Background Black patients hospitalized for heart failure have better reported short-term survival than white patients for unknown reasons. We sought to determine if initial severity of illness differed between black and white emergency department (ED) patients hospitalized for heart failure.Methods We analyzed 1,408 black and 7,260 white randomly selected patients in one state hospitalized from an ED during 2003 and 2004 and with a discharge diagnosis of heart failure. We used three validated clinical prediction rules to estimate severity of illness on admission.Results Black patients were younger than white patients (65.8 +/- 14.8 vs 77.4 +/- 11.5 years, P <.01) and were assigned to lower risk classes by all 3 prediction rules more frequently than white patients (P <.01). The odds ratio (95% Cl) for classification of black versus white patients into the lowest risk class within the three rules ranged from I. 16 (1.00-1.33) to 4.30 (3.75-4.94). After adjusting for hospital clustering, the odds ratio (95% Cl) for black versus white patient hospital death and complications was 0.75 (0.60-0.95) and, for 30-day death, was 0.34 (0.27-0.48).Conclusions Black ED patients hospitalized with heart failure are younger, less severely ill on admission and less likely to experience short-term fatal and nonfatal outcomes than white patients. Our findings suggest a varying opportunity between black and white patients when considering alternative initial treatment strategies and sites of care. (Am Heart J 2009; 157:306-11.)

We read with interest the study assessing 4 clinical risk prediction tools, including 2 from ADHERE, on predicting short-term mortality and hospital-based complications in patients hospitalized with heart failure.1Auble T.E. Hsieh M. McCausland J.B. et al.Comparison of four clinical prediction rules for estimating risk in heart failure.Ann Emerg Med. 2007; 50: 127-135Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar The ability to identify discharge-eligible emergency department (ED) patients with heart failure at low risk of complications would represent a valuable tool for emergency physicians. While it is very interesting and clinically relevant that these models predicted gradients of risk for 30-day mortality and inhospital complications, it is critical to note these four models were developed to stratify patients hospitalized with heart failure at different risks for short-term mortality and to identify patients in whom more intensive monitoring and inhospital therapy are warranted.2Fonarow G.C. Adams Jr, K.F. Abraham W.T. et al.Risk stratification for in-hospital mortality in acutely decompensated HF Classification and regression tree analysis.JAMA. 2005; 293: 572-580Crossref PubMed Scopus (1336) Google Scholar, 3Lee D.S. Austin P.C. Rouleau J.L. et al.Predicting mortality among patients hospitalized for HF: derivation and validation of a clinical model.JAMA. 2003; 290: 2581-2587Crossref PubMed Scopus (1131) Google Scholar They were not intended to identify heart failure patients for direct discharge from the ED. When evaluating a decision tool, it is essential to note the derivation population. The 4 models in this paper were developed in patients hospitalized with heart failure as the primary clinical diagnosis and did not include acute coronary syndromes complicated by heart failure.2Fonarow G.C. Adams Jr, K.F. Abraham W.T. et al.Risk stratification for in-hospital mortality in acutely decompensated HF Classification and regression tree analysis.JAMA. 2005; 293: 572-580Crossref PubMed Scopus (1336) Google Scholar, 3Lee D.S. Austin P.C. Rouleau J.L. et al.Predicting mortality among patients hospitalized for HF: derivation and validation of a clinical model.JAMA. 2003; 290: 2581-2587Crossref PubMed Scopus (1131) Google Scholar Risk predictors and outcomes in acute coronary syndromes are remarkably different than heart failure and require unique risk stratification considerations not relevant to heart failure (eg, prior aspirin use). In the present study, using administrative data and ICD-9 codes to identify patients, many clearly had an acute coronary syndrome; in fact, 17% had an EKG diagnostic for acute myocardial infarction. This does not reflect the usual heart failure population. Furthermore, outcomes for decision rule evaluation should be relevant to the population being considered. In this study by Auble et al, inhospital events defined as heart failure “complications” included coronary artery bypass grafting, percutaneous coronary intervention, and thrombolytic therapy. While reperfusion and revascularization are appropriate acute coronary syndrome endpoints, they should not be considered heart failure-related. As this study compares clinical decision rules to outcomes that they were not created for, and in a mixed population that includes a substantial proportion of patients for whom they were not intended to assess, no clinical utility would be expected. It is thus all the more remarkable that the various rules could stratify patients into risk groups and illustrates how well these models perform in a variety of clinical settings. Additional investigations on the performance of heart failure prediction rules to provide useful stratification for short-term fatal and nonfatal outcomes are warranted, as well as attempts to develop and validate new tools for patients hospitalized with acute coronary syndrome accompanied by heart failure. It may also be possible to develop a clinical tool that reliably identifies patients presenting to the ED with heart failure who are at sufficiently low risk that they can be managed on an outpatient basis. The latter will require prospective study of appropriate patients and necessitate effective collaboration of investigators from both emergency medicine and cardiology. In replyAnnals of Emergency MedicineVol. 50Issue 6PreviewWe appreciate the comments of Fonarow et al, who have 3 concerns. First, in contrast to their assertion, we did not recommend using the rules studied in any particular fashion or to “direct(ly) discharge from the emergency department [ED].” We simply noted risk assessment tools can guide disposition choices, since gauging the likelihood of a poor outcome is one key to making such choices. Full-Text PDF

