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Barrett TW, Rief K, Parisi F. The OPAL Trial Provides a Treasure of Evidence to Stop Using Opioids for Acute Neck and Back Pain: December 2023 Annals of Emergency Medicine Journal Club. Ann Emerg Med 2023; 82:758-759. [PMID: 37993223 DOI: 10.1016/j.annemergmed.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2023]
Affiliation(s)
- Tyler W Barrett
- Department of Emergency Medicine, MSCI Vanderbilt University Medical Center, Nashville, TN
| | - Katherine Rief
- Department of Emergency Medicine, MSCI Vanderbilt University Medical Center, Nashville, TN
| | - Frank Parisi
- Department of Emergency Medicine, MSCI Vanderbilt University Medical Center, Nashville, TN
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Hanna E, Barrett TW. Tenecteplase to Replace Alteplase? Comparing Thrombolytic Therapies for Acute Ischemic Stroke: June 2023 Annals of Emergency Medicine Journal Club. Ann Emerg Med 2023; 81:759-760. [PMID: 37210165 DOI: 10.1016/j.annemergmed.2023.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Affiliation(s)
- Eriny Hanna
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Tyler W Barrett
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
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Campbell BR, Esianor BI, Barrett TW, Casey JD, Steitz B, Du L, Gelbard A. Association of Educational Intervention With Knowledge of Airway Injury After Endotracheal Intubation and Tube Size Selection. JAMA Otolaryngol Head Neck Surg 2023; 149:372-374. [PMID: 36821123 PMCID: PMC9951102 DOI: 10.1001/jamaoto.2022.5099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 12/28/2022] [Indexed: 02/24/2023]
Abstract
In this nonrandomized controlled trial, an educational intervention for emergency medicine residents was developed to increase knowledge of airway injury following prolonged intubation and reduce the proportion of large-for-height endotracheal tubes placed in the emergency department.
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Affiliation(s)
- Benjamin R. Campbell
- Department of Otolaryngology–Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Brandon I. Esianor
- Department of Otolaryngology–Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Tyler W. Barrett
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jonathan D. Casey
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Bryan Steitz
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Liping Du
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alexander Gelbard
- Department of Otolaryngology–Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Reese TJ, Nelson SD, Marcovitz D, Shotwell M, Edwards DA, Wright A, Barrett TW. Evaluation of Compensatory Prescribing After Opioid-Restricting Legislation. J Gen Intern Med 2023; 38:1338-1340. [PMID: 36380174 PMCID: PMC10110774 DOI: 10.1007/s11606-022-07941-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 11/04/2022] [Indexed: 11/16/2022]
Affiliation(s)
- Thomas J. Reese
- Department of Biomedical Informatics, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 1475, Nashville, 37203 USA
| | - Scott D. Nelson
- Department of Biomedical Informatics, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 1475, Nashville, 37203 USA
| | - David Marcovitz
- Department of Psychiatry and Behavioral Science, Vanderbilt University Medical Center, Nashville, USA
| | - Matthew Shotwell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, USA
| | - David A. Edwards
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, USA
| | - Adam Wright
- Department of Biomedical Informatics, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 1475, Nashville, 37203 USA
| | - Tyler W. Barrett
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, USA
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Chen JW, Yengo-Kahn A, Chotai S, Bhamidipati A, Smith C, Davis P, Reynolds RA, Boyd MP, Barrett TW, Compton ES, Dennis BM, Norris MS, Patel MB, Schwarz JP, Thomason NR, Thompson RC, Guillamondegui OD. Assessment of safety and effectiveness of non-neurosurgical management for minimal traumatic brain injury (TBI). Injury 2023; 54:82-86. [PMID: 36028374 DOI: 10.1016/j.injury.2022.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 07/26/2022] [Accepted: 08/03/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Patients with mild traumatic brain injury (TBI) and intracranial hemorrhage often receive neurosurgical consultation. However, only a small proportion of patients require intervention. Our hypothesis is that low-risk minimal TBI patients managed without immediate neurosurgical consultation will have a reasonable safety and effectiveness outcome profile. METHODS A non-neurosurgical management protocol for adult minimal TBI was implemented at a level I trauma center as an interdisciplinary quality-improvement initiative in November 2018. Minimal TBI was defined as Glasgow Coma Scale (GCS) of 15 secondary to blunt mechanism, without anticoagulant or antiplatelet therapy, and isolated pneumocephalus and/or traumatic subarachnoid hemorrhage on head CT imaging. Safety was assessed by in-hospital mortality, neurosurgical interventions, and ED revisits within two weeks of discharge. Effectiveness was assessed by neurosurgical consult rate and length of stay. Outcomes were compared 8-months pre- and post-protocol implementation. RESULTS A total of 97 patients were included, of which 49 were pre-protocol and 48 were post-protocol There was no difference in rates of in-hospital mortality [0 (0%) vs 0 (0%)], neurosurgical procedure [1 (2.1%) vs 0 (0%)], operations [0 (0%) vs 0 (0%)], and ED revisits [1 (2.0%) vs 2 (4.2%), p = 0.985] between the periods. There was a significant reduction in neurosurgical consults post-protocol implementation (92% vs 29%, p<0.001). CONCLUSION A protocol for minimal TBI patients effectively reduced neurosurgical consultation without changes in safety profile. Such an interdisciplinary management protocol for low-risk neurotrauma can effectively utilize the neurosurgery consult services by stratifying neurologically stable TBI patient.
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Affiliation(s)
- Jeffrey W Chen
- Vanderbilt University School of Medicine, Nashville, TN, United States.
| | - Aaron Yengo-Kahn
- Department of Neurological Surgery, Vanderbilt University Medical Center, Section of Surgical Sciences, Nashville, TN United States.
| | - Silky Chotai
- Department of Neurological Surgery, Vanderbilt University Medical Center, Section of Surgical Sciences, Nashville, TN United States
| | | | - Candice Smith
- Division of Acute Care Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, TN United States
| | - Philip Davis
- Vanderbilt University School of Medicine, Nashville, TN, United States
| | - Rebecca A Reynolds
- Department of Neurological Surgery, Vanderbilt University Medical Center, Section of Surgical Sciences, Nashville, TN United States
| | - Mary Peyton Boyd
- Vanderbilt University School of Medicine, Nashville, TN, United States
| | - Tyler W Barrett
- Vanderbilt University School of Medicine, Nashville, TN, United States; Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Elizabeth S Compton
- Division of Acute Care Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, TN United States
| | - Bradley M Dennis
- Vanderbilt University School of Medicine, Nashville, TN, United States; Division of Acute Care Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, TN United States
| | - Michael S Norris
- Division of Acute Care Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, TN United States
| | - Mayur B Patel
- Vanderbilt University School of Medicine, Nashville, TN, United States; Department of Neurological Surgery, Vanderbilt University Medical Center, Section of Surgical Sciences, Nashville, TN United States; Division of Acute Care Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, TN United States; Department of Hearing and Speech Sciences, Vanderbilt University Medical Center, Nashville, TN, United States; Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, United States; Surgical Services, Geriatric Research Education and Clinical Centers, Tennessee Valley Healthcare System, United States Department of Veterans Affairs, Nashville, TN, United States; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt Brain Institute, United States
| | - Jacob P Schwarz
- Vanderbilt University School of Medicine, Nashville, TN, United States; Department of Neurological Surgery, Vanderbilt University Medical Center, Section of Surgical Sciences, Nashville, TN United States
| | - Nicholas R Thomason
- Division of Acute Care Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, TN United States
| | - Reid C Thompson
- Vanderbilt University School of Medicine, Nashville, TN, United States; Department of Neurological Surgery, Vanderbilt University Medical Center, Section of Surgical Sciences, Nashville, TN United States
| | - Oscar D Guillamondegui
- Vanderbilt University School of Medicine, Nashville, TN, United States; Department of Neurological Surgery, Vanderbilt University Medical Center, Section of Surgical Sciences, Nashville, TN United States; Division of Acute Care Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, TN United States; Department of Hearing and Speech Sciences, Vanderbilt University Medical Center, Nashville, TN, United States; Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, United States.
