Stephen J. Wolf

Clinical Policy: Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department

From the American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department: Thomas W. Lukens, MD, PhD, (Chair) Stephen J. Wolf, MD Jonathan A. Edlow, MD Samina Shahabuddin, MD Michael H. Allen, MD, (American Association for Emergency Psychiatry) Glenn W. Currier, MD, MPH, (American Association for Emergency Psychiatry) Andy S. Jagoda, MD, (Chair, Clinical Policies Committee)

Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Suspected Pulmonary Embolism

This clinical policy from the American College of Emergency Physicians is the revision of a 2003 clinical policy on the evaluation and management of adult patients presenting with suspected pulmonary embolism (PE).(1) A writing subcommittee reviewed the literature to derive evidence-based recommendations to help clinicians answer the following critical questions: (1) Do objective criteria provide improved risk stratification over gestalt clinical assessment in the evaluation of patients with possible PE? (2) What is the utility of the Pulmonary Embolism Rule-out Criteria (PERC) in the evaluation of patients with suspected PE? (3)What is the role of quantitative D-dimer testing in the exclusion of PE? (4) What is the role of computed tomography pulmonary angiogram of the chest as the sole diagnostic test in the exclusion of PE? (5) What is the role of venous imaging in the evaluation of patients with suspected PE? (6) What are the indications for thrombolytic therapy in patients with PE? Evidence was graded and recommendations were given based on the strength of the available data in the medical literature.

Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients in the Emergency Department With Asymptomatic Elevated Blood Pressure

This clinical policy from the American College of Emergency Physicians is the revision of a 2006 policy on the evaluation and management of adult patients with asymptomatic elevated blood pressure in the emergency department.1 A writing subcommittee reviewed the literature to derive evidence-based recommendations to help clinicians answer the following critical questions: (1) In emergency department patients with asymptomatic elevated blood pressure, does screening for target organ injury reduce rates of adverse outcomes? (2) In patients with asymptomatic markedly elevated blood pressure, does emergency department medical intervention reduce rates of adverse outcomes? A literature search was performed, the evidence was graded, and recommendations were given based on the strength of the available data in the medical literature.

Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Acute Carbon Monoxide Poisoning

This clinical policy focuses on critical issues concerning the management of adult patients presenting to the emergency department (ED) with acute symptomatic carbon monoxide (CO) poisoning. The subcommittee reviewed the medical literature relevant to the questions posed. The critical questions are: Should hyperbaric oxygen (HBO2) therapy be used for the treatment of patients with acute CO poisoning; and Can clinical or laboratory criteria identify CO-poisoned patients who are most or least likely to benefit from this therapy. Recommendations are provided on the basis of the strength of evidence of the literature. Level A recommendations represent patient management principles that reflect a high degree of clinical certainty; Level B recommendations represent patient management principles that reflect moderate clinical certainty; and Level C recommendations represent other patient management strategies that are based on preliminary, inconclusive, or conflicting evidence, or based on committee consensus. This clinical policy is intended for physicians working in hospital-based EDs.

Assessment of the pulmonary embolism rule-out criteria rule for evaluation of suspected pulmonary embolism in the emergency department

BACKGROUND Overuse of resources when evaluating pulmonary embolism (PE) is a concern if the D-dimer assay is improperly used in the evaluation of emergency department patients with suspected PE. The pulmonary embolism rule-out criteria (PERC) rule was derived to prevent unnecessary diagnostic testing in this patient population. The objective of this study was to assess the PERC rules performance in an external population. METHODS This was a secondary analysis of a prospectively collected database comparing PERC rule variables to diagnosis of PE in consecutive patients with suspicion for PE. Bivariate analysis on individual variables and the overall accuracy of the PERC rule were performed. RESULTS Patients on 120 randomly assigned shifts were enrolled with a PE prevalence of 12%. The sensitivity, specificity, positive predictive, and negative predictive values of the PERC rule were 100% (95% confidence interval [CI], 79%-100%), 16% (95% CI, 10%-24%), 14% (95% CI, 8%-14%), and 100% (95% CI, 80%-100%), respectively, for the total patient population, and 100% (95% CI, 25%-100%), 33% (95% CI, 12%-35%), 2% (95% CI, 0%-11%), and 100% (95% CI, 75%-100%), respectively, for the low pretest probability population. Bivariate analysis showed unilateral leg swelling, recent surgery, and a history of venous thromboembolic event to be predictive of the diagnosis of PE. CONCLUSIONS The PERC rule may identify a cohort of patients with suspected PE for whom diagnostic testing beyond history and physical examination is not indicated.

Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Seizures

This clinical policy from the American College of Emergency Physicians is the revision of a 2004 policy on critical issues in the evaluation and management of adult patients with seizures in the emergency department. A writing subcommittee reviewed the literature to derive evidence-based recommendations to help clinicians answer the following critical questions: (1) In patients with a first generalized convulsive seizure who have returned to their baseline clinical status, should antiepileptic therapy be initiated in the emergency department to prevent additional seizures? (2) In patients with a first unprovoked seizure who have returned to their baseline clinical status in the emergency department, should the patient be admitted to the hospital to prevent adverse events? (3) In patients with a known seizure disorder in which resuming their antiepileptic medication in the emergency department is deemed appropriate, does the route of administration impact recurrence of seizures? (4) In emergency department patients with generalized convulsive status epilepticus who continue to have seizures despite receiving optimal dosing of a benzodiazepine, which agent or agents should be administered next to terminate seizures? A literature search was performed, the evidence was graded, and recommendations were given based on the strength of the available data in the medical literature.

Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department with Acute Carbon Monoxide Poisoning

This clinical policy focuses on critical issues concerning the management of adult patients presenting to the emergency department (ED) with acute symptomatic carbon monoxide (CO) poisoning. The subcommittee reviewed the medical literature relevant to the questions posed. The critical questions are: Should hyperbaric oxygen (HBO(2)) therapy be used for the treatment of patients with acute CO poisoning; and Can clinical or laboratory criteria identify CO-poisoned patients who are most or least likely to benefit from this therapy? Recommendations are provided on the basis of the strength of evidence of the literature. Level A recommendations represent patient management principles that reflect a high degree of clinical certainty; Level B recommendations represent patient management principles that reflect moderate clinical certainty; and Level C recommendations represent other patient management strategies that are based on preliminary, inconclusive, or conflicting evidence, or based on committee consensus. This clinical policy is intended for physicians working in hospital-based EDs.

Clinical Policy: Critical Issues in the Evaluation of Adult Patients With Suspected Transient Ischemic Attack in the Emergency Department

This clinical policy from the American College of Emergency Physicians addresses key issues for adults presenting to the emergency department with suspected transient ischemic attack. A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions: (1) In adult patients with suspected transient ischemic attack, are there clinical decision rules that can identify patients at very low short-term risk for stroke who can be safely discharged from the emergency department? (2) In adult patients with suspected transient ischemic attack, what imaging can be safely delayed from the initial emergency department workup? (3) In adult patients with suspected transient ischemic attack, is carotid ultrasonography as accurate as neck computed tomography angiography or magnetic resonance angiography in identifying severe carotid stenosis? (4) In adult patients with suspected transient ischemic attack, can a rapid emergency department-based diagnostic protocol safely identify patients at short-term risk for stroke? Evidence was graded and recommendations were made based on the strength of the available data.

Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Suspected Acute Venous Thromboembolic Disease

