Charles L. Reese

Survival and Neurologic Recovery in Patients With ST-Segment Elevation Myocardial Infarction Resuscitated From Cardiac Arrest

OBJECTIVES We examined outcomes of patients resuscitated from cardiac arrest owing to ST-segment elevation myocardial infarction (STEMI) and predictors of survival and neurologic recovery. BACKGROUND Immediately after resuscitation from cardiac arrest owing to STEMI, many patients show signs of neurologic impairment, and benefits of percutaneous coronary intervention and subsequent prognosis are not well defined. METHODS Between January 1, 2002, and December 31, 2006, we retrospectively identified consecutive patients resuscitated from cardiac arrest, regardless of time to return of spontaneous circulation (ROSC) and neurologic status, and reviewed the outcomes of those who had STEMI. Mortality and neurologic recovery at discharge and long-term mortality were assessed by individual chart review for those who underwent emergent angiography. RESULTS Our study population consisted of 98 patients; 64% survived to discharge, and 92% had a full neurologic recovery. Predictors of survival were shorter time to ROSC, younger age, neurologic status post-resuscitation (alert or minimally responsive), and male sex. Predictors of neurologic recovery included shorter time to ROSC, neurologic status post-resuscitation (alert or minimally responsive), and younger age. Ninety-six percent of patients who were alert post-resuscitation survived. Ninety-three percent of patients who were minimally responsive post-resuscitation survived. Fifty-nine patients were unresponsive post-resuscitation, with 44% survival, of whom 88% had full neurologic recovery. In the unresponsive group, unwitnessed arrest, prolonged ROSC, and older age were associated with increased risk of death, and older age and prolonged ROSC predicted poor neurologic recovery. CONCLUSIONS When resuscitated patients with STEMI are being evaluated in the emergency department, serious consideration should be given to emergent angiography and revascularization, regardless of neurologic status.

Efficiency and economic benefits of a payer-based electronic health record in an emergency department

OBJECTIVES The objective was to evaluate the use of a payer-based electronic health record (P-EHR), which is a clinical summary of a patients medical and pharmacy claims history, in an emergency department (ED) on length of stay (LOS) and plan payments. METHODS A large urban ED partnered with the dominant health plan in the region and implemented P-EHR technology in September 2005 for widespread use for health plan members presenting to the ED. A retrospective observational study design was used to evaluate this previously implemented P-EHR. Health plan and electronic hospital data were used to identify 2,288 ED encounters. Encounters with P-EHR use (n = 779) were identified between September 1, 2005, and February 17, 2006; encounters from the same health plan (n = 1,509) between November 1, 2004, and March 31, 2005, were compared. Outcomes were ED LOS and plan payment for the ED encounter. Analyses evaluated the effect of using the P-EHR in the ED setting on study outcomes using multivariate regressions and the nonparametric bootstrap. RESULTS After covariate adjustment, among visits resulting in discharge (ED-only), P-EHR visits were 19 minutes shorter (95% confidence interval [CI] = 5 to 33 minutes) than non-P-EHR visits. Among visits resulting in hospitalization, the P-EHR was associated with an average 77-minute shorter ED LOS (95% CI = 28 to 126 minutes), compared to non-P-EHR visits. The P-EHR was associated with an average of

Emergency medical services transport of patients with headache: Mode of arrival may indicate serious etiology

1,560 (95% CI =

Overall ED efficiency is associated with decreased time to percutaneous coronary intervention for ST-segment elevation myocardial infarction

43 to

QUALITY MEASURE PERFORMANCE VARIES AMONG HOSPITALS BY PROPORTION OF LOW-INCOME PATIENTS

2,910) lower total plan expenditures for hospitalized visits. No significant difference in total payments was observed among discharged visits. CONCLUSIONS In the study ED, the P-EHR was associated with a significant reduction in ED LOS overall and was associated with lower plan payments for visits that resulted in hospitalization.

26. Emergency Medical Services Transport of Patients Complaining of Headache: Does Mode of Arrival Suggest Serious Etiology?

