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Belcher RM, Kay AB, Fontaine GV, Baldwin M, Bledsoe JR, Collingridge DS, Majercik S. Post-discharge venous thromboembolism prophylaxis in hospitalized trauma patients: A retrospective comparison of patients receiving versus not receiving post-discharge prophylaxis. Am J Surg 2024; 228:247-251. [PMID: 37863796 DOI: 10.1016/j.amjsurg.2023.10.032] [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: 08/03/2023] [Revised: 10/04/2023] [Accepted: 10/12/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND Risk of venous thromboembolism (VTE) in many trauma patients extends beyond hospitalization, but there is a paucity of evidence to guide the use of post-discharge prophylaxis (PDP). METHODS A retrospective cohort study of trauma patients deemed moderate-to-high risk for VTE (risk assessment profile score [RAP] ≥5) who were prescribed PDP based on an internal clinical guideline assessing injury pattern and mobility status. PDP patients were compared with those that did not receive post-discharge prophylaxis (NPDP). RESULTS 1512 patients were included. PDP group had higher mean RAP score (7.3 vs. 6.4, p < 0.001), more likely to have a complex orthopedic fracture and underwent a longer median hospital (4.7 vs. 2.9 days, p < 0.001). No difference between groups in 90-day VTE (11 [1.5 %] (PDP) vs. 8 [1.0 %] (NPDP), p = 0.50), clinically relevant bleeding (p = 0.58), or readmission (p = 0.46). CONCLUSIONS VTE incidence, clinically relevant bleeding, and readmission 90-days after hospital discharge were low and similar between PDP and NPDP groups. PDP prescribed in a presumably higher VTE risk trauma population may mitigate the long-term risk of VTE.
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Affiliation(s)
| | - Annika B Kay
- Intermountain Medical Center, Department of Trauma and Surgical Critical Care, USA.
| | | | | | - Joseph R Bledsoe
- Intermountain Medical Center, Department of Critical Care and Emergency Services, 5121 South Cottonwood Street, Murray, UT, 84107, USA.
| | | | - Sarah Majercik
- Intermountain Medical Center, Department of Trauma and Surgical Critical Care, USA.
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2
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Kay AB, Malone SA, Bledsoe JR, Majercik S, Morris DS. First steps toward a BIG change: A pilot study to implement the Brain Injury Guidelines across a 24-hospital system. Am J Surg 2023; 226:845-850. [PMID: 37517901 DOI: 10.1016/j.amjsurg.2023.07.002] [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: 03/24/2023] [Revised: 06/10/2023] [Accepted: 07/03/2023] [Indexed: 08/01/2023]
Abstract
INTRODUCTION The modified Brain Injury Guidelines (mBIG) support a subset of low-risk patients to be managed without repeat head computed tomography (RHCT), neurosurgical consult (NSC), or hospital transfer/admission. This pilot aimed to assess mBIG implementation at a single facility to inform future systemwide implementation. METHODS Single cohort pilot trial at a level I trauma center, December 2021-August 2022. Adult patients included if tICH meeting BIG 1 or 2 criteria. BIG 3 patients excluded. RESULTS No patients required neurosurgical intervention. 72 RHCT and 83 NSC were prevented. 21 isolated BIG 1 were safely discharged home from the ED. No hospital readmissions for tICH. Protocol adherence rate was 92%. CONCLUSION Implementation of the mBIG at a single trauma center is feasible and optimizes resource utilization. This pilot study will inform an implementation trial of the mBIG across a 24-hospital integrated health system.
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Affiliation(s)
- Annika Bickford Kay
- Division of Trauma Services and Surgical Critical Care, Intermountain Medical Center, Murray, UT, USA.
| | - Samantha A Malone
- Division of Trauma Services and Surgical Critical Care, Intermountain Medical Center, Murray, UT, USA.
| | - Joseph R Bledsoe
- Department of Emergency Medicine, Intermountain Medical Center, Murray, UT, USA.
| | - Sarah Majercik
- Division of Trauma Services and Surgical Critical Care, Intermountain Medical Center, Murray, UT, USA.
| | - David S Morris
- Division of Trauma Services and Surgical Critical Care, Intermountain Medical Center, Murray, UT, USA.
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Hooper GA, Stenehjem EA, Bledsoe JR, Brown SM, Peltan ID. Reply to Adelman et al. Clin Infect Dis 2023; 77:328-329. [PMID: 37092703 PMCID: PMC10371310 DOI: 10.1093/cid/ciad244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 04/11/2023] [Accepted: 04/19/2023] [Indexed: 04/25/2023] Open
Affiliation(s)
- Gabriel A Hooper
- University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Edward A Stenehjem
- Division of Infectious Diseases and Epidemiology, Department of Medicine, Intermountain Medical Center, Salt Lake City, Utah, USA
| | - Joseph R Bledsoe
- Department of Emergency Medicine, Intermountain Medical Center, Murray, Utah, USA
- Department of Emergency Medicine, Stanford University, Palo Alto, California, USA
| | - Samuel M Brown
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, Utah, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Ithan D Peltan
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, Utah, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
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4
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Hooper GA, Klippel CJ, McLean SR, Stenehjem EA, Webb BJ, Murnin ER, Hough CL, Bledsoe JR, Brown SM, Peltan ID. Concordance Between Initial Presumptive and Final Adjudicated Diagnoses of Infection Among Patients Meeting Sepsis-3 Criteria in the Emergency Department. Clin Infect Dis 2023; 76:2047-2055. [PMID: 36806551 PMCID: PMC10273369 DOI: 10.1093/cid/ciad101] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 01/21/2023] [Accepted: 02/16/2023] [Indexed: 02/21/2023] Open
Abstract
BACKGROUND Guidelines emphasize rapid antibiotic treatment for sepsis, but infection presence is often uncertain at initial presentation. We investigated the incidence and drivers of false-positive presumptive infection diagnosis among emergency department (ED) patients meeting Sepsis-3 criteria. METHODS For a retrospective cohort of patients hospitalized after meeting Sepsis-3 criteria (acute organ failure and suspected infection including blood cultures drawn and intravenous antimicrobials administered) in 1 of 4 EDs from 2013 to 2017, trained reviewers first identified the ED-diagnosed source of infection and adjudicated the presence and source of infection on final assessment. Reviewers subsequently adjudicated final infection probability for a randomly selected 10% subset of subjects. Risk factors for false-positive infection diagnosis and its association with 30-day mortality were evaluated using multivariable regression. RESULTS Of 8267 patients meeting Sepsis-3 criteria in the ED, 699 (8.5%) did not have an infection on final adjudication and 1488 (18.0%) patients with confirmed infections had a different source of infection diagnosed in the ED versus final adjudication (ie, initial/final source diagnosis discordance). Among the subset of patients whose final infection probability was adjudicated (n = 812), 79 (9.7%) had only "possible" infection and 77 (9.5%) were not infected. Factors associated with false-positive infection diagnosis included hypothermia, altered mental status, comorbidity burden, and an "unknown infection source" diagnosis in the ED (odds ratio: 6.39; 95% confidence interval: 5.14-7.94). False-positive infection diagnosis was not associated with 30-day mortality. CONCLUSIONS In this large multihospital study, <20% of ED patients meeting Sepsis-3 criteria had no infection or only possible infection on retrospective adjudication.
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Affiliation(s)
- Gabriel A Hooper
- University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Carolyn J Klippel
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, Utah, USA
| | - Sierra R McLean
- University of Utah School of Medicine, Salt Lake City, Utah, USA
- Department of Physical Medicine and Rehabilitation, University of North Carolina Health, Chapel Hill, North Carolina, USA
| | - Edward A Stenehjem
- Division of Infectious Diseases and Epidemiology, Department of Medicine, Intermountain Medical Center, Salt Lake City, Utah, USA
| | - Brandon J Webb
- Department of Medicine, University of Wisconsin School of Medicine, Madison, Wisconsin, USA
| | - Emily R Murnin
- University of Utah School of Medicine, Salt Lake City, Utah, USA
- Department of Medicine, University of Wisconsin School of Medicine, Madison, Wisconsin, USA
| | - Catherine L Hough
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Oregon Health and Sciences University, Portland, Oregon, USA
| | - Joseph R Bledsoe
- Department of Emergency Medicine, Intermountain Medical Center, Murray, Utah, USA
- Department of Emergency Medicine, Stanford University, Palo Alto, California, USA
| | - Samuel M Brown
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, Utah, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Ithan D Peltan
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, Utah, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
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Carmichael HL, Peltan ID, Palakanis K, Davis A, Dalto J, Jacobs JR, Rhodes R, Shah M, Webb B, Woller SC, Bledsoe JR. Remote Biometric Monitoring of Patients With COVID-19 With Exertional Hypoxia Treated With Supplemental Oxygen. Chest 2023; 163:498-501. [PMID: 36181880 PMCID: PMC9515005 DOI: 10.1016/j.chest.2022.09.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 08/01/2022] [Accepted: 09/21/2022] [Indexed: 11/30/2022] Open
Affiliation(s)
- Harris L Carmichael
- Department of Medicine, Intermountain Medical Center, Murray, UT; Department of Medicine, Stanford Medicine, Stanford, CA
| | - Ithan D Peltan
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT; Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Kerry Palakanis
- Intermountain Healthcare Telehealth and Outreach, Salt Lake City, UT
| | - Andrew Davis
- Intermountain Healthcare Telehealth and Outreach, Salt Lake City, UT
| | - Joe Dalto
- Intermountain Healthcare Enterprise Analytics, Salt Lake City, UT
| | - Jason R Jacobs
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT; Intermountain Healthcare Enterprise Analytics, Salt Lake City, UT
| | - Rachelle Rhodes
- Intermountain Healthcare Emergency Medicine and Trauma Operations, Salt Lake City, UT
| | - Mark Shah
- Intermountain Healthcare Emergency Medicine and Trauma Operations, Salt Lake City, UT
| | - Brandon Webb
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Salt Lake City, UT; Division of Infectious Diseases and Geographic Medicine, Stanford Medicine, Palo Alto, CA
| | - Scott C Woller
- Department of Medicine, Intermountain Medical Center, Murray, UT; Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Joseph R Bledsoe
- Intermountain Healthcare Emergency Medicine and Trauma Operations, Salt Lake City, UT; Department of Emergency Medicine, Stanford Medicine, Stanford, CA.
