.74).

Conclusion

In this prospective study, the CORC score and rule demonstrated good inter‐rater reliability and reproducible diagnostic accuracy for estimating the pretest probability of SARs‐CoV‐2 infection.

Guidelines for reasonable and appropriate care in the emergency department (GRACE): Recurrent, low-risk chest pain in the emergency department

This first Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-1) from the Society for Academic Emergency Medicine is on the topic: Recurrent, Low-risk Chest Pain in the Emergency Department. The multidisciplinary guideline panel used The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding eight priority questions for adult patients with recurrent, low-risk chest pain and have derived the following evidence based recommendations: (1) for those >3 h chest pain duration we suggest a single, high-sensitivity troponin below a validated threshold to reasonably exclude acute coronary syndrome (ACS) within 30 days; (2) for those with a normal stress test within the previous 12 months, we do not recommend repeat routine stress testing as a means to decrease rates of major adverse cardiac events at 30 days; (3) insufficient evidence to recommend hospitalization (either standard inpatient admission or observation stay) versus discharge as a strategy to mitigate major adverse cardiac events within 30 days; (4) for those with non-obstructive (<50% stenosis) coronary artery disease (CAD) on prior angiography within 5 years, we suggest referral for expedited outpatient testing as warranted rather than admission for inpatient evaluation; (5) for those with no occlusive CAD (0% stenosis) on prior angiography within 5 years, we recommend referral for expedited outpatient testing as warranted rather than admission for inpatient evaluation; (6) for those with a prior coronary computed tomographic angiography within the past 2 years with no coronary stenosis, we suggest no further diagnostic testing other than a single, normal high-sensitivity troponin below a validated threshold to exclude ACS within that 2 year time frame; (7) we suggest the use of depression and anxiety screening tools as these might have an effect on healthcare use and return emergency department (ED) visits; and (8) we suggest referral for anxiety or depression management, as this might have an impact on healthcare use and return ED visits.

Monotherapy Anticoagulation to Expedite Home Treatment of Patients Diagnosed With Venous Thromboembolism in the Emergency Department: A Pragmatic Effectiveness Trial

BACKGROUND

The objective was to test if low-risk emergency department patients with vitamin K antagonist (venous thromboembolism [VTE]; including venous thrombosis and pulmonary embolism [PE]) can be safely and effectively treated at home with direct acting oral (monotherapy) anticoagulation in a large-scale, real-world pragmatic effectiveness trial.

METHODS

This was a single-arm trial, conducted from 2016 to 2019 in accordance with the Standards for Reporting Implementation Studies guideline in 33 emergency departments in the United States. Participants had newly diagnosed VTE with low risk of death based upon either the modified Hestia criteria, or physician judgment plus the simplified PE severity index score of zero, together with nonhigh bleeding risk were eligible. Patients had to be discharged within 24 hours of triage and treated with either apixaban or rivaroxaban. Effectiveness was defined by the primary efficacy and safety outcomes, image-proven recurrent VTE and bleeding requiring hospitalization >24 hours, respectively, with an upper limit of the 95% CI for the 30-day frequency of VTE recurrence below 2.0% for both outcomes.

RESULTS

We enrolled 1421 patients with complete outcomes data, including 903 with venous thrombosis and 518 with PE. The recurrent VTE requiring hospitalization occurred in 14/1421 (1.0% [95% CI, 0.5%-1.7%]), and bleeding requiring hospitalization occurred in 12/1421 (0.8% [0.4%-1.5%). The rate of severe bleeding using International Society for Thrombosis and Haemostasis criteria was 2/1421 (0.1% [0%-0.5%]). No patient died, and serious adverse events occurred in 2.5% of venous thrombosis patients and 2.3% of patients with PE. Medication nonadherence was reported by patients in 8.0% (6.6%-9.5%) and was associated with a risk ratio of 6.0 (2.3-15.2) for VTE recurrence. Among all patients diagnosed with VTE in the emergency department during the period of study, 18% of venous thrombosis patients and 10% of patients with PE were enrolled.