OBJECTIVE To determine whether mode of arrival is associated with seriousness of etiology and use of diagnostic testing in patients treated in the emergency department for headache. METHODS This observational, retrospective study was conducted by consecutive review of the records of patients presenting to the emergency department with a chief complaint of headache from December 1994 through May 1995. Patients with altered mental status or seizures were excluded. Mode of arrival was classified as either by EMS or other (e.g., private vehicle). Patients with a final diagnosis of meningitis, intracranial hemorrhage, or central nervous system tumor were classified as having serious causes, whereas those with headache due to migraine, tension headache, or headache that was otherwise unspecified were classified as nonserious. The use of diagnostic studies, such as lumbar puncture or CT scan, and their results, was recorded. Patients were included in the category of patients having serious intracranial pathology even if the diagnosis was delayed. Statistical analysis was performed using the Yates-corrected chi-square test, and by determining odds ratios (ORs) with 95% confidence intervals. RESULTS For 967 patients presenting with a chief complaint of headache, 837 charts were included in the analysis. A total of 102 patients arrived by EMS, and 735 arrived by other means. Patients arriving by EMS had a higher rate of serious cause of headache than did those arriving by other means (OR = 18.5, p < 0.0001). EMS patients tended to undergo additional diagnostic testing (OR = 4.4, p < 0.0001), and those tests were more likely to be abnormal than for those arriving by other means (OR = 9.4, p < 0.0001). Males had a somewhat higher rate of serious diagnosis (OR = 2.6, p < 0.05). CONCLUSIONS In this EMS system, patients with headache who arrive by EMS are more likely to have serious causes. Mode of arrival may be of use to the clinician in assessing risk of serious illness among patients with headache. Whether this observation represents an element of self-triage or a combination of other factors remains to be determined.

Disagreement Among Health Care Professionals About the Urgent Care Needs of Emergency Department Patients

BACKGROUND Performance of percutaneous coronary intervention (PCI) within 90 minutes of hospital arrival for ST-segment elevation myocardial infarction patients is a commonly cited clinical quality measure. The Centers for Medicare and Medicaid Services use this measure to adjust hospital reimbursement via the Value-Based Purchasing Program. This study investigated the relationship between hospital performance on this quality measure and emergency department (ED) operational efficiency. METHODS Hospital-level data from Centers for Medicare and Medicaid Services on PCI quality measure performance was linked to information on operational performance from 272 US EDs obtained from the Emergency Department Benchmarking Alliance annual operations survey. Standard metrics of ED size, acuity, and efficiency were compared across hospitals grouped by performance on the door-to-balloon time quality measure. RESULTS Mean hospital performance on the 90-minute arrival to PCI measure was 94.0% (range, 42-100). Among hospitals failing to achieve the door-to-balloon time performance standard, median ED length of stay was 209 minutes, compared with 173 minutes among those hospitals meeting the benchmark standard (P < .001). Similarly, median time from ED patient arrival to physician evaluation was 39 minutes for hospitals below the performance standard and 23 minutes for hospitals at the benchmark standard (P < .001). Markers of ED size and acuity, including annual patient volume, admission rate, and the percentage of patients arriving via ambulance did not vary with door-to-balloon time. CONCLUSION Better performance on measures associated with ED efficiency is associated with more timely PCI performance.

Emergency Department Performance Measures and Benchmarking Summit

The Centers for Medicare and Medicaid Services (CMS) Value Based Purchasing Initiative ties hospital reimbursement to quality metric Results. We examined the relationship between performance on cardiac quality indicators and the proportion of low-income patients treated. Data were hospital-level

The Rate of Clinically Significant Plain Radiograph Misinterpretation by Faculty in an Emergency Medicine Residency Program

Purpose : Headache is a very common complaint in emergency medicine. Its causes are myriad, ranging from benign to life-threatening. Patients who access emergency medical services (EMS), often do so after self-assessment has indicated high acuity. We conducted this study to determine if patients transported by EMS with a chief complaint of headache have a higher rate of serious etiology. Methods : This observational, retrospective study, was conducted by consecutive review of charts on all patients presenting to the emergency department (ED) from December 1994 through May 1995 with a chief complaint of headache. Patients presenting with other manifestations of intracranial pathology (ICP), such as altered mental status or seizures, were excluded. Mode of arrival was determined to be either via emergency medical services (EMS) or other means. Patients were categorized as having serious (meningitis, hemorrhage, tumor) or benign (migraine, etc.) ICP, based final diagnosis. It was noted whether or not diagnostic studies (DS), such as CT scan and lumbar puncture, were performed. Statistical analysis was performed using the Yates corrected chi-square test.