John J. Kelly

Pulmonary Hypertension Predicts Mortality and Morbidity in Patients with Dilated Cardiomyopathy

OBJECTIVE To ascertain whether pulmonary hypertension, as assessed noninvasively by continuous-wave Doppler of tricuspid regurgitation, can be an important independent factor in the prognosis of patients with ischemic or idiopathic dilated cardiomyopathy. DESIGN Cohort study of consecutive patients with dilated cardiomyopathy in whom follow-up was obtained on all survivors for 28 months. SETTING Outpatient cardiology private practice office in a tertiary care center. PATIENTS Consecutive sample of 108 patients who presented for a scheduled office visit during a 15-month period. MEASUREMENTS M-mode, two-dimensional, and Doppler echocardiographic examinations were done on all patients at entry into the study and on survivors 1 year later. All examinations included extensive pulsed- and continuous-wave Doppler evaluation for tricuspid regurgitation. MAIN OUTCOME MEASURES Overall mortality, mortality due to myocardial failure, and hospitalization for congestive heart failure. RESULTS Twenty-eight patients had a high velocity of tricuspid regurgitation (greater than 2.5 m/s), and 80 patients had a low velocity (less than or equal to 2.5 m/s). After 28 months of follow-up, the mortality rate was 57% in patients with a high velocity compared with 17% in patients with a low velocity (difference of 40%, 95% CI, 20% to 60%). Hospitalization for congestive heart failure occurred in 75% and 26% of patients, respectively (difference of 49%, CI, 30% to 68%). Eighty-nine percent of patients with a high velocity either died or were hospitalized compared with only 32% of patients with a low velocity (difference of 57%, CI, 42% to 72%). The peak velocity of tricuspid regurgitation was the only prognostic variable selected using stepwise logistic regression models for the three outcome events. CONCLUSION Noninvasive assessment of pulmonary hypertension using continuous-wave Doppler of tricuspid regurgitation can predict morbidity and mortality in patients with ischemic or idiopathic dilated cardiomyopathy.

Public perception of safety and metal detectors in an urban emergency department

Violence within the emergency department (ED) is an area of concern for both the staff and public. Emergency physicians and nurses express a great deal of concern for their personal safety. The use of weapons in events occurring in the ED has prompted a call for the widespread use of metal detectors. The use of these devices can meet with resistance regarding concerns over the creation of a bad image. This study examined the opinion of the public as to personal safety in an urban ED and sought public opinion regarding the use of a metal detector. Although the majority of the 303 persons surveyed felt safe (75%) in the ED and were satisfied with the level of security (68%), two thirds reported they would feel better if a metal detector was in use. Women were more likely than men to prefer the use of a metal detector. A small percentage (11%) of the public reported a fear of being physically harmed in the ED. Concerns about the potential for a negative image caused by use of a metal detector do not appear warranted in this urban ED.

Assessment of Medicare's imaging efficiency measure for emergency department patients with atraumatic headache.

STUDY OBJECTIVE Computed tomography (CT) use has increased rapidly, raising concerns about radiation exposure and cost. The Centers for Medicare & Medicaid Services (CMS) developed an imaging efficiency measure (Outpatient Measure 15 [OP-15]) to evaluate the use of brain CT in the emergency department (ED) for atraumatic headache. We aim to determine the reliability, validity, and accuracy of OP-15. METHODS This was a retrospective record review at 21 US EDs. We identified 769 patient visits that CMS labeled as including an inappropriate brain CT to identify clinical indications for CT and reviewed the 748 visits with available records. The primary outcome was the reliability of OP-15 as determined by CMS from administrative data compared with medical record review. Secondary outcomes were the measures validity and accuracy. Outcome measures were defined according to the testing protocol of the American Medical Associations Physician Consortium for Performance Improvement. RESULTS On record review, 489 of 748 ED brain CTs identified as inappropriate by CMS had a measure exclusion documented that was not identified by administrative data; the measure was 34.6% reliable (95% confidence interval [CI] 31.2% to 38.0%). Among the 259 patient visits without measure exclusions documented in the record, the measures validity was 47.5% (95% CI 41.4% to 53.6%), according to a consensus list of indications for brain CT. Overall, 623 of the 748 ED visits had either a measure exclusion or a consensus indication for CT; the measures accuracy was 16.7% (95% CI 14% to 19.4%). Hospital performance as reported by CMS did not correlate with the proportion of CTs with a documented clinical indication (r=-0.11; P=.63). CONCLUSION The CMS imaging efficiency measure for brain CTs (OP-15) is not reliable, valid, or accurate and may produce misleading information about hospital ED performance.

