Initial experience regarding the safety and yield of rest-stress myocardial perfusion imaging in emergency department patients with mildly abnormal high-sensitivity cardiac troponins.

BACKGROUND: With high-sensitivity troponin testing, approximately a third of patients presenting to emergency departments (EDs) with suspected acute coronary syndromes will have mildly abnormal values. However, data regarding rest-stress myocardial perfusion imaging (MPI) in these patients are limited. We hypothesize that stress testing is safe and that the yield for detecting myocardial ischemia is associated with risk stratification by the HEART score. METHODS AND RESULTS: We conducted a retrospective cohort study of consecutive patients referred for rest-stress MPI with mildly abnormal high-sensitivity troponin T (hs-cTn) values. Outcomes were adverse events related to stress MPI, defined as myocardial infarction or ventricular tachyarrhythmia, and the presence of ischemia, defined as a reversible perfusion defect. Among 213 patients, the median age was 67, most were male (61.5%, n = 131), and prior CAD was common (53.5%, n = 114). Myocardial ischemia was present in 13.6% (n = 29), and there were no adverse events attributable to stress MPI. A higher HEART score was associated with myocardial ischemia (Odds Ratio [OR] 1.50, 95% Confidence Interval [CI] 1.08 to 2.08, P = .002). CONCLUSION: Rest-stress MPI appears safe in patients with mildly abnormal hs-cTn values, and the yield for detecting ischemia is associated with the HEART score, though further validation studies are needed.

A Pilot Study to Reduce Computed Tomography Utilization for Pediatric Mild Head Injury in the Emergency Department Using a Clinical Decision Support Tool and a Structured Parent Discussion Tool.

INTRODUCTION: The American College of Emergency Physicians embarked on the "Choosing Wisely" campaign to avoid computed tomographic (CT) scans in patients with minor head injury who are at low risk based on validated decision rules. We hypothesized that a Pediatric Mild Head Injury Care Path could be developed and implemented to reduce inappropriate CT utilization with support of a clinical decision support tool (CDST) and a structured parent discussion tool. METHODS: A quality improvement project was initiated for 9 weeks to reduce inappropriate CT utilization through 5 interventions: (1) engagement of leadership, (2) provider education, (3) incorporation of a parent discussion tool to guide discussion during the emergency department (ED) visit between the parent and the provider, (4) CDST embedded in the electronic medical record, and (5) importation of data into the note to drive compliance. Patients prospectively were enrolled when providers at a pediatric and a freestanding ED entered data into the CDST for decision making. Rate of care path utilization and head CT reduction was determined for all patients with minor head injury based on International Classification of Diseases, Ninth Revision codes. Targets for care path utilization and head CT reduction were established a priori. Results were compared with baseline data collected from 2013. RESULTS: The CDST was used in 176 (77.5%) of 227 eligible patients. Twelve patients were excluded based on a priori criteria. Adherence to recommendations occurred in 162 (99%) of 164 patients. Head CT utilization was reduced from 62.7% to 22% (odds ratio, 0.17; 95% confidence interval, 0.12-0.24) where CDST was used by the provider. There were no missed traumatic brain injuries in our study group. CONCLUSION: A Pediatric Mild Head Injury Care Path can be implemented in a pediatric and freestanding ED, resulting in reduced head CT utilization and high levels of adherence to CDST recommendations.

Comparison of critically ill patients from three freestanding ED's compared to a tertiary care hospital based ED.

BACKGROUND: Freestanding emergency departments (FEDs) care for all patients, including critically ill, 24/7/365. We characterized patients from three FEDs transferred to intensive care units (ICU) at a tertiary care hospital, and compared hospital length of stay(LOS) between patients admitted to ICUs from FEDs versus a hospital-based ED (HBED). METHODS: We performed a retrospective, observational cohort study from January 2014 to December 2016. Demographic and clinical information was compared between FED and HBED patients with chi-square and fisher's exact tests for categorical variables and Student's t-test for continuous variables. The main outcome of interest was hospital LOS. Multi-variable linear regression was performed to estimate association between LOS and emergency facility type, while adjusting for potential confounders. RESULTS: We included 500 critically ill patients (FED = 250 and HBED = 250). Patients did not differ by age, gender, or BMI. FED patients were more likely to be white (89.6% vs. 70.8%, p < 0.001) and have higher Charlson Co-morbidity Index scores (3.5 vs. 2.4, p < 0.001). Average LOS for FED patients was 5 days, compared to 7 days for HBED patients (p < 0.001). After adjusting for demographic and clinical confounders, there was significant correlation between ED facility type and LOS in hospital (p < 0.001). CONCLUSION: Patients transferred from FEDs to an ICU were similar in age and gender, but more likely to be white with a higher Charlson Comorbidity Index score. FED patients experienced shorter hospital length of stay compared to patients admitted from a HBED.

Procalcitonin as a biomarker for early sepsis in the emergency department.

