2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients.

METHODS

A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered.

STRUCTURE

Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.

2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients.

METHODS

A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered.

STRUCTURE

Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.

2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients.

METHODS

A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. Structure: Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.

2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

This executive summary of the clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients.

METHODS

A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. Structure: Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. These guidelines present an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated and shared decision-making with patients is recommended.

Credible Threat: Perceptions of Pandemic Coronavirus, Climate Change and the Morality and Management of Global Risks

Prior research suggests that the pandemic coronavirus pushes all the "hot spots" for risk perceptions, yet both governments and populations have varied in their responses. As the economic impacts of the pandemic have become salient, governments have begun to slash their budgets for mitigating other global risks, including climate change, likely imposing increased future costs from those risks. Risk analysts have long argued that global environmental and health risks are inseparable at some level, and must ultimately be managed systemically, to effectively increase safety and welfare. In contrast, it has been suggested that we have worry budgets, in which one risk crowds out another. "In the wild," our problem-solving strategies are often lexicographic; we seek and assess potential solutions one at a time, even one attribute at a time, rather than conducting integrated risk assessments. In a U.S. national survey experiment in which participants were randomly assigned to coronavirus or climate change surveys (N = 3203) we assess risk perceptions, and whether risk perception "hot spots" are driving policy preferences, within and across these global risks. Striking parallels emerge between the two. Both risks are perceived as highly threatening, inequitably distributed, and not particularly controllable. People see themselves as somewhat informed about both risks and have moral concerns about both. In contrast, climate change is seen as better understood by science than is pandemic coronavirus. Further, individuals think they can contribute more to slowing or stopping pandemic coronavirus than climate change, and have a greater moral responsibility to do so. Survey assignment influences policy preferences, with higher support for policies to control pandemic coronavirus in pandemic coronavirus surveys, and higher support for policies to control climate change risks in climate change surveys. Across all surveys, age groups, and policies to control either climate change or pandemic coronavirus risks, support is highest for funding research on vaccines against pandemic diseases, which is the only policy that achieves majority support in both surveys. Findings bolster both the finite worry budget hypothesis and the hypothesis that supporters of policies to confront one threat are disproportionately likely also to support policies to confront the other threat.

Unscheduled Procedural Sedation: A Multidisciplinary Consensus Practice Guideline

The American College of Emergency Physicians (ACEP) organized a multidisciplinary effort to create a clinical practice guideline specific to unscheduled, time-sensitive procedural sedation, which differs in important ways from scheduled, elective procedural sedation. The purpose of this guideline is to serve as a resource for practitioners who perform unscheduled procedural sedation regardless of location or patient age. This document outlines the underlying background and rationale, and issues relating to staffing, practice, and quality improvement.

Improving Care of STEMI in the United States 2008 to 2012

Background

We aimed to determine the change in treatment strategies and times to treatment over the first 5 years of the Mission: Lifeline program.

Methods and Results

We assessed pre‐ and in‐hospital care and outcomes from 2008 to 2012 for patients with ST‐segment–elevation myocardial infarction at US hospitals, using data from the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry—Get With The Guidelines Registry. In‐hospital adjusted mortality was calculated including and excluding cardiac arrest as a reason for primary percutaneous coronary intervention delay. A total of 147 466 patients from 485 hospitals were analyzed. There was a decrease in the proportion of eligible patients not treated with reperfusion (6.2% versus 3.3%) and treated with fibrinolytic therapy (13.4% versus 7.0%). Median time from symptom onset to first medical contact was unchanged (≈50 minutes). Use of prehospital ECGs increased (45% versus 71%). All major reperfusion times improved: median first medical contact‐to‐device for emergency medical systems transport to percutaneous coronary intervention–capable hospitals (93 to 84 minutes), first door‐to‐device for transfers for primary percutaneous coronary intervention (130 to 112 minutes), and door‐in–door‐out at non–percutaneous coronary intervention–capable hospitals (76 to 62 minutes) (all P<0.001 over 5 years). Rates of cardiogenic shock and cardiac arrest, and overall in‐hospital mortality increased (5.7% to 6.3%). Adjusted mortality excluding patients with known cardiac arrest decreased by 14% at 3 years and 25% at 5 years (P<0.001).