CONCLUSIONS

Monotherapy treatment of low-risk patients with venous thrombosis or PE in the emergency department setting produced a low rate of bleeding and VTE recurrence, but may be underused. Patients with venous thrombosis and PE should undergo risk-stratification before home treatment. Improved patient adherence may reduce rate of recurrent VTE. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03404635.

Acceptability of Contraceptive Services in the Emergency Department: A Cross-sectional Survey

Introduction

Unintended pregnancy disproportionately affects marginalized populations and has significant negative health and financial impacts on women, their families, and society. The emergency department (ED) is a promising alternative setting to increase access to sexual and reproductive health (SRH) services including contraception, especially among marginalized populations. The primary objective of this study was to determine the extent to which adult women of childbearing age who present to the ED would be receptive to receiving contraception and/or information about contraception in the ED. As a secondary objective, we sought to identify the barriers faced in attempting to obtain SRH care in the past.

Methods

We conducted a quantitative, cross-sectional, assisted, in-person survey of women aged 18–50 in the ED setting at two large, urban, academic EDs between June 2018–September 2019. The survey was approved by the institutional review board. Survey items included demographics, interest in contraception initiation and/or receiving information about contraception in the ED, desire to conceive, prior SRH care utilization, and barriers to SRH.

Results

A total of 505 patients participated in the survey. Participants were predominantly single and Black, with a mean age of 31 years, and reporting not wanting to become pregnant in the next year. Of those participants, 55.2% (n = 279) stated they would be interested in receiving information about birth control AND receiving birth control in the ED if it were available. Of those who reported the ability to get pregnant, and not desiring pregnancy in the next year (n = 279, 55.2%), 32.6% were not currently using anything to prevent pregnancy (n = 91). Only 10.5% of participants stated they had experienced barriers to SRH care in the past (n = 53). Participants who experienced barriers to SRH reported higher interest in receiving information and birth control in the ED (74%, n = 39) compared to those who had not experienced barriers (53%, n = 240); (P = 0.004, 95% confidence interval, 1.30–4.66).

Conclusion

The majority of women of childbearing age indicated the desire to access contraception services in the ED setting. This finding suggests favorable patient acceptability for an implementation study of contraception services in emergency care.

Outpatient treatment of emergency department patients diagnosed with venous thromboembolism

Venous thromboembolism (VTE) includes the diagnosis of either deep venous thrombosis (DVT) and/or pulmonary embolism (PE). This review discusses an evidence-based approach to the outpatient treatment of VTE in the emergency care setting. Main findings: The majority of patients diagnosed with VTE in the acute care setting are at low risk for an adverse event. Outpatient treatment for patients deemed low-risk by validated clinical decision tools leads to safe, efficacious, patient-centered, and cost-effective care. From a patient perspective, outpatient treatment of VTE can been simplified by the use of direct oral anticoagulant (DOACs) medications, and is supported by clinical trial evidence, and clinical practice guidelines from international societies. Outpatient treatment of patients with DVT has been more widely accepted as a best practice, while adoption of outpatient treatment of low-risk patients with acute PE has lagged. Many acute care clinicians remain wary of discharging patients with PE, concerned about drug access, adherence, and follow-up. Patients with VTE should be risk stratified identically as emerging evidence has demonstrated efficacy and safety in the interdependence of acute care protocols for the outpatient treatment of low-risk DVT and PE. Clinicians who practice in the acute care setting should be comfortable with risk stratification, anticoagulation, and discharge of low-risk VTE.

Clinical prediction rule for SARS-CoV-2 infection from 116 U.S. emergency departments 2-22-2021

Objectives

Accurate and reliable criteria to rapidly estimate the probability of infection with the novel coronavirus-2 that causes the severe acute respiratory syndrome (SARS-CoV-2) and associated disease (COVID-19) remain an urgent unmet need, especially in emergency care. The objective was to derive and validate a clinical prediction score for SARS-CoV-2 infection that uses simple criteria widely available at the point of care.