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Connors JM, Brooks MM, Sciurba FC, Krishnan JA, Bledsoe JR, Castro L, Eng H, Handberg E, Hou PC, Hulbert J, Kirwan BA, Lin JY, Martin D, Samuelson H, Shapiro NL, Zaharris E, Wisniewski SR, Ridker PM. Outpatient Randomized Controlled Trials in the Covid-19 Era and Beyond. NEJM Evid 2022; 1:EVIDctcs2200149. [PMID: 38319835 DOI: 10.1056/evidctcs2200149] [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] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Outpatient Trials in the Covid-19 Era and BeyondA group of investigators had a meeting at the National Heart, Lung, and Blood Institute in May 2020 to discuss ways to decrease thrombotic complications among symptomatic outpatients with Covid-19. The investigators discuss their approach to three specific challenges: conducting a trial remotely, working through regulatory hurdles, and recruiting a diverse population of participants.
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Woller IA, Woller SC, Stevens SM, Lloyd JF, Conner KE, Gordon BH, Snow GL, Jones P, Bledsoe JR. Synoptic reporting accuracy for computed tomography pulmonary arteriography among patients suspected of pulmonary embolism. J Am Coll Emerg Physicians Open 2022; 3:e12801. [PMID: 36226236 PMCID: PMC9530339 DOI: 10.1002/emp2.12801] [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: 11/19/2021] [Revised: 07/08/2022] [Accepted: 07/21/2022] [Indexed: 11/06/2022] Open
Abstract
Background Structured reporting is an efficient and replicable method of presenting diagnostic results that eliminates variability inherent in narrative descriptive reporting and may improve clinical decisions. Synoptic element reporting can generate discrete coded data that then may inform clinical decision support and trigger downstream actions in computerized electronic health records. Objective Limited evidence exists for use of synoptic reporting for computed tomography pulmonary arteriography (CTPA) among patients suspected of pulmonary embolism. We reported the accuracy of synoptic reporting for the outcome of pulmonary embolism among patients who presented to an integrated health care system with CTPA performed for suspected pulmonary embolism. Methods Structured radiology reports with embedded synoptic elements were implemented for all CTPA examinations on March 1, 2018. Four hundred CTPA reports between January 4, 2019 and July 30, 2020 (200 reports each for which synoptic reporting recorded the presence or absence of pulmonary embolism [PE]) were selected at random. One non-diagnostic study was excluded from analysis. We then assessed the accuracy of synoptic reporting compared with the gold standard of manual chart review. Results Synoptic reporting and manual review agreed in 99.2% of patients undergoing CTPA for suspected PE, agreed on the presence of PE in 196 of 199 (98.5%) cases, the absence of PE in 200 of 200 (100%) cases with a sensitivity of 87.6% (76.1-96.1) a specificity of 99.9% (99.7%-100%), a positive predictive value of 99.5% (98.1-100), and a negative predictive value of 98% (95.7%-99.5%). Conclusion The overall rate of agreement was 99.2%, but we observed an unacceptable false-negative rate for clinical reliance on synoptic element reporting in isolation from dictated reports.
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Affiliation(s)
| | - Scott C. Woller
- Department of MedicineIntermountain Medical Center and Department of Internal MedicineUniversity of Utah School of MedicineSalt Lake CityUtahUSA
| | - Scott M. Stevens
- Department of MedicineIntermountain Medical Center and Department of Internal MedicineUniversity of Utah School of MedicineSalt Lake CityUtahUSA
| | - James F. Lloyd
- Department of Medical InformaticsIntermountain HealthcareSalt Lake CityUtahUSA
| | - Karen E. Conner
- Department of RadiologyIntermountain Medical CenterSalt Lake CityUtahUSA
| | - Benjamin H. Gordon
- Department of RadiologyIntermountain Medical CenterSalt Lake CityUtahUSA
| | - Greg L. Snow
- Office of ResearchIntermountain HealthcareStatistical Data CenterSalt Lake CityUtahUSA
| | - Peter Jones
- Intermountain HealthcareEnterprise AnalyticsSalt Lake CityUtahUSA
| | - Joseph R. Bledsoe
- Department of Emergency Medicine Intermountain HealthcareSalt Lake CityUtahUSA,Department of Emergency MedicineStanford MedicinePalo AltoCaliforniaUSA
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8
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Woller SC, Stevens SM, Bledsoe JR, Fazili M, Lloyd JF, Snow GL, Horne BD. Biomarker derived risk scores predict venous thromboembolism and major bleeding among patients with COVID-19. Res Pract Thromb Haemost 2022; 6:e12765. [PMID: 35873221 PMCID: PMC9301476 DOI: 10.1002/rth2.12765] [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: 11/30/2021] [Revised: 05/21/2022] [Accepted: 06/19/2022] [Indexed: 12/15/2022] Open
Abstract
Background Venous thromboembolism (VTE) risk is increased in patients with COVID‐19 infection. Understanding which patients are likely to develop VTE may inform pharmacologic VTE prophylaxis decision making. The hospital‐associated venous thromboembolism–Intermountain Risk Score (HA‐VTE IMRS) and the hospital‐associated major bleeding–Intermountain Risk Score (HA‐MB IMRS) are risk scores predictive of VTE and bleeding that were derived from only patient age and data found in the complete blood count (CBC) and basic metabolic panel (BMP). Objectives We assessed the HA‐VTE IMRS and HA‐MB IMRS for predictiveness of 90‐day VTE and major bleeding, respectively, among patients diagnosed with COVID‐19, and further investigated if adding D‐dimer improved these predictions. We also reported 30‐day outcomes. Patients/Methods We identified 5047 sequential patients with a laboratory confirmed diagnosis of COVID‐19 and a CBC and BMP between 2 days before and 7 days following the diagnosis of COVID‐19 from March 12, 2020, to February 28, 2021. We calculated the HA‐VTE IMRS and the HA‐MB IMRS for all patients. We assessed the added predictiveness of D‐dimer obtained within 48 hours of the COVID test. Results The HA‐VTE IMRS yielded a c‐statistic of 0.70 for predicting 90‐day VTE and adding D‐dimer improved the c‐statistic to 0.764 with the corollary sensitivity/specificity/positive/negative predictive values of 49.4%/75.7%/6.7%/97.7% and 58.8%/76.2%/10.9%/97.4%, respectively. Among hospitalized and ambulatory patients separately, the HA‐VTE IMRS performed similarly. The HA‐MB IMRS predictiveness for 90‐day major bleeding yielded a c‐statistic of 0.64. Conclusion The HA‐VTE IMRS and HA‐MB IMRS predict 90‐ and 30‐day VTE and major bleeding among COVID‐19 patients. Adding D‐dimer improved the predictiveness of the HA‐VTE IMRS for VTE.
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Affiliation(s)
- Scott C Woller
- Department of Medicine Intermountain Medical Center, Intermountain Healthcare Murray Utah USA.,Department of Internal Medicine University of Utah School of Medicine Salt Lake City Utah USA
| | - Scott M Stevens
- Department of Medicine Intermountain Medical Center, Intermountain Healthcare Murray Utah USA.,Department of Internal Medicine University of Utah School of Medicine Salt Lake City Utah USA
| | - Joseph R Bledsoe
- Department of Emergency Medicine, Intermountain Medical Center Intermountain Healthcare Murray Utah USA.,Stanford University Stanford California USA
| | - Masarret Fazili
- Department of Medicine Intermountain Medical Center, Intermountain Healthcare Murray Utah USA
| | - James F Lloyd
- Department of Informatics Intermountain Medical Center, Intermountain Healthcare Murray Utah USA
| | - Greg L Snow
- Intermountain Statistical Data Center, Intermountain Medical Center Intermountain Healthcare Murray Utah USA
| | - Benjamin D Horne
- Intermountain Medical Center Heart Institute Murray Utah USA.,Division of Cardiovascular Medicine Stanford University Stanford California USA
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Horne BD, Bledsoe JR, Muhlestein JB, May HT, Peltan ID, Webb BJ, Carlquist JF, Bennett ST, Rea S, Bair TL, Grissom CK, Knight S, Ronnow BS, Le VT, Stenehjem E, Woller SC, Knowlton KU, Anderson JL. Association of the Intermountain Risk Score with major adverse health events in patients positive for COVID-19: an observational evaluation of a US cohort. BMJ Open 2022; 12:e053864. [PMID: 35332038 PMCID: PMC8948080 DOI: 10.1136/bmjopen-2021-053864] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES The Intermountain Risk Score (IMRS), composed using published sex-specific weightings of parameters in the complete blood count (CBC) and basic metabolic profile (BMP), is a validated predictor of mortality. We hypothesised that IMRS calculated from prepandemic CBC and BMP predicts COVID-19 outcomes and that IMRS using laboratory results tested at COVID-19 diagnosis is also predictive. DESIGN Prospective observational cohort study. SETTING Primary, secondary, urgent and emergent care, and drive-through testing locations across Utah and in sections of adjacent US states. Viral RNA testing for SARS-CoV-2 was conducted from 3 March to 2 November 2020. PARTICIPANTS Patients aged ≥18 years were evaluated if they had CBC and BMP measured in 2019 and tested positive for COVID-19 in 2020. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was a composite of hospitalisation or mortality, with secondary outcomes being hospitalisation and mortality separately. RESULTS Among 3883 patients, 8.2% were hospitalised and 1.6% died. Subjects with low, mild, moderate and high-risk IMRS had the composite endpoint in 3.5% (52/1502), 8.6% (108/1256), 15.5% (152/979) and 28.1% (41/146) of patients, respectively. Compared with low-risk, subjects in mild-risk, moderate-risk and high-risk groups had HR=2.33 (95% CI 1.67 to 3.24), HR=4.01 (95% CI 2.93 to 5.50) and HR=8.34 (95% CI 5.54 to 12.57), respectively. Subjects aged <60 years had HR=3.06 (95% CI 2.01 to 4.65) and HR=7.38 (95% CI 3.14 to 17.34) for moderate and high risks versus low risk, respectively; those ≥60 years had HR=1.95 (95% CI 0.99 to 3.86) and HR=3.40 (95% CI 1.63 to 7.07). In multivariable analyses, IMRS was independently predictive and was shown to capture substantial risk variation of comorbidities. CONCLUSIONS IMRS, a simple risk score using very basic laboratory results, predicted COVID-19 hospitalisation and mortality. This included important abilities to identify risk in younger adults with few diagnosed comorbidities and to predict risk prior to SARS-CoV-2 infection.