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Turer RW, Champion JC, Rothman BS, Dunn HS, Jenkins KM, Everham O, Barrett TW, Jones ID, Ward MJ, Miller NM. Decision Support to Improve Critical Care Services Documentation in an Academic Emergency Department. Appl Clin Inform 2022; 13:1100-1107. [PMID: 36162434 PMCID: PMC9668511 DOI: 10.1055/a-1950-9032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 09/20/2022] [Indexed: 11/02/2022] Open
Abstract
OBJECTIVES Critical care services (CCS) documentation affects billing, operations, and research. No studies exist on documentation decision support (DDS) for CCS in the emergency department (ED). We describe the design, implementation, and evaluation of a DDS tool built to improve CCS documentation at an academic ED. METHODS This quality improvement study reports the prospective design, implementation, and evaluation of a novel DDS tool for CCS documentation at an academic ED. CCS-associated ED diagnoses triggered a message to appear within the physician note attestation workflow for any patient seen in the adult ED. The alert raised awareness of CCS-associated diagnoses without recommending specific documentation practices. The message disappeared from the note automatically once signed. We measured current procedural terminology (CPT) codes 99291 or 99292 (representing CCS rendered) for 8 months before and after deployment to identify CCS documentation rates. We performed state-space Bayesian time-series analysis to evaluate the causal effect of our intervention on CCS documentation capture. We used monthly ED volume and monthly admission rates as covariate time-series for model generation. RESULTS The study included 92,350 ED patients with an observed mean proportion CCS of 3.9% before the intervention and 5.8% afterward. The counterfactual model predicted an average response of 3.9% [95% CI 3.5-4.3%]. The estimated absolute causal effect of the intervention was 2.0% [95% CI 1.5-2.4%] (p = 0.001). CONCLUSION A DDS tool measurably increased ED CCS documentation. Attention to user workflows and collaboration with compliance and billing teams avoided alert fatigue and ensures compliance.
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Affiliation(s)
- Robert W. Turer
- Department of Emergency Medicine and Clinical Informatics Center, UT Southwestern Medical Center, Dallas, Texas, United States
| | - John C. Champion
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Brian S. Rothman
- Department of Anesthesiology, Vanderbilt Medical Center, Nashville, Tennessee, United States
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Heather S. Dunn
- Department of Finance, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Kenneth M. Jenkins
- Department of Compliance, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Olayinka Everham
- Health IT, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Tyler W. Barrett
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Ian D. Jones
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, United States
- Health IT, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Michael J. Ward
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, United States
- Geriatric Research, Education, and Clinical Center, Tennessee Valley Healthcare System (Veterans Affairs), Nashville, Tennessee, United States
| | - Nathaniel M. Miller
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States
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McEvoy MD, Dear ML, Buie R, Edwards DA, Barrett TW, Allen B, Robertson AC, Fowler LC, Hennessy C, Miller BM, Garvey KV, Bland RP, Fleming GM, Moore D, Rice TW, Bernard GR, Lindsell CJ. Effect of Smartphone App-Based Education on Clinician Prescribing Habits in a Learning Health Care System: A Randomized Cluster Crossover Trial. JAMA Netw Open 2022; 5:e2223099. [PMID: 35881398 PMCID: PMC9327570 DOI: 10.1001/jamanetworkopen.2022.23099] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
IMPORTANCE Effective methods for engaging clinicians in continuing education for learning-based practice improvement remain unknown. OBJECTIVE To determine whether a smartphone-based app using spaced education with retrieval practice is an effective method to increase evidence-based practice. DESIGN, SETTING, AND PARTICIPANTS A prospective, unblinded, single-center, crossover randomized clinical trial was conducted at a single academic medical center from January 6 to April 24, 2020. Vanderbilt University Medical Center clinicians prescribing intravenous fluids were invited to participate in this study. INTERVENTIONS All clinicians received two 4-week education modules: 1 on prescribing intravenous fluids and 1 on prescribing opioid and nonopioid medications (counterbalancing measure), over a 12-week period. The order of delivery was randomized 1:1 such that 1 group received the fluid management module first, followed by the pain management module after a 4-week break, and the other group received the pain management module first, followed by the fluid management module after a 4-week break. MAIN OUTCOMES AND MEASURES The primary outcome was evidence-based clinician prescribing behavior concerning intravenous fluids in the inpatient setting and pain medication prescribing on discharge from the hospital. RESULTS A total of 354 participants were enrolled and randomized, with 177 in group 1 (fluid then pain management education) and 177 in group 2 (pain management then fluid education). During the overall study period, 16 868 questions were sent to 349 learners, with 11 783 (70.0%) being opened: 10 885 (92.4%) of those opened were answered and 7175 (65.9%) of those answered were answered correctly. The differences between groups changed significantly over time, indicated by the significant interaction between educational intervention and time (P = .002). Briefly, at baseline evidence-concordant IV fluid ordered 7.2% less frequently in group 1 than group 2 (95% CI, -19.2% to 4.9%). This was reversed after training at 4% higher (95% CI, -8.2% to 16.0%) in group 1 than group 2, a more than doubling in the odds of evidence-concordant ordering (OR, 2.56, 95% CI, 0.80-8.21). Postintervention, all gains had been reversed with less frequent ordering in group 1 than group 2 (-9.5%, 95% CI, -21.6% to 2.7%). There was no measurable change in opioid prescribing behaviors at any time point. CONCLUSIONS AND RELEVANCE In this randomized clinical trial, use of smartphone app learning modules resulted in statistically significant short-term improvement in some prescribing behaviors. However, this effect was not sustained over the long-term. Additional research is needed to understand how to sustain improvements in care delivery as a result of continuous professional development at the institutional level. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03771482.
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Affiliation(s)
- Matthew D. McEvoy
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mary Lynn Dear
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Reagan Buie
- Episodes of Care, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David A. Edwards
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Tyler W. Barrett
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Brian Allen
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Amy C. Robertson
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Leslie C. Fowler
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Cassandra Hennessy
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Bonnie M. Miller
- Department of the Office of Health Sciences Education, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kim V. Garvey
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert P. Bland
- Department of HealthIT Architecture and Integration, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Geoffrey M. Fleming
- Department of Pediatrics, Vanderbilt Children’s Hospital, Nashville, Tennessee
| | - Don Moore
- Professor of Medical Education and Administration, Emeritus, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Todd W. Rice
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Gordon R. Bernard
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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Nelson SD, McCoy AB, Rector H, Teare AJ, Barrett TW, Sigworth EA, Chen Q, Edwards DA, Marcovitz DE, Wright A. Assessment of a Naloxone Coprescribing Alert for Patients at Risk of Opioid Overdose: A Quality Improvement Project. Anesth Analg 2022; 135:26-34. [PMID: 35343932 PMCID: PMC10823563 DOI: 10.1213/ane.0000000000005976] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Patients taking high doses of opioids, or taking opioids in combination with other central nervous system depressants, are at increased risk of opioid overdose. Coprescribing the opioid-reversal agent naloxone is an essential safety measure, recommended by the surgeon general, but the rate of naloxone coprescribing is low. Therefore, we set out to determine whether a targeted clinical decision support alert could increase the rate of naloxone coprescribing. METHODS We conducted a before-after study from January 2019 to April 2021 at a large academic health system in the Southeast. We developed a targeted point of care decision support notification in the electronic health record to suggest ordering naloxone for patients who have a high risk of opioid overdose based on a high morphine equivalent daily dose (MEDD) ≥90 mg, concomitant benzodiazepine prescription, or a history of opioid use disorder or opioid overdose. We measured the rate of outpatient naloxone prescribing as our primary measure. A multivariable logistic regression model with robust variance to adjust for prescriptions within the same prescriber was implemented to estimate the association between alerts and naloxone coprescribing. RESULTS The baseline naloxone coprescribing rate in 2019 was 0.28 (95% confidence interval [CI], 0.24-0.31) naloxone prescriptions per 100 opioid prescriptions. After alert implementation, the naloxone coprescribing rate increased to 4.51 (95% CI, 4.33-4.68) naloxone prescriptions per 100 opioid prescriptions (P < .001). The adjusted odds of naloxone coprescribing after alert implementation were approximately 28 times those during the baseline period (95% CI, 15-52). CONCLUSIONS A targeted decision support alert for patients at risk for opioid overdose significantly increased the rate of naloxone coprescribing and was relatively easy to build.
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Affiliation(s)
- Scott D. Nelson
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Allison B. McCoy
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Hayley Rector
- Department of Pharmacy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Andrew J. Teare
- Department of HealthIT, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Tyler W. Barrett
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Qingxia Chen
- Department of Biostatistics, Vanderbilt University, Nashville, Tennessee
| | - David A. Edwards
- Department of Anesthesiology, Division of Pain Medicine, Anesthesiology, and Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David E. Marcovitz
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Adam Wright
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
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Barrett TW, Garland NM, Freeman CL, Klar K, Dahlke J, Lancaster P, Prisco L, Chang SS, Goff LW, Russ S, Jones ID. Catching Those Who Fall Through the Cracks: Integrating a Follow-Up Process for Emergency Department Patients with Incidental Radiologic Findings. Ann Emerg Med 2022; 80:235-242. [PMID: 35752517 DOI: 10.1016/j.annemergmed.2022.04.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 04/15/2022] [Accepted: 04/20/2022] [Indexed: 11/01/2022]
Abstract
STUDY OBJECTIVE Abnormal findings unrelated to the indication for testing are identified on emergency department (ED) imaging studies. We report the design and implementation of an electronic health record-based interdisciplinary referral system and our experience from the first 13 months of ensuring that patients with incidental radiology findings were connected with the appropriate outpatient surveillance. METHODS Our informatics team standardized the contemporaneous reporting of critical radiology alerts using our ED trackboard and created a companion follow-up request form for the treating ED clinicians to complete. The forms were routed to nurse case managers, who arranged follow-ups based on the findings and clinical significance. The primary outcome was the proportion of ED patient visits with identified incidental findings that had documented communication of the incidental findings and surveillance plans. RESULTS Over the first 13 months after implementation, 932 ED patient visits had critical radiology alert referrals, for a total of 982 incidental findings. The primary outcome (confirmed post-ED communication and documented follow-up plan) was attained in 888 (95.3%, 95% confidence interval [CI] 93.9% to 96.6%) ED patient visits with confirmed post-ED communication and documented follow-up plans. The team was unable to contact or confirm follow-up with 44 (4.7%, 95% CI 3.4 to 6.1) patients by telephone or through the health care system's electronic communication tools. CONCLUSION We report the implementation of a standardized notification and referral system for ED patients with incidental radiology findings. The development of a reliable notification and follow-up system is an important patient safety intervention given the opportunity to potentially identify undiagnosed malignancies.