Methods

Data came from the registry data from the national REgistry of suspected COVID-19 in EmeRgency care (RECOVER network) comprising 116 hospitals from 25 states in the US. Clinical variables and 30-day outcomes were abstracted from medical records of 19,850 emergency department (ED) patients tested for SARS-CoV-2. The criterion standard for diagnosis of SARS-CoV-2 required a positive molecular test from a swabbed sample or positive antibody testing within 30 days. The prediction score was derived from a 50% random sample (n = 9,925) using unadjusted analysis of 107 candidate variables as a screening step, followed by stepwise forward logistic regression on 72 variables.

Results

Multivariable regression yielded a 13-variable score, which was simplified to a 13-point score: +1 point each for age>50 years, measured temperature>37.5°C, oxygen saturation<95%, Black race, Hispanic or Latino ethnicity, household contact with known or suspected COVID-19, patient reported history of dry cough, anosmia/dysgeusia, myalgias or fever; and -1 point each for White race, no direct contact with infected person, or smoking. In the validation sample (n = 9,975), the probability from logistic regression score produced an area under the receiver operating characteristic curve of 0.80 (95% CI: 0.79–0.81), and this level of accuracy was retained across patients enrolled from the early spring to summer of 2020. In the simplified score, a score of zero produced a sensitivity of 95.6% (94.8–96.3%), specificity of 20.0% (19.0–21.0%), negative likelihood ratio of 0.22 (0.19–0.26). Increasing points on the simplified score predicted higher probability of infection (e.g., >75% probability with +5 or more points).

Conclusion

Criteria that are available at the point of care can accurately predict the probability of SARS-CoV-2 infection. These criteria could assist with decisions about isolation and testing at high throughput checkpoints.

Outpatient Treatment of Low-risk Pulmonary Embolism in the Era of Direct Oral Anticoagulants: A Systematic Review

BACKGROUND

Clinical guidelines have supported outpatient treatment of low-risk pulmonary embolism (PE) since 2014, but adoption of this practice has been slow. Direct oral anticoagulant (DOAC) therapy for venous thromboembolism (VTE) is now as common as vitamin K antagonist treatment, but data are sparse regarding outcomes for patients with low-risk PE treated with DOACs as outpatients. We conducted a systematic review of literature on outcomes of outpatient management for PE, including comparisons to inpatient treatment and differences by anticoagulant class.

METHODS

We searched Medline, Embase, PubMed, CENTRAL, clinicaltrials.gov, and ICTRN for studies published from January 1980 through February 2019 using a predefined strategy developed with a medical librarian. We included English-language randomized controlled trials (RCTs) and prospective nonrandomized trials (NRTs) of adult patients diagnosed with acute, symptomatic PE, and discharged from the emergency department or within 48 hours. Our primary outcome included four major adverse outcomes (all-cause mortality, PE-related mortality, recurrent VTE, and major bleeding) within 30 and 90 days. A preplanned subanalysis of high-quality studies assessed outcomes associated with different anticoagulation treatment classes.

RESULTS

Our initial search identified 6,818 records, of which 12 studies (four RCT, eight NRT) with a total of 3,191 patients were included in the review. All RCTs and six NRTs were determined to have low to moderate risk of bias and were classified as high quality. Outpatients in these studies (n = 1,814) had rates of 90-day major adverse outcomes below 1%, including all-cause mortality (0.7%, 95% confidence interval [CI] = 0.4% to 1.2%), PE-related mortality (0.06%, 95% CI = 0.01% to 0.3%), recurrent VTE (0.8%, 95% CI = 0.5% to 1.4%), and major bleeding (0.8%, 95% CI = 0.5% to 1.4%). Exploratory analysis revealed no association between anticoagulant treatment class and rates of major adverse outcomes.

CONCLUSION

Among patients with low-risk PE treated as outpatients, few patients experienced major adverse outcomes such as mortality, recurrent VTE, or major bleeding within 90 days.

