Emergency Medicine

Recent publications from the Department of Emergency Medicine

The listings below represent a selection of publications within the past year.  Our residents, fellows and faculty have published much more – visit individual faculty pages to learn more about their scholarship and academic interests. Please click title to see abstract.

 

Cardiac Arrest and Resuscitation Science

Association of Mechanical Cardiopulmonary Resuscitation Device Use With Cardiac Arrest Outcomes: A Population-Based Study Using the CARES Registry (Cardiac Arrest Registry to Enhance Survival)

Buckler DGBurke RVNaim MYMacPherson ABradley RNAbella BSRossano JWCARES Surveillance Group.

Circulation. 2016 Dec 20;134(25):2131-2133. No abstract available. PMID: 27994028

Excellent neurologic recovery after prolonged coma in a cardiac arrest patient with multiple poor prognostic indicators.

Weinstein JMallela ANAbella BSLevine JMBalu R.

Resuscitation. 2017 Feb 9. pii: S0300-9572(17)30043-6. doi: 10.1016/j.resuscitation.2017.01.022. [Epub ahead of print]. No abstract available. PMID: 28189599

Magnitude of temperature elevation is associated with neurologic and survival outcomes in resuscitated cardiac arrest patients with postrewarming pyrexia.

Grossestreuer AVGaieski DFDonnino MWWiebe DJAbella BS.

J Crit Care. 2017 Apr;38:78-83. doi: 10.1016/j.jcrc.2016.11.003. PMID: 27866109

Abstract

PURPOSE:

Avoidance of pyrexia is recommended in resuscitation guidelines, including after treatment with targeted temperature management (TTM). Which aspects of postresuscitation pyrexia are harmful and modifiable have not been conclusively determined.

MATERIALS AND METHODS:

This retrospective multicenter registry study collected serial temperatures during 72 hours postrewarming to assess the relationship between 3 aspects of pyrexia (maximum temperature, pyrexia duration, timing of first pyrexia) and neurologic outcome (primary) and survival (secondary) at hospital discharge. Adult TTM-treated patients from 13 US hospitals between 2005 and 2015 were included.

RESULTS:

One hundred seventy-nine of 465 patients had at least 1 temperature greater than or equal to 38°C. Pyrexic temperatures were associated with better survival than nonpyrexic temperatures (adjusted odds ratio [aOR], 1.54; 95% confidence interval [CI], 1.00-2.35). Higher maximum temperature was associated with worse outcome (neurologic aOR, 0.30 [95% CI, 0.10-0.84]; survival aOR, 0.25 [95% CI, 0.10-0.59]) in pyrexic patients. There was no significant relationship between pyrexia duration and outcomes unless duration was calculated as hours greater than or equal to 38.8°C, when longer duration was associated with worse outcomes (neurologic aOR, 0.86 [95% CI, 0.75-1.00]; survival aOR, 0.82 [95% CI, 0.72-0.93]).

CONCLUSIONS:

In postarrest TTM-treated patients, pyrexia was associated with increased survival. Patients experiencing postrewarming pyrexia had worse outcomes at higher temperatures. Longer pyrexia duration was associated with worse outcomes at higher temperatures.

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Video-Only Cardiopulmonary Resuscitation Education for High-Risk Families Before Hospital Discharge: A Multicenter Pragmatic Trial.

Blewer ALPutt MEBecker LBRiegel BJLi JLeary MShea JAKirkpatrick JNBerg RANadkarni VMGroeneveld PWAbella BSCHIP Study Group.

Circ Cardiovasc Qual Outcomes. 2016 Oct 4. pii: CIRCOUTCOMES.116.002493. [Epub ahead of print] PMID: 27703033

Abstract

BACKGROUND:

Cardiopulmonary resuscitation (CPR) training rates in the United States are low, highlighting the need to develop CPR educational approaches that are simpler, with broader dissemination potential. The minimum training required to ensure long-term skill retention remains poorly characterized. We compared CPR skill retention among laypersons randomized to training with video-only (VO; no manikin) with those trained with a video self-instruction kit (VSI; with manikin). We hypothesized that VO training would be noninferior to the VSI approach with respect to chest compression (CC) rate.