Marrie and Huang1Marrie T.J. Huang J.Q. Low-risk patients admitted with community-acquired pneumonia.Am J Med. 2005; 118: 1357-1363Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar found that 19% of low-risk patients with community-acquired pneumonia were admitted despite pneumonia severity index (PSI)-based recommendations for outpatient treatment and that 19% of these hospitalized low-risk patients had one or more medical complications. The authors and the accompanying editorial concluded that physician judgment is important in the initial site of treatment decision and that rules better than the PSI are needed to guide this decision.1Marrie T.J. Huang J.Q. Low-risk patients admitted with community-acquired pneumonia.Am J Med. 2005; 118: 1357-1363Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar, 2Siegel R.E. Clinical opinion prevails over the pneumonia severity index.Am J Med. 2005; 118: 1312-1313Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar We believe the study findings and conclusions deserve comment. First, the PSI was explicitly recommended to aid, not replace, provider judgment in the site of treatment decision, because no singular decision aid could possibly account for all prognostic factors or predict all possible patient complications.3Fine M.J. Auble T.E. Yealy D.M. et al.A prediction rule to identify low-risk patients with community-acquired pneumonia.New Engl J Med. 1997; 336: 243-250Crossref PubMed Scopus (3821) Google Scholar, 4Yealy D.M. Auble T.E. Stone R.A. et al.The emergency department community-acquired pneumonia trial: methodology of a quality improvement intervention.Ann Emerg Med. 2004; 43: 770-782Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar Second, the complication rates found by Marrie et al1Marrie T.J. Huang J.Q. Low-risk patients admitted with community-acquired pneumonia.Am J Med. 2005; 118: 1357-1363Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar might have been inflated by inclusion of low-risk patients with arterial oxygen desaturation. An alternative strategy we recommended and used in our PSI-based guideline implementation trial is that this criterion warrants hospitalization regardless of PSI risk class because of its prognostic implications.3Fine M.J. Auble T.E. Yealy D.M. et al.A prediction rule to identify low-risk patients with community-acquired pneumonia.New Engl J Med. 1997; 336: 243-250Crossref PubMed Scopus (3821) Google Scholar, 4Yealy D.M. Auble T.E. Stone R.A. et al.The emergency department community-acquired pneumonia trial: methodology of a quality improvement intervention.Ann Emerg Med. 2004; 43: 770-782Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar, 5Yealy D.M. Auble T.E. Stone R.A. et al.Effectiveness of guideline implementation to improve the quality of care for pneumonia: results of the Emergency Department Community Acquired Pneumonia (EDCAP) trial.Ann Intern Med. 2005; 143: 881-894Crossref PubMed Scopus (170) Google Scholar Third, the PSI is not intended for use in certain groups of patients who are virtually always candidates for inpatient care (eg, prisoners and homeless persons), and hospitalization is not recommended for low-risk patients with explicit medical and psychosocial reasons that should override outpatient treatment5Yealy D.M. Auble T.E. Stone R.A. et al.Effectiveness of guideline implementation to improve the quality of care for pneumonia: results of the Emergency Department Community Acquired Pneumonia (EDCAP) trial.Ann Intern Med. 2005; 143: 881-894Crossref PubMed Scopus (170) Google Scholar, 6Mandell L.A. Marrie T.J. Grossman R.F. Chow A.W. Hyland R.H. The Canadian Community-Acquired Pneumonia Working GroupCanadian guidelines for the initial management of community-acquired pneumonia: an evidence-based update by the Canadian Infectious Diseases Society and the Canadian Thoracic Society.Clin Infect Dis. 2000; 31: 383-421Crossref PubMed Scopus (630) Google Scholar, 7Mandell L.A. Bartlett J.G. Dowell S.F. File Jr, T.M. Musher D.M. Whitney C. Update of practice guidelines for the management of community-acquired pneumonia in immunocompetent adults.Clin Infect Dis. 2003; 37: 1405-1433Crossref PubMed Scopus (924) Google Scholar, 8Bartlett J.G. Dowell S.F. Mandell L.A. File Jr, T.M. Musher D.M. Fine M.J. Practice guidelines for the management of community-acquired pneumonia in adults Infectious Diseases Society of America.Clin Infect Dis. 2000; 31: 347-382Crossref PubMed Scopus (1459) Google Scholar; these caveats were not followed by Marrie et al.1Marrie T.J. Huang J.Q. Low-risk patients admitted with community-acquired pneumonia.Am J Med. 2005; 118: 1357-1363Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar Marrie and Huang1Marrie T.J. Huang J.Q. Low-risk patients admitted with community-acquired pneumonia.Am J Med. 2005; 118: 1357-1363Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar and Siegel2Siegel R.E. Clinical opinion prevails over the pneumonia severity index.Am J Med. 2005; 118: 1312-1313Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar assert that hospitalization should be based on a broader set of medical outcomes than mortality alone. Unfortunately, consensus surrounding serious complications that warrant hospitalization for patients with pneumonia do not exist. Furthermore, Marrie and Huang fail to distinguish complications that warrant hospitalization (eg, mechanical ventilation) from an iatrogenic complication or less serious complications (eg, medical errors, rash, or insertion of a urinary catheter). Finally, 3 randomized trials have demonstrated the safety and effectiveness of the PSI for guiding hospital admission decisions.5Yealy D.M. Auble T.E. Stone R.A. et al.Effectiveness of guideline implementation to improve the quality of care for pneumonia: results of the Emergency Department Community Acquired Pneumonia (EDCAP) trial.Ann Intern Med. 2005; 143: 881-894Crossref PubMed Scopus (170) Google Scholar, 9Marrie T.J. Lau C.Y. Wheeler S.L. Wong C.J. Vandervoort M.K. Feagan B.G. CAPITAL Study InvestigatorsA controlled trial of a critical pathway for treatment of community-acquired pneumonia Community-Acquired Pneumonia Intervention Trial Assessing Levofloxacin.JAMA. 2000; 283: 749-755Crossref PubMed Scopus (653) Google Scholar, 10Carratala J. Fernandez-Sabe N. Ortega L. et al.Outpatient care compared with hospitalization for community-acquired pneumonia: a randomized trial in low-risk patients.Ann Intern Med. 2005; 142: 165-172Crossref PubMed Scopus (205) Google Scholar Thus, the PSI, when implemented as recommended, is a safe and effective tool to aid decisions on the initial site of treatment for patients with community-acquired pneumonia.