Multicenter registry of United States emergency department patients tested for SARS-CoV-2

This paper summarizes the methodology for the registry of suspected COVID-19 in emergency care (RECOVER), a large clinical registry of patients from 155 United States (US) emergency departments (EDs) in 27 states tested for SARS-CoV-2 from March-September 2020. The initial goals are to derive and test: (1) a pretest probability instrument for prediction of SARS-CoV-2 test results, and from this instrument, a set of simple criteria to exclude COVID-19 (the COVID-19 Rule-Out Criteria-the CORC rule), and (2) a prognostic instrument for those with COVID-19. Patient eligibility included any ED patient tested for SARS-CoV-2 with a nasal or oropharyngeal swab. Abstracted clinical data included 204 variables representing the earliest manifestation of infection, including week of testing, demographics, symptoms, exposure risk, past medical history, test results, admission status, and outcomes 30 days later. In addition to the primary goals, the registry will provide a vital platform for characterizing the course, epidemiology, clinical features, and prognosis of patients tested for COVID-19 in the ED setting.

Synergistic effects of emergency physician empathy and burnout on patient satisfaction: a prospective observational study

BACKGROUND

Physician empathy and burnout have been shown to be independently associated with patient satisfaction. However, their correlations were uncertain in previous studies. We aimed to determine correlations among empathy, burnout, and patient satisfaction, and further analyse interactions among these factors.

METHOD

A single centre prospective observational study was conducted from December 2018 to August 2019 at JPS Health Network, USA. Emergency physician (EP) self-assessed empathy and burnout were measured by the Jefferson Scale of Empathy (JSE) and the Copenhagen Burnout Inventory (CBI) separately. We assessed patient perception of physician empathy and patient satisfaction with their treating physician by the Jefferson Scale of Patient Perception of Physician Empathy and a patient assessed satisfaction survey. Spearman's correlation was used to determine associations among JSE, patient assessed physician empathy, CBI and patient satisfaction. Additionally, JSE, patient assessed physician empathy and CBI predictive of patient satisfaction were measured by multivariate logistic regression analysis.

RESULTS

A total of 28 EPs and 423 patients were enrolled. Patient satisfaction had a weak correlation with JSE (ρ=0.11) but showed a strong correlation with patient assessed physician empathy (ρ=0.60). CBI showed no correlation with patient satisfaction (ρ<0.1). However, when JSE, patient assessed physician empathy and CBI were analysed together in relation to patient satisfaction, adjusted odds ratios (AOR) was 3.85 (95% CI 1.36 to 10.88) with high patient assessed physician empathy alone; AOR was 7.17 (2.62-19.67) when high patient assessed physician empathy was combined with low CBI; and AOR was 8.37 (3.07-22.83) when high patient assessed physician empathy, low CBI and high JSE were combined.

CONCLUSION

Patient assessed physician empathy had a strong positive correlation with patient satisfaction. Moreover, higher patient satisfaction was achieved from EPs of high patient assessed physician empathy, low CBI and high JSE, indicating a positive synergistic effect. These findings suggest different interventions might be applied to EPs of different wellness features to maximise patient satisfaction.

Fibrinolytics for the treatment of pulmonary embolism

The use of fibrinolytic agents in acute pulmonary embolism (PE), first described over 50 years ago, hastens the resolution of RV stain, leading to earlier hemodynamic improvement. However, this benefit comes at the increased risk of bleeding. The strongest indication for fibrinolysis is in high-risk PE, or that characterized by sustained hypotension, while its use in patients with intermediate-risk PE remains controversial. Fibrinolysis is generally not recommended for routine use in intermediate-risk PE, although most guidelines advise that it may be considered in patients with signs of acute decompensation and an overall low bleeding risk. The efficacy of fibrinolysis often varies significantly between patients, which may be at least partially explained by several factors found to promote resistance to fibrinolysis. Ultimately, treatment decisions should carefully weigh the risks and benefits of the individual clinical scenario at hand, including the overall severity, the patient's bleeding risk, and the presence of factors known to promote resistance to fibrinolysis. This review aims to further explore the use of fibrinolytic agents in the treatment of PE including specific indications, outcomes, and special considerations.

