An electronic health record alert increases human immunodeficiency virus screening and case identification in a high-risk emergency department population.

Increased screening for HIV is required to reduce mortality and transmission. Patients with risk factors for HIV may lack access to routine care and emergency departments are an important site for screening and linkage to care. We implemented an electronic health record algorithm to identify patients meeting criteria for HIV screening. Compared to unstructured clinical judgement, the EHR alert increased the number of patients screened and case identification.

Does a brief functional assessment in the emergency department predict outcomes of patients admitted with heart failure? The FASTER-HF study.

BACKGROUND: Evaluation of patients with acute decompensated heart failure includes symptom review, biomarker measurement and comorbidity assessment. Early objective evaluation of functional status is generally not performed. AIM: To investigate whether a simple low-impact functional assessment and measurement of sarcopenia would be safe, feasible and predictive of hospital length of stay and all-cause 30-day hospital readmission. METHODS: We administered 3-minute bicycle ergometry and hand grip strength tests at admission and discharge to patients for whom a decision to admit for heart failure management was made in the emergency department. Associations were examined between test results and length of stay and 30-day readmission. Exclusion criteria included acute coronary syndrome, hypoxia, end-stage renal disease, dementia/delirium and inability to sit at bedside. The Kansas City Cardiomyopathy Questionnaire-12, the Patient Health Questionnaire-2 and the visual analogue scale for dyspnoea were administered at admission, the visual analogue scale at discharge and the Kansas City Cardiomyopathy Questionnaire-12 at 30 days. RESULTS: Fifty patients were enrolled: 58% were female; the mean age was 66.2±12.5 years; 24% had heart failure with preserved ejection fraction. Bicycle ergometry variables did not correlate with outcomes. Change in handgrip strength correlated with readmission, but not after adjustment (rpartial=0.14; P=0.35). Total diuretic dose correlated with length of stay; only discharge visual analogue scale and baseline lung disease had significant adjusted correlations with readmission. CONCLUSIONS: Functional assessment in the emergency department of patients admitted for heart failure did not predict outcomes. However, the prognostic value of these assessments for decision-making about disposition (admission or discharge) may still be warranted.

Impact of non-guideline-based treatment of status epilepticus.

BACKGROUND: This retrospective study analyzed benzodiazepine usage patterns in relation to guideline recommendations for the treatment of generalized convulsive status epilepticus (GCSE) as practiced by emergency medical services (EMS) and the emergency department (ED) of an inner-city hospital. Secondary outcomes of interest were adverse events and admission/discharge outcomes. METHODS: Records of all patients≥18years old diagnosed with GCSE between June 2012 and September 2015 and transported by EMS to our hospital ED were reviewed. RESULTS: Of 44 patients analyzed, 43 (98%) had a history of epilepsy. Benzodiazepine utilization varied; EMS preferred midazolam (69% of cases) while the ED utilized lorazepam (91% of cases). Benzodiazepine dosages used were lower than guideline recommendations. Seizure activity was aborted with benzodiazepines alone in 22 (50%) patients. Twelve patients (27%) experienced seizure recurrence following SE treatment and achievement of seizure cessation. Twenty-three (52%) patients required intubation after arrival to ED. All 44 patients were admitted; 30 (68%) required admission to the intensive care unit. CONCLUSIONS: There was consistent underdosing of benzodiazepines in treatment of GCSE in both EMS and ED settings likely resulting in underachievement of seizure cessation, while intubation rates were higher than reported when compared to previous studies. Prospective studies are needed to identify barriers to optimal benzodiazepine usage in GCSE patients.

Improving Emergency Department Care for Aging Missourians: Guidelines, Accreditation, and Collaboration.

Aging baby-boomers present significant challenges to accessible, affordable emergency care in America for patients of all ages. St. Louis physicians served as early innovators in the field of geriatric emergency medicine. This manuscript summarizes a multi-institutional November 2016 symposium reviewing the Missouri history of geriatric emergency care. In addition, this manuscript describes multispecialty organizations' guidelines, healthcare outcomes research, contemporary medical education paradigms, and evolving efforts to disseminate guideline-based geriatric emergency care using a "Boot Camp" approach and implementation science. This manuscript also reviews local adaptations to emergency medical services and palliative care, as well as the perspectives of emergency department leaders exploring the balance between infrastructure and personnel required to promote guideline-based geriatric emergency care with the anticipated benefits. This discussion is framed within the context of the American College of Emergency Physician's planned geriatric emergency department accreditation process scheduled to begin in 2018.