Study objective: We examine the performance of 4 clinical prediction rules prognostic of short-term fatal and hospital-based nonfatal outcomes in heart failure patients.Methods: We used a retrospective cohort of 33,533 adult patients admitted to Pennsylvania hospitals in 1999 with a diagnosis of heart failure. We stratified patients into risk categories defined by each clinical prediction rule. We assessed prognostic accuracy according to sensitivity and specificity and compared discriminatory power according to area under the receiver operating characteristic (ROC) curves. The outcomes were inpatient death, 30-day mortality, and death or serious medical complications before hospital discharge.Results: The 4 rules each created risk groups of various proportions and frequencies of outcomes. The proportion of patients assigned to the lowest risk group ranged from 13.3% to 73.0%. The rates of inpatient death or complications in the lowest risk group ranged from 6.7% to 9.2%, and 30-day death rates varied from 1.7% to 6.0%. Patients categorized at the highest risk of death or complication demonstrated similar variability. The area under the ROC curve for inpatient death and complications differed only slightly among rules (0.58 to 0.62). The area under the ROC curve for fatal outcomes tended to be higher and differed among rules (0.59 to 0.74).Conclusion: Current acute heart failure prediction rules offer varying ability to predict short-term death or serious outcomes. Although each creates a risk gradient, differences in risk-group proportions and outcome frequencies should drive rule selection or use in clinical practice.

