Academic emergency medicine : official journal of the Society for Academic Emergency Medicine
-
Randomized Controlled Trial Multicenter Study Comparative Study
Validation of a clinical prediction model for early admission to the intensive care unit of patients with pneumonia.
The Risk of Early Admission to the Intensive Care Unit (REA-ICU) index is a clinical prediction model that was derived based on 4,593 patients with community-acquired pneumonia (CAP) for predicting early admission to the intensive care unit (ICU; i.e., within 3 days following emergency department [ED] presentation). This study aimed to validate the REA-ICU index in an independent sample. ⋯ The REA-ICU index reliably stratifies CAP patients into four categories of increased risk for early ICU admission within 3 days following ED presentation. Further research is warranted to determine whether inflammatory biomarkers may improve the performance of this clinical prediction model.
-
Comparative Study
Prevalence of acute lung injury among medical patients in the emergency department.
Acute lung injury (ALI) affects an estimated 190,000 persons per year in U.S. intensive care units (ICUs), but little is known about its prevalence in the emergency department (ED). ⋯ The prevalence of ALI was nearly 9% in adult nontrauma patients receiving mechanical ventilation in the ED. Further study is required to determine which types of patients present to the ED with ALI, the extent to which lung protective ventilation is used, and the need for ED ventilator management algorithms.
-
Review Case Reports
A model for emergency department end-of-life communications after acute devastating events--part I: decision-making capacity, surrogates, and advance directives.
Making decisions for a patient affected by sudden devastating illness or injury traumatizes a patient's family and loved ones. Even in the absence of an emergency, surrogates making end-of-life treatment decisions may experience negative emotional effects. Helping surrogates with these end-of-life decisions under emergent conditions requires the emergency physician (EP) to be clear, making medical recommendations with sensitivity. ⋯ EPs should also help the surrogate and family understand that palliative care addresses comfort needs of the patient including adequate treatment for pain, dyspnea, or anxiety. Part I of this communications model reviews determination of decision-making capacity, surrogacy laws, and advance directives, including legal definitions and application of these steps; Part II (which will appear in a future issue of AEM) covers communication moving from resuscitative to end-of-life and palliative treatment. EPs should recognize acute devastating illness or injuries, when appropriate, as opportunities to initiate end-of-life discussions and to implement shared decisions.
-
Review Case Reports
The mortality benefit threshold for patients with suspected pulmonary embolism.
The mortality benefit for pulmonary embolism (PE) is the difference in mortality between treated and untreated patients. The mortality benefit threshold is the mortality benefit above which testing for a condition should be initiated and below which it should not. To illustrate this concept, the authors developed a decision model to estimate the mortality benefit threshold at several pretest probabilities for low-risk emergency department (ED) patients with possible PE and compare those thresholds with contemporary management of PE in the United States and what is known and not known about treatment benefits with anticoagulation. ⋯ The mortality benefit threshold for initiating PE testing is very high at low pretest probabilities of PE, which should be considered by clinicians in their diagnostic approach to PE in the ED. The mortality benefit threshold is a novel way of exploring the benefits and risks of ED-based testing, particularly in situations like PE where testing (i.e., CT use) carries real risks and the benefits of treatment are uncertain.
-
Randomized Controlled Trial Multicenter Study Comparative Study
Observational study of telephone consults by stroke experts supporting community tissue plasminogen activator delivery.
Barriers to intravenous (IV) tissue plasminogen activator (tPA) use in ischemic stroke include limited treatment experience of community physicians. Models of acute stroke care have been designed to address these limitations by providing community support. These include support by telephone or televideo, with or without subsequent transport to tertiary care centers. The authors describe the frequency, characteristics, and effect of community phone consultations to a 24/7 stroke "hotline" staffed by stroke physicians at an academic stroke center using such a model. ⋯ Providing tPA decision-making support via telephone consult to community physicians is feasible and safe. Consultants may play a more prominent role in determining tPA ineligibility than acceptance. Future work should include a real-time survey of physician providers to ascertain such potential qualitative benefits of a stroke hotline.