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Affiliation(s)
- Tyler W Barrett
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN; Vanderbilt Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN.
| | - Nicholas M Garland
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN; Vanderbilt Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN
| | - Clifford L Freeman
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN; Vanderbilt Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN
| | - Katharine Klar
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN; Vanderbilt Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN
| | - Jan Dahlke
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN; Vanderbilt Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN
| | - Penny Lancaster
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN; Vanderbilt Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN
| | - Larry Prisco
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN; Vanderbilt Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN
| | - Sam S Chang
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN; Vanderbilt Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN
| | - Laura W Goff
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN; Vanderbilt Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN
| | - Stephan Russ
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN; Vanderbilt Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN
| | - Ian D Jones
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN; Vanderbilt Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN
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Hanna E, Barrett TW. To Bougie or Not to Bougie: Bougie versus Stylet for First-Pass Intubation Success: April 2022 Annals of Emergency Medicine Journal Club. Ann Emerg Med 2022; 79:409-411. [PMID: 35337479 DOI: 10.1016/j.annemergmed.2022.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Eriny Hanna
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Tyler W Barrett
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
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11
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Barrett TW, McEvoy MD, Fowler LC, Shotwell MS, Shi Y, Costello M, Rogers D, Slayton J, Edwards DA. Impact of an Asynchronous Spaced Education Learning Intervention on Emergency Medicine Clinician Opioid Prescribing. Cureus 2021; 13:e18165. [PMID: 34707949 PMCID: PMC8530747 DOI: 10.7759/cureus.18165] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2021] [Indexed: 11/14/2022] Open
Abstract
Introduction Opioid prescribing has contributed to the opioid crisis and education has focused on improved opioid stewardship. We aimed to evaluate the impact of an asynchronous high-quality education to change emergency medicine (EM) clinician opioid prescribing. Methods We conducted a retrospective cohort study of a spaced-education intervention in EM clinicians who work at an urban, university-affiliated academic medical center emergency department. We developed opioid prescribing educational content and investigated whether prescriber participation in a novel asynchronous educational program, QuizTime, was associated with a change in EM clinician opioid prescribing practices and whether those prescribing practice changes would be maintained. The primary outcome was the frequency of opioid prescriptions by attributable emergency department discharges. We compared the frequency during the post-intervention period, 24 months following QuizTime education (July 2018 - June 2020) to the baseline period (November 2016 - March 2018). The secondary outcomes were total morphine milligram equivalent (MME) and the number of tablets dispensed per prescription. We analyzed the outcomes by EM clinicians’ level of participation in QuizTime education. Results During the study period, there was an overall reduction in opioid prescribing per attributable emergency department discharge (p < 0.001). Among the 45 prescribers who enrolled in QuizTime, there was a significant reduction of 4.3 (95% CI: 3.9, 4.6, p < 0.001) opioid prescriptions per 100 ED discharges in the post-intervention period compared to baseline. Among the 11 non-enrollees, there was a significant reduction of 2.4 (95% CI: 1.7, 3.1, p < 0.001) opioid prescriptions per 100 emergency department discharges in the post-intervention period compared to baseline. The prescribers enrolled in QuizTime had a significantly larger reduction in prescriptions compared to those who did not enroll (p < 0.001). A decreasing trend of total MME and the number of tablets dispensed was observed (p < 0.001). However, there was insufficient evidence to show a reduction in the number of tablets dispensed or MME per day. Conclusion EM clinician participation in the QuizTime Pain Management educational program was associated with a nearly two-fold decrease in opioid prescriptions per emergency department discharge compared to peers who chose not to enroll.
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Affiliation(s)
- Tyler W Barrett
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, USA
| | - Matt D McEvoy
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, USA
| | - Leslie C Fowler
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, USA
| | - Matthew S Shotwell
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, USA
| | - Yaping Shi
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, USA
| | - Michael Costello
- Department of Quality, Safety and Risk Prevention, Vanderbilt University Medical Center, Nashville, USA
| | - Devin Rogers
- Department of Emergency Medicine, PeaceHealth Sacred Heart Medical Center University District, Eugene, USA
| | - Jennifer Slayton
- Department of Quality, Safety and Risk Prevention, Vanderbilt University Medical Center, Nashville, USA
| | - David A Edwards
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, USA
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12
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Scott KP, Lacy A, Freeman C, Barrett TW. Predicting Outcomes in Pediatric Pneumonia: Are We Omnipotent or Incompetent?: October 2021 Annals of Emergency Medicine Journal Club. Ann Emerg Med 2021; 78:570-571. [PMID: 34563303 DOI: 10.1016/j.annemergmed.2021.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Kelly P Scott
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Aaron Lacy
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Clifford Freeman
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Tyler W Barrett
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
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13
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Johnson LSB, Oldgren J, Barrett TW, McNaughton CD, Wong JA, McIntyre WF, Freeman CL, Murphy L, Engström G, Ezekowitz M, Connolly SJ, Xu L, Nakamya J, Conen D, Bangdiwala SI, Yusuf S, Healey JS. LVS-HARMED Risk Score for Incident Heart Failure in Patients With Atrial Fibrillation Who Present to the Emergency Department: Data from a World-Wide Registry. J Am Heart Assoc 2021; 10:e017735. [PMID: 34514842 PMCID: PMC8649506 DOI: 10.1161/jaha.120.017735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Heart failure (HF) is a common complication to atrial fibrillation (AF), leading to rehospitalization and death. Early identification of patients with AF at risk for HF might improve outcomes. We aimed to derive a score to predict 1-year risk of new-onset HF after an emergency department (ED) visit with AF. Methods and Results The RE-LY AF (Randomized Evaluation of Long-Term Anticoagulant Therapy) registry enrolled patients with AF presenting to an ED in 47 countries, and followed them for a year. The end point was HF hospitalization and/or HF death. Among 15 400 ED patients, 9765 had no prior HF (mean age, 64.9±14.9 years). Within 1 year, new-onset HF developed in 6.8% of patients, of whom 21% died of HF. Independent predictors of HF included left ventricular hypertrophy (odds ratio [OR], 1.47; 95% CI, 1.19-1.82), valvular heart disease (OR, 1.55; 95% CI, 1.18-2.04), smoking (OR, 1.42; 95% CI, 1.12-1.78), height (OR, 0.93; 95% CI, 0.90-0.95 per 3 cm), age (OR, 1.11; 95% CI, 1.07-1.15 per 5 years), rheumatic heart disease (OR, 1.77, 95% CI, 1.24-2.51), prior myocardial infarction (OR, 1.85; 95% CI, 1.45-2.36), remaining in AF at ED discharge (OR, 1.86; 95% CI, 1.46-2.36), and diabetes (OR, 1.33; 95% CI, 1.09-1.64). A continuous risk prediction score (LVS-HARMED [left ventricular, valvular heart disease, smoking or other tobacco use, height, age, rheumatic heart disease, myocardial infarction, emergency department discharge rhythm, and diabetes]) had good discrimination (C statistic, 0.735; 95% CI, 0.716-0.755). Validation was conducted internally using bootstrapping (optimism-corrected C statistic, 0.705) and externally (C statistic, 0.699). The 1-year incidence of HF hospitalization and/or HF death across quartile groups of the score was 1.1%, 4.5%, 6.9%, and 14.4%, respectively. LVS-HARMED also predicted incident stroke (C statistic, 0.753; 95% CI, 0.728-0.778). Conclusions The LVS-HARMED score predicts new-onset HF after an ED visit for AF. Preventative strategies should be considered in patients with high LVS-HARMED HF risk.