Conclusions

Quality of care for patients with ST‐segment–elevation myocardial infarction improved over time in Mission: Lifeline, including increased use of reperfusion therapy and faster times‐to‐treatment. In‐hospital mortality improved for patients without cardiac arrest but did not appear to improve overall as the number of these high‐risk patients increased.

Evaluating Patient-Centered Outcomes in Clinical Trials of Procedural Sedation, Part 2 Safety: Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research Recommendations

The Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research, established by the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks, a public-private partnership with the US Food and Drug Administration, convened a second meeting of sedation experts from a variety of clinical specialties and research backgrounds to develop recommendations for procedural sedation research. The previous meeting addressed efficacy and patient- and/or family-centered outcomes. This meeting addressed issues of safety, which was defined as "the avoidance of physical or psychological harm." A literature review identified 133 articles addressing safety measures in procedural sedation clinical trials. After basic reporting of vital signs, the most commonly measured safety parameter was oxygen saturation. Adverse events were inconsistently defined throughout the studies. Only 6 of the 133 studies used a previously validated measure of safety. The meeting identified methodological problems associated with measuring infrequent adverse events. With a consensus discussion, a set of core and supplemental measures were recommended to code for safety in future procedural clinical trials. When adopted, these measures should improve the integration of safety data across studies and facilitate comparisons in systematic reviews and meta-analyses.

Centers for Disease Control and Prevention Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children

Importance

Mild traumatic brain injury (mTBI), or concussion, in children is a rapidly growing public health concern because epidemiologic data indicate a marked increase in the number of emergency department visits for mTBI over the past decade. However, no evidence-based clinical guidelines have been developed to date for diagnosing and managing pediatric mTBI in the United States.

Objective

To provide a guideline based on a previous systematic review of the literature to obtain and assess evidence toward developing clinical recommendations for health care professionals related to the diagnosis, prognosis, and management/treatment of pediatric mTBI.

Evidence Review

The Centers for Disease Control and Prevention (CDC) National Center for Injury Prevention and Control Board of Scientific Counselors, a federal advisory committee, established the Pediatric Mild Traumatic Brain Injury Guideline Workgroup. The workgroup drafted recommendations based on the evidence that was obtained and assessed within the systematic review, as well as related evidence, scientific principles, and expert inference. This information includes selected studies published since the evidence review was conducted that were deemed by the workgroup to be relevant to the recommendations. The dates of the initial literature search were January 1, 1990, to November 30, 2012, and the dates of the updated literature search were December 1, 2012, to July 31, 2015.

Findings

The CDC guideline includes 19 sets of recommendations on the diagnosis, prognosis, and management/treatment of pediatric mTBI that were assigned a level of obligation (ie, must, should, or may) based on confidence in the evidence. Recommendations address imaging, symptom scales, cognitive testing, and standardized assessment for diagnosis; history and risk factor assessment, monitoring, and counseling for prognosis; and patient/family education, rest, support, return to school, and symptom management for treatment.

Conclusions and Relevance

This guideline identifies the best practices for mTBI based on the current evidence; updates should be made as the body of evidence grows. In addition to the development of the guideline, CDC has created user-friendly guideline implementation materials that are concise and actionable. Evaluation of the guideline and implementation materials is crucial in understanding the influence of the recommendations.

Diagnosis and Management of Mild Traumatic Brain Injury in Children: A Systematic Review

IMPORTANCE

In recent years, there has been an exponential increase in the research guiding pediatric mild traumatic brain injury (mTBI) clinical management, in large part because of heightened concerns about the consequences of mTBI, also known as concussion, in children. The CDC National Center for Injury Prevention and Control's (NCIPC) Board of Scientific Counselors (BSC), a federal advisory committee, established the Pediatric Mild TBI Guideline workgroup to complete this systematic review summarizing the first 25 years of literature in this field of study.

