Academic Emergency Medicine最新文献

{"title":"Facilitators to implementing preventive health interventions for adolescents in the emergency department: A multicenter qualitative analysis.","authors":"Emily Rutland, Mona Bugaighis, Andrea T Cruz, Monika K Goyal, Rakesh D Mistry, Jennifer L Reed, John S Santelli, Peter S Dayan, Lauren S Chernick","doi":"10.1111/acem.15043","DOIUrl":"https://doi.org/10.1111/acem.15043","url":null,"abstract":"<p><strong>Objectives: </strong>Adolescents frequently use the emergency department (ED) to meet their health care needs, and many use the ED as their primary source of care. The ED is therefore well situated to provide preventive health care to large numbers of adolescents. The objective of this multicenter qualitative analysis was to identify factors that influence the implementation of preventive health care interventions for adolescent patients in the ED.</p><p><strong>Methods: </strong>We conducted semistructured interviews with ED health care providers (HCPs) from five academic pediatric EDs in distinct geographic regions. We developed an interview guide to explore HCP attitudes and beliefs related to implementing preventive health interventions in the ED. Interviews were recorded, transcribed, and coded by three investigators. The Consolidated Framework for Implementation Research (CFIR) was used as a guide to code and analyze interview data. We collaboratively generated themes that represent factors that are perceived to facilitate the implementation of preventive health interventions for adolescent patients in the ED setting.</p><p><strong>Results: </strong>We conducted 38 interviews (18 pediatric emergency medicine attendings/fellows, 11 registered nurses, five nurse practitioners, or and four physician assistants). We generated 10 themes across the five CFIR domains: innovation characteristics (designing interventions to promote adolescent engagement), inner setting (integrating interventions into ED workflow and scope, minimizing provider burden), outer setting (involving the community, aligning with departmental and institutional missions), individuals (identifying champions), and implementation process (involving key stakeholders early, having patience, and targeting all patients to reduce stigma).</p><p><strong>Conclusions: </strong>Factors facilitating implementation of preventive health interventions for adolescent patients in the ED encompassed multiple CFIR domains, elucidating how the delivery of preventive health interventions for this patient population in the ED requires considering numerous factors comprehensively. These data suggest methods to enhance and facilitate implementation of preventive health interventions for adolescents in the ED.</p>","PeriodicalId":7105,"journal":{"name":"Academic Emergency Medicine","volume":null,"pages":null},"PeriodicalIF":3.4,"publicationDate":"2024-11-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142581859","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Risk-stratification tools for emergency department patients with syncope: A systematic review and meta-analysis of direct evidence for SAEM GRACE.","authors":"Abel Wakai, Richard Sinert, Shahriar Zehtabchi, Ian S de Souza, Roshanak Benabbas, Robert Allen, Eric Dunne, Rebekah Richards, Amelie Ardilouze, Isidora Rovic","doi":"10.1111/acem.15041","DOIUrl":"https://doi.org/10.1111/acem.15041","url":null,"abstract":"<p><strong>Objectives: </strong>Approximately 10% of patients with syncope have serious or life-threatening causes that may not be apparent during the initial emergency department (ED) assessment. Consequently, researchers have developed clinical decision rules (CDRs) to predict adverse outcomes and risk stratify ED syncope patients. This systematic review and meta-analysis (SRMA) aims to cohere and synthesize the best current evidence regarding the methodological quality and predictive accuracy of CDRs for developing an evidence-based ED syncope management guideline.</p><p><strong>Methods: </strong>We conducted a systematic literature search according to the patient-intervention-control-outcome question: In patients 16 years of age or older who present to the ED with syncope for whom no underlying serious/life-threatening condition was found during the index ED visit (population), are risk stratification tools (intervention), better than unstructured clinical judgment (i.e., usual care; comparison), for providing accurate prognosis and aiding disposition decision for outcomes within 30 days (outcome)? Two reviewers independently assessed articles for inclusion and methodological quality. We performed statistical analysis using Meta-DiSc. We used GRADEPro GDT software to determine the certainty of the evidence and create a summary of the findings (SoF) tables.</p><p><strong>Results: </strong>Of 2047 publications obtained through the search strategy, 31 comprising 13 CDRs met the inclusion criteria. There were 13 derivation studies (17,578 participants) and 24 validation studies (14,845 participants). Only three CDRs were validated in more than two studies. The San Francisco Syncope Rule (SFSR) was validated in 12 studies: positive likelihood ratio (LR+) 1.15-4.70 and negative likelihood ratio (LR-) 0.03-0.64. The Canadian Syncope Risk Score (CSRS) was validated in five studies: LR+ 1.15-2.58 and LR- 0.05-0.50. The Osservatorio Epidemiologico sulla Sincope nel Lazio (OESIL) risk score was validated in five studies: LR+ 1.16-3.32 and LR- 0.14-0.46.