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Affiliation(s)
- Linda S B Johnson
- Department of Clinical Physiology Skåne University Hospital Department of Clinical Sciences Lund University Malmö Sweden.,Population Health Research Institute McMaster University Hamilton Onatrio Canada
| | - Jonas Oldgren
- Uppsala Clinical Research Center and Department of Medical Sciences, Cardiology Uppsala University Uppsala Sweden
| | - Tyler W Barrett
- Department of Emergency Medicine Vanderbilt University School of Medicine Nashville TN
| | - Candace D McNaughton
- Department of Emergency Medicine Vanderbilt University School of Medicine Nashville TN.,Geriatric Research, Education, and Clinical Center Tennessee Valley Healthcare System VA Medical System Nashville TN
| | - Jorge A Wong
- Population Health Research Institute McMaster University Hamilton Onatrio Canada
| | - William F McIntyre
- Population Health Research Institute McMaster University Hamilton Onatrio Canada
| | - Clifford L Freeman
- Department of Emergency Medicine Vanderbilt University School of Medicine Nashville TN
| | - Laura Murphy
- Department of Emergency Medicine Vanderbilt University School of Medicine Nashville TN
| | - Gunnar Engström
- Department of Clinical Physiology Skåne University Hospital Department of Clinical Sciences Lund University Malmö Sweden
| | - Michael Ezekowitz
- Sidney Kimmel Medical College Bryn Mawr HospitalLankenau Heart Center Wynnewood PA
| | - Stuart J Connolly
- Population Health Research Institute McMaster University Hamilton Onatrio Canada
| | - Lizhen Xu
- Population Health Research Institute McMaster University Hamilton Onatrio Canada
| | - Juliet Nakamya
- Population Health Research Institute McMaster University Hamilton Onatrio Canada
| | - David Conen
- Population Health Research Institute McMaster University Hamilton Onatrio Canada
| | | | - Salim Yusuf
- Population Health Research Institute McMaster University Hamilton Onatrio Canada
| | - Jeff S Healey
- Population Health Research Institute McMaster University Hamilton Onatrio Canada
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14
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Melton M, Rupp JD, Blatt MI, Boyd JS, Barrett TW, Swarm M, Ward MJ. Description of the Use of Incentives and Penalties for Point-of-Care Ultrasound Documentation Compliance in an Academic Emergency Department. Cureus 2021; 13:e16199. [PMID: 34367802 PMCID: PMC8341210 DOI: 10.7759/cureus.16199] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2021] [Indexed: 11/05/2022] Open
Abstract
Objectives Incomplete documentation and submission to the electronic health record of performed point-of-care ultrasound (POCUS) studies is problematic from a patient care, medicolegal, and billing standpoint. Positive and negative financial incentives may be used to motivate physicians to complete documentation workflow. The most efficacious route to improve POCUS workflow completion remains to be determined. Materials and methods A retrospective analysis of POCUS documentation in an academic emergency department during four distinct six-month blocks was performed. POCUS workflow completion was assessed without incentives (Baseline), with financial bonus (Incentive), interim period (Washout), and with a negative financial incentive (Penalty) to determine the effect of these incentives on workflow completion. Results There was an appreciable increase in the rate of POCUS studies documented between the "Baseline" (no incentive) and "Incentive" (small financial bonus) time periods. The improvement remained stable during the "Washout" (interim) period, and then increased further in the "Penalty" (negative financial incentive) period. This improvement was relatively diffuse among the providers studied. A similar pattern - improvements in the Incentive and Penalty periods with stability in the Washout - was also observed in the POCUS volume data (number of studies performed). Conclusions This study reveals a positive association between the implementation of both financial incentives and financial penalties, which increases in POCUS documentation among attending physicians at an academic emergency department.
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Affiliation(s)
- Myles Melton
- Emergency Medicine, Olympia Emergency Services, Olympia, USA
| | - Jordan D Rupp
- Emergency Medicine, Vanderbilt University Medical Center, Nashville, USA
| | - Marc I Blatt
- School of Medicine, Vanderbilt University, Nashville, USA
| | - Jeremy S Boyd
- Emergency Medicine, Vanderbilt University Medical Center, Nashville, USA
| | - Tyler W Barrett
- Emergency Medicine, Vanderbilt University Medical Center, Nashville, USA
| | - Matthew Swarm
- Emergency Medicine, Vanderbilt University Medical Center, Nashville, USA
| | - Michael J Ward
- Emergency Medicine, Vanderbilt University Medical Center, Nashville, USA
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15
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Kloosterman M, Oldgren J, Conen D, Wong JA, Connolly SJ, Avezum A, Yusuf S, Ezekowitz MD, Wallentin L, Ntep-Gweth M, Joseph P, Barrett TW, Tanosmsup S, McIntyre WF, Lee SF, Parkash R, Amit G, Grinvalds A, Van Gelder IC, Healey JS. Characteristics and outcomes of atrial fibrillation in patients without traditional risk factors: an RE-LY AF registry analysis. Europace 2021; 22:870-877. [PMID: 32215649 DOI: 10.1093/europace/euz360] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 12/12/2019] [Indexed: 11/14/2022] Open
Abstract
AIMS Data on patient characteristics, prevalence, and outcomes of atrial fibrillation (AF) patients without traditional risk factors, often labelled 'lone AF', are sparse. METHODS AND RESULTS The RE-LY AF registry included 15 400 individuals who presented to emergency departments with AF in 47 countries. This analysis focused on patients without traditional risk factors, including age ≥60 years, hypertension, coronary artery disease, heart failure, left ventricular hypertrophy, congenital heart disease, pulmonary disease, valve heart disease, hyperthyroidism, and prior cardiac surgery. Patients without traditional risk factors were compared with age- and region-matched controls with traditional risk factors (1:3 fashion). In 796 (5%) patients, no traditional risk factors were present. However, 98% (779/796) had less-established or borderline risk factors, including borderline hypertension (130-140/80-90 mmHg; 47%), chronic kidney disease (eGFR < 60 mL/min; 57%), obesity (body mass index > 30; 19%), diabetes (5%), excessive alcohol intake (>14 units/week; 4%), and smoking (25%). Compared with patients with traditional risk factors (n = 2388), patients without traditional risk factors were more often men (74% vs. 59%, P < 0.001) had paroxysmal AF (55% vs. 37%, P < 0.001) and less AF persistence after 1 year (21% vs. 49%, P < 0.001). Furthermore, 1-year stroke occurrence rate (0.6% vs. 2.0%, P = 0.013) and heart failure hospitalizations (0.9% vs. 12.5%, P < 0.001) were lower. However, risk of AF-related re-hospitalization was similar (18% vs. 21%, P = 0.09). CONCLUSION Almost all patients without traditionally defined AF risk factors have less-established or borderline risk factors. These patients have a favourable 1-year prognosis, but risk of AF-related re-hospitalization remains high. Greater emphasis should be placed on recognition and management of less-established or borderline risk factors.
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Affiliation(s)
- Mariëlle Kloosterman
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jonas Oldgren
- Department of Medical Sciences, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - David Conen
- Population Health Research Institute, Department of Medicine, McMaster University, 30 Birge St. Room C3-121, Hamilton, Ontario L8L 0A6, Canada
| | - Jorge A Wong
- Population Health Research Institute, Department of Medicine, McMaster University, 30 Birge St. Room C3-121, Hamilton, Ontario L8L 0A6, Canada
| | - Stuart J Connolly
- Population Health Research Institute, Department of Medicine, McMaster University, 30 Birge St. Room C3-121, Hamilton, Ontario L8L 0A6, Canada
| | - Alvaro Avezum
- Division of Cardiology, Dante Pazzanese Institute of Cardiology, Sao Paulo, Brazil
| | - Salim Yusuf
- Population Health Research Institute, Department of Medicine, McMaster University, 30 Birge St. Room C3-121, Hamilton, Ontario L8L 0A6, Canada
| | - Michael D Ezekowitz
- Department of Medicine, Medical College and Lankenau Medical Center, Wynnewood, PA, USA
| | - Lars Wallentin
- Department of Medical Sciences, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Marie Ntep-Gweth
- Department of Medicine, Hôpital Central de Yaoundé, Yaounde, Cameroon
| | - Philip Joseph
- Population Health Research Institute, Department of Medicine, McMaster University, 30 Birge St. Room C3-121, Hamilton, Ontario L8L 0A6, Canada
| | - Tyler W Barrett
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - William F McIntyre
- Population Health Research Institute, Department of Medicine, McMaster University, 30 Birge St. Room C3-121, Hamilton, Ontario L8L 0A6, Canada
| | - Shun Fu Lee
- Population Health Research Institute, Department of Medicine, McMaster University, 30 Birge St. Room C3-121, Hamilton, Ontario L8L 0A6, Canada
| | - Ratika Parkash
- Department of Medicine, Queen Elizabeth II Health Sciences Center and Dalhousie University, Halifax, Nova Scotia, Canada
| | - Guy Amit
- Population Health Research Institute, Department of Medicine, McMaster University, 30 Birge St. Room C3-121, Hamilton, Ontario L8L 0A6, Canada
| | - Alex Grinvalds
- Population Health Research Institute, Department of Medicine, McMaster University, 30 Birge St. Room C3-121, Hamilton, Ontario L8L 0A6, Canada
| | - Isabelle C Van Gelder
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jeff S Healey
- Population Health Research Institute, Department of Medicine, McMaster University, 30 Birge St. Room C3-121, Hamilton, Ontario L8L 0A6, Canada
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16
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Freeman CL, Ritter KM, Barrett TW. Chronic Obstructive Pulmonary Disease in the Emergency Department: What Are We Missing?: May 2021 Annals of Emergency Medicine Journal Club. Ann Emerg Med 2021; 77:550-551. [PMID: 33902832 DOI: 10.1016/j.annemergmed.2021.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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17
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Freeman CL, Miller NM, Bastarache L, Peterson J, Self WH, Barrett TW, Ward MJ. Co-detection of SARS-CoV-2 with Secondary Respiratory Pathogen Infections. J Gen Intern Med 2021; 36:1159-1160. [PMID: 33506386 PMCID: PMC7840073 DOI: 10.1007/s11606-020-06471-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 12/14/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Clifford L Freeman
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Nathaniel M Miller
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lisa Bastarache
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Josh Peterson
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Tyler W Barrett
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael J Ward
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA.