METHODS AND RESULTS:

We performed a prospective, cluster randomized trial of CPR education for family members of patients with high-risk cardiac conditions on hospital cardiac units, using a multicenter pragmatic design. Eight hospitals were randomized to offer either VO or VSI training before discharge using volunteer trainers. CPR skills were assessed 6 months post training. Mean CC rate among those trained with VO compared with those trained with VSI was assessed with a noninferiority margin set at 8 CC per min; as a secondary outcome, mean differences in CC depth were assessed. From February 2012 to May 2015, 1464 subjects were enrolled and 522 subjects completed a skills assessment. The mean CC rates were 87.7 (VO) CC per min and 89.3 (VSI) CC per min; we concluded noninferiority for VO based on a mean difference of -1.6 (90% confidence interval, -5.2 to 2.1). The mean CC depth was 40.2 mm (VO) and 45.8 mm (VSI) with a mean difference of -5.6 (95% confidence interval, -7.6 to -3.7). Results were similar after multivariate regression adjustment.

CONCLUSIONS:

In this large, prospective trial of CPR skill retention, VO training yielded a noninferior difference in CC rate compared with VSI training. CC depth was greater in the VSI group. These findings suggest a potential trade-off in efforts for broad dissemination of basic CPR skills; VO training might allow for greater scalability and dissemination, but with a potential reduction in CC depth.

CLINICAL TRIAL REGISTRATION:

URL: https://www.clinicaltrials.gov. Unique identifier: NCT01514656.

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Emergency Care Health Services Research

A Randomized Trial Testing the Effect of Narrative Vignettes Versus Guideline Summaries on Provider Response to a Professional Organization Clinical Policy for Safe Opioid Prescribing.

Meisel ZFMetlay JPSinnenberg LKilaru ASGrossestreuer ABarg FKShofer FSRhodes KVPerrone J.

Ann Emerg Med. 2016 Dec;68(6):719-728. doi: 10.1016/j.annemergmed.2016.03.007 PMID: 27133392

Abstract

STUDY OBJECTIVE:

Clinical guidelines are known to be underused by practitioners. In response to the challenges of treating pain amid a prescription opioid epidemic, the American College of Emergency Physicians (ACEP) published an evidence-based clinical policy for opioid prescribing in 2012. Evidence-based narratives, an effective method of communicating health information in a variety of settings, offer a novel strategy for disseminating guidelines to physicians and engaging providers with clinical evidence. We compare whether narrative vignettes embedded in the ACEP daily e-newsletter improved dissemination of the clinical policy to ACEP members, and engagement of members with the clinical policy, compared with traditional summary text.

METHODS:

A prospective randomized controlled study, titled Stories to Promote Information Using Narrative trial, was performed. Derived from qualitative interviews with 61 ACEP physicians, 4 narrative vignettes were selected and refined, using a consensus panel of clinical and implementation experts. All ACEP members were then block randomized by state of residence to receive alternative versions of a daily e-mailed newsletter for a total of 24 days during a 9-week period. Narrative newsletters contained a selection of vignettes that referenced opioid prescription dilemmas. Control newsletters contained a selection of descriptive text about the clinical policy, using length and appearance similar to that of the narrative vignettes. Embedded in the newsletters were Web links to the complete vignette or traditional summary text, as well as additional links to the full ACEP clinical policy and a Web site providing assistance with prescription drug monitoring program enrollment. The newsletters were otherwise identical. Outcomes measured were the percentage of subjects who visited any of the Web pages that contained additional guideline-related information and the odds of any unique physician visiting these Web pages during the study.