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Affiliation(s)
- Benjamin D Horne
- Intermountain Heart Institute, Intermountain Medical Center, Salt Lake City, Utah, USA
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Joseph R Bledsoe
- Department of Emergency Medicine, Intermountain Medical Center, Salt Lake City, UT, USA
- Department of Emergency Medicine, Stanford University, Stanford, CA, USA
| | - Joseph B Muhlestein
- Intermountain Heart Institute, Intermountain Medical Center, Salt Lake City, Utah, USA
- Cardiology Division, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Heidi T May
- Intermountain Heart Institute, Intermountain Medical Center, Salt Lake City, Utah, USA
| | - Ithan D Peltan
- Pulmonary and Critical Care, Intermountain Medical Center, Salt Lake City, Utah, USA
- Division of Respiratory, Critical Care and Occupational Pulmonary Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Brandon J Webb
- Division of Infectious Diseases and Clinical Epidemiology, Department of Medicine, Intermountain Medical Center, Salt Lake City, Utah, USA
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University, Stanford, CA, USA
| | - John F Carlquist
- Intermountain Heart Institute, Intermountain Medical Center, Salt Lake City, Utah, USA
- Cardiology Division, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Sterling T Bennett
- Intermountain Central Laboratory, Intermountain Medical Center, Salt Lake City, UT, USA
- Department of Pathology, University of Utah, Salt Lake City, UT, USA
| | - Susan Rea
- Care Transformation Information Systems, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Tami L Bair
- Intermountain Heart Institute, Intermountain Medical Center, Salt Lake City, Utah, USA
| | - Colin K Grissom
- Pulmonary and Critical Care, Intermountain Medical Center, Salt Lake City, Utah, USA
- Division of Respiratory, Critical Care and Occupational Pulmonary Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Stacey Knight
- Intermountain Heart Institute, Intermountain Medical Center, Salt Lake City, Utah, USA
| | - Brianna S Ronnow
- Intermountain Heart Institute, Intermountain Medical Center, Salt Lake City, Utah, USA
| | - Viet T Le
- Intermountain Heart Institute, Intermountain Medical Center, Salt Lake City, Utah, USA
| | - Edward Stenehjem
- Division of Infectious Diseases and Clinical Epidemiology, Department of Medicine, Intermountain Medical Center, Salt Lake City, Utah, USA
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Scott C Woller
- Department of Medicine, Intermountain Medical Center, Salt Lake City, UT, USA
- Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Kirk U Knowlton
- Intermountain Heart Institute, Intermountain Medical Center, Salt Lake City, Utah, USA
- Division of Cardiovascular Medicine, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Jeffrey L Anderson
- Intermountain Heart Institute, Intermountain Medical Center, Salt Lake City, Utah, USA
- Cardiology Division, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
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Peltan ID, McLean SR, Murnin E, Butler AM, Wilson EL, Samore MH, Hough CL, Dean NC, Bledsoe JR, Brown SM. Prevalence, Characteristics, and Outcomes of Emergency Department Discharge Among Patients With Sepsis. JAMA Netw Open 2022; 5:e2147882. [PMID: 35142831 PMCID: PMC8832179 DOI: 10.1001/jamanetworkopen.2021.47882] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
IMPORTANCE Sepsis guidelines and research have focused on patients with sepsis who are admitted to the hospital, but the scope and implications of sepsis that is managed in an outpatient setting are largely unknown. OBJECTIVE To identify the prevalence, risk factors, practice variation, and outcomes for discharge to outpatient management of sepsis among patients presenting to the emergency department (ED). DESIGN, SETTING, AND PARTICIPANTS This cohort study was conducted at the EDs of 4 Utah hospitals, and data extraction and analysis were performed from 2017 to 2021. Participants were adult ED patients who presented to a participating ED from July 1, 2013, to December 31, 2016, and met sepsis criteria before departing the ED alive and not receiving hospice care. EXPOSURES Patient demographic and clinical characteristics, health system parameters, and ED attending physician. MAIN OUTCOMES AND MEASURES Information on ED disposition was obtained from electronic medical records, and 30-day mortality data were acquired from Utah state death records and the US Social Security Death Index. Factors associated with ED discharge rather than hospital admission were identified using penalized logistic regression. Variation in ED discharge rates between physicians was estimated after adjustment for potential confounders using generalized linear mixed models. Inverse probability of treatment weighting was used in the primary analysis to assess the noninferiority of outpatient management for 30-day mortality (noninferiority margin of 1.5%) while adjusting for multiple potential confounders. RESULTS Among 12 333 ED patients with sepsis (median [IQR] age, 62 [47-76] years; 7017 women [56.9%]) who were analyzed in the study, 1985 (16.1%) were discharged from the ED. After penalized regression, factors associated with ED discharge included age (adjusted odds ratio [aOR], 0.90 per 10-y increase; 95% CI, 0.87-0.93), arrival to ED by ambulance (aOR, 0.61; 95% CI, 0.52-0.71), organ failure severity (aOR, 0.58 per 1-point increase in the Sequential Organ Failure Assessment score; 95% CI, 0.54-0.60), and urinary tract (aOR, 4.56 [95% CI, 3.91-5.31] vs pneumonia), intra-abdominal (aOR, 0.51 [95% CI, 0.39-0.65] vs pneumonia), skin (aOR, 1.40 [95% CI, 1.14-1.72] vs pneumonia) or other source of infection (aOR, 1.67 [95% CI, 1.40-1.97] vs pneumonia). Among 89 ED attending physicians, adjusted ED discharge probability varied significantly (likelihood ratio test, P < .001), ranging from 8% to 40% for an average patient. The unadjusted 30-day mortality was lower in discharged patients than admitted patients (0.9% vs 8.3%; P < .001), and their adjusted 30-day mortality was noninferior (propensity-adjusted odds ratio, 0.21 [95% CI, 0.09-0.48]; adjusted risk difference, 5.8% [95% CI, 5.1%-6.5%]; P < .001). Alternative confounder adjustment strategies yielded odds ratios that ranged from 0.21 to 0.42. CONCLUSIONS AND RELEVANCE In this cohort study, discharge to outpatient treatment of patients who met sepsis criteria in the ED was more common than previously recognized and varied substantially between ED physicians, but it was not associated with higher mortality compared with hospital admission. Systematic, evidence-based strategies to optimize the triage of ED patients with sepsis are needed.
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Affiliation(s)
- Ithan D. Peltan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Intermountain Medical Center, Murray, Utah
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Sierra R. McLean
- University of Utah School of Medicine, Salt Lake City
- Department of Physical Medicine and Rehabilitation, University of North Carolina School of Medicine, Chapel Hill
| | - Emily Murnin
- University of Utah School of Medicine, Salt Lake City
- Department of Medicine, University of Wisconsin School of Medicine, Madison
| | | | - Emily L. Wilson
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Intermountain Medical Center, Murray, Utah
| | - Matthew H. Samore
- Divisions of Epidemiology and Infectious Disease, Department of Medicine, University of Utah School of Medicine, Salt Lake City
| | - Catherine L. Hough
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Oregon Health and Sciences University, Portland
| | - Nathan C. Dean
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Intermountain Medical Center, Murray, Utah
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Joseph R. Bledsoe
- Department of Emergency Medicine, Intermountain Medical Center, Murray, Utah
- Department of Emergency Medicine, Stanford University, Palo Alto, California
| | - Samuel M. Brown
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Intermountain Medical Center, Murray, Utah
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
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11
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Bledsoe JR, Knox D, Peltan ID, Woller SC, Lloyd JF, Snow GL, Horne BD, Connors JM, Kline JA. D-dimer Thresholds to Exclude Pulmonary Embolism among COVID-19 Patients in the Emergency Department: Derivation with Independent Validation. Clin Appl Thromb Hemost 2022; 28:10760296221117997. [PMID: 35942703 PMCID: PMC9373165 DOI: 10.1177/10760296221117997] [Citation(s) in RCA: 2] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective To derive and validate a D-dimer cutoff for ruling out pulmonary embolism
(PE) in COVID-19 patients presenting to the emergency department (ED). Methods A retrospective cohort study was performed in an integrated healthcare system
including 22 adult ED's between March 1, 2020, and January 31, 2021. Results
were validated among patients enrolled in the RECOVER Registry, representing
data from 154 ED's from 26 US states. Consecutive ED patients with
laboratory confirmed COVID-19, a D-dimer performed within 48 h of ED
arrival, and with objectively confirmed PE were compared to those without
PE. After identifying a D-dimer threshold at which the 95% confidence lower
bound of the negative predictive value for PE was higher than 98% in the
derivation cohort, it was validated using RECOVER registry data. Results Among 3978 patients with a D-dimer result, 3583 with confirmed COVID-19
infection were included in the derivation cohort. Overall, PE incidence was
4.1% and a D-dimer cutoff of <2 μ/mL (2000 ng/mL)
was associated with a NPV of 98.5% (95% CI = 98.0%−98.9%). In the validation
cohort of 13,091 patients with a D-dimer, 7748 had confirmed COVID-19
infection, and the PE incidence was 1.14%. A D-dimer cutoff of
<2 μ/mL was associated with a NPV of 99.5%
(95% CI = 99.3%−99.7%). Conclusion A D-dimer cutoff of <2 μ/ml was associated with a
high negative predictive value for PE among patients with COVID-19. However,
the resultant sensitivity for PE result at that threshold without pre-test
probability assessment would be considered clinically unsafe.