This clinical policy from the American College of Emergency Physicians addresses key issues in the evaluation and management of adult patients with suspected venous thromboembolism. A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions: (1) In adult patients with suspected acute pulmonary embolism, can a clinical prediction rule be used to identify a group of patients at very low risk for the diagnosis of pulmonary embolism for whom no additional diagnostic workup is required? (2) In adult patients with low to intermediate pretest probability for acute pulmonary embolism, does a negative age-adjusted D-dimer result identify a group of patients at very low risk for the diagnosis of pulmonary embolism for whom no additional diagnostic workup is required? (3) In adult patients with subsegmental pulmonary embolism, is it safe to withhold anticoagulation? (4) In adult patients diagnosed with acute pulmonary embolism, is initiation of anticoagulation and discharge from the emergency department safe? (5) In adult patients diagnosed with acute lower-extremity deep venous thrombosis who are discharged from the ED, is treatment with a non–vitamin K antagonist oral anticoagulant safe and effective compared with treatment with low-molecularweight heparin and vitamin K antagonist? Evidence was graded and recommendations were made based on the strength of the available data. INTRODUCTION Venous thromboembolism (VTE), a coagulation disorder encompassing both deep venous thrombosis (DVT) and pulmonary embolism (PE), is a major public health problem. Undiagnosed, untreated patients are believed to be at substantial risk for progressive disease and sudden death, typically because of worsening right-sided heart strain and, ultimately, cardiovascular collapse. Treated patients are at risk for chronic sequelae (eg, vein scarring, leg swelling, pulmonary hypertension) and adverse events from ongoing anticoagulation (eg, hemorrhage, medication adverse effects). Although the true incidence of VTE is not known, reports estimate that 600,000 to 900,000 individuals per year (1 to 2 per 1,000) may be affected in the United States, a number that increases with patient age. Others estimate that upwards of 294,000 fatal cases of PE occur in the United States annually, accounting for up to 10% of all hospital deaths. In selected patient populations, VTE has e60 Annals of Emergency Medicine been reported to have an associated mortality rate as low as 2% and as high as 30%, which is primarily attributed to PE. One significant challenge to health care providers evaluating patients for VTE lies in the variability of signs and symptoms of the disease that are related to the clot burden, location, and the individual patient’s cardiopulmonary reserve. Without perfect, cost-effective tests for the diagnosis, providers have come to rely on Bayesian decisionmaking to guide their workup, using pretest probability to interpret diagnostic evaluations and generate posttest probability of disease. Doing this allows providers to maximize diagnostic accuracy while minimizing overtesting and patient harm from the risks associated with unnecessary evaluation and treatment. Efforts to refine this Bayesian approach in emergency medicine have been ongoing. Original studies to determine pretest probability and the accuracy of various screening tests have been validated, and the limits of their efficacy are being explored. These structured clinical prediction rules, whether diagnostic (eg, Pulmonary Embolism Rule-out Criteria [PERC], Wells criteria, revised Geneva score [RGS]), or prognostic (eg, Pulmonary Embolism Severity Index [PESI], Hestia criteria), offer an adjunct to gestalt clinical assessment to assist in risk stratification and determination of pretest probability (ie, low, intermediate, high, nonhigh, PE unlikely, PE likely) or predict prognosis. In consideration of the cost of evaluation, the risk of false positives, and the risk of complications related to testing, studies have supported using a predefined posttest probability threshold of less than 2.0% to exclude the diagnosis of VTE. Last, substantial efforts are being made to advance the treatment of VTE by balancing outcomes, anticoagulation risks to patients, and patient preferences. New non–vitamin K antagonist oral anticoagulants (NOACs) (aka novel oral anticoagulants, direct oral anticoagulants, and targetspecific oral anticoagulants) directly bind to specific clotting factors (ie, IIa or Xa) to induce anticoagulation, and have been proposed as safer alternatives to vitamin K antagonists (VKAs) (ie, warfarin), which more broadly reduce circulating clotting factors (ie, II, VI, IX, and X). NOACs are particularly appealing for long-term anticoagulation because of their simple oral dosing regimens with no need for routine laboratory monitoring. Examples of approved NOACs include apixaban (Eliquis), dabigatran (Pradaxa), edoxaban (Savaysa), and rivaroxaban (Xarelto). The 2011 American College of Emergency Physicians (ACEP) clinical policy on this topic focused on 6 critical questions: pretest probability and clinical assessment, utility Volume 71, no. 5 : May 2018

Clinical Policy: Critical Issues in the Evaluation and Management of Emergency Department Patients With Suspected Non–ST-Elevation Acute Coronary Syndromes

&NA; This clinical policy from the American College of Emergency Physicians addresses key issues in the evaluation and management of patients with suspected non–ST‐elevation acute coronary syndromes. A writing subcommittee conducted a systematic review of the literature to derive evidence‐based recommendations to answer the following clinical questions: (1) In adult patients without evidence of ST‐elevation acute coronary syndrome, can initial risk stratification be used to predict a low rate of 30‐day major adverse cardiac events? (2) In adult patients with suspected acute non–ST‐elevation acute coronary syndrome, can troponin testing within 3 hours of emergency department presentation be used to predict a low rate of 30‐day major adverse cardiac events? (3) In adult patients with suspected non–ST‐elevation acute coronary syndrome in whom acute myocardial infarction has been excluded, does further diagnostic testing (eg, provocative, stress test, computed tomography angiography) for acute coronary syndrome prior to discharge reduce 30‐day major adverse cardiac events? (4) Should adult patients with acute non–ST‐elevation myocardial infarction receive immediate antiplatelet therapy in addition to aspirin to reduce 30‐day major adverse cardiac events? Evidence was graded and recommendations were made based on the strength of the available data.