Samuel D. Turnipseed

Endoscopy-based triage significantly reduces hospitalization rates and costs of treating upper GI bleeding: a randomized controlled trial.

BACKGROUND Many patients with upper gastrointestinal (GI) bleeding have a benign outcome and could receive less intensive and costly care if accurately identified. We sought to determine whether early endoscopy performed shortly after admission in the emergency department could significantly reduce the health care use and costs of caring for patients with nonvariceal upper GI bleeding without adversely affecting the clinical outcome. METHODS All eligible patients with upper GI bleeding and stable vital signs were randomized after admission to undergo endoscopy in 1 to 2 days (control) or early endoscopy in the emergency department. Patients with low-risk findings on early endoscopy were discharged directly from the emergency department. Clinical outcomes and costs were prospectively assessed for 30 days. RESULTS We randomized 110 consecutive stable patients with nonvariceal upper GI bleeding during the 12-month study period. The baseline demographic features, endoscopic findings, and the clinical outcomes were no different between the two groups. However the findings of the early endoscopy allowed us to immediately discharge 26 of 56 (46%) patients randomized to that group. No patient discharged from the emergency department suffered an adverse outcome. The hospital stay (median of 1 day [interquartile range of 0 to 3 days] vs. 2 days [interquartile range of 2 to 3 days], p = 0.0001) and the cost of care (

Immediate exercise testing to evaluate low-risk patients presenting to the emergency department with chest pain

2068 [interquartile range of

Immediate exercise testing of low risk patients with known coronary artery disease presenting to the emergency department with chest pain

928 to

Acute ischemic syndromes: Chest pain center concept

3960] versus

Relationship of Myocardial Ischemia and Injury to Coronary Artery Disease in Patients With Supraventricular Tachycardia

3662 [interquartile range of

Characteristics of the Pediatric Patients Treated by the Pediatric Emergency Care Applied Research Network's Affiliated EMS Agencies

2473 to

Utility of Immediate Exercise Treadmill Testing in Patients Taking Beta Blockers or Calcium Channel Blockers

7280], p = 0.00006) were significantly less for the early endoscopy group. CONCLUSIONS Early endoscopy performed shortly after admission in the emergency department safely triaged 46% of patients with nonvariceal upper GI bleeding to outpatient care, which significantly reduced hospital stay and costs.

Frequency of Non-ST-segment Elevation Injury Patterns on Prehospital Electrocardiograms

OBJECTIVES Our purpose was to determine the safety and accuracy of immediate exercise testing in low-risk patients presenting to the emergency department (ED) with chest pain suggestive of a cardiac etiology. BACKGROUND Safe, efficient management of low-risk patients presenting to the ED with chest pain is a continuing challenge. We have employed immediate exercise testing to evaluate a large, heterogeneous group of low-risk patients presenting with chest pain. METHODS Patients presenting to the ED with chest pain compatible with a cardiac origin and clinical evidence of low risk on initial assessment underwent immediate exercise treadmill testing in our chest pain evaluation unit. Indicators of low clinical risk included no evidence of hemodynamic instability, arrhythmias or electrocardiographic signs of ischemia. Serial measurements of cardiac injury markers were not obtained. RESULTS Exercise testing was performed to a sign- or symptom-limited end point in 1,000 patients (520 men, 480 women; age range 31 to 82 years) and was positive for ischemia in 13%, negative in 64% and nondiagnostic in 23% of patients. There were no adverse effects of exercise testing, and all patients with a negative exercise test were discharged directly from the ED. At 30-day follow-up there was no mortality in any of the three groups. Cardiac events in the three groups included: negative group, 1 non-Q-wave myocardial infarction (MI); positive group, 4 non-Q-wave MIs and 12 myocardial revascularizations; nondiagnostic group, 7 myocardial revascularizations. BACKGROUND Immediate exercise testing of patients presenting to the ED with chest pain and evidence of low clinical risk is safe and accurate for determining those who require admission and those who can be discharged to further outpatient evaluation.

Value of high-sensitivity C-reactive protein in low risk chest pain observation unit patients

OBJECTIVES The purpose of this study was to demonstrate the safety and utility of immediate exercise treadmill testing (IETT) of low risk patients presenting to the emergency department with known coronary artery disease (CAD). BACKGROUND More than 70% of the two million patients admitted to U.S. hospitals annually for suspected acute myocardial infarction (AMI) are found not to have had a cardiac event. We have previously demonstrated the safety and efficacy of IETT of selected low risk patients without known CAD presenting to the emergency department with chest pain. This study extends this approach to selected patients with a history of CAD. METHODS One hundred patients evaluated by the chest pain emergency room to rule out AMI underwent IETT using a modified Bruce protocol upon admission to the hospital (median time <1 h). RESULTS Twenty-three patients (23%) had positive exercise electrocardiograms (ExECGs); an uncomplicated non-Q wave AMI was diagnosed in two patients. Thirty-eight patients (38%) had negative ExECGs and 39 patients (39%) had nondiagnostic ExECGs. Of these 100 patients, 64 were discharged immediately after IETT, 19 were discharged in less than 24 h after negative serial cardiac enzymes and stable electrocardiograms and 17 were discharged after further evaluation and treatment. There were no complications from exercise testing and no late deaths or AMI during six-month follow-up. CONCLUSIONS Immediate exercise treadmill testing of low risk patients with chest pain and known CAD is effective in further stratifying this group into patients who can be safely discharged and those who require hospital admission.

Methamphetamine Use and Emergency Department Utilization: 20 Years Later

CPCs have been developed to meet the clinical challenge posed by the diverse group of patients presenting to the ED with findings suggestive of a coronary event. Using a protocol-driven approach, high- and low-risk patients can be identified on presentation, facilitating urgent therapy in the former and triage of the latter to more deliberate management. Most CPCs focus on low-risk patients who are being increasingly managed by accelerated diagnostic protocols. These methods comprise systematic strategies that include innovative diagnostic approaches during a 6 to 12 hour period of observation with serial ECGs, continuous monitoring and cardiac biomarker measurements. A negative evaluation is usually followed by predischarge stress testing, and positive findings mandate admission. An essential aspect of the CPC strategy is continuity of care for patients with negative cardiac evaluations. Current data indicate that management of low-risk patients with chest pain in a CPC is safe accurate, and appears to be cost-effective.