Rate of Successful Shoulder Reduction on First Confirmatory Imaging in the Emergency Department

BACKGROUND

Management of acute shoulder dislocation in the emergency department (ED) is common.

OBJECTIVE

This study describes the rate, risk factors, and length of stay (LOS) associated with shoulder dislocation reduction failure in the ED.

METHODS

The study was a retrospective case-control study of patients 18 years and older presenting to the ED with acute shoulder dislocation who underwent attempted reduction. Patients with successful reduction on post-reduction first confirmatory imaging are compared with those requiring multiple attempts.

RESULTS

Of 398 ED encounters when a shoulder reduction was attempted in the ED, 18.8% (75/398 [95% CI 15.2-22.9%]) required multiple reduction attempts. Patients with successful reduction on first confirmatory imaging were more commonly male (80.2% [95% CI 75.6-84.3%] vs. 68.0% [95% CI 56.8-77.8%]; p = 0.0220), discharged home from the ED (95.4% [95% CI 92.6-97.3%] vs. 84.0% [95% CI 74.4-91.0%]; p = 0.0004), reduced using a traction/countertraction technique (42.1% [95% CI 36.8-47.6%] vs. 29.3% [95% CI 19.9-40.4%]; p = 0.0415), and less likely to have a pre-reduction fracture (26.0% [95% CI 21.4-31.0%] vs. 45.3% [95% CI 34.4-56.7%]; p = 0.0010). Mean length of stay (LOS) for those with successful reduction on first confirmatory imaging was 2 hours and 8 minutes shorter than for those with more than one attempt (p < 0.001).

CONCLUSIONS

The rate of failed first-pass reduction is higher than previously reported. Furthermore, the ED LOS was significantly longer in patients requiring multiple attempts. Knowledge of the failure rate and risk factors may raise physician awareness and guide future studies evaluating approaches for verification of reduction success.

Implementation of a Novel Residency-Based Electrocardiogram Curriculum Based on Free Open Access Content

BACKGROUND

Interpretation of the electrocardiogram (ECG) is fundamental in the practice and teaching of emergency medicine. Previous studies have shown that providers of all levels have expressed interest in additional education with ECGs. Asynchronous learning has been shown to be beneficial for improving residents' ability to recognize findings of acute myocardial ischemia.

OBJECTIVES

The goal of the study was to know whether a new format based on free, online content would improve residents' ability to interpret ECGs.

METHODS

In this 1-year educational pilot study at a single urban teaching hospital, resident physicians participated in a longitudinal curriculum based on free, online content, which was delivered to them electronically on a weekly basis. The study was conducted during the 2016-2017 academic year. Prior to and after the study period, their subjective attitudes toward ECG interpretation, and their objective ability to interpret them successfully, were assessed.

RESULTS

Of 42 residents, 25 (59.5%) completed the pre- and post-ECG testing. During the study period, trainees demonstrated improvement in both their subjective attitude toward ECG interpretation and their objective ability to interpret various abnormalities.

CONCLUSIONS

Despite some important limitations, we believe this study represents an essential step in the development of training methods for the modern emergency medicine trainee.

Impact of the COVID-19 Pandemic on Emergency Department Encounters in a Major Metropolitan Area

BACKGROUND

The end of 2019 marked the emergence of the COVID-19 pandemic. Public avoidance of health care facilities, including the emergency department (ED), has been noted during prior pandemics.

OBJECTIVE

This study described pandemic-related changes in adult and pediatric ED presentations, acuity, and hospitalization rates during the pandemic in a major metropolitan area.

METHODS

The study was a cross-sectional analysis of ED visits occurring before and during the pandemic. Sites collected daily ED patient census; monthly ED patient acuity, as the Emergency Severity Index (ESI) score; and disposition. Prepandemic ED visits occurring from January 1, 2019 through December 31, 2019 were compared with ED visits occurring during the pandemic from January 1, 2020 through March 31, 2021. The change in prepandemic and pandemic ED volume was found using 7-day moving average of proportions.

RESULTS

The study enrolled 83.8% of the total ED encounters. Pandemic adult and pediatric visit volume decreased to as low as 44.7% (95% CI 43.1-46.3%; p < 0.001) and 22.1% (95% CI 19.3-26.0%; p < 0.001), respectively, of prepandemic volumes. There was also a relative increase in adult and pediatric acuity (ESI level 1-3) and the admission percentage for adult (20.3% vs. 22.9%; p < 0.01) and pediatric (5.1% vs. 5.6%; p < 0.01) populations.

CONCLUSIONS

Total adult and pediatric encounters were reduced significantly across a major metropolitan area. Patient acuity and hospitalization rates were relatively increased. The development of strategies for predicting ED avoidance will be important in future pandemics.