RESULTS:

There were 27,592 physicians randomized, and 21,226 received the newsletter during the study period. When each physician was counted once during the study period, there were 509 unique visitors in the narrative group and 173 unique visitors in the control group (4.8% versus 1.6%; difference 3.2%; 95% confidence interval [CI] 2.7% to 3.7%). There were 744 gross visits from the e-newsletter to any of the 3 Web pages in the narrative group compared with 248 in the control group (7.0% versus 2.3%; odds ratio 3.2; 95% CI 2.7 to 3.6). During the study, the odds ratio of any physician in the narrative group visiting one of the 3 informational Web sites compared with the control group was 3.1 (95% CI 2.6 to 3.6).

CONCLUSION:

Among a national sample of emergency physicians, narrative vignettes outperformed traditional guideline text in promoting engagement with an evidence-based clinical guideline related to opioid prescriptions.

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Urban Blight Remediation as a Cost-Beneficial Solution to Firearm Violence.

Branas CCKondo MCMurphy SMSouth ECPolsky DMacDonald JM.

Am J Public Health. 2016 Dec;106(12):2158-2164. PMID: 27736217

Abstract

OBJECTIVES:

To determine if blight remediation of abandoned buildings and vacant lots can be a cost-beneficial solution to firearm violence in US cities.

METHODS:

We performed quasi-experimental analyses of the impacts and economic returns on investment of urban blight remediation programs involving 5112 abandoned buildings and vacant lots on the occurrence of firearm and nonfirearm violence in Philadelphia, Pennsylvania, from 1999 to 2013. We adjusted before-after percent changes and returns on investment in treated versus control groups for sociodemographic factors.

RESULTS:

Abandoned building remediation significantly reduced firearm violence -39% (95% confidence interval [CI] = -28%, -50%; P < .05) as did vacant lot remediation (-4.6%; 95% CI = -4.2%, -5.0%; P < .001). Neither program significantly affected nonfirearm violence. Respectively, taxpayer and societal returns on investment for the prevention of firearm violence were $5 and $79 for every dollar spent on abandoned building remediation and $26 and $333 for every dollar spent on vacant lot remediation.

CONCLUSIONS:

Abandoned buildings and vacant lots are blighted structures seen daily by urban residents that may create physical opportunities for violence by sheltering illegal activity and illegal firearms. Urban blight remediation programs can be cost-beneficial strategies that significantly and sustainably reduce firearm violence.

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Perceptions of Family Participation in Intensive Care Unit Rounds and Telemedicine: A Qualitative Assessment.

Stelson EACarr BGGolden KEMartin NRichmond TSDelgado MKHolena DN.

Am J Crit Care. 2016 Sep;25(5):440-7. doi: 10.4037/ajcc2016465. PMID: 27587425

Abstract

BACKGROUND:

Family-centered rounds involve purposeful interactions between patients' families and care providers to refocus the delivery of care on patients' needs.

OBJECTIVES:

To examine perspectives of patients' family members and health care providers on family participation in rounds in the surgical intensive care unit (ICU) and the potential use of telemedicine to facilitate this process.

METHODS:

Patients' family members and surgical ICU care providers were recruited for semistructured interviews exploring stakeholders' perspectives on family participation in ICU rounds and the potential role of telemedicine. Thirty-two interviews were conducted, audio recorded, and transcribed verbatim. Common coding methods were facilitated by using NVivo 10. A mean coding agreement of 97.3% was calculated for 22% of transcripts.

RESULTS:

Both patients' family members and health care providers described inconsistent practices surrounding family participation in ICU rounds as well as barriers to and facilitators of family participation. Family members identified 3 primary logistical challenges to participation in ICU rounds: distance to hospitals, work/family obligations, and the rounding schedule. Both family members and providers reported receptivity to virtual participation as a potential solution to these challenges.

CONCLUSIONS:

Understanding the barriers to and facilitators of family participation in ICU rounds is key to encouraging adoption of family-centered rounds. For families that live far away or have competing demands, telemedical options may facilitate participation.