STUDY OBJECTIVE:Validate a clinical prediction rule prognostic of short-term fatal and inpatient nonfatal outcomes for heart failure patients admitted through the emergency department.METHODS:We retrospectively studied a random cohort of 8,384 adult patients admitted to Pennsylvania hospitals in 2003 and 2004 with a diagnosis of heart failure as defined by primary discharge diagnosis codes. We reported the proportions of inpatient death, serious medical complications before discharge, and 30-day death in the patients identified as low risk by the prediction rule.RESULTS:The prediction rule classified 1,609 (19.2%) of the patients as low risk. Within this subgroup, there were 12 (0.7%; 95% confidence interval [CI] 0.3% to 1.2%) inpatient deaths, 28 (1.7%; 95% CI 1.1% to 2.4%) patients survived to hospital discharge after a serious complication, and 47 (2.9%; 95% CI 2.1% to 3.7%) patients died within 30 days of the index hospitalization.CONCLUSION:This prediction rule identifies a group of admitted heart failure patients at low risk of inpatient mortal and nonmortal complications. Our validation findings suggest the rule could assist physicians in making site-of-care decisions for this patient population and aid in analyzing presenting illness burden in study populations.

BACKGROUND:Many low-risk patients with pneumonia are hospitalized despite recommendations to treat such patients in the outpatient setting.OBJECTIVE:To identify the factors associated with the hospitalization of low-risk patients with pneumonia.METHODS:We analyzed data collected by retrospective chart review for 1,889 low-risk patients (Pneumonia Severity Index [PSI] risk classes I to III without evidence of arterial oxygen desaturation) enrolled in a cluster-randomized trial conducted in 32 emergency departments.RESULTS:Overall, 845 (44.7%) of all low-risk patients were treated as inpatients. Factors independently associated with an increased odds of hospitalization included PSI risk classes II and III, the presence of medical or psychosocial contraindications to outpatient treatment, comorbid conditions that were not contained in the PSI (cognitive impairment, history of coronary artery disease, diabetes mellitus, or pulmonary disease), multilobar radiographic infiltrates, and home therapy with oxygen, corticosteroids, or antibiotics before presentation. While 32.8% of low-risk inpatients had a contraindication to outpatient treatment and 47.1% had one or more preexisting treatments, comorbid conditions, or radiographic abnormalities not contained in the PSI, 20.1% had no identifiable risk factors for hospitalization other than PSI risk class II or III.CONCLUSIONS:Hospital admission appears justified for one-third of low-risk inpatients based upon the presence of one or more contraindications to outpatient treatment. At least one-fifth of low-risk inpatients did not have a contraindication to outpatient treatment or an identifiable risk factor for hospitalization, suggesting that treatment of a larger proportion of such low-risk patients in the outpatient setting could be achieved without adversely affecting patient outcomes.

The authors implemented a guideline for deciding whether to manage community-acquired pneumonia in the hospital or at home. Guideline implementation strategies were low, moderate, and high intensit...