Prevalence of Diarrhea and its Relation with Severity of the Disease among Covid-19 Positive Patient in a Selected Covid Dedicated Hospital

Covid-19 has become a pandemic since its emergence in Wuhan, China. It involves Gastro intestinal (GI) system and diarrhea is recognized as an important symptom. Diarrhea is also associated with disease severity. This study was conducted to see the prevalence of diarrhea in Covid-19 positive patient and its relation with disease severity. Prospective observational study done among consecutive Covid-19 positive patient of both sex admitted in Mugda Medical College Hospital in Dhaka from February 2021 to April 2021. Informations were collected by face to face interview and severity was assessed on bedside. Among 166 Covid-19 positive patient 40.0% developed diarrhea. Mean age of the diarrheal patients was 44.21±14.40. Women affected more than men (51.0% versus 49.0%). In majority patient (62.0%) diarrhea persist for 3-7 days and majority had frequency of bowel movement 3-5 times per day. Regarding Bristol stool type 47.0% had stool type 6 followed by stool type 7(43.0%) and stool type 5(10.0%). Half of the diarrheal patient (48.0%) had severe pneumonia. Severe pneumonia is significantly more common in non-diarrheal patients (65.0%) than in diarrheal patient (35.0%) (p=0.007). This study reflects that a large number of Covid-19 positive patients developed diarrhea. Half of the diarrheal patients had severe pneumonia. But severe pneumonia is significantly common in non-diarrheal patient than diarrheal patients.

Guidelines for reasonable and appropriate care in the emergency department 3 (GRACE-3): Acute dizziness and vertigo in the emergency department

This third Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-3) from the Society for Academic Emergency Medicine is on the topic adult patients with acute dizziness and vertigo in the emergency department (ED). A multidisciplinary guideline panel applied the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding five questions for adult ED patients with acute dizziness of less than 2 weeks' duration. The intended population is adults presenting to the ED with acute dizziness or vertigo. The panel derived 15 evidence-based recommendations based on the timing and triggers of the dizziness but recognizes that alternative diagnostic approaches exist, such as the STANDING protocol and nystagmus examination in combination with gait unsteadiness or the presence of vascular risk factors. As an overarching recommendation, (1) emergency clinicians should receive training in bedside physical examination techniques for patients with the acute vestibular syndrome (AVS; HINTS) and the diagnostic and therapeutic maneuvers for benign paroxysmal positional vertigo (BPPV; Dix-Hallpike test and Epley maneuver). To help distinguish central from peripheral causes in patients with the AVS, we recommend: (2) use HINTS (for clinicians trained in its use) in patients with nystagmus, (3) use finger rub to further aid in excluding stroke in patients with nystagmus, (4) use severity of gait unsteadiness in patients without nystagmus, (5) do not use brain computed tomography (CT), (6) do not use routine magnetic resonance imaging (MRI) as a first-line test if a clinician trained in HINTS is available, and (7) use MRI as a confirmatory test in patients with central or equivocal HINTS examinations. In patients with the spontaneous episodic vestibular syndrome: (8) search for symptoms or signs of cerebral ischemia, (9) do not use CT, and (10) use CT angiography or MRI angiography if there is concern for transient ischemic attack. In patients with the triggered (positional) episodic vestibular syndrome, (11) use the Dix-Hallpike test to diagnose posterior canal BPPV (pc-BPPV), (12) do not use CT, and (13) do not use MRI routinely, unless atypical clinical features are present. In patients diagnosed with vestibular neuritis, (14) consider short-term steroids as a treatment option. In patients diagnosed with pc-BPPV, (15) treat with the Epley maneuver. It is clear that as of 2023, when applied in routine practice by emergency clinicians without special training, HINTS testing is inaccurate, partly due to use in the wrong patients and partly due to issues with its interpretation. Most emergency physicians have not received training in use of HINTS. As such, it is not standard of care, either in the legal sense of that term ("what the average physician would do in similar circumstances") or in the common parlance sense ("the standard action typically used by physicians in routine practice").

qSOFA does not predict bacteremia in patients with severe manifestations of sepsis

BACKGROUND

Bloodstream infections in septic patients may be missed due to preceding antibiotic therapy prior to obtaining blood cultures. We leveraged the FABLED cohort study to determine if the quick Sequential Organ Failure Assessment (qSOFA) score could reliably identify patients at higher risk of bacteremia in patients who may have false negative blood cultures due to previously administered antibiotic therapy.

METHODS

We conducted a multi-centre diagnostic study among adult patients with severe manifestations of sepsis. Patients were enrolled in one of seven participating centres between November 2013 and September 2018. All patients from the FABLED cohort had two sets of blood cultures drawn prior to the administration of antimicrobial therapy, as well as additional blood cultures within 4 hours of treatment initiation. Participants were categorized according to qSOFA score, with a score ≥2 being considered positive.

RESULTS

Among 325 patients with severe manifestations of sepsis, a positive qSOFA score (defined as a score ≥2) on admission was 58% sensitive (95% CI 48% to 67%) and 41% specific (95% CI 34% to 48%) for predicting bacteremia. Among patients with negative post-antimicrobial blood cultures, a positive qSOFA score was 57% sensitive (95% CI 42% to 70%) and 42% specific (95% CI 35% to 49%) to detect patients who were originally bacteremic prior to the initiation of therapy.

CONCLUSIONS

Our results suggest that the qSOFA score cannot be used to identify patients at risk for occult bacteremia due to the administration of antibiotics pre-blood culture.

The Association of Latitude and Altitude with COVID-19 Symptoms: A VIRUS: COVID-19 Registry Analysis

Background:

Better delineation of COVID-19 presentations in different climatological conditions might assist with prompt diagnosis and isolation of patients.

Objectives:

To study the association of latitude and altitude with COVID-19 symptomatology.

Methods:

This observational cohort study included 12267 adult COVID-19 patients hospitalized between 03/2020 and 01/2021 at 181 hospitals in 24 countries within the SCCM Discovery VIRUS: COVID-19 Registry. The outcome was symptoms at admission, categorized as respiratory, gastrointestinal, neurological, mucocutaneous, cardiovascular, and constitutional. Other symptoms were grouped as atypical. Multivariable regression modeling was performed, adjusting for baseline characteristics. Models were fitted using generalized estimating equations to account for the clustering.

