Are We Overusing Coagulation Studies in the Emergency Department?

Methods: This retrospective observational study, conducted in the ED of King Saud University Medical City (KSUMC) in Riyadh, Saudi Arabia, during July and August of 2021(2 months) examined coagulation profile requests. Patients' demographic data (age and gender), medical and clinical history (presenting complaint, comorbidities, and diagnosis), the use of antiplatelets or anticoagulant agents and laboratory values for PT, APTT, and INR were collected. We calculated the total cost of unnecessary coagulation profile testing based on the independent assessment of two ED consultants. Results: Of 1,754 patients included in the study, 811 (46.2%) were males and 943 (53.8%) were females, with a mean age of 42.1 ± 18.5 years. There were 29 (1.7%) patients with liver disease and 21 (1.2%) patients had thromboembolic disease. The majority of the patients' results were within normal levels of PT (n = 1,409, 80.3%), APTT (n = 1,262, 71.9%), and INR (n = 1,711, 97.4%). Evidence of active bleeding was detected in 29 patients (1.7%). Among patients with bleeding only one had an abnormal INR (3.01) and was on warfarin. Forty-six (2.6%) patients had elevated INR level. Cohen's kappa between the two consultants was recorded at 0.681 (substantial agreement) in their assessment of the appropriateness of coagulation tests requests and both consultants believed that 1,051 tests (59.9%) were not indicated and were unnecessary. The expected annual cost saving if the unnecessary tests were removed would be around SAR 1,897,200 (approximately US$ 503,232) which is about SAR 180000 (US$ 48000)/1000 patients. Conclusion: This study showed that coagulation tests are overused in the ED. More than half of coagulation profile tests in our study population were deemed unnecessary and associated with significant cost. Targeted testing based on specific patient presentation and medical history can guide physicians in wisely choosing who needs coagulation studies.

Valuation of EQ-5D-5L in the Kingdom of Saudi Arabia: A National Representative Study.

OBJECTIVES: To estimate a Saudi-specific value set for the EQ-5D-5L questionnaire using the EuroQol Valuation Technology program and the EuroQol Group's standard protocol. METHODS: Participants were quota-sampled from the Saudi adult population based on residency location, age group, gender, education level, and employment status. The participants were guided through the completion of composite time trade-off (cTTO) and discrete choice experiment (DCE) tasks by trained interviewers using EuroQol Valuation Technology software. Quality control (QC) measures were used to ensure good data quality. Random intercept and Tobit models analyzed the cTTO data, as well as models correcting for heteroskedasticity. DCE data were analyzed using conditional logit models, whereas hybrid models were used to analyze the cTTO and DCE data jointly. To evaluate model performance, prediction accuracy, logical consistency, significance level, and goodness of fit were used. RESULTS: The valuation study included a representative sample of the Saudi population (N = 1000). The hybrid heteroskedastic model without a constant was chosen as the preferred model for generating the value set. The predicted values ranged from -0.683 for the worst health state ("55555") to 1 for the full health state ("11111"). Pain and discomfort had the largest impact on health-state preference values, whereas usual activities had the least. CONCLUSION: The value set for the Kingdom of Saudi Arabia is the first value set for the EQ-5D-5L for any country in the Middle East. The value set can be used in Saudi health system economic evaluations and decision making.

Diagnosis and management of arrhythmogenic right ventricular cardiomyopathy.

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a genetic disorder of the myocardium that can lead to ventricular arrhythmia and sudden cardiac death. The condition has been identified as a significant cause of arrhythmic death among young people and athletes, therefore, early recognition of the disease by emergency clinicians is critical to prevent subsequent death. The diagnosis of ARVC can be very challenging and requires a systematic approach. This publication reviews the pathophysiology, classification, clinical presentations, and appropriate approach to diagnosis and management of ARVC.

Dysrhythmias associated with COVID-19: Review and management considerations.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes coronavirus disease 2019 (COVID-19), is known to affect the cardiovascular system. Cardiac manifestations in COVID-19 can be due to direct damage to the myocardium and conduction system as well as by the disease's effect on the various organ systems. These manifestations include acute coronary syndrome, ST- segment elevations, cardiomyopathy, and dysrhythmias. Some of these dysrhythmias can be detrimental to the patient. Therefore, it is important for the emergency physician to be aware of the different arrhythmias associated with COVID-19 and how to manage them. This narrative review discusses the pathophysiology underlying the various arrhythmias associated with COVID-19 and their management considerations.

Narrow Complex Tachycardias.