Background: Despite the development of evidence-based pneumonia guidelines, limited data exist on the most effective means to implement guideline recommendations into clinical practice. Objective: To compare the effectiveness and safety of 3 guideline implementation strategies. Design: Cluster-randomized, controlled trial. Setting: 32 emergency departments in Pennsylvania and Connecticut. Patients: 3219 patients with a clinical and radiographic diagnosis of pneumonia. Interventions: The authors implemented a project-developed guideline for the initial site of treatment based on the Pneumonia Severity Index and performance of evidence-based processes of care at the emergency department level. Guideline implementation strategies were defined as low (n = 8), moderate (n = 12), and high intensity (n = 12). Measurements: Effectiveness outcomes were the rate at which low-risk patients were treated on an outpatient basis and the performance of recommended processes of care. Safety outcomes included death, subsequent hospitalization for outpatients, and medical complications for inpatients. Results: More low-risk patients (n = 1901) were treated as outpatients in the moderate-intensity and high-intensity groups in the low-intensity group (high-intensity group, 61.9%; moderate-intensity group, 61.0%; low-intensity group, 37.5%; P = 0.004). More outpatients (n = 1125) in the high-intensity group received all 4 recommended processes of care (high-intensity group, 60.9%; moderate-intensity group, 28.3%; low-intensity group, 25.3%; P < 0.001); more inpatients (n = 2076) in the high-intensity group received all 4 recommended processes of care (high-intensity group, 44.3%; moderate-intensity group, 30.1 %; low-intensity group, 23.0%; P < 0.001). No statistically significant differences in safety outcomes were observed across interventions. Limitations: Twenty percent of eligible patients were not enrolled, and data on effectiveness outcomes were not collected before the trial. Conclusions: Both moderate-intensity and high-intensity guideline implementation strategies safely increased the proportion of low-risk patients with pneumonia who were treated as outpatients. The high-intensity strategy was most effective for increasing the performance of the recommended processes of care for outpatients and inpatients.

Community-acquired pneumonia causes more than 4 million episodes of illness each year and has high morbidity, mortality, and total cost of care. Nationwide, nearly 75% of community-acquired pneumonia patients are initially evaluated and treated in hospital-based emergency departments (EDs). Substantial variation exists in illness severity assessment, hospital admission decisions, and performance of recommended processes of care. We designed an ED-based quality improvement trial focused on the initial care of patients with community-acquired pneumonia. We used the Pneumonia Severity Index and level of arterial oxygenation to identify patients at low risk for 30-day mortality and to guide admission decisionmaking. We assessed the performance of recommended "best practices," consisting of assessment of arterial oxygenation, the collection of blood cultures for inpatients, and the timely initiation of appropriate empiric antibiotic therapy for inpatients and outpatients. We conducted a 32-site, cluster-randomized trial in Pennsylvania and Connecticut, comparing the effectiveness and safety of 3 guideline implementation strategies of increasing intensity. The multifaceted implementation plans were carried out in conjunction with each state's quality improvement organization. This article describes the background, objectives, and methodology of this trial to translate evidence-based knowledge on the quality and efficiency of care for community-acquired pneumonia into clinical practice.