</p><p><strong>Conclusions: </strong>Most CDRs for ED adult syncope management have low-quality evidence for routine clinical practice use. Only three CDRs (SFSR, CSRS, OESIL) are validated by more than two studies, with significant overlap in operating characteristics.</p>","PeriodicalId":7105,"journal":{"name":"Academic Emergency Medicine","volume":null,"pages":null},"PeriodicalIF":3.4,"publicationDate":"2024-11-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142574981","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Implications of inadequate communication: Emergency care for deaf and hard-of-hearing patients.","authors":"Jason Rotoli, Christopher Moreland, Carl Mirus","doi":"10.1111/acem.15040","DOIUrl":"https://doi.org/10.1111/acem.15040","url":null,"abstract":"","PeriodicalId":7105,"journal":{"name":"Academic Emergency Medicine","volume":null,"pages":null},"PeriodicalIF":3.4,"publicationDate":"2024-11-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142567188","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Change in emergency department telehealth use for various indications, 2016 to 2020.","authors":"Krislyn M Boggs, Rain E Freeman, Kori S Zachrison, Margaret E Samuels-Kalow, Jingya Gao, Lily Y Lu, Ashley F Sullivan, Carlos A Camargo","doi":"10.1111/acem.14945","DOIUrl":"10.1111/acem.14945","url":null,"abstract":"","PeriodicalId":7105,"journal":{"name":"Academic Emergency Medicine","volume":null,"pages":null},"PeriodicalIF":3.4,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141155123","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Emergency department visit frequency and health care costs following implementation of an integrated practice unit for frequent utilizers.","authors":"Ruixuan Wang, Kiran Lukose, Olga S Ensz, Lee Revere, Noah Hammarlund","doi":"10.1111/acem.14973","DOIUrl":"10.1111/acem.14973","url":null,"abstract":"<p><strong>Objectives: </strong>The integrated practice unit (IPU) aims to improve care for patients with complex medical and social needs through care coordination, medication reconciliation, and connection to community resources. This study examined the effects of IPU enrollment on emergency department (ED) utilization and health care costs among frequent ED utilizers with complex needs.</p><p><strong>Methods: </strong>We extracted electronic health records (EHR) data from patients in a large health care system who had at least four distinct ED visits within any 6-month period between March 1, 2018, and May 30, 2021. Interrupted time series (ITS) analyses were performed to evaluate the impact of IPU enrollment on monthly ED visits and health care costs. A control group was matched to IPU patients using a propensity score at a 3:1 ratio.</p><p><strong>Results: </strong>We analyzed EHRs of 775 IPU patients with a control group of 2325 patients (mean [±SD] age 43.6 [±17]; 45.8% female; 50.9% White, 42.3% Black). In the single ITS analysis, IPU enrollment was associated with a decrease of 0.24 ED visits (p < 0.001) and a cost reduction of $466.37 (p = 0.040) in the first month, followed by decreases of 0.11 ED visits (p < 0.001) and $417.61 in costs (p < 0.001) each month over the subsequent year. Our main results showed that, compared to the matched control group, IPU patients experienced 0.20 more ED visits (p < 0.001) after their fourth ED visit within 6 months, offset by a reduction of 0.02 visits (p < 0.001) each month over the next year. No significant immediate or sustained increase in costs was observed for IPU-enrolled patients compared to the control group.</p><p><strong>Conclusions: </strong>This quasi-experimental study of frequent ED utilizers demonstrated an initial increase in ED visits following IPU enrollment, followed by a reduction in ED utilization over subsequent 12 months without increasing costs, supporting IPU's effectiveness in managing patients with complex needs and limited access to care.</p>","PeriodicalId":7105,"journal":{"name":"Academic Emergency Medicine","volume":null,"pages":null},"PeriodicalIF":3.4,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141454576","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Willingness to participate in an active exception from informed consent trial in the pediatric intensive care unit.","authors":"Catherine E Ross, Muhammad Asad, Harshannie Kundun, Cody-Aaron L Gathers, Robert A Berg, Monica E Kleinman","doi":"10.1111/acem.14978","DOIUrl":"10.1111/acem.14978","url":null,"abstract":"","PeriodicalId":7105,"journal":{"name":"Academic Emergency Medicine","volume":null,"pages":null},"PeriodicalIF":3.4,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141750776","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Feasibility of adolescent contraceptive care in the pediatric emergency department: A pilot randomized controlled trial.","authors":"Melissa K Miller, Kathy Goggin, Stephani L Stancil, Elizabeth Miller, Tara Ketterer, Vince Staggs, April D McNeill-Johnson, Amber Adams, Cynthia J Mollen","doi":"10.1111/acem.14965","DOIUrl":"10.1111/acem.14965","url":null,"abstract":"<p><strong>Background: </strong>This study assessed feasibility constructs of adolescent contraceptive care in the pediatric emergency department (PED), including contraception initiation.