- VA Tennessee Valley Healthcare System, Nashville, TN, USA.
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18
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Murphy L, Miller N, Barrett TW. Antibiotics Versus Appendectomy for Acute Appendicitis: Are Antibiotics Really Noninferior?: March 2021 Annals of Emergency Medicine Journal Club. Ann Emerg Med 2021; 77:378-380. [PMID: 33618814 DOI: 10.1016/j.annemergmed.2021.01.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Laura Murphy
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Nathaniel Miller
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Tyler W Barrett
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
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19
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Freeman CL, McNaughton CD, Barrett TW. A Hard Day’s Night: Exhaustion and Errors in Resident Work Hours. Ann Emerg Med 2020; 76:683-685. [DOI: 10.1016/j.annemergmed.2020.09.448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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20
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Miller NM, Jones I, Russ S, Slovis C, Yeatman J, Clark G, Jeffrey A, Barrett TW. A model for rapid emergency department expansion for the COVID-19 pandemic. Am J Emerg Med 2020; 38:2065-2069. [PMID: 33142176 PMCID: PMC7832102 DOI: 10.1016/j.ajem.2020.06.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 06/12/2020] [Accepted: 06/12/2020] [Indexed: 12/15/2022] Open
Abstract
COVID-19 has caused global dramatic change in medical practices including the introduction of temporary screening and assessment areas outside the footprint of the main hospital structures. Following the initial surge of patients with novel coronavirus (2019-nCoV) in the United States, our medical center rapidly designed and constructed an alternative assessment and treatment site in a converted parking garage deck for emergency department patients with suspected or confirmed 2019-nCoV. During the first month after opening, 651 patients were treated in this alternative assessment area including 54 patients who tested positive for 2019-nCoV. This accounted for 55% of the 98 patients with confirmed novel coronavirus (2019-nCoV) who were treated in our ED. This report provides a blueprint for the necessary steps, materials, labor needs and barriers, both anticipated and unanticipated, to rapidly construct an alternative ED treatment site during a pandemic.
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21
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Vinson DR, Kea B, Coll-Vinent B, Barrett TW. Emergency department cardioversion of acute atrial fibrillation. Lancet 2020; 396:885. [PMID: 32979973 PMCID: PMC7737852 DOI: 10.1016/s0140-6736(20)31314-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 05/28/2020] [Indexed: 11/17/2022]
Affiliation(s)
- David R Vinson
- The Permanente Medical Group, Kaiser Permanente Division of Research, Oakland, CA 94612, USA; CREST Network, Oakland, California, CA, USA.
| | - Bory Kea
- Department of Emergency Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Blanca Coll-Vinent
- Arrhythmia Division, Spanish Society of Emergency Medicine, Madrid, Spain; Emergency Area Research Group, Hospital Clinic, Barcelona, Spain
| | - Tyler W Barrett
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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22
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Freeman CL, Evans CS, Barrett TW. Managing sedation in the mechanically ventilated emergency department patient: a clinical review. J Am Coll Emerg Physicians Open 2020; 1:263-269. [PMID: 33000041 PMCID: PMC7493591 DOI: 10.1002/emp2.12045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 01/21/2020] [Accepted: 02/20/2020] [Indexed: 11/29/2022] Open
Abstract
Managing sedation in the ventilated emergency department (ED) patient is increasingly important as critical care unit admissions from EDs increase and hospital crowding results in intubated patients boarding for longer periods. The objectives of this review are 3-fold; (1) describe the historical perspective of how sedation of the ventilated patient has changed, (2) summarize the most commonly used sedation and analgesic agents, and (3) provide a practical approach to sedation and analgesia in mechanically ventilated ED patients. We searched PubMed using keywords "emergency department post-intubation sedation," "emergency department critical care length of stay," and "sedation in mechanically ventilated patient." The search results were limited to English language and reviewed for relevance to the subject of interest. Our search resulted in 723 articles that met the criteria for managing sedation in the ventilated ED patient, of which 19 articles were selected and reviewed. Our review of the literature found that the level of sedation and practices of sedation and analgesia in the ED environment have downstream consequences on patient care including overall patient centered outcomes even after the patient has left the ED. It is reasonable to begin with analgesia in isolation, although sedating medications should be used when patients remain uncomfortable and agitated after initial interventions are performed.
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Affiliation(s)
- Clifford L. Freeman
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennessee
| | - Christopher S. Evans
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennessee
| | - Tyler W. Barrett
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennessee
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23
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Freeman CL, Barrett TW. Stop the Clot: Should Emergency Clinicians Champion Stroke Prevention and Prescribe Anticoagulation for Patients With Atrial Fibrillation? Ann Emerg Med 2019; 73:419-421. [DOI: 10.1016/j.annemergmed.2019.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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24
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Barrett TW, Freeman CL. Outpatient Pulmonary Embolism Management: If You Walk Into the Emergency Department With a Pulmonary Embolism, Maybe You Should Also Walk Out. Ann Emerg Med 2018; 72:725-730. [DOI: 10.1016/j.annemergmed.2018.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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25
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Bellew SD, Collins SP, Barrett TW, Russ SE, Jones ID, Slovis CM, Self WH. Implementation of an Opioid Detoxification Management Pathway Reduces Emergency Department Length of Stay. Acad Emerg Med 2018; 25:1157-1163. [PMID: 29799649 PMCID: PMC6185770 DOI: 10.1111/acem.13457] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 05/16/2018] [Accepted: 05/18/2018] [Indexed: 02/05/2023]
Abstract
OBJECTIVES With the rise of opioid use in the United States, the increasing demand for treatment for opioid use disorders presents both a challenge and an opportunity to develop new care pathways for emergency department (ED) patients seeking opioid detoxification. We set out to improve the care of patients presenting to our ED seeking opioid detoxification by implementing a standardized management pathway and to measure the effects of this intervention. METHODS We conducted a before-after study of the effects of an opioid detoxification management pathway on ED length of stay (EDLOS), use of resources (social worker consultation, laboratory tests obtained), and return visits to the same ED within 30 days of discharge. All data were collected retrospectively by review of the electronic health record. RESULTS Ultimately, 107 patients presented to the ED that met criteria, 52 in the intervention period and 55 in the preintervention period. Median EDLOS in the intervention period was 152 (interquartile range [IQR] = 93-237) minutes compared to 312 (IQR = 187-468) minutes in the preintervention period (p < 0.001). Patients in the intervention period less frequently had a social work consultation (32.7% vs. 83.6%, p < 0.001) or had laboratory tests obtained (32.7% vs 74.5%, p < 0.001) and more frequently were prescribed a medication for withdrawal symptoms (57.7% vs. 29.1%, p = 0.003). CONCLUSIONS Implementation of an opioid detoxification management pathway reduced EDLOS, reduced utilization of resources, and increased the proportion of patients prescribed medications for symptom relief.