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Affiliation(s)
- Joseph R Bledsoe
- Department of Emergency Medicine, Intermountain Healthcare, Salt Lake City, UT, USA.,Department of Emergency Medicine, 158423Stanford Medicine, Stanford, CA, USA
| | - Daniel Knox
- Department of Medicine, Division of Pulmonary/Critical Care, Intermountain Medical Center and University of Utah, Salt Lake City, UT, USA
| | - Ithan D Peltan
- Department of Medicine, Division of Pulmonary/Critical Care, Intermountain Medical Center and University of Utah, Salt Lake City, UT, USA
| | - Scott C Woller
- Department of Internal Medicine, Intermountain Medical Center Department of Medicine and University of Utah, Salt Lake City, UT, USA
| | - James F Lloyd
- Medical Informatics and Analytics, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Gregory L Snow
- Intermountain Healthcare, Office of Research, Statistical Data Center, Salt Lake City, UT, USA
| | - Benjamin D Horne
- Intermountain Medical Center Heart Institute, Salt Lake City, UT, USA.,Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Jean M Connors
- Department of Hematology, Brigham and Womens Hospital, Boston, MA, USA
| | - Jeffrey A Kline
- Department of Emergency Medicine, 12267Wayne State University School of Medicine, Detroit, MI, USA
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12
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Connors JM, Brooks MM, Sciurba FC, Krishnan JA, Bledsoe JR, Kindzelski A, Baucom AL, Kirwan BA, Eng H, Martin D, Zaharris E, Everett B, Castro L, Shapiro NL, Lin JY, Hou PC, Pepine CJ, Handberg E, Haight DO, Wilson JW, Majercik S, Fu Z, Zhong Y, Venugopal V, Beach S, Wisniewski S, Ridker PM. Effect of Antithrombotic Therapy on Clinical Outcomes in Outpatients With Clinically Stable Symptomatic COVID-19: The ACTIV-4B Randomized Clinical Trial. JAMA 2021; 326:1703-1712. [PMID: 34633405 PMCID: PMC8506296 DOI: 10.1001/jama.2021.17272] [Citation(s) in RCA: 156] [Impact Index Per Article: 52.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 09/14/2021] [Indexed: 12/13/2022]
Abstract
Importance Acutely ill inpatients with COVID-19 typically receive antithrombotic therapy, although the risks and benefits of this intervention among outpatients with COVID-19 have not been established. Objective To assess whether anticoagulant or antiplatelet therapy can safely reduce major adverse cardiopulmonary outcomes among symptomatic but clinically stable outpatients with COVID-19. Design, Setting, and Participants The ACTIV-4B Outpatient Thrombosis Prevention Trial was designed as a minimal-contact, adaptive, randomized, double-blind, placebo-controlled trial to compare anticoagulant and antiplatelet therapy among 7000 symptomatic but clinically stable outpatients with COVID-19. The trial was conducted at 52 US sites between September 2020 and June 2021; final follow-up was August 5, 2021. Prior to initiating treatment, participants were required to have platelet count greater than 100 000/mm3 and estimated glomerular filtration rate greater than 30 mL/min/1.73 m2. Interventions Random allocation in a 1:1:1:1 ratio to aspirin (81 mg orally once daily; n = 164), prophylactic-dose apixaban (2.5 mg orally twice daily; n = 165), therapeutic-dose apixaban (5 mg orally twice daily; n = 164), or placebo (n = 164) for 45 days. Main Outcomes and Measures The primary end point was a composite of all-cause mortality, symptomatic venous or arterial thromboembolism, myocardial infarction, stroke, or hospitalization for cardiovascular or pulmonary cause. The primary analyses for efficacy and bleeding events were limited to participants who took at least 1 dose of trial medication. Results On June 18, 2021, the trial data and safety monitoring board recommended early termination because of lower than anticipated event rates; at that time, 657 symptomatic outpatients with COVID-19 had been randomized (median age, 54 years [IQR, 46-59]; 59% women). The median times from diagnosis to randomization and from randomization to initiation of study treatment were 7 days and 3 days, respectively. Twenty-two randomized participants (3.3%) were hospitalized for COVID-19 prior to initiating treatment. Among the 558 patients who initiated treatment, the adjudicated primary composite end point occurred in 1 patient (0.7%) in the aspirin group, 1 patient (0.7%) in the 2.5-mg apixaban group, 2 patients (1.4%) in the 5-mg apixaban group, and 1 patient (0.7%) in the placebo group. The risk differences compared with placebo for the primary end point were 0.0% (95% CI not calculable) in the aspirin group, 0.7% (95% CI, -2.1% to 4.1%) in the 2.5-mg apixaban group, and 1.4% (95% CI, -1.5% to 5.0%) in the 5-mg apixaban group. Risk differences compared with placebo for bleeding events were 2.0% (95% CI, -2.7% to 6.8%), 4.5% (95% CI, -0.7% to 10.2%), and 6.9% (95% CI, 1.4% to 12.9%) among participants who initiated therapy in the aspirin, prophylactic apixaban, and therapeutic apixaban groups, respectively, although none were major. Findings inclusive of all randomized patients were similar. Conclusions and Relevance Among symptomatic clinically stable outpatients with COVID-19, treatment with aspirin or apixaban compared with placebo did not reduce the rate of a composite clinical outcome. However, the study was terminated after enrollment of 9% of participants because of an event rate lower than anticipated. Trial Registration ClinicalTrials.gov Identifier: NCT04498273.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Heather Eng
- University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | | | | | | | | | | | - Peter C. Hou
- Brigham and Women’s Hospital, Boston, Massachusetts
| | | | | | | | | | | | - Zhuxuan Fu
- University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Yongqi Zhong
- University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Scott Beach
- University of Pittsburgh, Pittsburgh, Pennsylvania
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13
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Bledsoe JR, Kelly C, Stevens SM, Woller SC, Haug P, Lloyd JF, Allen TL, Butler AM, Jacobs JR, Elliott CG. Electronic pulmonary embolism clinical decision support and effect on yield of computerized tomographic pulmonary angiography: ePE-A pragmatic prospective cohort study. J Am Coll Emerg Physicians Open 2021; 2:e12488. [PMID: 34263250 PMCID: PMC8254596 DOI: 10.1002/emp2.12488] [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: 09/23/2020] [Revised: 05/29/2021] [Accepted: 06/03/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Multiple professional societies recommend pre-test probability (PTP) assessment prior to imaging in the evaluation of patients with suspected pulmonary embolism (PE), however, PTP testing remains uncommon, with imaging occurring frequently and rates of confirmed PE remaining low. The goal of this study was to assess the impact of a clinical decision support tool embedded into the electronic health record to improve the diagnostic yield of computerized tomography pulmonary angiography (CTPA) in suspected patients with PE in the emergency department (ED). METHODS Between July 24, 2014 and December 31, 2016, 4 hospitals from a healthcare system embedded an optional electronic clinical decision support system to assist in the diagnosis of pulmonary embolism (ePE). This system employs the Pulmonary Embolism Rule-out Criteria (PERC) and revised Geneva Score (RGS) in series prior to CT imaging. We compared the diagnostic yield of CTPA) among patients for whom the physician opted to use ePE versus the diagnostic yield of CTPA when ePE was not used. RESULTS During the 2.5-year study period, 37,288 adult patients were eligible and included for study evaluation. Of eligible patients, 1949 of 37,288 (5.2%) were enrolled by activation of the tool. A total of 16,526 CTPAs were performed system-wide. When ePE was not engaged, CTPA was positive for PE in 1556 of 15,546 scans for a positive yield of 10.0%. When ePE was used, CTPA identified PE in 211 of 980 scans (21.5% yield) (P < 0.001). CONCLUSIONS ePE significantly increased the diagnostic yield of CTPA without missing 30-day clinically overt PE.
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Affiliation(s)
- Joseph R. Bledsoe
- Department of Emergency MedicineHealthcare Delivery InstituteIntermountain HealthcareMurrayUtahUSA
- Department of Emergency MedicineStanford MedicinePalo AltoCaliforniaUSA
| | - Christopher Kelly
- Department of SurgeryDivision of Emergency MedicineUniversity of Utah School of MedicineSalt Lake CityUtahUSA
| | - Scott M. Stevens
- Department of MedicineIntermountain Medical CenterMurrayUtahUSA
- Department of Internal MedicineUniversity of Utah School of MedicineSalt Lake CityUtahUSA
| | - Scott C. Woller
- Department of MedicineIntermountain Medical CenterMurrayUtahUSA
- Department of Internal MedicineUniversity of Utah School of MedicineSalt Lake CityUtahUSA
| | - Peter Haug
- Medical InformaticsIntermountain HealthcareMurrayUtahUSA
| | - James F. Lloyd
- Medical InformaticsIntermountain HealthcareMurrayUtahUSA
| | - Todd L. Allen
- Department of Emergency MedicineHealthcare Delivery InstituteIntermountain HealthcareMurrayUtahUSA
- Department of Emergency MedicineStanford MedicinePalo AltoCaliforniaUSA
| | | | | | - C. Gregory Elliott
- Department of MedicineIntermountain Medical CenterMurrayUtahUSA
- Department of Internal MedicineUniversity of Utah School of MedicineSalt Lake CityUtahUSA
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14
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Woller SC, Stevens SM, Fazili M, Lloyd JF, Wilson EL, Snow GL, Bledsoe JR, Horne BD. Post-discharge thrombosis and bleeding in medical patients: A novel risk score derived from ubiquitous biomarkers. Res Pract Thromb Haemost 2021; 5:e12560. [PMID: 34263106 PMCID: PMC8265782 DOI: 10.1002/rth2.12560] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 05/20/2021] [Accepted: 05/31/2021] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Some hospitalized medical patients experience venous thromboembolism (VTE) following discharge. Prophylaxis extended beyond hospital discharge (extended duration thromboprophylaxis [EDT]) may reduce this risk. However, EDT is costly and can cause bleeding, so selecting appropriate patients is essential. We formerly reported the performance of a mortality risk prediction score (Intermountain Risk Score [IMRS]) that was minimally predictive of 90-day hospital-associated venous thromboembolism (HA-VTE) and major bleeding (HA-MB). We used the components of the IMRS to calculate de novo risk scores to predict 90-day HA-VTE (HA-VTE IMRS) and major bleeding (HA-MB IMRS). METHODS From 45 669 medical patients we randomly assigned 30 445 to derive the HA-VTE IMRS and the HA-MB IMRS. Backward stepwise regression and bootstrapping identified predictor covariates from the blood count and basic chemistry. These candidate variables were split into quintiles, and the referent quintile was that with the lowest event rate for HA-VTE and HA-MB; respectively. A clinically relevant rate of HA-VTE and HA-MB was used to inform outcome rates. Performance was assessed in the derivation set of 15 224 patients. RESULTS The HA-VTE IMRS and HA-MB IMRS area under the receiver operating curve (AUC) in the derivation set were 0.646, and 0.691, respectively. In the validation set, the HA-VTE IMRS and HA-MB IMRS AUCs were 0.60 and 0.643. CONCLUSIONS Risk scores derived from components of routine labs ubiquitous in clinical care identify patients that are at risk for 90-day postdischarge HA-VTE and major bleeding. This may identify a subset of patients with high HA-VTE risk and low HA-MB risk who may benefit from EDT.