</p><p><strong>Methods: </strong>We conducted a randomized trial in two PEDs with pregnancy-capable adolescents aged 15-18 years who were assigned to enhanced usual care (usual) or same-day initiation (same day). All received counseling and clinic referral, but same-day participants could also receive contraception in the PED. We trained PED clinicians in counseling and prescribing. Adolescents and clinicians rated feasibility using five Likert-type items (1 = strongly disagree to 5 = strongly agree) after the session. We assessed PED medication initiation and appropriateness via medical record review and contraception use and side effects at 30 days via adolescent survey. To further explore feasibility, we conducted clinician interviews at study completion; these were audio-recorded, transcribed, and analyzed. We hypothesized contraceptive care would be feasible (defined as average score ≥ 4 across five survey items).</p><p><strong>Results: </strong>We enrolled 37 adolescents (12 in usual and 25 in same-day), mean age was 16.6 years, 73% were Black, and 19% were Hispanic. We trained 27 clinicians. Average feasibility scores were 4.6 ± 0.4 (adolescents) and 4.1 ± 0.8 (clinicians). Eleven (44%) same-day participants initiated contraception in the PED. One adolescent with migraines initially received estrogen-containing pills; this was corrected after discharge. At 30 days, same-day participants were more likely to report contraception use (78% vs. 13%; p = 0.007). One adolescent reported bloating as a side effect. Clinicians enjoyed delivering contraceptive care, found study resource materials useful, and identified staffing shortages as a barrier to care delivery.</p><p><strong>Conclusions: </strong>We are among the first to report on PED-based adolescent contraception initiation to prevent unintended pregnancy. Adolescents and clinicians reported that contraceptive care was feasible. Initiation was common and medications were largely appropriate and tolerated. Future efforts should explore integrating contraceptive care into routine PED care.</p>","PeriodicalId":7105,"journal":{"name":"Academic Emergency Medicine","volume":null,"pages":null},"PeriodicalIF":3.4,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141330129","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Study of pediatric appendicitis scores and management strategies: A prospective observational feasibility study.","authors":"Wei Hao Lee, Sharon O'Brien, Elizabeth McKinnon, Michael Collin, Stuart R Dalziel, Simon S Craig, Meredith L Borland","doi":"10.1111/acem.14985","DOIUrl":"10.1111/acem.14985","url":null,"abstract":"<p><strong>Objective: </strong>The objective was to investigate the feasibility of prospectively validating multiple clinical prediction scores (CPSs) for pediatric appendicitis in an Australian pediatric emergency department (ED).</p><p><strong>Methods: </strong>A literature search was conducted to identify potential CPSs and a single-center prospective observational feasibility study was performed between November 2022 and May 2023 to evaluate the performance of identified CPSs. Children 5-15 years presenting with acute right-sided or generalized abdominal pain and clinician suspicion of appendicitis were included. CPSs were calculated by the study team from prospectively clinician-collected data and/or review of medical records. Accuracy of CPSs were assessed by area under the receiver operating characteristic curve (AUC) and proportions correctly identifiable as either low-risk or high-risk with the best performing CPS compared to clinician gestalt. Final diagnosis of appendicitis was confirmed on histopathology or by telephone/email follow-up for those discharged directly from ED.</p><p><strong>Results: </strong>Thirty CPSs were identified in the literature search and 481 patients were enrolled in the study. A total of 150 (31.2%) patients underwent appendectomy with three (2.0%) having a normal appendix on histopathology. All identified CPSs were calculable for at least 50% of the patient cohort. The pediatric Appendicitis Risk Calculator for pediatric EDs (pARC-ED; n = 317) was the best performing CPS with AUC 0.90 (95% confidence interval [CI] 0.86-0.94) and specificity 99.0% (95% CI 96.4%-99.7%) in diagnosing high-risk cases and a misclassification rate of 4.5% for low-risk cases.</p><p><strong>Conclusions: </strong>The study identified 30 CPSs that could be validated in a majority of patients to compare their ability to assess risk of pediatric appendicitis. The pARC-ED had the highest predictive accuracy and can potentially assist in risk stratification of children with suspected appendicitis in pediatric EDs. A multicenter study is now under way to evaluate the potential of these CPSs in a broader range of EDs to aid clinical decision making in more varied settings.