Systematic review of emergency medicine clinical practice guidelines: Implications for research and policy.

INTRODUCTION: Over 25 years, emergency medicine in the United States has amassed a large evidence base that has been systematically assessed and interpreted through ACEP Clinical Policies. While not previously studied in emergency medicine, prior work has shown that nearly half of all recommendations in medical specialty practice guidelines may be based on limited or inconclusive evidence. We sought to describe the proportion of clinical practice guideline recommendations in Emergency Medicine that are based upon expert opinion and low level evidence. METHODS: Systematic review of clinical practice guidelines (Clinical Policies) published by the American College of Emergency Physicians from January 1990 to January 2016. Standardized data were abstracted from each Clinical Policy including the number and level of recommendations as well as the reported class of evidence. Primary outcomes were the proportion of Level C equivalent recommendations and Class III equivalent evidence. The primary analysis was limited to current Clinical Policies, while secondary analysis included all Clinical Policies. RESULTS: A total of 54 Clinical Policies including 421 recommendations and 2801 cited references, with an average of 7.8 recommendations and 52 references per guideline were included. Of 19 current Clinical Policies, 13 of 141 (9.2%) recommendations were Level A, 57 (40.4%) Level B, and 71 (50.4%) Level C. Of 845 references in current Clinical Policies, 67 (7.9%) were Class I, 272 (32.3%) Class II, and 506 (59.9%) Class III equivalent. Among all Clinical Policies, 200 (47.5%) recommendations were Level C equivalent, and 1371 (48.9%) of references were Class III equivalent. CONCLUSIONS: Emergency medicine clinical practice guidelines are largely based on lower classes of evidence and a majority of recommendations are expert opinion based. Emergency medicine appears to suffer from an evidence gap that should be prioritized in the national research agenda and considered by policymakers prior to developing future quality standards.

Hospital-level variation and predictors of admission after ED visits for atrial fibrillation: 2006 to 2011.

BACKGROUND: Outpatient management of atrial fibrillation can be a safe alternative to inpatient admission after emergency department (ED) visits. We aim to describe trends and predictors of hospital admission for atrial fibrillation and determine the variation in admission among US hospitals. METHODS: We analyzed ED visits and hospital admissions for adult patients with a principal diagnosis of atrial fibrillation or atrial flutter in the Nationwide Emergency Department Sample 2006 to 2011. We identified patient and hospital characteristics associated with admission using hierarchical multivariate logistic regression. We analyzed admission rates overall and for patients at low risk of thromboembolic complications (CHA2DS2-VASc score 0). We compared hospital-level variance with residual variance to estimate the intraclass correlation in models with and without hospital characteristics. RESULTS: From 2006 to 2011, annual ED visits for atrial fibrillation and atrial flutter increased by 30.9% and admission rates decreased from 69.7% to 67.4% (P= .02). Admission was associated with setting (metropolitan teaching vs nonmetropolitan, odds ratio = 1.93 [1.62-2.29]) and region (Northeast vs West, odds ratio = 2.09 [1.67-2.60]). Among patients with 0 CHA2DS2-VASc score, the national average admission rate was 46.4%. The intraclass correlation was 20.7% adjusting for patient characteristics and hospital clustering, and 19.2% after additionally adjusting for hospital variables. CONCLUSIONS: From 2006 to 2011, ED visits for atrial fibrillation in the United States increased by almost a third, with a minimal change in ED admission rates. One-fifth of variation in admission rates is due to hospital site and not explained by hospital characteristics. Hospital-specific practice patterns may identify opportunities to increase outpatient management.

Reversible Cerebral Vasoconstriction Syndrome.

BACKGROUND: Reversible cerebral vasoconstriction syndrome (RCVS) is an underappreciated and poorly understood cause of thunderclap headache (TCH). Although self-limited in the majority of patients, incidence is increasing, with presentations overlapping considerably with life-threatening conditions, such as aneurysmal subarachnoid hemorrhage and stroke. In addition, radiographic findings seen in RCVS are also present in primary angiitis of the central nervous system (PACNS). Misdiagnosis of RCVS might subject patients to unnecessary invasive testing and immunosuppressive therapy. Furthermore, the recommended treatment of glucocorticoids used in PACNS can be harmful in RCVS. RCVS is not a benign condition, as patients can have ischemic or hemorrhagic complications leading to persistent neurologic deficits and even death. Current treatments, guided only by expert consensus, have no proven effect on these complications, which argues the need for accurate identification of patients with RCVS and prospective studies to validate treatment and inform prognoses. CASE REPORT: We describe a previously healthy male who presented to the emergency department after 2 episodes of TCH and angiography consistent with RCVS. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: RCVS is a common but underappreciated cause of TCH. The likelihood of misdiagnosing RCVS following the accepted diagnostic algorithm of acute headache in the emergency department is high due to a lack of clinical awareness and common features shared with other headache syndromes. Emergency department physicians must broaden the differential in patients presenting to the emergency department with TCH to include RCVS and be familiar with the accepted treatments and appropriate follow-up.

Life-threatening flecainide overdose treated with intralipid and extracorporeal membrane oxygenation.

Flecainide is a Class Ic antiarrythmic agent associated with adverse events due to its pro-arrythmic effects. We report the case of a 33-year-old female presenting in cardiac arrest after a flecainide overdose treated with intravenous fat emulsion (IFE), sodium bicarbonate (NaHCO3), and extracorporeal membrane oxygenation (ECMO). This case reviews the pathophysiology and management of flecainide toxicity including novel strategies of IFE and ECMO.