Results:

The median age was 62 years, with 57% males. The median age and percentage of patients with comorbidities increased with higher latitude. Conversely, patients with comorbidities decreased with elevated altitudes. The most common symptoms were respiratory (80%), followed by constitutional (75%). Presentation with respiratory symptoms was not associated with the location. After adjustment, at lower latitudes (<30º), patients presented less commonly with gastrointestinal symptoms (p<.001, odds ratios for 15º, 25º, and 30º: 0.32, 0.81, and 0.98, respectively). Atypical symptoms were present in 21% of the patients and showed an association with altitude (p=.026, odds ratios for 75, 125, 400, and 600 meters above sea level: 0.44, 0.60, 0.84, and 0.77, respectively).

Conclusions:

We observed geographic variability in symptoms of COVID-19 patients. Respiratory symptoms were most common but were not associated with the location. Gastrointestinal symptoms were less frequent in lower latitudes. Atypical symptoms were associated with higher altitude.

Impact of COVID-19 Pandemic on Emergency Department Visits: A Regional Case Study of Informatics Challenges and Opportunities

In this paper, we examined informatics challenges and opportunities related to emergency department visit data during public health emergencies. We investigated the impact of COVID-19 pandemic on the volume and acuity of adult patients visiting the emergency department (ED) of a medical center in Arizona during the pandemic compared to the pre-pandemic period. We performed a negative binomial regression analysis to understand how different public health-related mandates and statewide business opening/closing orders in Arizona affected the daily emergency department visits. The results of this study show that the average daily ED visits decreased by 20% during the COVID-19 pandemic in comparison with the same period in 2019. In addition, the business closure order had the most impact on emergency department visits in comparison to other public health mandates.

Frequency of Eosinophilic Esophagitis among Patients with Gastroesophageal Reflux Symptoms in an Academic Hospital of Bangladesh: A Cross Sectional Study

Eosinophilic esophagitis (EoE) is a disease of modern era. It was first described 40 years back. Since then it has drawn an immense interest among the clinicians. It is diagnosed by the presence of eosinophils count ≥15/HPF on esophageal biopsied mucosa in patients with symptoms of esopohageal dysfunction. It is more prevalent among patients with gastroesophageal reflux disease. As its symptoms overlap with that of gastroesophageal reflux disease (GERD), it is frequently overlooked & misdiagnosed which increases patients' sufferings. No data is available in Bangladesh. The objective of the study was to find out the frequency of eosinophilic esophagitis among patients with gastroesophageal reflux symptoms. The study was conducted at the Outpatient department of the department of Gastroenterology of Dhaka Medical College Hospital, Dhaka, Bangladesh from September 2018 to April 2019. One hundred and thirty three (133) consecutive patients with symptoms suggestive of gastroesophageal reflux disease based on validated questionnaire underwent upper GI endoscopy. Biopsies were taken from proximal and distal esophagus as well as any other endoscopically abnormal esophageal mucosal lesion. Among 133 patients with gastroesophageal reflux symptoms, 7 patients (5.3%) were found to be positive for eosinophilic esophagitis. Mean age at diagnosis was 37.28±13.38 years. It was more common in younger age group. Female patients (56%) were more than male patients (44%). Heart burn was the major symptom followed by acid regurgitation. Nocturnal cough showed statistically significant relationship with eosinophilic esophagitis. Although the frequency is low, it may be considered as a differential diagnosis among patients with GERD.

Clinical Risk Index for Babies II Score as a Predictor of Neonatal Death among Preterm Low Birth Weight Babies

Clinical risk index for babies II (CRIB II) score is simple, validated and widely used risk-adjustment instrument for predicting mortality among preterm low birth weight babies. To assess the efficacy of CRIB II score as a tool to predict the risk for neonatal death among the preterm and LBW babies admitted in NICU of BSMMU, a tertiary care hospital in Bangladesh. This prospective observational study was conducted in Department of Neonatology in BSMMU from September 2016 to August 2017. Inborn preterm neonates with gestational age ≤34 weeks admitted were enrolled in the study. CRIB-II score was calculated for each infant within 1 hour of birth from birth weight, gestational age, sex, admission temperature and base excess. The primary outcome measured in the study was neonatal death or survival up to 28 days. Total 112 patients were finally analyzed in this study. Mean CRIB II score was significantly higher in the non-survivor group compared to the survivor group (p-value <0.0001). Receiver operating characteristic (ROC) curve analysis for mortality prediction by CRIB II score, gestational age and birth weight showed AUC 0.87 (95% CI 0.76-0.97), 0.76 (95% CI 0.63-0.88) and 0.79 (95% CI 0.66-0.92) respectively. ROC curve analysis also revealed that the most suitable cut-off points for predicting mortality were 5 for CRIB II score, 32 weeks for gestational age and 1250 gram for birth weight. Using these most suitable cut-off points, CRIB II score had the highest sensitivity and specificity followed by birth weight and gestational age. In this study, CRIB II score was found to be an effective tool for predicting neonatal death among preterm LBW babies. It predicted outcome more accurately than birth weight or gestational age alone.