BACKGROUND: Patients at risk for stroke often receive warfarin therapy to reduce that risk, but little is known about patient understanding of either stroke or warfarin therapy itself, especially among ethnically diverse patients.METHODS: Bilingual research assistants interviewed English-.Spanish-and Cantonesespeaking patients with atrial fibrillation or valvular heart disease in a public hospital anticoagulation clinic.To determine patient knowledge of warfarin therapy and stroke and to examine patient characteristics associated with poor knowledge, we asked patients two openended questions: ``In your own words, why are you taking warfarin?''and ``Can you describe what is a stroke?''We developed a coding scheme to categorize knowledge of warfarin therapy based on indication for warfarin therapy (e.g.heart problem), mechanism of action (i.e.blood thinning), or stroke prevention; and a scheme for knowledge of stroke based on location of injury (i.e.brain), mechanism of injury (i.e.disruption of blood flow), and sequelae (e.g.paralysis).We considered patients to have poor knowledge of warfarin therapy and stroke if they did not provide correct information for any of the categories described above.We then used logistic regression to determine the extent to which communication barriers, such as non-English language and inadequate functional health literacy (FHL), were associated with patient knowledge about warfarin therapy and stroke, respectively, adjusting for age, gender, ethnicity, duration of therapy, and history of stroke.We measured FHL via the short-form Test of Functional Health Literacy in Adults.RESULTS: We enrolled 141 patients; 54% were English speakers, 28% Spanish speakers, and 17% Cantonese speakers.Of English and Spanish speakers, 54% had inadequate functional health literacy (FHL).Regarding warfarin therapy, 22% did not know why they were taking warfarin or stated health beliefs outside the coding scheme, 55% named one category within the coding scheme, 20% named two, and 3% named all three categories.Only 9% stated that they take warfarin in order to prevent stroke.Regarding stroke, 41% did not know what a stroke was or stated health beliefs outside the coding scheme, 31% named one category within the coding scheme, 24% named two, and 4% of patients named all three categories.In bivariate analyses, when compared to patients with adequate FHL, patients with inadequate FHL were more likely to have poor knowledge of warfarin therapy (OR 3.41, p = .02)and stroke (OR 10.8, p < .01);compared to English speakers, Spanish speakers were more likely to have poor knowledge of stroke (OR 2.65, p = .01).In multivariate analysis, the relationship between inadequate FHL and poor knowledge of stroke persisted (adjusted OR 9.25, p < .01).CONCLUSION: Despite being at risk for stroke and receiving warfarin therapy to reduce that risk, patients cared for in a public hospital anticoagulation clinic have poor knowledge of the purpose of warfarin therapy and the meaning of stroke.Given that the aim of warfarin therapy is stroke prevention, efforts are needed to better inform anticoagulant patients about the nature of stroke and the related goal of warfarin therapy.This may be particularly important for patients with communication barriers.

Clinicians currently order imaging studies for most patients with blunt head or neck trauma if there is even a remote possibility of cervical-spine injury, in order to avoid missing a potentially disabling fracture, dislocation, or ligamentous injury. The result of this practice is that 96 percent or more of cervical-spine radiographs reveal no clinically important injuries.1,2 A decision rule, or clinical prediction rule, that could reliably identify patients with trauma who are at very low risk for cervical anatomical disruption could help reduce unnecessary radiographic testing, improve efficiency, and decrease health care expenditures that accompany testing.In this issue . . .

OBJECTIVE:Emergency medical services (EMS) agencies may be an underutilized resource for provision of preventive health services. This study sought to demonstrate the feasibility for EMS agencies to provide influenza immunizations.METHODS:This prospective, observational cohort study was conducted with urban, suburban, and rural EMS agencies that volunteered to participate. EMS managers and paramedics attended an orientation program, and then developed and implemented recruitment strategies. Adult volunteer subjects who met Centers for Disease Control and Prevention criteria for influenza vaccination were enrolled. Paramedics obtained informed consent, determined subject eligibility, administered the vaccine, and observed each subject for 10 minutes. Paramedics, EMS managers, and subjects completed surveys; EMS managers reported costs and resource utilization. Data were analyzed descriptively.RESULTS:Ninety paramedics from 15 EMS agencies in three counties participated. Subjects were recruited by print and broadcast media and enrolled at 73 events held at retail establishments, community events, EMS stations, churches, senior citizen complexes, and private residences. Of the 2,075 adults immunized, 1,014 (49%) did not receive influenza vaccination in the previous year. Seven hundred five (34%) reported that they probably would not have been vaccinated elsewhere. Fixed cost for each immunization was $3.42. The EMS managers estimated their variable costs to range from zero dollars (volunteer agencies with all donated expenses) to $15.31 per immunization. No adverse events were reported. Subjects, paramedics, and EMS managers indicated a high level of satisfaction with the project.CONCLUSION:The MEDICVAX Project demonstrated the feasibility of EMS agencies to safely provide influenza immunizations. The project reached some adults who likely would not have been immunized.