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National Differences in Regional Emergency Department Boarding Times: Are US Emergency Departments Prepared for a Public Health Emergency?

Love JSKarp DDelgado MKMargolis GWiebe DJCarr BG.

Disaster Med Public Health Prep. 2016 Aug;10(4):576-82. doi: 10.1017/dmp.2015.184. PMID: 26927882

Abstract

OBJECTIVES:

Boarding admitted patients decreases emergency department (ED) capacity to accommodate daily patient surge. Boarding in regional hospitals may decrease the ability to meet community needs during a public health emergency. This study examined differences in regional patient boarding times across the United States and in regions at risk for public health emergencies.

METHODS:

A retrospective cross-sectional analysis was performed by using 2012 ED visit data from the American Hospital Association (AHA) database and 2012 hospital ED boarding data from the Centers for Medicare and Medicaid Services Hospital Compare database. Hospitals were grouped into hospital referral regions (HRRs). The primary outcome was mean ED boarding time per HRR. Spatial hot spot analysis examined boarding time spatial clustering.

RESULTS:

A total of 3317 of 4671 (71%) hospitals were included in the study cohort. A total of 45 high-boarding-time HRRs clustered along the East/West coasts and 67 low-boarding-time HRRs clustered in the Midwest/Northern Plains regions. A total of 86% of HRRs at risk for a terrorist event had high boarding times and 36% of HRRs with frequent natural disasters had high boarding times.

CONCLUSIONS:

Urban, coastal areas have the longest boarding times and are clustered with other high-boarding-time HRRs. Longer boarding times suggest a heightened level of vulnerability and a need to enhance surge capacity because these regions have difficulty meeting daily emergency care demands and are at increased risk for disasters. (Disaster Med Public Health Preparedness. 2016;10:576-582).

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Emergency Bedside Ultrasound

Effect of Inhalational Anesthetics and Positive-pressure Ventilation on Ultrasound Assessment of the Great Vessels: A Prospective Study at a Children's Hospital.

Lin EEChen AEPanebianco NConlon TJu NRCarlson DKopenitz JNishisaki A.

Anesthesiology. 2016 Apr;124(4):870-7. doi: 10.1097/ALN.0000000000001032. PMID: 26835646

Abstract

BACKGROUND:

Bedside ultrasound has emerged as a rapid, noninvasive tool for assessment and monitoring of fluid status in children. The inferior vena cava (IVC) varies in size with changes in blood volume and intrathoracic pressure, but the magnitude of change to the IVC with inhalational anesthetic and positive-pressure ventilation (PPV) is unknown.

METHODS:

Prospective observational study of 24 healthy children aged 1 to 12 yr scheduled for elective surgery. Ultrasound images of the IVC and aorta were recorded at five time points: awake; spontaneous ventilation with sevoflurane by mask; intubated with peak inspiratory pressure/positive end-expiratory pressure of 15/0, 20/5, and 25/10 cm H2O. A blinded investigator measured IVC/aorta ratios (IVC/Ao) and changes in IVC diameter due to respiratory variation (IVC-RV) from the recorded videos.

RESULTS:

Inhalational anesthetic decreased IVC/Ao (1.1 ± 0.3 vs. 0.6 ± 0.2; P < 0.001) but did not change IVC-RV (median, 43%; interquartile range [IQR], 36 to 58% vs. 46%; IQR, 36 to 66%; P > 0.99). The initiation of PPV increased IVC/Ao (0.64 ± 0.21 vs. 1.16 ± 0.27; P < 0.001) and decreased IVC-RV (median, 46%; IQR, 36 to 66% vs. 9%; IQR, 4 to 14%; P < 0.001). There was no change in either IVC/Ao or IVC-RV with subsequent incremental increases in peak inspiratory pressure/positive end-expiratory pressure (P > 0.99 for both).