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Affiliation(s)
| | | | | | | | - Ian D Jones
- Vanderbilt University Medical Center, Nashville, TN
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26
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Vinson DR, Kea B, Coll-Vinent B, Barrett TW, Atzema CL. Enlisting Emergency Medicine Clinicians to Help Reduce Strokes in High-Risk Patients With Atrial Fibrillation and Flutter. Clin Pharmacol Ther 2018; 104:613-614. [PMID: 30006942 DOI: 10.1002/cpt.1144] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 05/17/2018] [Indexed: 11/09/2022]
Affiliation(s)
- David R Vinson
- The Permanente Medical Group, Oakland, California, USA.,Kaiser Permanente Division of Research, Oakland, California, USA.,The CREST Network, Oakland, California, USA.,Department of Emergency Medicine, Kaiser Permanente Sacramento Medical Center, Sacramento, California, USA
| | - Bory Kea
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Blanca Coll-Vinent
- Arrhythmia Division, Spanish Society of Emergency Medicine, Madrid, Spain.,Emergency Area Research Group, Hospital Clinic, Barcelona, Spain
| | - Tyler W Barrett
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Clare L Atzema
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Division of Emergency Medicine, Department of Medicine, the Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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27
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Barrett TW. Outpatient Pulmonary Embolism Management: If You Walk Into the Emergency Department With a Pulmonary Embolism, Maybe You Should Also Walk Out. Ann Emerg Med 2018; 72:100-101. [DOI: 10.1016/j.annemergmed.2018.04.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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28
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Kloosterman M, Conen D, Oldgren J, Wong J, Connolly SJ, Avezum A, Yusuf S, Ezekowitz MD, Wallentin L, Ntep-Gweth M, Barrett TW, Mcintyre WF, Parkash R, Van Gelder IC, Healey JS. 47Characteristics and outcomes of atrial fibrillation in patients without conventional risk factors: A RE-LY AF registry analysis. Europace 2018. [DOI: 10.1093/europace/euy015.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- M Kloosterman
- University of Groningen, University Medical Center Groningen, Department of Cardiology, Groningen, Netherlands
| | - D Conen
- Population Health Research Institute, Hamilton, Canada
| | - J Oldgren
- Uppsala Clinical Research Center, Uppsala, Sweden
| | - J Wong
- Population Health Research Institute, Hamilton, Canada
| | - S J Connolly
- Population Health Research Institute, Hamilton, Canada
| | - A Avezum
- Dante Pazzanese Institute of Cardiology, Sao Paulo, Brazil
| | - S Yusuf
- Population Health Research Institute, Hamilton, Canada
| | - M D Ezekowitz
- Lankenau Hospital, Wynnewood, United States of America
| | - L Wallentin
- Uppsala Clinical Research Center, Uppsala, Sweden
| | | | - T W Barrett
- Vanderbilt University, Nashville, United States of America
| | - W F Mcintyre
- Population Health Research Institute, Hamilton, Canada
| | - R Parkash
- QE II Health Sciences Center, Halifax, Canada
| | - I C Van Gelder
- University of Groningen, University Medical Center Groningen, Department of Cardiology, Groningen, Netherlands
| | - J S Healey
- Population Health Research Institute, Hamilton, Canada
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Barrett TW, Bellew SD. What Role Has Emergency Medicine Played in the Opioid Epidemic: Partner in Crime or Canary in the Coal Mine?: March 2018 Annals of Emergency Medicine Journal Club. Ann Emerg Med 2018; 71:426-428. [PMID: 29458802 DOI: 10.1016/j.annemergmed.2018.01.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Yiadom MYAB, Baugh CW, Barrett TW, Liu X, Storrow AB, Vogus TJ, Tiwari V, Slovis CM, Russ S, Liu D. Measuring Emergency Department Acuity. Acad Emerg Med 2018; 25:65-75. [PMID: 28940546 DOI: 10.1111/acem.13319] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Revised: 08/31/2017] [Accepted: 09/19/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Emergency department (ED) acuity is the general level of patient illness, urgency for clinical intervention, and intensity of resource use in an ED environment. The relative strength of commonly used measures of ED acuity is not well understood. METHODS We performed a retrospective cross-sectional analysis of ED-level data to evaluate the relative strength of association between commonly used proxy measures with a full spectrum measure of ED acuity. Common measures included the percentage of patients with Emergency Severity Index (ESI) scores of 1 or 2, case mix index (CMI), academic status, annual ED volume, inpatient admission rate, percentage of Medicare patients, and patients seen per attending-hour. Our reference standard for acuity is the proportion of high-acuity charts (PHAC) coded and billed according to the Centers for Medicare and Medicaid Service's Ambulatory Payment Classification (APC) system. High-acuity charts included those APC 4 or 5 or critical care. PHAC was represented as a fractional response variable. We examined the strength of associations between common acuity measures and PHAC using Spearman's rank correlation coefficients (rs ) and regression models including a quasi-binomial generalized linear model and linear regression. RESULTS In our univariate analysis, the percentage of patients ESI 1 or 2, CMI, academic status, and annual ED volume had statistically significant associations with PHAC. None explained more than 16% of PHAC variation. For regression models including all common acuity measures, academic status was the only variable significantly associated with PHAC. CONCLUSION Emergency Severity Index had the strongest association with PHAC followed by CMI and annual ED volume. Academic status captures variability outside of that explained by ESI, CMI, annual ED volume, percentage of Medicare patients, or patients per attending per hour. All measures combined only explained only 42.6% of PHAC variation.
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Affiliation(s)
| | - Christopher W. Baugh
- Department of Emergency Medicine, Brigham and Women's Hospital Harvard University Boston MA
| | - Tyler W. Barrett
- Department of Emergency Medicine Vanderbilt University Nashville TN
| | - Xulei Liu
- Department of Biostatistics Vanderbilt University Nashville TN
| | - Alan B. Storrow
- Department of Emergency Medicine Vanderbilt University Nashville TN
| | - Timothy J. Vogus
- Owen Graduate School of Management Vanderbilt University Nashville TN
| | - Vikram Tiwari
- Departments of Anesthesia and Bioinformatics Vanderbilt University Nashville TN
| | - Corey M. Slovis
- Department of Emergency Medicine Vanderbilt University Nashville TN
| | - Stephan Russ
- Department of Emergency Medicine Vanderbilt University Nashville TN
| | - Dandan Liu
- Department of Emergency Medicine, Brigham and Women's Hospital Harvard University Boston MA
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Gardner RM, Friedman NA, Carlson M, Bradham TS, Barrett TW. Impact of revised triage to improve throughput in an ED with limited traditional fast track population. Am J Emerg Med 2018; 36:124-127. [DOI: 10.1016/j.ajem.2017.10.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 09/17/2017] [Accepted: 10/07/2017] [Indexed: 10/18/2022] Open
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Thompson CM, Self WH, Barrett TW. Nonoperative Management of Appendicitis: A Paradigm Shift?: Answers to the July 2017 Journal Club Questions. Ann Emerg Med 2017; 70:915-920. [PMID: 29157691 DOI: 10.1016/j.annemergmed.2017.07.485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Callie M Thompson
- Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, TN
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Tyler W Barrett
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
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Thompson CM, Self WH, Barrett TW. Nonoperative Management of Appendicitis: A Paradigm Shift?: July 2017 Annals of Emergency Medicine Journal Club. Ann Emerg Med 2017. [PMID: 28645384 DOI: 10.1016/j.annemergmed.2017.04.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Callie M Thompson
- Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, TN
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Tyler W Barrett
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
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Vasudevan A, Singer AJ, DeFilippi C, Headden G, Schussler JM, Daniels LB, Reed M, Than MP, Birkhahn R, Smith SW, Barrett TW, Arnold W, Peacock WF, McCullough PA. Renal Function and Scaled Troponin in Patients Presenting to the Emergency Department with Symptoms of Myocardial Infarction. Am J Nephrol 2017; 45:304-309. [PMID: 28192777 DOI: 10.1159/000458451] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 12/28/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Cardiac troponins are often found to be elevated in patients with renal dysfunction, even in the absence of acute myocardial injury. The objective of this report was to characterize the scaled troponin values and proportion of adjudicated acute myocardial infarction (AMI) among patients with and without renal dysfunction. METHODS The data was from a multicenter prospective study including patients presenting to the emergency department with symptoms of AMI. Troponin measurements were standardized across various assays by calculating the observed results as multiples of the assay-specific 99th percentile upper limit of normal. Patients with an estimated glomerular filtration rate (eGFR; calculated by the Chronic Kidney Disease Epidemiology Collaboration formula) <60 mL/min/1.73 m2 were considered to have renal dysfunction. RESULTS Of 430 included patients, 249 (58%) were male and 181 (42%) were female, with a mean age of 55.9 ± 12.3 and 57.3 ± 12.8 years, respectively. Eighty-seven (20.2%) had renal dysfunction. The proportions of patients with at least one scaled troponin value above the 99th percentile cut-off point among patients with and without renal dysfunction were 40 (45.9%) and 81 (23.6%) respectively (p < 0.001). The proportions of patients with an adjudicated diagnosis of AMI among those with and without renal dysfunction were 20.7 and 18.7%, respectively (p = 0.67). Using scaled troponins, by the second test there was >5X and by the third test >15X separation in the excursion of troponin among those with AMI compared to those without. CONCLUSIONS One or more elevated troponin values are common in those with renal dysfunction. Scaled troponins for eGFR groups were similar, indicating that the use of this interpretative technique is applicable in discerning AMI for those with and without renal dysfunction.