OBJECTIVE

To conduct a systematic review of the pediatric mTBI literature to serve as the foundation for an evidence-based guideline with clinical recommendations associated with the diagnosis and management of pediatric mTBI.

EVIDENCE REVIEW

Using a modified Delphi process, the authors selected 6 clinical questions on diagnosis, prognosis, and management or treatment of pediatric mTBI. Two consecutive searches were conducted on PubMed, Embase, ERIC, CINAHL, and SportDiscus. The first included the dates January 1, 1990, to November 30, 2012, and an updated search included December 1, 2012, to July 31, 2015. The initial search was completed from December 2012 to January 2013; the updated search, from July 2015 to August 2015. Two authors worked in pairs to abstract study characteristics independently for each article selected for inclusion. A third author adjudicated disagreements. The risk of bias in each study was determined using the American Academy of Neurology Classification of Evidence Scheme. Conclusion statements were developed regarding the evidence within each clinical question, and a level of confidence in the evidence was assigned to each conclusion using a modified GRADE methodology. Data analysis was completed from October 2014 to May 2015 for the initial search and from November 2015 to April 2016 for the updated search.

FINDINGS

Validated tools are available to assist clinicians in the diagnosis and management of pediatric mTBI. A significant body of research exists to identify features that are associated with more serious TBI-associated intracranial injury, delayed recovery from mTBI, and long-term sequelae. However, high-quality studies of treatments meant to improve mTBI outcomes are currently lacking.

CONCLUSIONS AND RELEVANCE

This systematic review was used to develop an evidence-based clinical guideline for the diagnosis and management of pediatric mTBI. While an increasing amount of research provides clinically useful information, this systematic review identified key gaps in diagnosis, prognosis, and management.

Evaluating Patient-Centered Outcomes in Clinical Trials of Procedural Sedation, Part 1 Efficacy: Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research Recommendations

The Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research, established by the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks public-private partnership with the US Food and Drug Administration, convened a meeting of sedation experts from a variety of clinical specialties and research backgrounds with the objective of developing recommendations for procedural sedation research. Four core outcome domains were recommended for consideration in sedation clinical trials: (1) safety, (2) efficacy, (3) patient-centered and/or family-centered outcomes, and (4) efficiency. This meeting identified core outcome measures within the efficacy and patient-centered and/or family-centered domains. Safety will be addressed in a subsequent meeting, and efficiency will not be addressed at this time. These measures encompass depth and levels of sedation, proceduralist and patient satisfaction, patient recall, and degree of pain experienced. Consistent use of the recommended outcome measures will facilitate the comprehensive reporting across sedation trials, along with meaningful comparisons among studies and interventions in systematic reviews and meta-analyses.

Optimizing neurologically intact survival from sudden cardiac arrest: a call to action

The U.S. national out-of-hospital and in-hospital cardiac arrest survival rates, although improving recently, have remained suboptimal despite the collective efforts of individuals, communities, and professional societies. Only until very recently, and still with inconsistency, has focus been placed specifically on survival with pre-arrest neurologic function. The reality of current approaches to sudden cardiac arrest is that they are often lacking an integrative, multi-disciplinary approach, and without deserved funding and outcome analysis. In this manuscript, a multidisciplinary group of authors propose practice, process, technology, and policy initiatives to improve cardiac arrest survival with a focus on neurologic function.

Nonurgent commercial air travel after acute coronary syndrome: a review of 288 patient events

OBJECTIVES

We studied a population of individuals who experienced an acute coronary syndrome (ACS) event while traveling abroad and required nonurgent commercial air travel to the home region.

METHODS

This retrospective study gathered data from 288 patients enrolled in a travel-based medical assistance program. Interventions, complications, and travel home were assessed for trends. Descriptive and comparison statistical analyses were performed.