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Affiliation(s)
- Scott C. Woller
- Department of MedicineIntermountain Medical CenterIntermountain HealthcareMurrayUTUSA
- Department of Internal MedicineUniversity of Utah School of MedicineSalt Lake CityUTUSA
| | - Scott M. Stevens
- Department of MedicineIntermountain Medical CenterIntermountain HealthcareMurrayUTUSA
- Department of Internal MedicineUniversity of Utah School of MedicineSalt Lake CityUTUSA
| | - Masarret Fazili
- Department of MedicineIntermountain Medical CenterIntermountain HealthcareMurrayUTUSA
| | - James F. Lloyd
- Department of InformaticsIntermountain Medical CenterIntermountain HealthcareMurrayUTUSA
| | - Emily L. Wilson
- Intermountain Statistical Data CenterIntermountain Medical CenterIntermountain HealthcareMurrayUTUSA
| | - Gregory L. Snow
- Intermountain Statistical Data CenterIntermountain Medical CenterIntermountain HealthcareMurrayUTUSA
| | - Joseph R. Bledsoe
- Department of Emergency MedicineIntermountain Medical CenterIntermountain HealthcareMurrayUTUSA
- Department of Emergency MedicineStanford UniversityStanfordCAUSA
| | - Benjamin D. Horne
- Intermountain Medical Center Heart InstituteMurrayUTUSA
- Division of Cardiovascular MedicineStanford UniversityStanfordCAUSA
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15
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Kline JA, Adler DH, Alanis N, Bledsoe JR, Courtney DM, d'Etienne JP, Diercks DB, Garrett JS, Jones AE, Mackenzie DC, Madsen T, Matuskowitz AJ, Mumma BE, Nordenholz KE, Pagenhardt J, Runyon MS, Stubblefield WB, Willoughby CB. Monotherapy Anticoagulation to Expedite Home Treatment of Patients Diagnosed With Venous Thromboembolism in the Emergency Department: A Pragmatic Effectiveness Trial. Circ Cardiovasc Qual Outcomes 2021; 14:e007600. [PMID: 34148351 DOI: 10.1161/circoutcomes.120.007600] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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] [Indexed: 01/19/2023]
Abstract
BACKGROUND The objective was to test if low-risk emergency department patients with vitamin K antagonist (venous thromboembolism [VTE]; including venous thrombosis and pulmonary embolism [PE]) can be safely and effectively treated at home with direct acting oral (monotherapy) anticoagulation in a large-scale, real-world pragmatic effectiveness trial. METHODS This was a single-arm trial, conducted from 2016 to 2019 in accordance with the Standards for Reporting Implementation Studies guideline in 33 emergency departments in the United States. Participants had newly diagnosed VTE with low risk of death based upon either the modified Hestia criteria, or physician judgment plus the simplified PE severity index score of zero, together with nonhigh bleeding risk were eligible. Patients had to be discharged within 24 hours of triage and treated with either apixaban or rivaroxaban. Effectiveness was defined by the primary efficacy and safety outcomes, image-proven recurrent VTE and bleeding requiring hospitalization >24 hours, respectively, with an upper limit of the 95% CI for the 30-day frequency of VTE recurrence below 2.0% for both outcomes. RESULTS We enrolled 1421 patients with complete outcomes data, including 903 with venous thrombosis and 518 with PE. The recurrent VTE requiring hospitalization occurred in 14/1421 (1.0% [95% CI, 0.5%-1.7%]), and bleeding requiring hospitalization occurred in 12/1421 (0.8% [0.4%-1.5%). The rate of severe bleeding using International Society for Thrombosis and Haemostasis criteria was 2/1421 (0.1% [0%-0.5%]). No patient died, and serious adverse events occurred in 2.5% of venous thrombosis patients and 2.3% of patients with PE. Medication nonadherence was reported by patients in 8.0% (6.6%-9.5%) and was associated with a risk ratio of 6.0 (2.3-15.2) for VTE recurrence. Among all patients diagnosed with VTE in the emergency department during the period of study, 18% of venous thrombosis patients and 10% of patients with PE were enrolled. CONCLUSIONS Monotherapy treatment of low-risk patients with venous thrombosis or PE in the emergency department setting produced a low rate of bleeding and VTE recurrence, but may be underused. Patients with venous thrombosis and PE should undergo risk-stratification before home treatment. Improved patient adherence may reduce rate of recurrent VTE. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03404635.
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Affiliation(s)
- Jeffrey A Kline
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis (J.A.K.)
| | - David H Adler
- Department of Emergency Medicine, University of Rochester, NY (D.H.A.)
| | - Naomi Alanis
- Department of Emergency Medicine, University of North Texas, Denton (N.A.)
| | - Joseph R Bledsoe
- Department of Emergency Medicine, Healthcare Delivery Institute, Intermountain Healthcare, Salt Lake City, UT (J.R.B.)
| | - Daniel M Courtney
- Department of Emergency Medicine, University of Texas Southwestern, Dallas (D.M.C., D.B.D.)
| | - James P d'Etienne
- Department of Emergency Medicine, John Peter Smith Hospital, Fort Worth, TX (J.P.d.)
| | - Deborah B Diercks
- Department of Emergency Medicine, University of Texas Southwestern, Dallas (D.M.C., D.B.D.)
| | - John S Garrett
- Department of Emergency Medicine, Baylor University Medical Center, Dallas, TX (J.S.G.)
| | - Alan E Jones
- Department of Emergency Medicine, University of Mississippi, Jackson (A.E.J.)
| | - David C Mackenzie
- Department of Emergency Medicine, Maine Medical Center, Portland (D.C.M.)
| | - Troy Madsen
- Department of Emergency Medicine, University of Utah, Salt Lake City (T.M.)
| | - Andrew J Matuskowitz
- Department of Emergency Medicine, Medical University of South Carolina, Charleston (A.J.M.)
| | - Bryn E Mumma
- Department of Emergency Medicine, University of California, Davis (B.E.M.)
| | | | - Justine Pagenhardt
- Department of Emergency Medicine, West Virginia University, Morgantown (J.P.)
| | - Michael S Runyon
- Department of Emergency Medicine, Atrium Health, Charlotte, NC (M.S.R.)
| | - William B Stubblefield
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville TN (W.B.S.)
| | - Christopher B Willoughby
- Department of Internal Medicine, Division of Emergency Medicine, Louisiana State University, New Orleans (C.B.W.)
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16
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Kay AB, Morris DS, Woller SC, Stevens SM, Bledsoe JR, Lloyd JF, Collingridge DS, Majercik S. Trauma patients at risk for venous thromboembolism who undergo routine duplex ultrasound screening experience fewer pulmonary emboli: A prospective randomized trial. J Trauma Acute Care Surg 2021; 90:787-796. [PMID: 33560104 DOI: 10.1097/ta.0000000000003104] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Although guidelines are established for the prevention and management of venous thromboembolism (VTE) in trauma, no consensus exists regarding protocols for the diagnostic approach. We hypothesized that at-risk trauma patients who undergo duplex ultrasound (DUS) surveillance for lower extremity deep venous thrombosis (DVT) will have a lower rate of symptomatic or fatal pulmonary embolism (PE) than those who do not undergo routine surveillance. METHODS Prospective, randomized trial between March 2017 and September 2019 of trauma patients admitted to a single, level 1 trauma center, with a risk assessment profile score of ≥5. Patients were randomized to receive either bilateral lower extremity DUS surveillance on days 1, 3, and 7 and weekly during hospitalization ultrasound group (US) or no surveillance no ultrasound group (NoUS). Rates of in-hospital and 90-day DVT and PE were reported as was DVT propagation and all-cause mortality. Standard care for the prevention and management of VTE per established institutional protocols was provided to all patients. RESULTS A total of 3,236 trauma service admissions were screened, and 1,989 moderate- and high-risk patients were randomized (US, 995; NoUS, 994). The mean ± SD age was 62 ± 20.1 years, Injury Severity Score was 14 ± 9.7, risk assessment profile was 7.1 ± 2.4, and 97% suffered blunt trauma. There was no difference in demographics or VTE risk factors between the groups. There were significantly fewer in-hospital PE in the US group than the NoUS group (1 [0.1%] vs. 9 [0.9%], p = 0.01). The US group experienced more in-hospital below-knee DVTs (124 [12.5%] vs. 8 [0.8%], p < 0.001) and above-knee DVTs (19 [1.9%] vs. 8 [0.8%], p = 0.05). There was no difference in 90-day PE or DVT, or overall mortality. CONCLUSION The implementation of a selective routine DUS protocol was associated with significantly fewer in-hospital PE. More DVTs were identified with routine screening; however, surveillance bias appears to exist primarily with distal DVT. Larger trials are needed to further characterize the relationship between routine DUS screening and VTE outcomes in the high-risk trauma population. LEVEL OF EVIDENCE Therapeutic/care management, level II.
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Affiliation(s)
- Annika B Kay
- From the Division of Trauma Services and Surgical Critical Care (A.B.K., D.S.M., S.M.), Department of Medicine (S.C.W., S.M.S.), Intermountain Medical Center, Murray; Department of Medicine (S.C.W., S.M.S.), University of Utah School of Medicine, Salt Lake City; Department of Emergency Medicine (J.R.B.), Intermountain Medical Center, Murray; Medical Informatics (J.F.L.), Intermountain Medical Center; and Office of Research (D.S.C.), Intermountain Medical Center, Murray, Utah
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17
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Kumar A, Niknam K, Lumba-Brown A, Woodruff M, Bledsoe JR, Kohn MA, Perry JJ, Govindarajan P. Practice Variation in the Diagnosis of Aneurysmal Subarachnoid Hemorrhage: A Survey of US and Canadian Emergency Medicine Physicians. Neurocrit Care 2020; 31:321-328. [PMID: 30790225 DOI: 10.1007/s12028-019-00679-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND AIMS Spontaneous subarachnoid hemorrhage (SAH) from a brain aneurysm, if untreated in the acute phase, leads to loss of functional independence in about 30% of patients and death in 27-44%. To evaluate for SAH, the American College of Emergency Physicians (ACEP) Clinical Policy recommends obtaining a non-contrast brain computed tomography (CT) scan followed by a lumbar puncture (LP) if the CT is negative. On the other hand, current evidence from prospectively collected data suggests that CT alone may be sufficient to rule out SAH in patients who present within 6 h of symptom onset while anecdotal evidence suggests that CT angiogram (CTA) may be used to detect aneurysms, which are the probable cause of SAH. Since many different options are available to emergency physicians, we examined their practice pattern variation by observing their diagnostic approaches and their adherence to the ACEP Clinical Policy. METHODS We developed, validated, and distributed a survey to emergency physicians at three practice sites: (1) Stanford Healthcare, California, (2) Intermountain Healthcare (five emergency departments), Utah, and (3) Ottawa General Hospital, Toronto. The survey questions examined physician knowledge on CT and LP's test performance and used case-based scenarios to assess diagnostic approaches, variation in practice, and adherence to guidelines. Results were presented as proportions with 95% CIs. RESULTS Of the 216 physicians surveyed, we received 168 responses (77.8%). The responses by site were: (1) (n = 38, 23.2%), (2) (n = 70, 42.7%), (3) (n = 56, 34.1%). To the CT and LP test performance question, most physicians indicated that CT alone detects > 90% of SAH in those with a confirmed SAH [n = 150 (89.3%, 95% CI 83.6-93.5]. To the case-based questions, most physicians indicated that they would perform a CTA along with a CT [n = 110 (65.5%, 95% CI 57.8-72.6)], some indicated a LP along with a CT [n = 57, 33.9% 95% CI 26.8-41.6)], and a few indicated both a CTA and a LP [n = 16, 9.5%, 95% CI 5.5-15.0]. We also observed practice site variation in the proportion of physicians who indicated that they would use CTA: (1) (n = 25, 65.8%), (2) (n = 54, 77.1%), and (3) (n = 28, 50.0%) (p = 0.006). CONCLUSIONS Survey responses indicate that physicians use some or all of the imaging tests, with or without LP to diagnose SAH. We observed variation in the use of CTA by site and academic setting and divergence from ACEP Clinical Policy.
