Does advanced age matter in outcomes after out-of-hospital cardiac arrest in community-dwelling adults?

OBJECTIVE: To assess whether advanced age is an independent predictor of survival to hospital discharge in community-dwelling adult patients who sustained an out-of-hospital cardiac arrest in a suburban county. METHODS: A prospective cohort study was conducted in a suburban county emergency medical services system of community-dwelling adults who had an arrest from a presumed cardiac cause and who received out-of-hospital resuscitative efforts from July 1989 to December 1993. The cohorts were defined by grouping ages by decade: 19-39, 40-49, 50-59, 60-69, 70-79, and 80 or more. The variables measured included age, gender, witnessed arrest, response intervals, location of arrest, documented bystander cardiopulmonary resuscitation, and initial rhythms. The primary outcome was survival to hospital discharge. Results are reported using analysis of variance, chi square, and adjusted odds ratios from a logistic regression model. Age group 50-59 served as the reference group for the regression model. RESULTS: Of the 2,608 total presumed cardiac arrests, the overall survival rate to hospital discharge was 7.25%. Patients in age groups 40-49 and 50-59 experienced the best rate of successful resuscitation (10%). Each subsequent decade had a steady decline in successful outcome: 8.1% for ages 60-69; 7.1% for ages 70-79; and 3.3% for age 80+. In a post-hoc analysis, further separation of the older age group revealed a successful outcome in 3.9% of patients ages 80-89 and 1% in patients 90 and older. Patients aged 80 years or more were more likely to arrest at home, were more likely to have an initial bradyasystolic rhythm, yet had a similar rate of resuscitation to hospital admission. In the regression model, age 80 or older was associated with a significantly worse survival to hospital discharge (OR = 0.4, 95% CI = 0.20 to 0.82). CONCLUSIONS: There was a twofold decrease in survival following out-of-hospital cardiac arrest to discharge in patients aged 80 or more when compared with the reference group in this suburban county setting. However, resuscitation for community-dwelling elders aged 65-89 is not futile. These data support that out-of-hospital resuscitation of elders up to age 90 years is not associated with a universal dismal outcome.

Analysis of insurance payment denials using the prudent layperson standard.

STUDY OBJECTIVES: To review a sample of emergency department payment denials characterized as "not a medical emergency" and to determine medical necessity for each visit using an arbitrary "prudent layperson" standard. METHODS: This study was conducted at a university hospital and was an analysis of a convenience sample of ED payment denials classified as "not a medical emergency" by 2 managed care providers. Each corresponding visit was analyzed if the bill was still outstanding in September 1998. ED records were analyzed for chief complaint and risk factors for morbidity. Any minor disorder lasting 1 day or more and with normal vital signs recorded was considered to not meet the prudent layperson standard of an emergency. Visits for minor trauma that occurred the same day that also required radiographs or suturing were considered emergencies. RESULTS: Two hundred ED visits were retrospectively reviewed. Payer 1 denied 44 visits, of which 38 (86%) met the prudent layperson standard; payer 2 denied 156 visits, of which 113 (62%) met the standard (P >.05). CONCLUSION: A large proportion of ED visits for which payment is denied as "not a medical emergency" may meet the prudent layperson definition of an emergency.

Emergency medical evaluation of psychiatric patients.

STUDY OBJECTIVES: To determine the completeness of documentation and accuracy of medical evaluation for a sample of emergency psychiatric patients. DESIGN: Descriptive, retrospective chart review. SETTING: Nine hundred-bed community teaching hospital with a voluntary psychiatric inpatient unit. TYPE OF PARTICIPANTS: Two hundred ninety-eight emergency department patients with psychiatric chief complaints, all of whom were admitted to the voluntary psychiatric unit of the same community teaching hospital. INTERVENTIONS: None MEASUREMENTS AND MAIN RESULTS: There was failure to document mental status at triage in 56% of patients. The most frequent process deficiencies in the medical evaluation were in the neurological examination. Twelve patients (4%) required acute medical treatment within 24 hours of psychiatric admission, and the ED history and physical examination should have identified an acute condition in 83%. The chart was documented "medically clear" in 80% of patients in whom medical disease should have been identified. Patients less than 55 years old had a four times greater chance of a missed medical diagnosis. CONCLUSION: Process deficiencies in the medical history and physical examination accounted for the vast majority of missed acute medical conditions. The statement "medically clear" is inaccurate and should be replaced by a thorough discharge note.

Importance of emergency physicians as referral sources for academic medical centers. The Gallup Organization Healthcare Group.