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Sharma P, Barrett TW, Ng J, Knoten C, Ferreira AJ, Goldberger JJ. Surface ECG f Wave Analysis at Initial Onset of Paroxysmal and Persistent Atrial Fibrillation. J Cardiovasc Electrophysiol 2017; 28:498-503. [PMID: 28190278 DOI: 10.1111/jce.13188] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Revised: 01/24/2017] [Accepted: 02/06/2017] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Dominant frequency (DF) analysis of electrocardiograms (ECGs) from patients with paroxysmal (PAF) and persistent (PeAF) atrial fibrillation has identified higher DFs in PeAF. We therefore hypothesized that among patients initially presenting to the emergency department (ED) with new onset AF, surface ECG features could differentiate PeAF from PAF. METHODS AND RESULTS Initial 12-lead ECGs from patients presenting to the ED with a first episode of symptomatic AF were analyzed. Following QRS-T subtraction, fast Fourier transform (FFT) analysis of the AF fibrillatory waves was performed to measure DF and organization index (OI). Median DF of all leads and the DF in the lead with maximum OI were determined. Maximum f wave amplitude and vector magnitudes were measured. One hundred sixty-one patients (age 59 ± 16 years, 68% men) were included in this analysis, of whom 96 (58%) spontaneously converted to sinus rhythm within 7 days (PAF group). The remaining 65 patients underwent cardioversion or remained in AF (PeAF group). ECG features (DF, OI, f wave amplitude, and vector magnitude) did not differ among PAF and PeAF patients. CONCLUSIONS ECG features (DF, OI, amplitude, vector magnitude) do not differ among patients with PAF versus PeAF when the ECGs are obtained at the initial onset of symptoms. Thus, prior data showing higher DF in PeAF likely reflect electrophysiologic remodeling rather than a marker for any specific type of AF or extent of underlying substrate.
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Affiliation(s)
- Parth Sharma
- Feinberg School of Medicine, Northwestern University, USA
| | - Tyler W Barrett
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jason Ng
- Center for Cardiovascular Innovation and the Division of Cardiology, Feinberg School of Medicine, Northwestern University, Illinois, USA
| | - Claire Knoten
- Center for Cardiovascular Innovation and the Division of Cardiology, Feinberg School of Medicine, Northwestern University, Illinois, USA
| | | | - Jeffrey J Goldberger
- Center for Cardiovascular Innovation and the Division of Cardiology, Feinberg School of Medicine, Northwestern University, Illinois, USA.,Miller School of Medicine, University of Miami, Florida, USA
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Bellew S, Schriger DL, Barrett TW. Loperamide Will Stop You Up but It Can Also Bring You Down. Ann Emerg Med 2017; 69:142-143. [DOI: 10.1016/j.annemergmed.2016.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Barrett TW, Rising KL, Bellolio MF, Hall MK, Brody A, Dodd KW, Grieser M, Levy PD, Raja AS, Self WH, Weingarten G, Hess EP, Hollander JE. The 2016 Academic Emergency Medicine Consensus Conference, "Shared Decision Making in the Emergency Department: Development of a Policy-relevant Patient-centered Research Agenda" Diagnostic Testing Breakout Session Report. Acad Emerg Med 2016; 23:1354-1361. [PMID: 27404959 DOI: 10.1111/acem.13050] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 06/28/2016] [Accepted: 07/07/2016] [Indexed: 12/15/2022]
Abstract
Diagnostic testing is an integral component of patient evaluation in the emergency department (ED). Emergency clinicians frequently use diagnostic testing to more confidently exclude "worst-case" diagnoses rather than to determine the most likely etiology for a presenting complaint. Increased utilization of diagnostic testing has not been associated with reductions in disease-related mortality but has led to increased overall healthcare costs and other unintended consequences (e.g., incidental findings requiring further workup, unnecessary exposure to ionizing radiation or potentially nephrotoxic contrast). Shared decision making (SDM) presents an opportunity for clinicians to discuss the benefits and harms associated with diagnostic testing with patients to more closely tailor testing to patient risk. This article introduces the challenges and opportunities associated with incorporating SDM into emergency care by summarizing the conclusions of the diagnostic testing group at the 2016 Academic Emergency Medicine Consensus Conference on SDM. Three primary domains emerged: 1) characteristics of a condition or test appropriate for SDM, 2) critical elements of and potential barriers to SDM discussions on diagnostic testing, and 3) financial aspects of SDM applied to diagnostic testing. The most critical research questions to improve engagement of patients in their acute care diagnostic decisions were determined by consensus.
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Affiliation(s)
- Tyler W. Barrett
- Department of Emergency Medicine; Vanderbilt University Medical Center; Nashville TN
| | - Kristin L. Rising
- Department of Emergency Medicine; Thomas Jefferson University Hospital; Philadelphia PA
| | | | - M. Kennedy Hall
- Division of Emergency Medicine; University of Washington; Seattle WA
| | - Aaron Brody
- Department of Emergency Medicine; Wayne State University; Detroit MI
| | - Kenneth W. Dodd
- Department of Emergency Medicine; Hennepin County Medical Center; Minneapolis MN
| | - Mira Grieser
- Program Officer, Addressing Disparities; Patient-Centered Outcomes Research Institute; Washington DC
| | - Phillip D. Levy
- Department of Emergency Medicine; Wayne State University; Detroit MI
| | - Ali S. Raja
- Department of Emergency Medicine; Massachusetts General Hospital and Harvard Medical School; Boston MA
| | - Wesley H. Self
- Department of Emergency Medicine; Vanderbilt University Medical Center; Nashville TN
| | | | - Erik P. Hess
- Department of Emergency Medicine; Mayo Clinic; Rochester MN
| | - Judd E. Hollander
- Department of Emergency Medicine; Thomas Jefferson University Hospital; Philadelphia PA
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Garg N, Barrett TW, Schriger DL. Finding Factors Associated With Post–Emergency Department Morbidity and Mortality in Elderly Patients: Analyzing a Case-Control Study. Ann Emerg Med 2016; 68:772-777. [DOI: 10.1016/j.annemergmed.2016.09.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Davis WT, Barrett TW. One and Done: Steroids for Adult Asthma: November 2016 Annals of Emergency Medicine Journal Club. Ann Emerg Med 2016; 68:636-637. [PMID: 27772679 DOI: 10.1016/j.annemergmed.2016.08.459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- William T Davis
- San Antonio Uniformed Services Health Education Consortium, San Antonio, TX
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Wolfe CC, Barrett TW. Cleaning Out Practice Myths: Another Emergency Medicine Treatment Debunked. Ann Emerg Med 2016; 68:238-43. [DOI: 10.1016/j.annemergmed.2016.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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41
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Wolfe CC, Barrett TW. Cleaning Out Practice Myths: Another Emergency Medicine Treatment Debunked. Ann Emerg Med 2016; 67:411-2. [DOI: 10.1016/j.annemergmed.2016.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Barrett TW, Self WH, Darbar D, Jenkins CA, Wasserman BS, Kassim NA, Casner M, Shoemaker MB. Association of atrial fibrillation risk alleles and response to acute rate control therapy. Am J Emerg Med 2016; 34:735-40. [PMID: 26920668 DOI: 10.1016/j.ajem.2016.01.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Revised: 01/23/2016] [Accepted: 01/25/2016] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVES Given the sparse evidence for selection of first-line therapy for acute atrial fibrillation (AF) based on clinical factors alone, incorporation of genotype data may improve the effectiveness of treatment algorithms and advance the understanding of interpatient heterogeneity. We tested whether candidate nucleotide polymorphisms (SNPs) related to AF physiologic responses are associated with ventricular rate control after intravenous diltiazem in the emergency department (ED). METHODS We conducted an analysis within a prospective observational cohort of ED patients with acute symptomatic AF, ventricular rate >110 beats per minute within the first 2 hours, initially treated with intravenous diltiazem, and who had DNA available for analysis. We evaluated 24 candidate SNPs that were grouped into 3 categories based on their phenotype response (atrioventricular nodal [AVN] conduction, resting heart rate, disease susceptibility) and calculated 3 genetic scores for each patient. Our primary outcome was maximum heart rate reduction within 4 hours of diltiazem administration. Multivariable regression was used to identify associations with the outcome while adjusting for age, sex, baseline heart rate, and diltiazem dose. RESULTS Of the 142 patients, 127 had complete data for the primary outcome. None of the genetic scores for AVN conduction, resting heart rate, or AF susceptibility showed a significant association with maximal heart rate response. CONCLUSION Using a candidate SNP approach, screening for genetic variants associated with AVN conduction, resting heart rate, or AF susceptibility failed to provide significant data for predicting successful rate control response to intravenous diltiazem for treating acute AF in the ED.
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Affiliation(s)
- Tyler W Barrett
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN.