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Affiliation(s)
- Aarti Kumar
- University of Pittsburgh School of Medicine, University of Pittsburgh, Pittsburgh, USA
| | - Kian Niknam
- Department of Emergency Medicine, Stanford University Medical Center, Palo Alto, USA.,Department of Epidemiology and Biostatistics, University of California - San Francisco, San Francisco, USA
| | - Angela Lumba-Brown
- Department of Emergency Medicine, Stanford University Medical Center, Palo Alto, USA
| | - Michael Woodruff
- Department of Emergency Medicine, Intermountain Healthcare, Salt Lake City, USA
| | - Joseph R Bledsoe
- Department of Emergency Medicine, Stanford University Medical Center, Palo Alto, USA.,Department of Emergency Medicine, Intermountain Healthcare, Salt Lake City, USA
| | - Michael A Kohn
- Department of Epidemiology and Biostatistics, University of California - San Francisco, San Francisco, USA
| | - Jeffrey J Perry
- Department of Emergency Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Canada
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Snow GL, Bledsoe JR, Butler A, Wilson EL, Rea S, Majercik S, Anderson JL, Horne BD. Comparative evaluation of the clinical laboratory-based Intermountain risk score with the Charlson and Elixhauser comorbidity indices for mortality prediction. PLoS One 2020; 15:e0233495. [PMID: 32437416 PMCID: PMC7241706 DOI: 10.1371/journal.pone.0233495] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 05/06/2020] [Indexed: 11/19/2022] Open
Abstract
Background The Charlson and Elixhauser comorbidity indices are mortality predictors often used in clinical, administrative, and research applications. The Intermountain Mortality Risk Scores (IMRS) are validated mortality predictors that use all factors from the complete blood count and basic metabolic profile. How IMRS, Charlson, and Elixhauser relate to each other is unknown. Methods All inpatient admissions except obstetric patients at Intermountain Healthcare’s 21 adult care hospitals from 2010–2014 (N = 197,680) were examined in a observational cohort study. The most recent admission was a patient’s index encounter. Follow-up to 2018 used hospital death records, Utah death certificates, and the Social Security death master file. Three Charlson versions, 8 Elixhauser versions, and 3 IMRS formulations were evaluated in Cox regression and the one of each that was most predictive was used in dual risk score mortality analyses (in-hospital, 30-day, 1-year, and 5-year mortality). Results Indices with the strongest mortality associations and selected for dual score study were the age-adjusted Charlson, the van Walraven version of the acute Elixhauser, and the 1-year IMRS. For in-hospital mortality, Charlson (c = 0.719; HR = 4.75, 95% CI = 4.45, 5.07), Elixhauser (c = 0.783; HR = 5.79, CI = 5.41, 6.19), and IMRS (c = 0.821; HR = 17.95, CI = 15.90, 20.26) were significant predictors (p<0.001) in univariate analyses. Dual score analysis of Charlson (HR = 1.79, CI = 1.66, 1.92) with IMRS (HR = 13.10, CI = 11.53, 14.87) and of Elixhauser (HR = 3.00, CI = 2.80, 3.21) with IMRS (HR = 11.42, CI = 10.09, 12.92) found significance for both scores in each model. Results were similar for 30-day, 1-year, and 5-year mortality. Conclusions IMRS provided the strongest ability to predict mortality, adding to and attenuating the predictive ability of the Charlson and Elixhauser indices whose mortality associations remained statistically significant. IMRS uses common, standardized, objective laboratory data and should be further evaluated for integration into mortality risk evaluations.
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Affiliation(s)
- Gregory L. Snow
- Office of Research, Intermountain Healthcare, Salt Lake City, Utah, United States of America
| | - Joseph R. Bledsoe
- Emergency Department, Intermountain Medical Center, Salt Lake City, Utah, United States of America
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, United States of America
| | - Allison Butler
- Office of Research, Intermountain Healthcare, Salt Lake City, Utah, United States of America
| | - Emily L. Wilson
- Pulmonary and Critical Care Division, Department of Medicine, Intermountain Medical Center, Salt Lake City, Utah, United States of America
| | - Susan Rea
- Care Transformation, Intermountain Healthcare, Salt Lake City, Utah, United States of America
| | - Sarah Majercik
- Emergency Department, Intermountain Medical Center, Salt Lake City, Utah, United States of America
| | - Jeffrey L. Anderson
- Intermountain Medical Center Heart Institute, Salt Lake City, Utah, United States of America
- Cardiology Division, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, United States of America
| | - Benjamin D. Horne
- Intermountain Medical Center Heart Institute, Salt Lake City, Utah, United States of America
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, United States of America
- * E-mail:
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19
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Peltan ID, Bledsoe JR, Brems D, McLean S, Murnin E, Brown SM. Institution of an emergency department "swarming" care model and sepsis door-to-antibiotic time: A quasi-experimental retrospective analysis. PLoS One 2020; 15:e0232794. [PMID: 32369531 PMCID: PMC7199941 DOI: 10.1371/journal.pone.0232794] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 04/21/2020] [Indexed: 12/20/2022] Open
Abstract
Background Prompt sepsis treatment is associated with improved outcomes but requires a complex series of actions by multiple clinicians. We investigated whether simply reorganizing emergency department (ED) care to expedite patients’ initial evaluation was associated with shorter sepsis door-to-antibiotic times. Methods Patients eligible for this retrospective study received IV antibiotics and demonstrated acute organ failure after presenting to one of three EDs in Utah. On May 1, 2016, the intervention ED instituted “swarming” as the default model for initial evaluation of all mid- and low-acuity patients. Swarming involved simultaneous patient evaluation by the ED physician, nurse, and technician followed by a team discussion of the initial care plan. Care was unchanged at the two control EDs. A 30-day wash-in period separated the baseline (May 16, 2015 to April 15, 2016) and post-intervention (May 16, 2016 to November 15, 2016) analysis periods. We conducted a quasi-experimental analysis comparing door-to-antibiotic time for sepsis patients at the intervention ED after versus before care reorganization, applying difference-in-differences methods to control for trends in door-to-antibiotic time unrelated to the studied intervention and multivariable regression to adjust for patient characteristics. Results The analysis included 3,230 ED sepsis patients, including 1,406 from the intervention ED. Adjusted analyses using difference-in-differences methods to control for temporal trends unrelated to the studied intervention revealed no significant change in door-to-antibiotic time after care reorganization (-7 minutes, 95% CI -20 to 6 minutes, p = 0.29). Multivariable pre/post analyses using data only from the intervention ED overestimated the magnitude and statistical significance of outcome changes associated with ED care reorganization. Conclusions Implementation of an ED care model involving parallel multidisciplinary assessment and early team discussion of the care plan was not associated with improvements in mid- and low-acuity sepsis patients’ door-to-antibiotic time after accounting for changes in the outcome unrelated to the studied intervention.
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Affiliation(s)
- Ithan D. Peltan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Intermountain Medical Center, Murray, UT, United States of America
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States of America
- * E-mail:
| | - Joseph R. Bledsoe
- Department of Emergency Medicine, Intermountain Medical Center, Murray, UT, United States of America
- Department of Emergency Medicine, Stanford Medicine, Palo Alto, CA, United States of America
| | - David Brems
- Department of Emergency Medicine, LDS Hospital, Salt Lake City, UT, United States of America
| | - Sierra McLean
- University of Utah School of Medicine, Salt Lake City, UT, United States of America
| | - Emily Murnin
- University of Utah School of Medicine, Salt Lake City, UT, United States of America
| | - Samuel M. Brown
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Intermountain Medical Center, Murray, UT, United States of America
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States of America
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20
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Kelly C, Bledsoe JR, Woller SC, Stevens SM, Jacobs JR, Butler AM, Quinn J. Diagnostic yield of pulmonary embolism testing in patients presenting to the emergency department with syncope. Res Pract Thromb Haemost 2020; 4:263-268. [PMID: 32110757 PMCID: PMC7040541 DOI: 10.1002/rth2.12294] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 10/28/2019] [Accepted: 11/04/2019] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Syncope occurs in 1 in 4 people during their lifetime and accounts for 1% to 1.5% of emergency department (ED) visits. Most causes of syncope are benign, but syncope may be caused by life-threatening conditions including pulmonary embolism (PE) in up to 2% of cases. A recent publication reported the prevalence of PE in patients with syncope to be over 17%. AIMS We sought to determine the frequency and diagnostic yield of testing for PE in patients presenting to the ED with syncope in our large, integrated health care system. METHODS We performed a retrospective, longitudinal cohort study of patients who presented with syncope to EDs within a 21-hospital integrated health care system from 2010 to 2015 to find the frequency and diagnostic yield of testing for PE in patients with syncope at index ED visit and within 180 days afterward. RESULTS We screened 2 749 371 ED encounters to find 32 440 (1.2%) with syncope. Median age was 52 (interquartile range, 31-71), 57.5% were female, and 90% were Caucasian. PE was diagnosed on the index ED visit in 259 (0.8%; 95% confidence interval [CI], 0.7%-0.9%) cases. Assessment for suspected PE with D-dimer occurred in 5089 (15.7%) patients, and 2338 (7.2%) underwent computed tomography pulmonary angiography (CTPA). The yield of CTPA was 7.9%. PE was detected in 2.2% in whom a D-dimer was performed. From index visit to 180 days, 467 (1.4%; 95% CI, 1.3%-1.6%) patients were diagnosed with a PE, and 1051 (3.2%, 95% CI, 3.0%-3.4%) patients died. CONCLUSION Diagnostic testing for PE is frequent in patients with syncope presenting to the EDs of a large, integrated health care system. The yield of diagnostic testing is low.