CONCLUSIONS:

Addition of inhalational anesthetic affects IVC/Ao but not IVC-RV, and significant changes in IVC/Ao and IVC-RV occur with initiation of PPV in healthy children. Clinicians should be aware of these expected vascular changes when managing patients. Establishing these IVC parameters will enable future studies to better evaluate these measurements as tools for diagnosing hypovolemia or predicting fluid responsiveness.

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First-Attempt Success, Longevity, and Complication Rates of Ultrasound-Guided Peripheral Intravenous Catheters in Children.

Vinograd AMZorc JJDean AJAbbadessa MKChen AE.

Pediatr Emerg Care. 2017 Feb 18. doi: 10.1097/PEC.0000000000001063. [Epub ahead of print] PMID: 28221281

Abstract

OBJECTIVE:

The aim of this study was to examine the success rates, longevity, and complications of ultrasound-guided peripheral intravenous lines (USgPIVs) placed in a pediatric emergency department.

METHODS:

The study analyzed 300 USgPIV attempts in an urban tertiary-care pediatric emergency department. Data regarding USgPIV placement were collected from a 1-page form completed by the clinician placing the USgPIV. The time and reason for USgPIV removal were extracted from the medical record for patients with USgPIVs admitted to the hospital. A Kaplan-Meier survival analysis was performed.

RESULTS:

This study demonstrated a success rate of 68% and 87% for the first and second attempts with USgPIV. Fifty-five percent of patients had 1 or more prior traditional intravenous access attempt. Most USgPIVs placed on patients admitted to the hospital were removed because they were no longer needed (101/160). We calculated a Kaplan-Meier median survival of 143 hours (6 days; interquartile range, 68-246 hours). The failure rate at 48 hours was 25%.

CONCLUSION:

Ultrasound-guided intravenous access is a feasible alternative to traditional peripheral intravenous access in the pediatric emergency setting. We observed a high first-stick success rate even in patients who had failed traditional peripheral intravenous access attempts, few complications, and a long intravenous survival time.

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Intensive point-of-care ultrasound training with long-term follow-up in a cohort of Rwandan physicians.

Henwood PCMackenzie DCRempell JSDouglass EDukundane DLiteplo ASLeo MMMurray AFVaillancourt SDean AJLewiss RERulisa SKrebs ERaja Rao AKRudakemwa ERusanganwa VKyanmanywa PNoble VE.

Trop Med Int Health. 2016 Dec;21(12):1531-1538. doi: 10.1111/tmi.12780. PMID: 27758005

Abstract

OBJECTIVE:

We delivered a point-of-care ultrasound training programme in a resource-limited setting in Rwanda, and sought to determine participants' knowledge and skill retention. We also measured trainees' assessment of the usefulness of ultrasound in clinical practice.

METHODS:

This was a prospective cohort study of 17 Rwandan physicians participating in a point-of-care ultrasound training programme. The follow-up period was 1 year. Participants completed a 10-day ultrasound course, with follow-up training delivered over the subsequent 12 months. Trainee knowledge acquisition and skill retention were assessed via observed structured clinical examinations (OSCEs) administered at six points during the study, and an image-based assessment completed at three points.

RESULTS:

Trainees reported minimal structured ultrasound education and little confidence using point-of-care ultrasound before the training. Mean scores on the image-based assessment increased from 36.9% (95% CI 32-41.8%) before the initial 10-day training to 74.3% afterwards (95% CI 69.4-79.2; P < 0.001). The mean score on the initial OSCE after the introductory course was 81.7% (95% CI 78-85.4%). The mean OSCE performance at each subsequent evaluation was at least 75%, and the mean OSCE score at the 58-week follow up was 84.9% (95% CI 80.9-88.9%).

CONCLUSIONS:

Physicians providing acute care in a resource-limited setting demonstrated sustained improvement in their ultrasound knowledge and skill 1 year after completing a clinical ultrasound training programme. They also reported improvements in their ability to provide patient care and in job satisfaction.

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