Neither Blood Culture Positivity nor Time to Positivity Is Associated With Mortality Among Patients Presenting With Severe Manifestations of Sepsis: The FABLED Cohort Study

Background

Sepsis is a leading cause of morbidity, mortality, and health care costs worldwide.

Methods

We conducted a multicenter, prospective cohort study evaluating the yield of blood cultures drawn before and after empiric antimicrobial administration among adults presenting to the emergency department with severe manifestations of sepsis. Enrolled patients who had the requisite blood cultures drawn were followed for 90 days. We explored the independent association between blood culture positivity and its time to positivity in relation to 90-day mortality.

Results

Three hundred twenty-five participants were enrolled; 90-day mortality among the 315 subjects followed up was 25.4% (80/315). Mortality was associated with age (mean age [standard deviation] in those who died was 72.5 [15.8] compared with 62.9 [17.7] years among survivors; P < .0001), greater Charlson Comorbidity Index (2 [interquartile range {IQR}, 1–3] vs 1 [IQR, 0–3]; P = .008), dementia (13/80 [16.2%] vs 18/235 [7.7%]; P = .03), cancer (27/80 [33.8%] vs 47/235 [20.0%]; P = .015), positive quick Sequential Organ Failure Assessment score (57/80 [71.2%] vs 129/235 [54.9%]; P = .009), and normal white blood cell count (25/80 [31.2%] vs 42/235 [17.9%]; P = .02). The presence of bacteremia, persistent bacteremia after antimicrobial infusion, and shorter time to blood culture positivity were not associated with mortality. Neither the source of infection nor pathogen affected mortality.

Conclusions

Although severe sepsis is an inflammatory condition triggered by infection, its 90-day survival is not influenced by blood culture positivity nor its time to positivity.

Clinical Trials Registration

NCT01867905.

Neonatal COVID-19 Infection: Is Neonate Safe?

No Abstract.

Treacher Collins Syndrome: A Case Report

Treacher collins syndrome (TCS) or Franceschetti syndrome is an autosomal dominant inherited disorder with variable expressivity. It affects mainly craniofacial structure that derives from 1st and 2nd branchial arches approximately between the 20th day and 12th week of intrauterine life. This syndrome has different clinical types. Most common features are antimongoloid slanting of the palpebral fissures, hypoplasia of zygoma, maxilla & mandible with various eye and ear abnormalities. Here we present a case of an 11 days old female neonate, who was ill looking, dyspnoeic having significant facial profile, multiple congenital anomalies and dolicocephaly; admitted in the department of Neonatology, Mymensingh Medical College Hospital (MMCH), Mymensingh, Bangladesh on 7th August 2020. After taking all the diagnostic assistance of the multidisciplinary approach mainly on the basis of clinical features and radiology we diagnosed the case as TCS. We managed the patient by maintaining temperature, giving nutritional support and injectable antibiotic, took consultation from Otolaryngology department then we discharged the baby with proper counseling, advised regarding further follow up and to consult with paediatric surgeon and cardiologist.

An update on the rod microglia variant in experimental and clinical brain injury and disease

Contemporary microglia morphologies include ramified, activated and amoeboid, with the morphology of microglia considered highly coupled to the cellular function. Rod microglia are an additional activated microglia variant observed in the ageing, injured and diseased brain. Rod microglia were reported frequently in the early 1900s by neuropathologists in post-mortem cases of general paresis, Alzheimer's disease and encephalitis, and then remained largely ignored for almost 100 years. Recent reports have renewed interest in rod microglia, most notably after experimental traumatic brain injury. Rod microglia are formed by the narrowing of the soma and retraction of planar processes, which results in the appearance of an elongated, rod-shaped cell. Rod microglia are most commonly observed in the cortex, aligned perpendicular to the dural surface and adjacent to neuronal processes; in the hippocampus, they are aligned perpendicular to hippocampal layers. Furthermore, rod microglia form trains with one another, apical end to basal end. By replicating the process of sketching microscopic observation, rod microglia are re-defined by circumnutation around the long axis. In this update, we summarize the rod microglia variant in clinical and experimental literature and advocate for investigation into mechanisms of rod microglia origin and function.

Real-world Time to Positivity of 2 Widely Used Commercial Blood Culture Systems in Patients With Severe Manifestations of Sepsis: An Analysis of the FABLED Study

Background

Of all microbiological tests performed, blood cultures have the most impact on patient care. Timely results are essential, especially in the management of sepsis. While there are multiple available blood culture systems on the market, they have never been compared in a prospective study in a critically ill population.

Methods

We performed an analysis of the FABLED study cohort to compare culture results and time to positivity (TTP) of 2 widely used blood culture systems: BacT/Alert and BACTEC. In this multisite prospective study, patients with severe manifestations of sepsis had cultures drawn before antibiotics using systematic enrollment criteria and blood drawing methodology allowing for minimization of pre-analytical biases.

Results

We enrolled 315 patients; 144 had blood cultures (47 positive) with BacT/Alert and 171 with BACTEC (53 positive). Patients whose blood cultures were processed using the BacT/Alert system were younger (median, 64 vs 70 years; P = .003), had a higher proportion of HIV (9.03% vs 1.75%; P = .008) and a lower qSOFA (P = .003). There were no statistically significant differences in the most commonly identified bacterial species. TTP was shorter for BACTEC (median [interquartile range {IQR}], 12.5 [10-14] hours) compared with BacT/Alert (median [IQR], 17 [14-21] hours; P < .0001).