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Affiliation(s)
| | - Joseph R. Bledsoe
- Intermountain Medical CenterMurrayUtah
- Stanford UniversityStanfordCalifornia
| | - Scott C. Woller
- University of UtahSalt Lake CityUtah
- Intermountain Medical CenterMurrayUtah
| | - Scott M. Stevens
- University of UtahSalt Lake CityUtah
- Intermountain Medical CenterMurrayUtah
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21
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Shi R, Quinones A, Bair J, Hopkins RO, Butler AM, Inglet S, Anctil C, Woods J, Jones J, Bledsoe JR. Patient utilization of prescription opioids after discharge from the emergency department. Am J Emerg Med 2019; 38:1568-1571. [PMID: 31493981 DOI: 10.1016/j.ajem.2019.158421] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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: 04/11/2019] [Revised: 08/22/2019] [Accepted: 08/29/2019] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Emergency department (ED) visits associated with prescription opioids have increased in the last ten years. This study describes the opioid utilization of patients discharged from the ED with an opioid prescription for pain, 14 to 21 days post discharge. METHODS This is a prospective, single-centered, survey-based observational descriptive study conducted from December 2017 to February 2018 in the ED at a tertiary level 1 trauma center. The primary outcomes were the percentage of patients with unused opioids and the quantity of opioids remaining 14 to 21 days post ED discharge. A sample of ED patients who received an oral opioid prescription were approached for informed consent and received a telephone survey 14 to 21 days post discharge. RESULTS Of 178 patients approached for consent, 122 were enrolled. Among them, 98 were successfully surveyed (80.3%). The median number of pills prescribed was 8 (IQR:8-12). Nearly half (49%) of patients had unused opioids 14 to 21 days post ED discharge, not including 9.2% of patients who never filled their prescriptions. Of the total 980 pills prescribed, 327 pills remained unused (33.4%). Only 55.1% of patients reported receiving counseling on side effect of opioids and 21.4% of patients reported they received counseling on storage and disposal. CONCLUSION The majority of patients in this study had unused or unfilled opioids 14 to 21 days post ED discharge, and approximately one third of the opioids prescribed remained unused. Most patients did not recall receiving opioid related education including proper disposal of medication.
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Affiliation(s)
- Ruixin Shi
- Department of Pharmacy, University of Virginia Health System, Charlottesville, VA 22908, USA; Department of Pharmacy, Intermountain Medical Center, Murray, UT 84107, USA.
| | - Amie Quinones
- Department of Pharmacy, Intermountain Medical Center, Murray, UT 84107, USA; Department of Pharmacy, Layton Hospital, Layton, UT 84041, USA
| | - Jeremy Bair
- Department of Pharmacy, Intermountain Medical Center, Murray, UT 84107, USA
| | - Ramona O Hopkins
- Department of Psychology and Neuroscience Center, Brigham Young University, Provo, UT 84602, USA; Center for Humanizing Critical Care, Intermountain Medical Center, Murray, UT 84107, USA; Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT 84107, USA
| | - Allison M Butler
- Statistical Data Center, Intermountain Medical Center, Murray, UT 84107, USA
| | - Shannon Inglet
- Department of Pharmacy, Intermountain Medical Center, Murray, UT 84107, USA; Intermountain Drug Information Services, Intermountain Healthcare, Taylorsville, UT 84129, USA
| | | | - Jake Woods
- Brigham Young University, Provo, UT 84602, USA
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Woller SC, Stevens SM, Johnson SA, Bledsoe JR, Galovic B, Lloyd JF, Wilson EL, Armbruster B, Evans RS. Apixaban for Routine Management of Upper Extremity Deep Venous Thrombosis (ARM-DVT): Methods of a prospective single-arm management study. Res Pract Thromb Haemost 2019; 3:340-348. [PMID: 31294320 PMCID: PMC6611360 DOI: 10.1002/rth2.12208] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 04/05/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Upper extremity deep vein thrombosis (UEDVT) constitutes approximately 10% of all deep vein thromboses (DVTs). The incidence of UEDVT is increasing in association with use of peripherally inserted central venous catheters. Treatment for UEDVT is derived largely from evidence for treatment of lower extremity DVT. Limited evidence exists for the use of a direct oral anticoagulant for the treatment of UEDVT. POPULATION Sequential patients identified within the Intermountain Healthcare System and University of Utah Healthcare system with symptomatic UEDVT defined as the formation of thrombus within the internal jugular, subclavian, axillary, brachial, ulnar, or radial veins of the arm. INTERVENTION Apixaban 10 mg PO twice daily for 7 days followed by apixaban 5 mg twice daily for 11 weeks. COMPARISON The historical literature review rate of venous thrombosis reported for recurrent clinically overt objective venous thromboembolism (VTE) and VTE-related death. If the confidence interval for the observed rate excludes the threshold event rate of 4%, we will conclude that treatment with apixaban is noninferior and therefore a clinically valid approach to treat UEDVT. SAMPLE SIZE We elected a sample size of 375 patients so that an exact 95% confidence interval would exclude an event rate of VTE in the observation cohort of 4%. OUTCOME Ninety-day rate of new or recurrent objectively confirmed symptomatic venous thrombosis and VTE-related death. The primary safety outcome is the composite of major and clinically relevant nonmajor bleeding.
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Affiliation(s)
- Scott C. Woller
- Intermountain Medical CenterUniversity of Utah School of MedicineEccles Outpatient Care CenterMurrayUtah
| | - Scott M. Stevens
- Intermountain Medical CenterUniversity of Utah School of MedicineEccles Outpatient Care CenterMurrayUtah
| | - Stacy A. Johnson
- Intermountain Medical CenterUniversity of Utah School of MedicineEccles Outpatient Care CenterMurrayUtah
| | - Joseph R. Bledsoe
- Intermountain Medical CenterUniversity of Utah School of MedicineEccles Outpatient Care CenterMurrayUtah
| | - Brian Galovic
- Intermountain Medical CenterUniversity of Utah School of MedicineEccles Outpatient Care CenterMurrayUtah
| | - James F. Lloyd
- Intermountain Medical CenterUniversity of Utah School of MedicineEccles Outpatient Care CenterMurrayUtah
| | - Emily L. Wilson
- Intermountain Medical CenterUniversity of Utah School of MedicineEccles Outpatient Care CenterMurrayUtah
| | - Brent Armbruster
- Intermountain Medical CenterUniversity of Utah School of MedicineEccles Outpatient Care CenterMurrayUtah
| | - R. Scott Evans
- Intermountain Medical CenterUniversity of Utah School of MedicineEccles Outpatient Care CenterMurrayUtah
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Peltan ID, Brown SM, Bledsoe JR, Sorensen J, Samore MH, Allen TL, Hough CL. ED Door-to-Antibiotic Time and Long-term Mortality in Sepsis. Chest 2019; 155:938-946. [PMID: 30779916 DOI: 10.1016/j.chest.2019.02.008] [Citation(s) in RCA: 130] [Impact Index Per Article: 26.0] [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: 11/10/2018] [Revised: 01/28/2019] [Accepted: 02/01/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The impact of antibiotic timing on sepsis outcomes remains controversial due to conflicting results from previous studies. OBJECTIVES This study investigated the association of door-to-antibiotic time with long-term mortality in ED patients with sepsis. METHODS This retrospective cohort study included nontrauma adult ED patients with clinical sepsis admitted to four hospitals from 2013 to 2017. Only patients' first eligible encounter was included. Multivariable logistic regression was used to measure the adjusted association between door-to-antibiotic time and 1-year mortality. Secondary analyses used alternative antibiotic timing measures (antibiotic initiation within 1 or 3 h and separate comparison of antibiotic exposure at each hour up to hour 6), alternative outcomes (hospital, 30-day, and 90-day mortality), and alternative statistical methods to mitigate indication bias. RESULTS Among 10,811 eligible patients, median door-to-antibiotic time was 166 min (interquartile range, 115-230 min), and 1-year mortality was 19%. After adjustment, each additional hour from ED arrival to antibiotic initiation was associated with a 10% (95% CI, 5-14; P < .001) increased odds of 1-year mortality. The association remained linear when each 1-h interval of door-to-antibiotic time was independently compared with door-to-antibiotic time ≤ 1 h and was similar for hospital, 30-day, and 90-day mortality. Mortality at 1 year was higher when door-to-antibiotic times were > 3 h vs ≤ 3 h (adjusted OR, 1.27; 95% CI, 1.13-1.43) but not > 1 h vs ≤ 1 h (adjusted OR, 1.26; 95% CI, 0.98-1.62). CONCLUSIONS Delays in ED antibiotic initiation time are associated with clinically important increases in long-term, risk-adjusted sepsis mortality.
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Affiliation(s)
- Ithan D Peltan
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT; Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT.
| | - Samuel M Brown
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT; Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Joseph R Bledsoe
- Departments of Medicine and Emergency Medicine, Intermountain Medical Center, Murray, UT
| | - Jeffrey Sorensen
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT
| | - Matthew H Samore
- Division of Epidemiology, Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Todd L Allen
- Departments of Medicine and Emergency Medicine, Intermountain Medical Center, Murray, UT
| | - Catherine L Hough
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, WA
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Bledsoe JR, Woller SC, Stevens SM, Aston V, Patten R, Allen T, Horne BD, Dong L, Lloyd J, Snow G, Madsen T, Elliott CG. Management of Low-Risk Pulmonary Embolism Patients Without Hospitalization. Chest 2018; 154:249-256. [DOI: 10.1016/j.chest.2018.01.035] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 01/17/2018] [Accepted: 01/19/2018] [Indexed: 12/18/2022] Open
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Kay AB, Majercik S, Sorensen J, Woller SC, Stevens SM, White TW, Morris DS, Baldwin M, Bledsoe JR. Weight-based enoxaparin dosing and deep vein thrombosis in hospitalized trauma patients: A double-blind, randomized, pilot study. Surgery 2018; 164:S0039-6060(18)30094-1. [PMID: 29699807 DOI: 10.1016/j.surg.2018.03.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 02/15/2018] [Accepted: 03/07/2018] [Indexed: 01/25/2023]
Abstract
BACKGROUND Venous thromboembolism is a cause of morbidity and mortality in trauma patients. Chemoprophylaxis with low-molecular-weight heparin at a standardized dose is recommended. Conventional chemoprophylaxis may be inadequate. We hypothesized that a weight-adjusted enoxaparin prophylaxis regimen would reduce the frequency of venous thromboembolism in hospitalized trauma patients and at 90-day follow-up. METHODS This prospective, randomized pilot study enrolled adult patients admitted to a level 1 trauma center between July 2013 and January 2015. Subjects were randomized to receive either standard (30 mg subcutaneously every 12 hours) or weight-based (0.5mg/kg subcutaneously every 12 hours) enoxaparin. Surveillance duplex ultrasound for lower extremity deep vein thrombosis was performed on hospital days 1, 3, and 7, and weekly thereafter. The primary outcome was deep vein thrombosis during hospitalization. Secondary outcomes included venous thromboembolism at 90 days and significant bleeding events. RESULTS Two hundred thirty-four (124 standard, 110 weight-based) subjects were enrolled. There was no difference between standard and weight-based regarding age, body mass index, percentage female gender, injury severity score, or percentage that had surgery. There was a trend toward less in-hospital deep vein thrombosis in weight-based (12 [9.7%] standard vs 4 [3.6%] weight-based, P = .075). At 90 days, there was no difference in venous thromboembolism (12 [9.7%] standard vs 6 [5.5%] weight-based, P =.34). There was 1 bleeding event, which occurred in a standard subject. CONCLUSION Weight-based enoxaparin dosing for venous thromboembolism chemoprophylaxis in trauma patients may provide better protection against venous thromboembolism than standard. A definitive study is necessary to determine whether weight-based dosing is superior to standard.