OBJECTIVES:Existing clinical practice guidelines for ordering prothrombin time (PT) and partial thromboplastin time (PTT) tests in the emergency department (ED) include physician expectation of an invasive procedure as a criterion. This study sought to determine whether this criterion accurately identifies patients who undergo an invasive procedure and whether an amalgam of these guidelines identifies patients at low risk of an adverse medical outcome.METHODS:A prospective observational cohort study of adults treated in a university medical center ED between July 1997 and March 1998. Physicians were surveyed at order placement to determine the presence of guideline criteria. Adverse clinical outcomes defined as an International Normalized Ratio [INR] > 1.3 or PTT > 39.9 seconds combined with consequent directed medical therapy were abstracted from ED and the first 24 hours of inpatient medical records.RESULTS:The sensitivity of ED physician expectation of an invasive procedure was 60.0%; therefore, it was excluded from both the PT and PTT guidelines. There were 553 patients with a PT test order; test order indications were absent in 190 (34.4%), of which one (0.5%, 95% CI = 0.1% to 2.9%) had adverse outcomes. There were 547 patients with a PTT test; test order indications were absent in 226 (41.3%), of which three (1.3%, 95% CI = 0.4 to 3.8%) had adverse outcomes. All three were taking warfarin when they presented to the ED.CONCLUSIONS:Emergency department physician expectation of an invasive procedure for patients with PT or PTT test orders is an insensitive predictor of patients who undergo such procedures. Clinical practice guidelines that exclude this criterion identify ED patients at the time of ED presentation at low risk for adverse medical outcomes in the ED or shortly after admission.

STUDY OBJECTIVES Pseudoephedrine (Sudafed® ) and dimenhydrinate (Dramamine® ) are often used by recreational scuba divers to avoid ear barotrauma and to control seasickness, respectively. However, these drugs have been little studied in the hyperbaric environment. This study examines the psychometric and cardiac effects of pseudoephedrine and dimenhydrinate at one (100 kPa, sea level) and three (300 kPa, 20 m) atmospheres absolute (bar). METHODS

Academic Emergency MedicineVolume 8, Issue 7 p. 754-755 Free Access How “Low” Can We Go: Assessing Risk in Chest Pain Patients Margaret Hsieh MD, Corresponding Author Margaret Hsieh MD Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA*,*,*[email protected]Search for more papers by this authorThomas E. Auble PhD, Thomas E. Auble PhD Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PASearch for more papers by this authorDonald M. Yealy MD, Donald M. Yealy MD Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PASearch for more papers by this author Margaret Hsieh MD, Corresponding Author Margaret Hsieh MD Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA*,*,*[email protected]Search for more papers by this authorThomas E. Auble PhD, Thomas E. Auble PhD Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PASearch for more papers by this authorDonald M. Yealy MD, Donald M. Yealy MD Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PASearch for more papers by this author First published: 28 June 2008 https://doi.org/10.1111/j.1553-2712.2001.tb00199.xAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat No abstract is available for this article. References 1 Goldman L., Weinberg M., Weisberg M. A computer-derived protocol to aid in the diagnosis of emergency room patients with acute chest pain. N Engl J Med 1982; 307: 588–96. 2 Lee TH, Cook EF, Weisberg M. Acute chest pain in the emergency room. Identification and examination of low-risk patients. Arch Intern Med 1985; 145: 65–9. 3 Hutter AM, Amsterdam EA, Jaffe AS. Task force 2: acute coronary syndrome: section 2B—chest discomfort evaluation in the hospital. J Am Coll Cardiol 2000; 35: 825–80. 4 Walker NJ, Sites FD, Shofer FS, Hollander JE. Characteristics and outcomes of young adults who present to the emergency department with chest pain. Acad Emerg Med 2001; 8: 703–8. 5 Limkakeng A. Jr, Gibler WB, Pollack C. Combination of Goldman risk and initial cardiac troponin I for emergency department chest pain patient risk stratification. Acad Emerg Med 2001; 8: 696–702. 6 Goldman L., Cook EF, Brand DA. A computer protocol to predict myocardial infarction in emergency department patients with chest pain. N Engl J Med 1988; 318: 797–803. 7 Antman EM, Tanasijevic MJ, Thompson B. Cardiac-specific troponin I levels to predict the risk of mortality in patients with acute coronary syndrome. N Engl J Med 1996; 335: 1342–9. 8 Hamm CW, Goldmann BU, Heeschen C., Kreymann G., Berger J., Meinertz T. Emergency room triage of patients with acute chest pain by means of rapid testing for cardiac troponin T or troponin I. N Engl J Med 1997; 337: 1648–53. 9 Tucker JF, Collins RA, Anderson AJ, Hauser J., Kalas J., Apple FS. Early diagnostic efficiency of cardiac troponin I and troponin T for acute myocardial infarction. Acad Emerg Med 1997; 4: 13–21. 10 Green GB, Li DJ, Bessman ES, Cox JL, Kelen GD, Chan DW. The prognostic significance of troponin I and troponin T. Acad Emerg Med 1998; 5: 758–67. 11 Morrow DA, Rifai N., Tanasijevic MJ, Wybenga DR, De Lemos JA, Antman EM. Clinical efficacy of three assays for cardiac troponin I for risk stratification in acute coronary syndromes: a Thrombolysis In Myocardial Infarction (TIMI) IIB substudy. Clin Chem 2000; 46: 453–60. 12 Kosnick JW, Zalenski RJ, Shamsa F. Resting sestamibi imaging for the prognosis of low-risk chest pain. Acad Emerg Med 1999; 6: 998–1004. Volume8, Issue7July 2001Pages 754-755 ReferencesRelatedInformation