RESULTS

Two hundred eighty-eight patients were identified and entered into the review. Of the patients in this study, 77.1% were male with an average age of 67.7 years. One hundred sixteen (40.3%) patients were diagnosed with unstable angina pectoris (USAP), whereas the remaining 172 (59.7%) patients experienced acute myocardial infarction (AMI). Regarding inpatient complications during the initial admission, 121 (42.0%) patients experienced 1 or more adverse event. The average number of days after an ACS event that a patient began to travel home was 10.5 days for the entire patient population (USAP patients = 8.8 days, AMI patients = 11.8 days). Two hundred twenty (76.4%) patients traveled with a medical escort, and 48 (16.7%) patients received supplemental oxygen during air travel. Four (1.4%) in-flight adverse events occurred in the following ACS diagnostic groups: 2 in the complicated AMI group, 1 in the uncomplicated USAP group, and 1 in the uncomplicated AMI group. No in-flight deaths occurred. Nine (3.1%) deaths were noted within 2 weeks after returning to the home region. The deaths after returning to the home region occurred in the following ACS diagnostic groups: 2 in the complicated USAP group, 1 in the uncomplicated USAP group, and 6 in the complicated AMI group. None of the patients who experienced in-flight events died after returning to their home region.

CONCLUSIONS

Upon discharge, the vast majority of ACS patients who travel to their home region via commercial air do not experience adverse events in-flight; when such adverse events occur in-flight, these events do not result in a poor outcome. No in-flight deaths occurred; death occurred in a minority of patients after returning to their home region, particularly in the complicated USAP and AMI groups, who were planned readmissions to the hospital.

Nonurgent commercial air travel after nonhemorrhagic cerebrovascular accident

Nonurgent commercial air travel in patients who have experienced a nonhemorrhagic cerebrovascular accident (CVA) may occur, particularly in the elderly traveling population. A recent CVA, particularly occurring during a person's travel, presents a significant challenge to the patient, companions, family, and health care team. Specific medical recommendation, based on accumulated scientific data and interpreted by medical experts, is needed so that travel health care professionals can appropriately guide the patient. Unfortunately, such recommendations are almost entirely lacking despite the relative frequency of CVA and air travel. This article reviews the existing recommendations with conclusions based on both these limited data and rationale conjecture.

Emergency medical services management of ST-segment elevation myocardial infarction in the United States--a report from the American Heart Association Mission: Lifeline Program

OBJECTIVE

ST-segment elevation myocardial infarction (STEMI) is a major cause of morbidity and mortality in the United States. Emergency medical services (EMS) agencies play a critical role in its initial identification and treatment. We conducted this study to assess EMS management of STEMI care in the United States.

METHODS

A structured questionnaire was administered to leaders of EMS agencies to define the elements of STEMI care related to 4 core measures: (1) electrocardiogram (ECG) capability at the scene, (2) destination protocols, (3) catheterization laboratory activation before hospital arrival, and (4) 12-lead ECG quality review. Geographic areas were grouped into large metropolitan, small metropolitan, micropolitan, and noncore (or rural) by using Urban Influence Codes, with a stratified analysis.

RESULTS

Data were included based on responses from 5296 EMS agencies (36% of those in the United States) serving 91% of the US population, with at least 1 valid response from each of the 50 states and the District of Columbia. Approximately 63% of agencies obtained ECGs at the scene using providers trained in ECG acquisition and interpretation. A total of 46% of EMS systems used protocols to determine hospital destination, cardiac catheterization laboratory activation, and communications with the receiving hospital. More than 75% of EMS systems used their own agency funds to purchase equipment, train personnel, and provide administrative oversight. A total of 49% of agencies have quality review programs in place. In general, EMS systems covering higher population densities had easier access to resources needed to maintain STEMI systems of care. Emergency medical services systems that have adopted all 4 core elements cover 14% of the US population.