</p>","PeriodicalId":7105,"journal":{"name":"Academic Emergency Medicine","volume":null,"pages":null},"PeriodicalIF":3.4,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141632333","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Failure rate of D-dimer testing in patients with high clinical probability of pulmonary embolism: Ancillary analysis of three European studies.","authors":"Héloïse Bannelier, Thomas Kapfer, Mélanie Roussel, Yonathan Freund, Karine Alame, Pierre Catoire, Amélie Vromant","doi":"10.1111/acem.15032","DOIUrl":"https://doi.org/10.1111/acem.15032","url":null,"abstract":"<p><strong>Background: </strong>In patients with a high clinical probability of pulmonary embolism (PE), the high prevalence can lower the D-dimer negative predictive value and increase the risk of diagnostic failure. It is therefore recommended that these high-risk patients should undergo chest imaging without D-dimer testing although no evidence supports this recommendation.</p><p><strong>Objective: </strong>The objective was to evaluate the safety of ruling out PE based on D-dimer testing among patients with a high clinical probability of PE.</p><p><strong>Methods: </strong>This was a post hoc analysis of three European studies (PROPER, MODIGLIANI, and TRYSPEED). Patients were included if they presented a high clinical probability of PE (according to either the Wells or the revised Geneva score) and underwent D-dimer testing. The D-dimer-based strategy ruled out PE if the D-dimer level was below the age-adjusted threshold (i.e., <500 ng/mL in patients aged less than 50 and age × 10 ng/mL in patients older than 50). The primary endpoint was a thromboembolic event in patients with negative D-dimer either at index visit or at 3-month follow-up. A Bayesian approach estimated the probability that the failure rate of the D-dimer-based strategy was below 2% given observed data.</p><p><strong>Results: </strong>Among the 12,300 patients included in the PROPER, MODIGLIANI, and TRYSPEED studies, 651 patients (median age 68 years, 60% female) had D-dimer testing and a high clinical probability of PE and were included in the study. PE prevalence was 31.3%. Seventy patients had D-dimer levels under the age-adjusted threshold, and none of them had a PE after follow-up (failure rate 0.0% [95% CI 0.0%-6.5%]). Bayesian analysis reported a credible interval of 0.0%-4.1%, with a 76.2% posterior probability of a failure rate below 2%.</p><p><strong>Conclusions: </strong>In this study, ruling out PE in high-risk patients based on D-dimer below the age-adjusted threshold was safe, with no missed PE. However, the large CI of the primary endpoint precludes a definitive conclusion.</p>","PeriodicalId":7105,"journal":{"name":"Academic Emergency Medicine","volume":null,"pages":null},"PeriodicalIF":3.4,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142563677","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Geriatric screening in the emergency department increases consultations to geriatric medicine and physical and occupational therapy: A pre/post cohort study.","authors":"Katherine M Hunold, Jeffrey M Caterino, Christopher R Carpenter, Lorraine C Mion, Lauren T Southerland","doi":"10.1111/acem.14964","DOIUrl":"10.1111/acem.14964","url":null,"abstract":"<p><strong>Background: </strong>The Geriatric Emergency Department (ED) Guidelines recommend screening older patients for need for evaluation by geriatric medicine, physical therapy (PT), and occupational therapy (OT), but explicit evidence that geriatric screening changes care compared to physician gestalt is lacking. We assessed changes in multidisciplinary consultation after implementation of standardized geriatric screening in the ED.</p><p><strong>Methods: </strong>Retrospective single-site observational cohort of older adult ED patients from 2019 to 2023 with three time periods: (1) preimplementation, (2) implementation of geriatric screening, and (3) postimplementation. Geriatric, PT, and OT consultations/referrals were available during all time periods. Descriptive analysis was stratified by disposition: discharged, observation and discharged, observation and hospital admission, and hospital admission. The independent variable was completion of three geriatric screening tools by ED nurses. The dependent variable was consultation and/or referral to geriatrics, PT, and OT. Secondary outcomes were disposition, ED revisits, and 30-day rehospitalizations.</p><p><strong>Results: </strong>There were 57,775 qualifying ED visits of patients age ≥ 65 years during the time periods: implementation increased geriatric screening from 0.5% to 63.2%; postimplementation, discharge patients who received screening had more consultations/referrals to geriatrics (1.5% vs. 0.4%), PT (7.9% vs. 1.9%), and OT (6.5% vs. 1.2%) compared to unscreened patients. Patients observed and then discharged had more consultations/referrals to geriatrics (15.1% vs. 11.3%), PT (74.1% vs. 64.5%), and OT (65.7% vs. 56.5%). Admitted patients had no change in consultation rates. Geriatric screening was not associated with a change in 7-day ED revisits for discharged patients but was associated with decreased revisits for patients discharged from observation (11.6% vs. 42.9%, p < 0.001).</p><p><strong>Conclusion: </strong>Geriatric screening was associated with increased consultations/referrals to geriatrics, PT, and OT in the ED and ED observation unit. This suggests that geriatric screening changes ED care for older adults.</p>","PeriodicalId":7105,"journal":{"name":"Academic Emergency Medicine","volume":null,"pages":null},"PeriodicalIF":3.4,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141316452","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}