Conclusions

In this large prospective multi-centre study comparing the two blood culture systems among patients with severe manifestations of sepsis, and using a rigorous pre-analytical methodology, the BACTEC system yielded positive culture results 4.5 hours earlier than BacT/Alert. These results apply to commonly isolated bacteria. However, our study design did not allow direct comparison of TTP for unusual pathogens nor of clinical sensitivity between systems. More research is needed to determine the clinical implications of this finding.

Risk of contrast extravasation with vascular access in computed tomography

PURPOSE

Diagnostic computed tomography (CT) imaging, utilizing intravenous (IV) contrast administration, has become increasingly common. Potential IV contrast-associated complications include local skin and soft tissue reactions due to extravasation. The goal of this study is to describe the risk of contrast extravasation based on IV catheter anatomic location in patients receiving contrast-enhanced CT imaging.

METHODS

The study was conducted as a retrospective cohort study of patients receiving contrast-enhanced CT imaging performed over a 26-month period at a single institution. The rate of contrast extravasation was calculated by IV catheter vessel anatomic location and compared by relative risk (RR) and absolute risk reduction (ARR).

RESULTS

Of 17,767 contrast administrations for CT imaging studies performed, 14,558 met study inclusion criteria. Forty-nine (0.34%) extravasation events were identified. Forty-one (0.28%, 95% CI 0.21-0.39%) extravasation events were observed in 14,275 peripheral IV catheters placed in a non-upper arm location. Eight (2.8%, 95% CI 1.3-5.3%) extravasation events were observed in 283 IV catheters placed, most commonly with point-of-care ultrasound (POCUS) guidance, in upper arm vessels (RR 10.1, 95% CI 4.69-21.8). Non-upper arm located IV catheters were associated with an ARR of 2.54% (95% CI 0.61-4.47%) when compared to upper arm catheters.

CONCLUSIONS

IV catheter placement in upper arm vessels is associated with a relatively minimal increase in extravasation risk when compared to catheters placed in a non-upper arm location. In patients without alternative available peripheral vascular access, POCUS-guided upper arm IV cannulation may be an appropriate approach.

Freestanding Emergency Department Entry and Market-level Spending on Emergency Care

Background

Freestanding emergency departments (FrEDs) could reduce wait times in overcrowded emergency departments (EDs), but they might also increase usage and overall spending for emergency care. We investigate the relationship between the number of FrEDs entering a local market and overall spending on emergency care.

Methods

We accessed data from Arizona, Florida, North Carolina, and Texas in Blue Cross Blue Shield Axis; a limited data set of deidentified insurance data claims that we linked to Public Use Microdata Area (PUMA) data from the American Community Survey; and lists of licensed FrEDs from state agencies. Regression analysis was used to estimate the association between changes in the number of FrEDs in 495 PUMAs and total spending on emergency care, out‐of‐pocket spending, utilization, and price per visit from January 2013 to December 2017. Final estimates came from a PUMA‐level fixed‐effects model, with controls for state, quarter, and PUMA‐level demographics.

Results

Entry of an additional FrED in a PUMA was associated with a 3.6 percentage point (pp; CI = 2.4 to 4.9) increase in emergency provider reimbursement per insured beneficiary in Texas, Florida, and North Carolina. There was no change in spending (2.5 pp; CI = −8.2 to 3.1) associated with a FrED's entry in Arizona. Entry of an additional FrED was associated with a 0.18 (CI = 0.12 to 0.23) increase in the number of emergency care visits per 100 enrollees in Texas, Florida, and Arizona. In contrast, entry of another FrED was not associated with a change in utilization (−0.03; CI =  −0.09 to 0.02) in North Carolina. Estimated out‐of‐pocket payments for emergency care increased 3.6 pp (CI = 2.5 to 4.8) with the entry of a FrED in Texas, Florida, and Arizona, but declined by 15.3 pp (CI = −26.8 to −3.7) in North Carolina.

Conclusions

Rather than functioning as substitutes for hospital‐based EDs, FrEDs have increased local market spending on emergency care in three of four states’ markets where they have entered. State policy makers and researchers should carefully track spending and utilization of emergency care as FrEDs disseminate to better understand their potential health benefits and cost implications for patients.

847. The Effect of Antimicrobial Administration on Blood Culture Positivity in Patients with Severe Manifestations of Sepsis

Background

Current guidelines recommend obtaining blood cultures prior to antimicrobial therapy in patients with sepsis. Administering antimicrobials immediately without waiting for blood cultures could potentially decrease time to treatment and improve outcomes, but it is unclear the degree to which this strategy impacts diagnostic yield.

Methods

We performed a patient-level, single-arm, diagnostic trial. Seven urban emergency departments affiliated with academic medical centers across Canada and the United States participated in the study. Adults ≥18 years of age presenting to the emergency department with evidence of severe manifestations of sepsis, including a systolic blood pressure <90 mmHg and/or a serum lactate ≥4 mmol/L were included. Study participants had 2 sets of blood cultures drawn prior to and immediately following antimicrobial administration. The primary outcome was the difference in blood culture pathogen recovery rates before and after administration of antimicrobial therapy.