CONCLUSIONS

There are large differences in EMS systems of STEMI care in the United States. Most EMS agencies have implemented at least 1 of the 4 core elements of STEMI care, with many having implemented multiple elements.

Primary outcomes for resuscitation science studies: a consensus statement from the American Heart Association

BACKGROUND AND PURPOSE

The guidelines presented in this consensus statement are intended to serve researchers, clinicians, reviewers, and regulators in the selection of the most appropriate primary outcome for a clinical trial of cardiac arrest therapies. The American Heart Association guidelines for the treatment of cardiac arrest depend on high-quality clinical trials, which depend on the selection of a meaningful primary outcome. Because this selection process has been the subject of much controversy, a consensus conference was convened with national and international experts, the National Institutes of Health, and the US Food and Drug Administration.

METHODS

The Research Working Group of the American Heart Association Emergency Cardiovascular Care Committee nominated subject leaders, conference attendees, and writing group members on the basis of their expertise in clinical trials and a diverse perspective of cardiovascular and neurological outcomes (see the online-only Data Supplement). Approval was obtained from the Emergency Cardiovascular Care Committee and the American Heart Association Manuscript Oversight Committee. Preconference position papers were circulated for review; the conference was held; and postconference consensus documents were circulated for review and comments were invited from experts, conference attendees, and writing group members. Discussions focused on (1) when after cardiac arrest the measurement time point should occur; (2) what cardiovascular, neurological, and other physiology should be assessed; and (3) the costs associated with various end points. The final document underwent extensive revision and peer review by the Emergency Cardiovascular Care Committee, the American Heart Association Science Advisory and Coordinating Committee, and oversight committees.

RESULTS

There was consensus that no single primary outcome is appropriate for all studies of cardiac arrest. The best outcome measure is the pairing of a time point and physiological condition that will best answer the question under study. Conference participants were asked to assign an outcome to each of 4 hypothetical cases; however, there was not complete agreement on an ideal outcome measure even after extensive discussion and debate. There was general consensus that it is appropriate for earlier studies to enroll fewer patients and to use earlier time points such as return of spontaneous circulation, simple "alive versus dead," hospital mortality, or a hemodynamic parameter. For larger studies, a longer time point after arrest should be considered because neurological assessments fluctuate for at least 90 days after arrest. For large trials designed to have a major impact on public health policy, longer-term end points such as 90 days coupled with neurocognitive and quality-of-life assessments should be considered, as should the additional costs of this approach. For studies that will require regulatory oversight, early discussions with regulatory agencies are strongly advised. For neurological assessment of post-cardiac arrest patients, researchers may wish to use the Cerebral Performance Categories or modified Rankin Scale for global outcomes.

CONCLUSIONS

Although there is no single recommended outcome measure for trials of cardiac arrest care, the simple Cerebral Performance Categories or modified Rankin Scale after 90 days provides a reasonable outcome parameter for many trials. The lack of an easy-to-administer neurological functional outcome measure that is well validated in post-cardiac arrest patients is a major limitation to the field and should be a high priority for future development.

The introduction of public access defibrillation to a university community: the University of Virginia public access defibrillation program

The use of the automatic external defibrillator (AED) can significantly reduce the time to defibrillation in patients with sudden cardiac death. This early defibrillation via the AED can also improve patient outcome, including survival and neurologic status among survivors. We undertook the addition of a public access defibrillation program at a large mid-Atlantic university. In our design of the system, we found little useful information to guide us in the development and construction our system. This article is a review of the process of public access defibrillation AED system development such that other medical and academic leaders at similar institutions can more easily develop such systems.

Higher inpatient medical surgical bed occupancy extends admitted patients' stay

Objective:

Determine the effect that increased medical surgical (med/surg) bed occupancy has on the time interval from admission order to arrival in the bed for the patients admitted from the emergency department (ED).