STUDY OBJECTIVE: To identify physician referral patterns and factors involved in the patient referral process. DESIGN: A telephone survey conducted on a systematic sample of physicians who referred at least one patient a month to a tertiary care center. SETTING: A major southeastern tertiary care academic medical center. TYPE OF PARTICIPANTS: Self-identified emergency physicians, family physicians, general surgeons, internists, obstetrician-gynecologists, and pediatricians. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Emergency physicians comprised 6% of the surveyed sample. Emergency physicians referred the largest number of patients each month to a tertiary care center (40 patients per month) compared with the other target specialists, who referred an average of 16 patients per month (P < .05). Specialty services most often requested by emergency physicians were internal medicine, trauma, and cardiology. CONCLUSION: Emergency physicians refer more patients to academic medical centers than any other specialty. Academic medical centers should target emergency physicians if they wish to increase their patient referral base.

Violent patients and the prehospital provider.

STUDY OBJECTIVES: To estimate the frequency of violence directed toward prehospital providers; to identify the methods used to manage violent patients in the prehospital setting; and to identify the educational, medical, and legal issues in the prehospital management of violent patients. DESIGN: A convenient sample survey and a descriptive review of ambulance call reports from June to December 1991. SETTING: The survey was distributed to registrants at the National Association of EMS Physicians in Pittsburgh, Pennsylvania, in June 1992. Ambulance call reports were reviewed for a metropolitan county with a service population of 60,000. INTERVENTIONS: None. RESULTS: Only about 50% of survey respondents reported having protocols for the management of violent patients. Law enforcement officers provided assistant in managing violent patients for 97% of respondents, and 81% reported that a violent patient who refused transport could be arrested. Injury to prehospital providers in the past year was reported by 67% of respondents. Although 67% reported some training in the management of violent patients, only 9% had training by law enforcement officers and only 25% thought that they were trained in assessing the scene for potential violence. Ambulance call report review identified an 0.8% incidence of violent episodes. Weapons were evident in 12% of violent encounters. Transport was refused by 18% of violent patients. In 9% of violent encounters, patients were hypoglycemic. No emergency medical technician injuries were reported for the study period. CONCLUSION: The potential for injury to prehospital providers from violent patients is probably widespread, and no mechanism for identifying injuries or exposure to violent patients currently exists. All systems should have protocols for managing violent patients and for restraint application. Educational sessions for self-defense and assessment of the scene for violence may be indicated.

Evaluation and treatment of the gravida and fetus following trauma during pregnancy.

The management of trauma during pregnancy requires an interdisciplinary team approach involving surgeons, emergency medicine physicians, and obstetricians. Management principles are similar to those utilized in nonpregnant patients, but a number of unique circumstances must be considered, including physiologic changes of pregnancy, diagnosis and management of abruptio placentae and fetomaternal hemorrhage, and the management of traumatic cardiac arrest during pregnancy. The routine use of cardiotocography, Kleihauer-Betke assay, and perimortem cesarean section are discussed as new principles in the management of trauma during pregnancy.

Associated reactions during and immediately after rtPA infusion.

The complications of IV recombinant tissue-type plasminogen activator (rtPA) have not been previously reported specifically for the first hours after initiation of the therapy when patients are often in emergency departments or in transport. The charts of 124 patients who received rtPA between April 1986 and December 1987 were retrospectively reviewed for reactions associated with rtPA infusion occurring in the first ten hours after the onset of rtPA administration. Minor bleeding developed in 19% of the patients, and life-threatening bleeding in 3%. Half of the life-threatening bleeding episodes were not predictable by history or physical examination. Arrhythmias were frequent despite the fact that all patients were maintained on IV lidocaine. New premature ventricular contractions occurred in 67%, accelerated idioventricular rhythm in 34%, ventricular tachycardia in 30%, and ventricular fibrillation in 2%. Many of the arrhythmias other than ventricular fibrillation had little hemodynamic consequence and did not require treatment. Neurologic episodes occurred in 3%, including two patients with intracerebral bleeding (1.5%); hypotension requiring treatment developed in 3%; and minor symptoms of allergy in 2%. Administration of rtPA in the ED requires careful patient selection to avoid bleeding complications and close monitoring to detect arrhythmias and changes in vital signs.

Evaluation of emergency medicine residents by nurses.

Emergency medicine residents at William Beaumont Hospital are evaluated quarterly by the nursing staff. The nurse discuss each resident and reach consensus on each evaluation item. Copies of the evaluations are given to each resident, and a copy is used at the resident's biannual evaluation meeting with the program director. Between September 1985 and December 1987, 45 residents in all three years of training were evaluated by the nursing staff on four aspects of performance: managerial skills, communication, teamwork, and clinical organization. The nurses were able to evaluate behavior not usually seen by supervising physicians. Although the residents' attitudes toward these evaluations have not been entirely favorable, overall their behavioral interactions have improved markedly.