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Dawood Darbar
- Departments of Medicine and Pharmacology, Division of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, TN
| | - Cathy A Jenkins
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN
| | - Brian S Wasserman
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN
| | - Natasha A Kassim
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN
| | - Michael Casner
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - M Benjamin Shoemaker
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN
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Barrett TW, Schriger DL. ANNALS OF EMERGENCY MEDICINE JOURNAL CLUB. Move Over Morphine: Is Ketamine an Effective and Safe Alternative for Treating Acute Pain?: Answers to the September 2015 Journal Club. Ann Emerg Med 2016; 67:289-94. [PMID: 26801381 DOI: 10.1016/j.annemergmed.2015.12.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Self WH, Storrow AB, Hartmann O, Barrett TW, Fermann GJ, Maisel AS, Struck J, Bergmann A, Collins SP. Plasma bioactive adrenomedullin as a prognostic biomarker in acute heart failure. Am J Emerg Med 2015; 34:257-62. [PMID: 26577429 DOI: 10.1016/j.ajem.2015.10.033] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 10/02/2015] [Accepted: 10/14/2015] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVE The objective was to evaluate the prognostic performance of a new biomarker, plasma bioactive adrenomedullin (bio-ADM), for short-term clinical outcomes in acute heart failure. METHODS A multicenter prospective cohort study of adult emergency department (ED) patients suspected of having acute heart failure was conducted to evaluate the association between plasma bio-ADM concentration and clinical outcomes. The primary outcome was a composite of the following within 30 days: death, cardiac arrest with resuscitation, respiratory failure, emergency dialysis, acute coronary syndrome, hospitalization >5 days, and repeat ED visit or hospitalization. Prognostic accuracy was evaluated with a nonparametric receiver operating characteristic curve. In addition, a multivariable logistic regression model was constructed to assess the additive prognostic performance of bio-ADM while adjusting for other biomarkers routinely used clinically, including B-type natriuretic peptide, cardiac troponin I, creatinine, and sodium concentration. RESULTS Two hundred forty-six patients were enrolled, including 85 (34.6%) patients with the primary outcome. Plasma bio-ADM concentrations were higher among patients who experienced the primary outcome (median, 80.5 pg/mL; interquartile range [IQR], 53.7-151.5 pg/mL) compared with those who did not (median, 54.4 pg/mL; IQR, 43.4-78.4 pg/mL) (P < .01). Area under the receiver operating characteristic curve was 0.70 (95% confidence interval, 0.63-0.75). After adjusting for the other biomarkers, plasma bio-ADM remained a strong predictor of the primary outcome (adjusted odds ratio per IQR change, 2.68; 95% confidence interval, 1.60-4.51). CONCLUSIONS Bioactive adrenomedullin concentrations at the time of ED evaluation for acute heart failure were predictive of clinically important 30-day outcomes, suggesting that bio-ADM is a promising prognostic marker for further study.
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Affiliation(s)
- Wesley H Self
- Department of Emergency Medicine, Vanderbilt University, Nashville, TN, USA.
| | - Alan B Storrow
- Department of Emergency Medicine, Vanderbilt University, Nashville, TN, USA
| | | | - Tyler W Barrett
- Department of Emergency Medicine, Vanderbilt University, Nashville, TN, USA
| | - Gregory J Fermann
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Alan S Maisel
- Coronary Care Unit and Heart Failure Program, San Diego Veterans Affairs Medical Center, San Diego, CA, USA
| | | | | | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University, Nashville, TN, USA
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Hertz JT, Lescallette RD, Barrett TW, Ward MJ, Self WH. External validation of an ED protocol for reflex urine culture cancelation. Am J Emerg Med 2015; 33:1838-9. [PMID: 26472506 DOI: 10.1016/j.ajem.2015.09.026] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 09/17/2015] [Accepted: 09/18/2015] [Indexed: 11/28/2022] Open
Affiliation(s)
- Julian T Hertz
- Department of Emergency Medicine; Vanderbilt University Medical Center Nashville, TN 37232
| | - Richard D Lescallette
- Department of Emergency Medicine; Vanderbilt University Medical Center Nashville, TN 37232
| | - Tyler W Barrett
- Department of Emergency Medicine; Vanderbilt University Medical Center Nashville, TN 37232
| | - Michael J Ward
- Department of Emergency Medicine; Vanderbilt University Medical Center Nashville, TN 37232
| | - Wesley H Self
- Department of Emergency Medicine; Vanderbilt University Medical Center Nashville, TN 37232.
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Barrett TW, Schriger DL. Annals of Emergency Medicine Journal Club. Move Over Morphine: Is Ketamine an Effective and Safe Alternative for Treating Acute Pain?: September 2015 Annals of Emergency Medicine Journal Club. Ann Emerg Med 2015; 66:336-7. [PMID: 26304255 DOI: 10.1016/j.annemergmed.2015.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Barrett TW, Vermeulen MJ, Self WH, Jenkins CA, Ferreira AJ, Atzema CL. Emergency department management of atrial fibrillation in the United States versus Ontario, Canada. J Am Coll Cardiol 2015; 65:2258-60. [PMID: 25998673 DOI: 10.1016/j.jacc.2015.01.064] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Revised: 01/10/2015] [Accepted: 01/20/2015] [Indexed: 11/26/2022]
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Lardaro T, Self WH, Barrett TW. Thirty-day mortality in ED patients with new onset atrial fibrillation and actively treated cancer. Am J Emerg Med 2015; 33:1483-8. [PMID: 26283615 DOI: 10.1016/j.ajem.2015.07.033] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 07/09/2015] [Accepted: 07/10/2015] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES Studies suggest that inflammatory, autonomic, and coagulation alterations associated with cancer may increase incident atrial fibrillation (AF). New-onset AF is associated with increased mortality in other nonneoplastic disease processes. We investigated the association of active cancer with 30-day mortality in emergency department (ED) patients with new-onset AF. METHODS We conducted an analysis within an observational cohort study at a tertiary care hospital that included ED patients with new-onset AF. The exposure variable was presence of active cancer. We defined active cancer as the patient received chemotherapy, radiotherapy, or recent cancer-related surgery within 90 days of the ED visit. The primary outcome was 30-day mortality. Logistic regression was used to analyze the association between cancer status and 30-day mortality adjusting for patient age and sex. RESULTS During the 5.5-year study period, 420 patients with new-onset AF were included in our cohort, including 37 (8.8%) with active cancer. Patients with active cancer had no clinically relevant differences in their hemodynamic stability. Among the 37 patients with active cancer, 9 (24%) died within 30 days. Of the 383 patients without active cancer, 11 (3%) died within 30 days. After adjusting for age and sex, active cancer was an independent predictor of 30-day mortality, with an adjusted odds ratio of 10.8 (95% confidence interval, 3.8-31.1). CONCLUSIONS Among ED patients with new-onset AF, active cancer appears to be associated with 11-fold increased odds of 30-day mortality; new-onset AF may represent progressive organ dysfunction leading to an increased risk of short-term mortality in patients with cancer.
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Affiliation(s)
- Thomas Lardaro
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Tyler W Barrett
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN.
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Self WH, Wunderink RG, Williams DJ, Barrett TW, Baughman AH, Grijalva CG. Comparison of clinical prediction models for resistant bacteria in community-onset pneumonia. Acad Emerg Med 2015; 22:730-40. [PMID: 25996620 DOI: 10.1111/acem.12672] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Revised: 10/24/2014] [Accepted: 12/04/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Six recently published algorithms classify pneumonia patients presenting from the community into high- and low-risk groups for resistant bacteria. Our objective was to compare performance of these algorithms for identifying patients infected with bacteria resistant to traditional community-acquired pneumonia antibiotics. METHODS This was a retrospective study of consecutive adult patients diagnosed with pneumonia in an emergency department and subsequently hospitalized. Each patient was classified as high or low risk for resistant bacteria according to the following algorithms: original health care-associated pneumonia (HCAP) criteria, Summit criteria, Brito and Niederman strategy, Shorr model, Aliberti model, and Shindo model. The reference for comparison was detection of resistant bacteria, defined as methicillin-resistant Staphylococcus aureus or Gram-negative bacteria resistant to ceftriaxone or levofloxacin. RESULTS A total of 614 patients were studied, including 36 (5.9%) with resistant bacteria. The HCAP criteria classified 304 (49.5%) patients as high risk, with an area under the receiver operating characteristic curve (AUC) of 0.63 (95% confidence interval [CI] = 0.54 to 0.72), sensitivity of 0.69 (95% CI = 0.52 to 0.83), and specificity of 0.52 (95% CI = 0.48 to 0.56). None of the other algorithms improved both sensitivity and specificity or significantly improved the AUC. Compared to the HCAP criteria, the Shorr and Aliberti models classified more patients as high risk, resulting in higher sensitivity and lower specificity. The Shindo model classified fewer patients as high risk, with lower sensitivity and higher specificity. CONCLUSIONS All algorithms for identification of resistant bacteria included in this study had suboptimal performance to guide antibiotic selection. New strategies for selecting empirical antibiotics for community-onset pneumonia are necessary.
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Affiliation(s)
- Wesley H. Self
- Department of Emergency Medicine; Vanderbilt University School of Medicine; Nashville TN
| | - Richard G. Wunderink
- Division of Pulmonary and Critical Care Medicine; Department of Medicine; Feinberg School of Medicine; Northwestern University; Chicago IL
| | - Derek J. Williams
- Department of Pediatrics; Vanderbilt University School of Medicine; Nashville TN
| | - Tyler W. Barrett
- Department of Emergency Medicine; Vanderbilt University School of Medicine; Nashville TN
| | - Adrienne H. Baughman
- Department of Emergency Medicine; Vanderbilt University School of Medicine; Nashville TN
| | - Carlos G. Grijalva
- Department of Health Policy; Vanderbilt University School of Medicine; Nashville TN
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Affiliation(s)
- Clare L Atzema
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Sunnybrook Health Sciences Centre, and the Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
| | - Tyler W Barrett
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
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