Academic emergency medicine : official journal of the Society for Academic Emergency Medicine
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Current guideline recommendations for optimal management of nonpurulent skin and soft tissue infections (SSTIs) are based on expert consensus. There is a lack of evidence to guide emergency physicians regarding selection of patients for oral versus intravenous antibiotic therapy. The primary objective was to identify predictors associated with oral antibiotic treatment failure. ⋯ We identified 500 patients (mean ± SD age = 64 ± 19 years, 279 male [55.8%], and 126 [25.2%] with diabetes). Of 288 patients who had received a minimum of 48 hours of oral antibiotics, there were 85 oral antibiotic treatment failures (29.5%). Tachypnea at triage (odds ratio [OR] = 6.31, 95% confidence interval [CI] = 1.80 to 22.08), chronic ulcers (OR = 4.90, 95% CI = 1.68-14.27), history of methicillin-resistant Staphylococcus aureus (MRSA) colonization or infection (OR = 4.83, 95% CI = 1.51 to 15.44), and cellulitis in the past 12 months (OR = 2.23, 95% CI = 1.01 to 4.96) were independently associated with oral antibiotic treatment failure CONCLUSION: This is the first study to evaluate predictors of oral antibiotic treatment failure for nonpurulent SSTIs treated in the ED. Tachypnea at triage, chronic ulcers, history of MRSA colonization or infection, and cellulitis within the past year were independently associated with oral antibiotic treatment failure. Emergency physicians should consider these risk factors when deciding on oral versus intravenous antimicrobial therapy for outpatient management of nonpurulent SSTIs.
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Review Meta Analysis
Ultrasound-assisted Lumbar Punctures: A Systematic Review and Meta-Analysis.
Lumbar punctures (LPs) are a common procedure in emergency medicine. However, studies have found that failed procedure rates can be as high as 50%. Ultrasound has been suggested to improve success rates by visually identifying the location and trajectory for the LP procedure. This systematic review and meta-analysis was performed to determine whether the use of ultrasound improved the rate of successful LP performance. ⋯ Ultrasound-assisted LPs were associated with higher success rates, fewer traumatic LPs, shorter time to successful LP, fewer needle passes, and lower patient pain scores. Ultrasound should be considered prior to performing all LPs, especially in patients with difficult anatomy. Further studies are recommended to determine whether this effect is consistent in both adult and pediatric subgroups, as well as the impact of transducer type and body habitus on this technique.
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Multicenter Study
The Impact of Maryland's Global Budget Payment Reform on Emergency Department Admission Rates in a Single Health System.
In 2014, the state of Maryland (MD) moved away from fee-for-service payments and into a global budget revenue (GBR) structure where hospitals have a fixed revenue target, independent of patient volume or services provided. We assess the effects of GBR adoption on emergency department (ED) admission decisions among adult encounters. ⋯ Within the same health system, implementation of global budgeting in MD hospitals was associated with a decline in ED admissions-particularly lower-acuity admissions-compared to DC hospitals that remained under fee-for-service payments.