Results

Of the 3,164 participants screened, 325 were included in the study (mean age, 65.6 years; 63.0% men) and had repeat blood cultures drawn after the initiation of antimicrobial therapy (median time of 70 minutes, IQR 50 to 110 minutes). Pre-antimicrobial blood cultures were positive for one or more microbial pathogens in 102/325 (31.4%) patients. Fifty-four participants (52.9%) had matching blood culture results after initiation of antimicrobial treatment. The absolute difference in pathogen recovery rates was 14.5% ([95% CI 8.0 to 21.0%]; P < 0.0001) between pre- and post-antimicrobial blood cultures. Results were consistent in an analysis of the per-protocol population (absolute difference, 13.3% [95% CI 6.1 to 20.4%]; P < 0.0001). Including the results of other microbiological cultures done as part of routine care, microbial pathogens were recovered in 69 of 102 (67.7%) participants (absolute difference, 10.2% [95% CI 3.4 to 16.8%]; P < 0.0001).

Conclusion

Among patients with severe manifestations of sepsis, the administration of empiric antimicrobial therapy significantly reduces the yield of pathogen recovery when blood cultures are drawn shortly after treatment initiation.

Disclosures

All Authors: No reported Disclosures.

Blood Culture Results Before and After Antimicrobial Administration in Patients With Severe Manifestations of Sepsis: A Diagnostic Study

BACKGROUND

Administering antimicrobial agents before obtaining blood cultures could potentially decrease time to treatment and improve outcomes, but it is unclear how this strategy affects diagnostic sensitivity.

OBJECTIVE

To determine the sensitivity of blood cultures obtained shortly after initiation of antimicrobial therapy in patients with severe manifestations of sepsis.

DESIGN

Patient-level, single-group, diagnostic study. (ClinicalTrials.gov: NCT01867905).

SETTING

7 emergency departments in North America.

PARTICIPANTS

Adults with severe manifestations of sepsis, including systolic blood pressure less than 90 mm Hg or a serum lactate level of 4 mmol/L or more.

INTERVENTION

Blood cultures were obtained before and within 120 minutes after initiation of antimicrobial treatment.

MEASUREMENTS

Sensitivity of blood cultures obtained after initiation of antimicrobial therapy.

RESULTS

Of 3164 participants screened, 325 were included in the study (mean age, 65.6 years; 62.8% men) and had repeated blood cultures drawn after initiation of antimicrobial therapy (median time, 70 minutes [interquartile range, 50 to 110 minutes]). Preantimicrobial blood cultures were positive for 1 or more microbial pathogens in 102 of 325 (31.4%) patients. Postantimicrobial blood cultures were positive for 1 or more microbial pathogens in 63 of 325 (19.4%) patients. The absolute difference in the proportion of positive blood cultures between pre- and postantimicrobial testing was 12.0% (95% CI, 5.4% to 18.6%; P < 0.001). Sensitivity of postantimicrobial culture was 52.9% (CI, 42.8% to 62.9%). When the results of other microbiological cultures were included, microbial pathogens were found in 69 of 102 (67.6% [CI, 57.7% to 76.6%]) patients.

LIMITATION

Only a proportion of screened patients were recruited.

CONCLUSION

Among patients with severe manifestations of sepsis, initiation of empirical antimicrobial therapy significantly reduces the sensitivity of blood cultures drawn shortly after treatment initiation.

PRIMARY FUNDING SOURCE

Vancouver Coastal Health, St. Paul's Hospital Foundation Emergency Department Support Fund, the Fonds de recherche Santé-Québec, and the Maricopa Medical Foundation.

Impact of Emergency Department Phlebotomists on Left-Before-Treatment-Completion Rates

Introduction

The emergency department (ED) serves as the primary access point to the healthcare system. ED throughput efficiency is critical. The percentage of patients who leave before treatment completion (LBTC) is an important marker of department efficiency. Our study aimed to assess the impact of an ED phlebotomist, dedicated to obtaining blood specimen collection on waiting patients, on LBTC rates.

Methods

This study was conducted as a retrospective observational analysis over approximately 18 months (October 5, 2015–March 31, 2017) for patients evaluated by a triage provider with a door-to-room (DtR) time of > 20 minutes (min). LBTC rates were compared in 10-min DtR increments for when the ED phlebotomist collected the patient’s specimen vs not.

Results

Of 71,942 patient encounters occurring during the study period, 17,349 (24.1%) met study inclusion criteria. Of these, 1842 (10.6%) had blood specimen collection performed by ED phlebotomy. The overall LBTC rate for encounters included in the analysis was 5.26% (95% confidence interval [CI], 4.94%–5.60%). Weighting the LBTC rates for each 10-min DtR interval using the fixed effects model led to an overall LBTC rate of 2.74% (95% CI, 2.09%–3.59%) for patient encounters with ED phlebotomist collection vs 5.31% (95% CI, 4.97%–5.67%) in those which did not, yielding a relative reduction of 48% (95% CI, 34%–63%). The effect of the phlebotomist on LBTC rates increased as DtR times increased. The difference in the rate of the rise of LBTC percentages, per 10-min interval, was 0.50% (95% CI, 0.19%–0.81%) higher for non-ED phlebotomist encounters vs phlebotomist encounters.

Conclusion

ED phlebotomy demonstrated a significant reduction in ED LBTC rates. Further, as DtR times increased, the impact of ED phlebotomy became increasingly significant. Adult EDs with increased rates of LBTC patient encounters may want to consider the implementation of ED phlebotomy.

Concordance between blood and cerebrospinal fluid cultures in meningitis

OBJECTIVE

To examine the association between cerebrospinal fluid (CSF) cultures and blood cultures in patients with suspected bacterial or fungal meningitis.