Use of multiple views in the echocardiographic assessment of pulmonary artery systolic pressure

The purpose of this study was to determine which echocardiographic views most reliably demonstrate the maximum velocity of a tricuspid regurgitant jet in the evaluation of pulmonary artery systolic pressure. Consecutive patients seen in three echocardiographic laboratories during a 3-month period were enrolled. A complete Doppler examination was performed on each patient, including a continuous-wave Doppler evaluation of tricuspid regurgitation in each of seven views. All seven views were used to determine the maximum velocity of tricuspid regurgitation. Of the 1163 studies, 866 (75%) had some tricuspid regurgitation by color-flow Doppler and 614 (53%) had a measurable velocity of tricuspid regurgitation in at least one view. No single echocardiographic view consistently yielded the maximum velocity of tricuspid regurgitation. The apical four-chamber view alone was inadequate. All seven views must be used to be certain that the maximum velocity of tricuspid regurgitation has been obtained.

Effectiveness of a Glasgow Coma Scale instructional video for EMS providers.

INTRODUCTION The Glasgow Coma Scale (GCS) is the standard measure used to quantify the level of consciousness of patients who have sustained head injuries. Rapid and accurate GCS scoring is essential. OBJECTIVE To evaluate the effectiveness of a GCS teaching video shown to prehospital emergency medical services (EMS) providers. METHODS Participants and setting--United States, Mid-Atlantic region EMS providers. Intervention--Each participant scored all of the three components of the GCS for each of four scenarios provided before and after viewing a video-tape recording containing four scenarios. Design--Before-and-after single (Phase I) and parallel Cohort (Phase II). Analysis--Proportions of correct scores were compared using chi-square, and relative risk was calculated to measure the strength of the association. RESULTS 75 participants were included in Phase I. In Phase II, 46 participants participated in a parallel cohort design: 20 used GCS reference cards and 26 did not use the cards. Before observing the instructional video, only 14.7% score all of the scenarios correctly, where as after viewing the video, 64.0% scored the scenarios results were observed after viewing the video for those who used the GCS cards (p = 0.001; RR = 2.0; 95% CI = 1.29 to 3.10) than for those not using the cards (p < 0.0001; RR = 10.0; 95% CI = 2.60 to 38.50). CONCLUSIONS Post-video viewing scores were better than those observed before the video presentation. Ongoing evaluations include analysis of long-term skill retention and scoring accuracy in the clinical environment.

A Survey of the Use of Time-Out Protocols in Emergency Medicine

BACKGROUND Time-outs, as one of the elements of the Joint Commission Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery has been in effect since July 1, 2004. Time-outs are required by The Joint Commission for all hospital procedures regardless of location, including emergency departments (EDs). Attitudes about ED time-outs were assessed for a sample of senior emergency physicians serving in leadership roles for a national professional society. METHODS A survey questionnaire was administered to members of the American College of Emergency Physicians (ACEP) Council at the October 2009 ACEP Council meeting on the use of time-outs in the ED. A total of 225 (72%) of the 331 councilors present filled out the survey. RESULTS Twenty-nine (13%) of respondents were unaware of a formal time-out policy in their ED, 79 (35%) reported that ED time-outs were warranted, and 5 (2%) reported they knew of an instance where a time-out may have prevented an error. Chest tubes (167 respondents [74%]) and the use of sedation (142 respondents [63%]) were most commonly identified as ED procedures that necessitated a time-out. Episodes of any wrong-site error in their EDs were reported by 16 (7%) of the respondents. Wrong patient (9 respondents [4%]) and wrong procedure (2 respondents [1%]) errors were less common. CONCLUSIONS Although the time-out requirement has been in effect since 2004, more than 1 in 10 of ED physicians in this sample ofED physician leaders were unaware of it. According to the respondents, medical errors preventable by time-outs were rare; however, time-outs may be useful for certain procedures, particularly when there is a risk of wrong-site, wrong-patient, or wrong-procedure medical errors.