Annals of emergency medicine
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Heart failure causes substantial morbidity and mortality in the United States and accounts for a higher proportion of Medicare costs than any other disease. Most of these costs result from the high rate of hospital admissions and protracted length of stay associated with episodes of acute decompensation of heart failure. Thus, effective clinical strategies to obviate hospitalization and readmission can result in substantial savings. ⋯ In institutions with specialized heart failure observation units, patients are triaged to this setting shortly after presentation to the emergency department (ED), and clinic referrals can be directed to this unit after minimal ED evaluation. Aggressive follow-up is also arranged at discharge. Recent additions to the therapeutic armamentarium and future advances in diagnostics and monitoring will continue to improve patient care and prevent avoidable hospitalizations.
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Current risk stratification tools do not identify very-low-risk patients who can be safely discharged without prolonged emergency department (ED) observation, expensive rule-out protocols, or provocative testing. We seek to develop a clinical prediction rule applicable within 2 hours of ED arrival that would miss fewer than 2% of acute coronary syndrome patients and allow discharge within 2 to 3 hours for at least 30% of patients without acute coronary syndrome. ⋯ The Vancouver Chest Pain Rule for early discharge defines a group of patients who can be safely discharged after a brief evaluation in the ED. Prospective validation is needed.
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Comparative Study
Prevalence of negative chest radiography results in the emergency department patient with decompensated heart failure.
Although chest radiography is quick and inexpensive, previous research suggests that it is often misleading in emergency department (ED) patients with decompensated heart failure, resulting in misdiagnosis and inappropriate treatment. This study determines the rate of negative chest radiography results in patients found to have disease and the potential contribution of negative findings to a diagnosis discordant with heart failure by an emergency physician. ⋯ Approximately 1 of every 5 patients admitted from the ED with acute decompensated heart failure had no signs of congestion on chest radiography. Patients lacking signs of congestion on ED chest radiography were more likely to have an ED non-heart failure diagnosis than patients with signs of congestion. Clinicians should not rule out heart failure in patients with no radiographic signs of congestion.
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Disaster planning is only as good as the assumptions on which it is based. However, some of these assumptions are derived from a conventional wisdom that is at variance with empirical field disaster research studies. Knowledge of disaster research findings might help planners avoid common disaster management pitfalls, thereby improving disaster response planning. ⋯ Authorities at the scene will ensure that area hospitals are promptly notified of the disaster and the numbers, types, and severities of casualties to be transported to them. 7. The most serious casualties will be the first to be transported to hospitals. The current status and limitations of disaster research are discussed, and potential interventions to response problems are offered that may be of help to planners and practitioners and that may serve as hypotheses for future research.