OBJECTIVE:To determine whether there were differences in tidal volume (Vt), minute volume (MV), average mask leak per breath (ML), gastric insufflation (GI), and peak airway pressure (PAP) when ventilating a nonintubated mannikin with a bag-valve-mask (BV), manually triggered ventilator (MTV), and automated ventilator (AV). The authors' hypothesis was that there would be no differences among the devices for any of these variables.METHODS:This was a prospective in-vitro experimental model. A convenience sample of 19 emergency medical technicians (EMTs) ventilated a nonintubated mannikin-mechanical test lung model with the BV, MTV (flow rate 40 L/min; pressure relief 55 cm H2O), and AV (800 mL/breath; rate 12). Each subject, blinded to volume and pressure gauges, used each device for 2 minutes at both normal (0.1 cm H2O) and poor (0.04 cm H2O) compliances. Vt, MV, GI, and PAP were measured directly and ML was calculated. A survey was issued to the EMTs who participated in the study. Data were analyzed with repeated-measures ANOVA and the Bonferroni-Dunn multiple comparison test with alpha set at 0.05.RESULTS:At the normal compliance, PAP was higher for the BV than the MTV (p = 0.0001) and AV (p < 0.0001). MV was also greater with the BV than with the AV (p = 0.001). PAP was also higher at the poor compliance with the BV than with the MTV and AV (p = 0.008 and 0.013, respectively). The BV had a higher GI at this compliance (p < 0.0001) and a higher ML than the AV (p = 0.002).CONCLUSION:All three devices delivered similar volumes when used by EMTs, but the BV was associated with higher PAP, ML, and GI.

OBJECTIVE:Portable transport ventilators (TV) and demand valves (DV) may be effective and easy-to-use alternatives to bag-valve (BV) for prehospital ventilation of adults. The purpose of the study was to determine whether such devices maintain arterial blood gases and airway pressures similar to those for BV in a pediatric swine model.METHOD:This study was a prospective, randomized, crossover design using immature swine (9.6 +/- 0.9 kg) to model ventilation in small children. Anesthetized, intubated, paralyzed, and cannulated animals were ventilated initially on standard mechanical hospital ventilation (HV). They were then assigned in random order to 10-minute intervals of ventilation using BV, TV, low-frequency jet ventilation (JV), and DV. Data were analyzed using repeated-measures ANOVA and Tukey multiple comparisons (alpha = 0.05).RESULTS:The PaO2 exceeded 90 mm Hg for all animal/ventilation combinations. Blood PaCO2 was lower for BV and DV than it was for TV, JV, or HV. In contrast, blood pH was higher for BV and DV than it was for TV, JV, or HV. Peak airway pressure was higher for BV than it was for HV, TV, or JV; it was lower for JV than it was for HV, TV, or BV.CONCLUSION:This animal model suggests that automated TV and JV may provide more effective ventilation of children than do manual BV or DV devices. Although promising, these findings require application in children under prehospital emergent conditions.

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