METHODS

A 5-year retrospective chart review, conducted from April 2012 to January 2017 of consecutive patient encounters with bacterial or fungal organism growth in CSF culture, when a blood culture was also obtained. Patients were excluded if they received antibiotics prior to either lumbar puncture (LP) or blood culture acquisition, or if CSF cultures were positive for common bacterial skin contaminants. Descriptive statistics were used to characterize the dataset.

RESULTS

21 patient encounters met study inclusion criteria. 13 (61.9%; 95% CI 40.2-80.5%) had blood culture growth of the same organism as the CSF culture. 1 patient had a different organism in the blood culture compared to the CSF culture. 6 patients (33.3%, 95% CI 14.8%-56.9%) with positive CSF cultures had negative blood cultures.

CONCLUSIONS

Our results suggest an insufficient degree of agreement between CSF and blood culture results. PCR may be a prudent approach in patients requiring immediate antibiotics and delayed LP.

Evaluation and Management of the Emergency Department Headache

The acute headache in the emergency department (ED) poses a diagnostic dilemma that may overwhelm providers attempting to weigh the cost of advanced workups against the risk of missing serious pathology. While the majority of headache concerns are benign primary headache disorders, identifying life-threatening secondary causes of headache-which may be broadly categorized into structural, infectious, and vascular causes-is the primary focus of evaluation in the ED. Secondary headaches are associated with a high morbidity and mortality, and require strict scrutiny of the history and physical examination to adequately risk-stratify patients. Innovative and emerging technologies may further assist providers in the diagnosis of headache, and challenge previous gold-standard diagnostic evaluations. Herein, we present a general overview of the workup and management of headaches in the ED, with a special section for diagnostic considerations in evaluating for acute meningitis, subarachnoid hemorrhage, and acute angle-closure glaucoma.

The ASOS Surgical Risk Calculator: development and validation of a tool for identifying African surgical patients at risk of severe postoperative complications

BACKGROUND

The African Surgical Outcomes Study (ASOS) showed that surgical patients in Africa have a mortality twice the global average. Existing risk assessment tools are not valid for use in this population because the pattern of risk for poor outcomes differs from high-income countries. The objective of this study was to derive and validate a simple, preoperative risk stratification tool to identify African surgical patients at risk for in-hospital postoperative mortality and severe complications.

METHODS

ASOS was a 7-day prospective cohort study of adult patients undergoing surgery in Africa. The ASOS Surgical Risk Calculator was constructed with a multivariable logistic regression model for the outcome of in-hospital mortality and severe postoperative complications. The following preoperative risk factors were entered into the model; age, sex, smoking status, ASA physical status, preoperative chronic comorbid conditions, indication for surgery, urgency, severity, and type of surgery.

RESULTS

The model was derived from 8799 patients from 168 African hospitals. The composite outcome of severe postoperative complications and death occurred in 423/8799 (4.8%) patients. The ASOS Surgical Risk Calculator includes the following risk factors: age, ASA physical status, indication for surgery, urgency, severity, and type of surgery. The model showed good discrimination with an area under the receiver operating characteristic curve of 0.805 and good calibration with c-statistic corrected for optimism of 0.784.

CONCLUSIONS

This simple preoperative risk calculator could be used to identify high-risk surgical patients in African hospitals and facilitate increased postoperative surveillance.

CLINICAL TRIAL REGISTRATION

NCT03044899.

Timing of INR reversal using fresh-frozen plasma in warfarin-associated intracerebral hemorrhage

Rapid reversal of coagulopathy is recommended in warfarin-associated intracerebral hemorrhage (WAICH). However, rapid correction of the INR has not yet been proven to improve clinical outcomes, and the rate of correction with fresh-frozen plasma (FFP) can be variable. We sought to determine whether faster INR reversal with FFP is associated with decreased hematoma expansion and improved outcome. We performed a retrospective analysis of a prospectively collected cohort of consecutive patients with WAICH presenting to an urban tertiary care hospital from 2000 to 2013. Patients with baseline INR > 1.4 treated with FFP and vitamin K were included. The primary outcomes are occurrence of hematoma expansion, discharge modified Rankin Scale (mRS), and 30-day mortality. The association between timing of INR reversal, ICH expansion, and outcome was investigated with logistic regression analysis. 120 subjects met inclusion criteria (mean age 76.9, 57.5% males). Median presenting INR was 2.8 (IQR 2.3-3.4). Hematoma expansion is not associated with slower INR reversal [median time to INR reversal 9 (IQR 5-14) h vs. 10 (IQR 7-16) h, p = 0.61]. Patients with ultimately poor outcome received more rapid INR reversal than those with favorable outcome [9 (IQR 6-14) h vs. 12 (8-19) h, p = 0.064). We find no evidence of an association between faster INR reversal and either reduced hematoma expansion or better outcome.

Rho-kinase inhibitors do not expand hematoma volume in acute experimental intracerebral hemorrhage

Rho‐associated kinase (ROCK) is an emerging target in acute ischemic stroke. Early pre‐hospital treatment with ROCK inhibitors may improve their efficacy, but their antithrombotic effects raise safety concerns in hemorrhagic stroke, precluding use prior to neuroimaging. Therefore, we tested whether ROCK inhibition affects the bleeding times, and worsens hematoma volume in a model of intracerebral hemorrhage (ICH) induced by intrastriatal collagenase injection in mice. Tail bleeding time was measured 1 h after treatment with isoform‐nonselective inhibitor fasudil, or ROCK2‐selective inhibitor KD025, or their vehicles. In the ICH model, treatments were administered 1 h after collagenase injection. Although KD025 but not fasudil prolonged the tail bleeding times, neither drug expanded the volume of ICH or worsened neurological deficits at 48 h compared with vehicle. Although more testing is needed in aged animals and comorbid models such as diabetes, these results suggest ROCK inhibitors may be safe for pre‐hospital administration in acute stroke.