Narrow-complex tachycardias are commonly seen on shift in the emergency department. Although a portion of patients present with hemodynamic instability because of arrhythmia, it is important to know that the tachycardia can be a result of an underlying condition. Rapid identification of the type and etiology of the arrhythmia is vital to directing appropriate management strategies and disposition decisions.

Wide Complex Tachycardias.

Wide complex tachycardias (WCT) are frequently encountered in the emergency department. Causes of WCT vary from benign (eg, supraventricular with rate-related aberrancy) to life threatening (eg, atrial fibrillation with WPW, or ventricular tachycardia). It is imperative that emergency physicians are familiar with the clinical presentation, underlying causes, and electrocardiographic features of the different causes of WCT. Treatment of WCT depends on patient stability, regularity of the rhythm, and QRS morphology. When in doubt, monomorphic WCT should be presumed to be ventricular tachycardia and treated as such.

Comparison of a formatted versus traditional sign out process for physicians in the emergency department.

INTRODUCTION: Frequent interruptions, critically ill patients, and high patient turnover can make Emergency Department (ED) physician transitions of care (TOCs) challenging. Currently, there is no strict format for TOC in the ED. We structured a formatted ED TOC and evaluated the comparative effects from traditional TOC practice on the perceived quality of sign-out among physicians working in the ED. METHODS: We performed a prospective pre/post-interventional study utilizing convenience sampling in an urban community teaching hospital. The primary outcome was perceived quality of sign-out, as evaluated by the incoming physician one-hour after TOC, using the handoff-Clinical Evaluation Exercise (h-CEX) score with a 9-point scale for each category: Organized/Efficient, Communications Skills, Included Pertinent Information, Clinical Judgment, Patient Focused, Setting, and Overall Sign-Out Quality. Additional evaluation of unexpected tasks and errors from TOC w performed. RESULTS: We included 344 patient TOC observed, of which 147 (43%) were formatted interventions while 197 (57%) were standard TOCs. After analysis in a random effects model, statistically significant improvements among resident physicians were seen for the formatted TOC: patient focused (mean difference 0.40), setting (mean difference 1.05), and overall (mean difference 0.68). The rate of unexpected tasks and errors were higher in the standard TOC, though not statistically significant. CONCLUSION: Resident physicians saw improvement in several h-CEX categories with a formatted TOC. Consistent with prior studies, a formatted TOC for emergency medicine should be strongly considered, especially among learners.

Resistance Patterns of Escherichia coli in Women with Uncomplicated Urinary Tract Infection Do Not Correlate with Emergency Department Antibiogram.

BACKGROUND: Urine cultures are not always performed for female Emergency Department (ED) patients with uncomplicated urinary tract infection (UTI). Accordingly, hospital, and even ED-specific, antibiograms might be skewed toward elderly patients with many comorbidities and relatively high rates of antimicrobial resistance, and thus do not accurately reflect otherwise healthy women. Our ED antibiogram indicates Escherichia coli resistance rates for ciprofloxacin, levofloxacin, and trimethoprim-sulfamethoxazole (TMP-SMX) of 42%, 26%, and 33%, respectively. OBJECTIVES: This study aims to compare resistance rates of urinary E. coli from otherwise healthy women with uncomplicated UTI and pyelonephritis in the ED to rates in our ED antibiogram. METHODS: Females > 18 years old with acute onset of urinary frequency, urgency, or dysuria with pyuria identified on urinalysis (white blood cell count > 10/high-power field) were prospectively enrolled in the ED of an urban, academic medical center. Exclusion criteria indicating a complicated UTI were consistent with Infectious Diseases Society of America guidelines. Susceptibility patterns of E. coli to ciprofloxacin, levofloxacin, and TMP-SMX in the study group were compared to our ED antibiogram. RESULTS: Forty-five patients grew E. coli. Pyelonephritis was suspected in nine (20%) subjects. Compared with the ED antibiogram, significantly lower rates of resistance to ciprofloxacin (2% vs. 42%, p < 0.001), levofloxacin (2% vs. 26%, p < 0.001), and TMP-SMX (16% vs. 33%, p = 0.016) were observed. Six patients grew non-E. coli uropathogens. All were susceptible to both levofloxacin and TMP-SMX. CONCLUSIONS: ED antibiograms may overestimate resistance rates for uropathogens causing uncomplicated UTIs. In cases where nitrofurantoin cannot be used, fluoroquinolones and possibly TMP-SMX may remain viable options for treatment of uncomplicated UTI and pyelonephritis in women.