Statin Use is Associated with Reduced Risk of Recurrence in Patients with Venous Thromboembolism

BACKGROUND

Statin therapy appears to reduce incidence of venous thromboembolism in secondary analyses of non-venous thromboembolism trials, but no evidence has shown effect of statins in large population samples. The objective of this study was to examine the magnitude of the effect of statin therapy on venous thromboembolism recurrence across a large statewide population.

METHODS

This was a retrospective analysis of the Indiana Network for Patient Care database. All patients with an International Classification of Diseases-defined diagnosis of either deep vein thrombosis or pulmonary embolism from 2004-2017 were included. We collected Generic Product Identifier codes to determine whether patients had been prescribed a statin medication and divided patients into 2 groups: + or - statin. We then performed a propensity-matching analysis to balance covariates and created a final logistic regression model with statin use as the predictor variable and venous thromboembolism recurrence as the dependent variable.

RESULTS

This study included a total of 192,908 patients with documented statin use in 13.5%. Venous thromboembolism recurrence occurred in 16% of all patients over the study period. After propensity matching, patients not on a statin were found to have significantly higher rates of venous thromboembolism recurrence (20% vs 16%, P < .0001). Logistic regression yielded an odds ratio of 0.75 (95% confidence interval, 0.72-0.79) for venous thromboembolism recurrence for those on statin therapy.

CONCLUSIONS

We found that a statin prescription reduced risk of venous thromboembolism recurrence by approximately 25% after adjusting for risk factors, supporting the adjunctive role of statins in the prevention of venous thromboembolism recurrence.

Misdiagnosis and failure to diagnose in emergency care: Causes and empathy as a solution

Diagnostic error is the most frequent cause of allegations of negligence in emergency care in the United States and is estimated to contribute to the death of hundreds of thousands of patients worldwide each year. In this special contribution, we elucidate the cognitive mechanisms that emergency physicians use to make decisions and identify how these mechanisms can become sources of diagnostic error. The discussion centers on the appraisal of proposed methods to reduce the risk of diagnostic error, including debiasing strategies and a brief discussion of the theoretical basis for interventions to improve clinician empathy.

Clinical characteristics and treatment patterns of patients with venous thromboembolism (VTE) transitioning from hospital to post-discharge settings

OBJECTIVE

This study examined anticoagulant use during and after a hospital encounter for venous thromboembolism (VTE), a transition of care largely uncharacterized in the literature.

METHODS

Adults with a VTE diagnosis code during a hospital encounter (emergency department [ED], observation area [OBS], or inpatient hospital [IP]) from January 2012 to August 2017 were identified in an electronic health records database. The first such hospital encounter was defined as the index VTE encounter. Patients were linked to a claims database and required to be continuously enrolled for six months before the index admission date through six months after the index discharge date. Anticoagulants administered during the index VTE encounter and filled on or within 30 days of discharge were summarized descriptively overall, and by the type of index VTE encounter (IP, No IP) and anticoagulants administered during the index VTE encounter.

RESULTS

Among 2,968 eligible patients, mean (SD) age was 64 (16) years, 51% were female, 67% had an IP index VTE encounter, and 77% received anticoagulation therapy during the index VTE encounter. In total, 60% filled a prescription order for anticoagulant within 30 days post-discharge. Of those who received a direct oral anticoagulant (DOAC), warfarin, or parenteral anticoagulant only during the index VTE encounter, 74%, 69%, and 34%, respectively, filled a prescription for the same anticoagulant post-discharge. Patients treated with a DOAC or warfarin during an ED or OBS VTE encounter without a subsequent inpatient hospitalization were more likely to remain on the same anticoagulation therapy post-discharge than those with an inpatient hospitalization (81% vs 69% for DOAC and 75% vs 68% for warfarin).

CONCLUSIONS

Many patients treated with anticoagulation therapy during a VTE hospital encounter did not fill a prescription for an anticoagulant within 30 days post-discharge, highlighting an opportunity for improved management of care transitions in this patient population.