Assessment of Linked Associations in Predictors of Life Expectancy Inequality

This data analysis compares the rise of income inequality, as well as racial inequality, over a same time frame as the rise in life expectancy inequality.

Ruling out Pulmonary Embolism in Patients with High Pretest Probability

Introduction

The American College of Emergency Physicians guidelines recommend more aggressive workup beyond imaging alone in patients with a high pretest probability (PTP) of pulmonary embolism (PE). However, the ability of multiple tests to safely rule out PE in high PTP patients is not known. We sought to measure the ability of negative computed tomography pulmonary angiography (CTPA) along with negative D-dimer to rule out PE in these high-risk patients.

Methods

We analyzed data from a previous prospective observational study conducted in 12 emergency departments (ED). Wells score criteria were entered by providers before final PE testing. PE was diagnosed by imaging on the index ED visit, or within 45 days, demonstrating either PE or deep vein thrombosis (DVT), or if the patient died of PE during the 45-day, follow-up period. Testing threshold was set at 1.8%.

Results

A total of 7,940 patients were enrolled and tested for PE, and 257 had high PTP (Wells >6). Sixteen of these high-risk patients had negative CTPA and negative D-dimer, of whom two were positive for PE (12.5% [95% confidence interval {2.2%–40.0%}]). One of these patients had a DVT on CT venogram and the other was diagnosed at follow-up.

Conclusion

Our analysis suggests that in patients with high PTP of PE, neither negative CTPA by itself nor a negative CTPA plus a negative D-dimer are sufficient to rule out PE. More aggressive workup strategies may be required for these patients.

Neurology Concepts: Young Women and Ischemic Stroke-Evaluation and Management in the Emergency Department

OBJECTIVE

Ischemic stroke is a leading cause of morbidity and mortality worldwide. While the incidence of ischemic stroke is highest in older populations, incidence of ischemic stroke in adults has been rising particularly rapidly among young (e.g., premenopausal) women. The evaluation and timely diagnosis of ischemic stroke in young women presents a challenging situation in the emergency department, due to a range of sex-specific risk factors and to broad differentials. The goals of this concepts paper are to summarize existing knowledge regarding the evaluation and management of young women with ischemic stroke in the acute setting.

METHODS

A panel of six board-certified emergency physicians, one with fellowship training in stroke and one with training in sex- and sex-based medicine, along with one vascular neurologist were coauthors involved in the paper. Each author used various search strategies (e.g., PubMed, PsycINFO, and Google Scholar) for primary research and reviewed articles related to their section. The references were reviewed and evaluated for relevancy and included based on review by the lead authors.

RESULTS

Estimates on the incidence of ischemic stroke in premenopausal women range from 3.65 to 8.9 per 100,000 in the United States. Several risk factors for ischemic stroke exist for young women including oral contraceptive (OCP) use and migraine with aura. Pregnancy and the postpartum period (up to 12 weeks) is also an important transient state during which risks for both ischemic stroke and cerebral hemorrhage are elevated, accounting for 18% of strokes in women under 35. Current evidence regarding the management of acute ischemic stroke in young women is also summarized including use of thrombolytic agents (e.g., tissue plasminogen activator) in both pregnant and nonpregnant individuals.

CONCLUSION

Unique challenges exist in the evaluation and diagnosis of ischemic stroke in young women. There are still many opportunities for future research aimed at improving detection and treatment of this population.

Implications of language barrier on the diagnostic yield of computed tomography in pulmonary embolism

OBJECTIVES

To determine if a physician-patient language barrier impacts the diagnostic accuracy of pulmonary embolism (PE) evaluation.

METHODS

A retrospective chart review, conducted between June 2015 and December 2016, of a consecutive sample of diagnostic computed tomography pulmonary angiogram (CTPA) studies performed on adult patients. Positive and negative CTPA scans were further categorized by patient language and the positive diagnostic yield was determined for each language group. A post collection sub-analysis was performed to determine the yield when interpreter services were identified as necessary.

RESULTS

The yield for English speaking patients was 10.24% (92/898, 95% CI 8.39% to 12.36%), similar to the yield in Spanish speaking patients of 9.40% (25/266, 95% CI 6.31% to 13.37%, P=0.69). This contrasted with the yield in patients who identified as bilingual, which was significantly lower at 1.41% (1/71, 95% CI 0.07% to 6.75%) compared to both English-(P<0.02) and Spanish-only speakers (P<0.03). The yield for non-English speaking patients who requested an interpreter was 7.37% (14/190, 95% CI 4.26% to 11.77%) versus 3.23% (2/62, 95% CI 0.54% to 10.25%, P=0.25) in those who did not.

CONCLUSIONS

The diagnostic yield in English- and Spanish-only speaking patients was similar, however, the yield in those that self-identified as bilingual was significantly lower. In patient groups in which a language barrier existed and an interpreter was not utilized, there was a trend toward a lower diagnostic yield. This suggests an increased propensity to order diagnostic imaging when potential communication barriers exist.