Methods:

This retrospective observational study compares the total hospital bed occupancy rate and the medical surgical inpatient bed occupancy rate to daily averages for the time interval from admission order (patient posting for admission) to the patient’s arrival in the inpatient bed. Medical surgical inpatient bed occupancy of 92% was chosen because beyond that rate we observed more frequent extended daily transfer times. The data is from a single large tertiary care institute with 590 beds and an annual ED census of 80,000.

Results:

Group 1 includes 38 days with (med/surg) inpatient bed occupancy rate of less than 92%, with an average ED daily wait of 2.5 hrs (95% confidence interval 2.23–2.96) for transfer from the ED to the appropriate hospital bed. Group 2 includes 68 days with med/surg census greater than 92% with an average ED daily wait of 4.1 hours (95% confidence interval 3.7–4.5). Minimum daily average for the two groups was 1.2 hrs and 1.3 hrs, respectively. The maximum average was 5.6 hrs for group 1 and 8.6 hrs for group 2. Comparison of group 1 to 2 for wait time to hospital bed yielded p <0.01. Total reported hospital occupied capacity shows a correlation coefficient of 0.16 to transfer time interval, which indicates a weak relationship between total occupancy and transfer time into the hospital. Med/surg occupancy, the beds typically used by ED patients, has a 0.62 correlation coefficient for a moderately strong relationship.

Conclusions:

Med/surg bed occupancy has a better correlation to extended transfer times, and occupancy over 92% at 5 AM in our institution corresponds to an increased frequency of extended transfer times from the ED. The process of ED evaluation, hospital admission, and subsequent transfer into the hospital are all complex processes. This study begins to demonstrate one variable, med/surg occupancy, as one of the intervals that can be followed to evaluate the process of ED admission and hospital flow.

The diagnosis and management of seizures and status epilepticus in the prehospital setting

Seizure is one of the most common complaints encountered in the prehospital setting. In this review the authors discuss the prehospital management of seizures and review the evidence for specific treatment approaches. Specific attention is devoted to prehospital care of the pediatric seizure patient. Topics of interest to Emergency Medical Services directors such as patient refusal, resource allocation, and dispatch priority are also addressed.

Regional Systems of Care for Out-of-Hospital Cardiac Arrest

Out-of-hospital cardiac arrest continues to be an important public health problem, with large and important regional variations in outcomes. Survival rates vary widely among patients treated with out-of-hospital cardiac arrest by emergency medical services and among patients transported to the hospital after return of spontaneous circulation. Most regions lack a well-coordinated approach to post–cardiac arrest care. Effective hospital-based interventions for out-of-hospital cardiac arrest exist but are used infrequently. Barriers to implementation of these interventions include lack of knowledge, experience, personnel, resources, and infrastructure. A well-defined relationship between an increased volume of patients or procedures and better outcomes among individual providers and hospitals has been observed for several other clinical disorders. Regional systems of care have improved provider experience and patient outcomes for those with ST-elevation myocardial infarction and life-threatening traumatic injury. This statement describes the rationale for regional systems of care for patients resuscitated from cardiac arrest and the preliminary recommended elements of such systems. Many more people could potentially survive out-of-hospital cardiac arrest if regional systems of cardiac resuscitation were established. A national process is necessary to develop and implement evidence-based guidelines for such systems that must include standards for the categorization, verification, and designation of components of such systems. The time to do so is now.

Urban sprawl and delayed ambulance arrival in the U.S

BACKGROUND

Minimizing emergency medical service (EMS) response time is a central objective of prehospital care, yet the potential influence of built environment features such as urban sprawl on EMS system performance is often not considered.

PURPOSE

This study measures the association between urban sprawl and EMS response time to test the hypothesis that features of sprawling development increase the probability of delayed ambulance arrival.

METHODS

In 2008, EMS response times for 43,424 motor-vehicle crashes were obtained from the Fatal Analysis Reporting System, a national census of crashes involving > or =1 fatality. Sprawl at each crash location was measured using a continuous county-level index previously developed by Ewing et al. The association between sprawl and the probability of a delayed ambulance arrival (> or =8 minutes) was then measured using generalized linear mixed modeling to account for correlation among crashes from the same county.