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Affiliation(s)
- Annika Bickford Kay
- Division of Trauma Services and Surgical Critical Care, Intermountain Medical Center, Murray, UT
| | - Sarah Majercik
- Division of Trauma Services and Surgical Critical Care, Intermountain Medical Center, Murray, UT.
| | - Jeffrey Sorensen
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT
| | - Scott C Woller
- Department of Internal Medicine, Intermountain Medical Center, Murray, UT; Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Scott M Stevens
- Department of Internal Medicine, Intermountain Medical Center, Murray, UT; Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Thomas W White
- Division of Trauma Services and Surgical Critical Care, Intermountain Medical Center, Murray, UT
| | - David S Morris
- Division of Trauma Services and Surgical Critical Care, Intermountain Medical Center, Murray, UT
| | - Margaret Baldwin
- Division of Trauma Services and Surgical Critical Care, Intermountain Medical Center, Murray, UT
| | - Joseph R Bledsoe
- Department of Emergency Medicine, Intermountain Medical Center, Murray, UT
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Woller SC, Stevens SM, Adams DM, Evans RS, Lloyd JF, Snow GL, Bledsoe JR, Gay DZ, Patten RM, Aston VT, Elliott CG. Assessment of the safety and efficiency of using an age-adjusted D-dimer threshold to exclude suspected pulmonary embolism. Chest 2015; 146:1444-1451. [PMID: 24831769 DOI: 10.1378/chest.13-2386] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND D-dimer levels increase with age, and research has suggested that using an age-adjusted D-dimer threshold may improve diagnostic efficiency without compromising safety. The objective of this study was to assess the safety of using an age-adjusted D-dimer threshold in the workup of patients with suspected pulmonary embolism (PE). METHODS We report the outcomes of 923 patients aged > 50 years presenting to our ED with suspected PE, a calculated Revised Geneva Score (RGS), and a D-dimer test. All patients underwent CT pulmonary angiography (CTPA). We compared the false-negative rate for PE of a conventional D-dimer threshold with an age-adjusted D-dimer threshold and report the proportion of patients for whom an age-adjusted D-dimer threshold would obviate the need for CTPA. RESULTS Among 104 patients with a negative conventional D-dimer test result and an RGS ≤ 10, no PE was observed within 90 days (false-negative rate, 0%; 95% CI, 0%-2.8%). Among 273 patients with a negative age-adjusted D-dimer result and an RGS ≤ 10, four PEs were observed within 90 days (false-negative rate, 1.5%; 95% CI, 0.4%-3.7%). We observed an 18.3% (95% CI, 15.9%-21.0%) absolute reduction in the proportion of patients aged > 50 years who would merit CTPA by using an age-adjusted D-dimer threshold compared with a conventional D-dimer threshold. CONCLUSIONS Use of an age-adjusted D-dimer threshold reduces imaging among patients aged > 50 years with an RGS ≤ 10. Although the adoption of an age-adjusted D-dimer threshold is probably safe, the CIs surrounding the additional 1.5% of PEs missed necessitate prospective study before this practice can be adopted into routine clinical care.
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Affiliation(s)
- Scott C Woller
- Department of Medicine, Intermountain Medical Center, Murray, UT; Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT.
| | - Scott M Stevens
- Department of Medicine, Intermountain Medical Center, Murray, UT; Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Daniel M Adams
- Tufts Medical Center Department of Radiology, Boston, MA
| | - R Scott Evans
- Department of Medical Informatics, LDS Hospital, Salt Lake City, UT
| | - James F Lloyd
- Department of Medical Informatics, LDS Hospital, Salt Lake City, UT
| | - Gregory L Snow
- Department of Medical Statistics, LDS Hospital, Salt Lake City, UT
| | - Joseph R Bledsoe
- Department of Emergency Medicine, Intermountain Medical Center, Murray, UT
| | - David Z Gay
- Department of Ophthalmology, Georgia Regents University, Augusta, GA
| | | | - Valerie T Aston
- Department of Medicine, Intermountain Medical Center, Murray, UT; Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT
| | - C Gregory Elliott
- Department of Medicine, Intermountain Medical Center, Murray, UT; Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT
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Adams DM, Stevens SM, Woller SC, Evans RS, Lloyd JF, Snow GL, Allen TL, Bledsoe JR, Brown LM, Blagev DP, Lovelace TD, Shill TL, Conner KE, Aston VT, Elliott CG. Adherence to PIOPED II investigators' recommendations for computed tomography pulmonary angiography. Am J Med 2013. [PMID: 23177546 DOI: 10.1016/j.amjmed.2012.05.028] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Computed tomography (CT) pulmonary angiography use has increased dramatically, raising concerns for patient safety. Adherence to recommendations and guidelines may protect patients. We measured adherence to the recommendations of Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED II) investigators for evaluation of suspected pulmonary embolism and the rate of potential false-positive pulmonary embolism diagnoses when recommendations of PIOPED II investigators were not followed. METHODS We used a structured record review to identify 3500 consecutive CT pulmonary angiograms performed to investigate suspected pulmonary embolism in 2 urban emergency departments, calculating the revised Geneva score (RGS) to classify patients as "pulmonary embolism unlikely" (RGS≤10) or "pulmonary embolism likely" (RGS>10). CT pulmonary angiograms were concordant with PIOPED II investigator recommendations if pulmonary embolism was likely or pulmonary embolism was unlikely and a highly sensitive D-dimer test result was positive. We independently reviewed 482 CT pulmonary angiograms to measure the rate of potential false-positive pulmonary embolism diagnoses. RESULTS A total of 1592 of 3500 CT pulmonary angiograms (45.5%) followed the recommendations of PIOPED II investigators. The remaining 1908 CT pulmonary angiograms were performed on patients with an RGS≤10 without a D-dimer test (n=1588) or after a negative D-dimer test result (n=320). The overall rate of pulmonary embolism was 9.7%. Potential false-positive diagnoses of pulmonary embolism occurred in 2 of 3 patients with an RGS≤10 and a negative D-dimer test result. CONCLUSIONS Nonadherence to recommendations for CT pulmonary angiography is common and exposes patients to increased risks, including potential false-positive diagnoses of pulmonary embolism.
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Affiliation(s)
- Daniel M Adams
- Department of Medicine, Intermountain Medical Center, Murray, Utah 84107, USA
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Silverton NA, Youngquist ST, Mallin MP, Bledsoe JR, Barton ED, Schroeder ED, Bledsoe AD, Axelrod DA. GlideScope versus flexible fiber optic for awake upright laryngoscopy. Ann Emerg Med 2011; 59:159-64. [PMID: 21831478 DOI: 10.1016/j.annemergmed.2011.07.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2011] [Revised: 06/24/2011] [Accepted: 07/08/2011] [Indexed: 10/17/2022]
Abstract
STUDY OBJECTIVES We compare laryngoscopic quality and time to highest-grade view between a face-to-face approach with the GlideScope and traditional flexible fiber-optic laryngoscopy in awake, upright volunteers. METHODS This was a prospective, randomized, crossover study in which we performed awake laryngoscopy under local anesthesia on 23 healthy volunteers, using both a GlideScope video laryngoscopy face-to-face technique with the blade held upside down and flexible fiber-optic laryngoscopy. Operator reports of Cormack-Lehane laryngoscopic views and video-reviewed time to highest-grade view, as well as number of attempts, were recorded. RESULTS Ten women and 13 men participated. A grade II or better view was obtained with GlideScope video laryngoscopy in 22 of 23 (95.6%) participants and in 23 of 23 (100%) participants with flexible fiber-optic laryngoscopy (relative risk GlideScope video laryngoscopy versus flexible fiber-optic laryngoscopy 0.96; 95% confidence interval 0.88 to 1.04). Median time to highest-grade view for GlideScope video laryngoscopy was 16 seconds (interquartile range 9 to 34) versus 51 seconds (interquartile range 35 to 96) for flexible fiber-optic laryngoscopy. A distribution of interindividual differences demonstrated that GlideScope video laryngoscopy was, on average, 39 seconds faster than flexible fiber-optic laryngoscopy (95% confidence interval 0.2 to 76.9 seconds). CONCLUSION GlideScope video laryngoscopy can be used to obtain a Cormack-Lehane grade II or better view in the majority of awake, healthy volunteers when an upright face-to-face approach is used and was slightly faster than traditional flexible fiber-optic laryngoscopy. However, flexible fiber-optic laryngoscopy may be more reliable at obtaining high-grade views of the larynx. Awake, face-to-face GlideScope use may offer an alternative approach to the difficulty airway, particularly among providers uncomfortable with flexible fiber-optic laryngoscopy.
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Affiliation(s)
- Natalie A Silverton
- Division of Emergency Medicine, University of Utah, Salt Lake City, UT, USA.
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Abstract
BACKGROUND At this 35 000 visits/year emergency department (ED) at a level one trauma centre, a trauma protocol was implemented for the ED observation unit. Data on all trauma observation unit admissions were then collected to evaluate for safety, efficiency and admission rates. METHODS A retrospective chart review was performed of all trauma patients in the observation unit during a 14-month period. Exclusion criteria for observation unit admission included: abnormal vital signs, positive focussed abdominal sonography for trauma examination, abnormal ECG, abnormal chest radiograph, abnormal head computed tomography, Glasgow coma score less than 14, or multisystem trauma. RESULTS 364 trauma patients were admitted to the observation unit. 84.6% were trauma II activations and 3.8% were trauma I activations. There were no deaths, intubations, loss of vital signs or other adverse events. The average length of stay was 12 h 46 minutes and 11.5% of patients were admitted to an inpatient unit. At 30-day follow-up, there were no significant missed injuries. CONCLUSION The observation unit is a safe alternative to inpatient admission for the evaluation of the minimally injured trauma activation patient.
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Affiliation(s)
- T E Madsen
- University of Utah, 30 N 1900 E 1C26, Salt Lake City, UT 84132, USA.
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Abstract
The subjects, 60 undergraduate students, were administered the Test of Nonverbal Intelligence (TONI) individually. The Shipley Institute of Living Scale was administered in small groups. A Pearson correlation of .56 was obtained for TONI Quotients, Forms A and B. TONI Quotients, Forms A and B, correlated with Shipley estimated WAIS--R IQ .50 and .46, respectively, and correlated to .71 and .64, with Shipley Total T scores, .52 and .44, respectively (corrected to .71 and .61), with Shipley Abstraction T scores, .51 and .42, respectively (corrected, .63 and .52), and with Shipley Vocabulary T scores .26 and .32, respectively (corrected to .63 and .52). TONI scores seem more closely related to Shipley Total and Abstraction scores than to Shipley Vocabulary.
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Affiliation(s)
- J D Martin
- Austin Peay State University, Clarksville, TN 37044
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