OBJECTIVES: In the critical care setting, increasing levels of midregional proadrenomedullin (MRproADM), midregional proatrial natriuretic peptide (MRproANP), procalcitonin (PCT), copeptin, and proendothelin-1 (proET-1) have been shown to be correlated with increasing severity of sepsis. The objective of this study was to investigate the utility of sepsis biomarkers in an Emergency Department (ED) population. METHODS: Through a prospective, observational pilot study, we investigated the utility of MRproADM, MRproANP, PCT, copeptin, and proET-1 in predicting a diagnosis of early sepsis in patients presenting to the ED for suspected infection. Data were analyzed using nonparametric Mann-Whitney U-tests, χ²-tests, and receiver operating characteristic curves. RESULTS: Of the 66 patients enrolled in this study, 37 (56.1%) were men, with a median age of 58 years [interquartile range (IQR) 39-69 years], and 19 (28.8%) had a final diagnosis of early sepsis. A higher percentage of sepsis patients compared with no-sepsis patients met systemic inflammatory response syndrome (SIRS) criteria at initial presentation (85.7 vs. 41.3%; P<0.0001) and were admitted to the hospital (84.2 vs. 55.6%; P=0.02). PCT was higher in sepsis patients [median 0.32 ng/ml (IQR 0.19-1.17) vs. 0.18 ng/ml (IQR 0.07-0.54); P=0.04]. There were no differences between groups for MRproADM, MRproANP, copeptin, or proET-1 (P≥0.53). The C-statistic was maximized with the combination of SIRS criteria and PCT levels (0.92±0.05), which was better than PCT alone (0.67±0.08; P=0.005) or SIRS alone (0.75±0.07; P=0.04). CONCLUSION: In this pilot study, we found that the combination of SIRS criteria and PCT levels is useful for the early detection of sepsis in ED patients with suspected infection. Larger studies investigating use of PCT are necessary.

ST2 in emergency department patients with noncardiac dyspnea.

OBJECTIVES: Serum levels of soluble ST2, a member of the interleukin-1 receptor family, predict mortality in emergency department (ED) patients with dyspnea secondary to acute heart failure and acute coronary syndrome. Elevated levels of ST2 have also been described in pulmonary disease, but it is unclear if these are associated with adverse outcomes. The hypothesis for this study was that elevated ST2 levels would be associated with 180-day mortality and 180-day return ED visits or hospital readmission in patients presenting to the ED with noncardiac causes of dyspnea. METHODS: This prospective observational cohort study enrolled a convenience sample of patients presenting to a single academic tertiary care ED with a chief complaint of dyspnea. Exclusion criteria included dyspnea due to chest wall trauma, airway obstruction, and known cardiac etiology (new onset heart failure, prior heart failure with current brain natriuretic peptide > 500 pg/mL, presumed ischemic chest pain, elevated troponin, electrocardiogram changes indicating myocardial infarction or ischemia, heart transplant). ST2 levels were measured at ED presentation and compared between those with and without adverse outcomes. Staff were blinded to ST2 levels. Differences between groups were assessed using the Mann-Whitney U test. RESULTS: Of the 82 patients enrolled, 45 (55%) were female, 48 (59%) were African American, and 34 (42%) were hospitalized. The most frequent ED or hospital diagnosis was chronic obstructive pulmonary disease (COPD) or asthma, in 29 (35%) patients. At 180 days, 36 of 81 patients (44%) had return ED visits, 21 of 81 patients (26%) were readmitted, and five of 82 patients (6%) were deceased. Median ST2 level was 227 ng/mL in patients who died versus 32 ng/mL in those who survived (difference = 195 ng/mL, 95% confidence interval [CI] = 48 to 342 ng/mL, p = 0.006). Median ST2 level was 59 ng/mL in readmitted patients versus 31 ng/mL in nonreadmitted patients (difference = 28 ng/mL, 95% CI = -3 to 60 ng/mL, p = 0.036). Median ST2 levels were 41 ng/mL in patients with return ED visits versus 31 ng/mL in those without return visits (difference = 10 ng/mL, 95% CI = -10 to 20 ng/mL, p = 0.23). CONCLUSIONS: Patients with noncardiac dyspnea who died or required readmission to the hospital within 180 days had higher levels of ST2 compared with nonadmitted survivors. Further research into ST2 as a prognostic tool in pathologic processes not involving the heart, such as pulmonary disease, is warranted.

Hemodynamic changes as a diagnostic tool in acute heart failure--a pilot study.

OBJECTIVES: To examine whether posturally induced changes in cardiac output differentiate patients presenting with dyspnea to the emergency department (ED) with acute heart failure (AHF) from other causes. METHODS: This was an observational study of patients presenting to the ED with dyspnea. Exclusion criteria included ischemic chest pain, electrocardiographic changes diagnostic of acute myocardial infarction, pericardial effusion or chest wall deformities causing dyspnea, or heart transplant. Hemodynamic variables of cardiac index (CI), total peripheral resistance index, and thoracic fluid content (TFC) were determined in upright seated and supine positions 3 minutes apart using bioreactance technology (Cheetah Medical Inc, Portland, Ore). Acute heart failure was defined as either B-type natriuretic peptide 100 to 500 pg/mL and discharge diagnosis of AHF or a B-type natriuretic peptide greater than 500 pg/mL. RESULTS: Of 92 patients, 25 had AHF, 23 had asthma/chronic obstructive pulmonary disease (COPD), and 44 had dyspnea related to other conditions; 41 (44.1%) were male, 56 (60.2%) were African American, and the mean age was 58 ± 15.0 years. Mean baseline TFC was higher in AHF vs asthma/COPD (59.3 ± 26.0 vs 39.7 ± 14.8 1/kW, P = .003) and trended higher compared to other patients with dyspnea (49.2 ± 22.0, P = .10). Postural changes in mean CI were lower in AHF (-0.20 ± 0.84 L min(-1) m(-2)) vs asthma/COPD (1.20 ± 1.23 L min(-1) m(-2); P = .002) and other dyspnea patients (0.82 ± 0.91 L min(-1) m(-2); P = .007). CONCLUSION: Patients with AHF have greater TFC but lower CI responses to postural changes compared to patients with asthma and COPD. Knowledge of these changes may help rapidly differentiate AHF from asthma and COPD in the ED.