RESULTS

Urban sprawl is significantly associated with increased EMS response time and a higher probability of delayed ambulance arrival (p=0.03). This probability increases quadratically as the severity of sprawl increases while controlling for nighttime crash occurrence, road conditions, and presence of construction. For example, in sprawling counties (e.g., Fayette County GA), the probability of a delayed ambulance arrival for daytime crashes in dry conditions without construction was 69% (95% CI=66%, 72%) compared with 31% (95% CI=28%, 35%) in counties with prominent smart-growth characteristics (e.g., Delaware County PA).

CONCLUSIONS

Urban sprawl is significantly associated with increased EMS response time and a higher probability of delayed ambulance arrival following motor-vehicle crashes in the U.S. The results of this study suggest that promotion of community design and development that follows smart-growth principles and regulates urban sprawl may improve EMS performance and reliability.

Evaluating emergency care research networks: what are the right metrics?

Research networks can enable the inclusion of large, diverse patient populations in different settings. However, the optimal measures of a research network's failure or success are not well defined or standardized. To define a framework for metrics used to measure the performance and effectiveness of emergency care research networks (ECRN), a conference for emergency care investigators, funding agencies, patient advocacy groups, and other stakeholders was held and yielded the following major recommendations: 1) ECRN metrics should be measurable, explicitly defined, and customizable for the multiple stakeholders involved and 2) continuing to develop and institute metrics to evaluate ECRNs will be critical for their accountability and sustainability.

The importance of emergency medicine in organ donation: successful donation is more likely when potential donors are referred from the emergency department

OBJECTIVES

This study sought to identify factors that are associated with successful organ retrieval among patients referred to organ procurement services for potential organ donation. Particular attention was paid to the frequency, patient characteristics, and outcomes of patients referred for donation from the emergency department (ED).

METHODS

For this retrospective cohort study, data were collected on all solid-organ donor referrals made to a single organ procurement organization serving 78 hospitals over a 45-month period. Data retrieved included patient age, sex, race, referral site (ED vs. inpatient), and mechanism of injury. Outcome of referral (organs retrieved or not) was the primary outcome variable. Pearson chi-square and Student's t-tests were used for bivariate statistical analysis. Multiple logistic regression analysis was used to determine which variables remained associated with organ retrieval after controlling for potential confounders.

RESULTS

A total of 6,886 donor referrals were made in the study population. Of these, 155 were excluded due to incomplete data, leaving 6,731 subjects for analysis. Using bivariate statistical analysis, we found that successful organ retrieval was associated with younger age (donor mean age 40.8 years, 95% confidence interval [CI] = 39.1 to 42.5 vs. nondonor mean age 59.4, 95% CI = 58.9 to 59.9), mechanism of injury (p < 0.001), and referral from the ED (ED 15.5% retrieved, inpatient 5.9%, odds ratio [OR] = 2.92, 95% CI = 2.32 to 3.67). After controlling for potential confounders with multiple logistic regression, referral from the ED remained significantly associated with successful organ retrieval (OR = 1.52, 95% CI = 1.18 to 1.97), as did age (OR = 0.96, 95% CI = 0.96 to 0.97) and mechanism of injury (p < 0.001). On regression analysis, race emerged as a significant predictor of organ retrieval (p < 0.001). Medically suitable patients referred from the ED were significantly more likely on bivariate analysis to have consent for donation granted compared to patients referred from inpatient settings (OR = 1.48, 95% CI = 1.03 to 2.12), but this association was not found to be significant on regression analysis (OR = 1.37, 95% CI = 0.93 to 2.02).

CONCLUSIONS

Referral of potential organ donors from the ED is associated with an increased likelihood of successful organ retrieval. The authors conclude that further attention and resources should be directed toward the role of emergency medicine (EM) in the organ procurement process, owing to the relatively high likelihood of successful organ retrieval among patients referred from the ED.