Design and implementation of the hospital airway resuscitation trial.

Guidelines for the management of in-hospital cardiac arrest resuscitation are often drawn from evidence generated in out-of-hospital cardiac arrest populations and applied to the in-hospital setting. Approach to airway management during resuscitation is one example of this phenomenon, with the recommendation to place either a supraglottic airway or endotracheal tube when performing advanced airway management during in-hospital cardiac arrest based mainly in clinical trials conducted in the out-of-hospital setting. The Hospital Airway Resuscitation Trial (HART) is a pragmatic cluster-randomized superiority trial comparing a strategy of first choice supraglottic airway to a strategy of first choice endotracheal intubation during resuscitation from in-hospital cardiac arrest. The design includes a number of innovative elements such as a highly pragmatic design drawing from electronic health records and a novel primary outcome measure for cardiac arrest trials-alive-and-ventilator free days. Many of the topics explored in the design of HART have wide relevance to other trials in in-hospital cardiac arrest populations.

A prospective observational study evaluating the use of remote patient monitoring in ED discharged COVID-19 patients in NYC.

OBJECTIVES: We investigated whether continuous remote patient monitoring (RPM) could significantly reduce return Emergency Department (ED) revisits among coronavirus disease 2019 (COVID-19) patients discharged from the emergency Department. MATERIALS AND METHODS: A prospective observational study was conducted from a total of 2833 COVID-19 diagnosed patients who presented to the Montefiore Medical Center ED between September 2020-March 2021. Study patients were remotely monitored through a digital platform that was supervised 24/7 by licensed healthcare professionals. Age and time-period matched controls were randomly sampled through retrospective review. The primary outcome was ED revisit rates among the two groups. RESULTS: In our study, 150 patients enrolled in the RPM program and 150 controls were sampled for a total of 300 patients. Overall, 59.1% of the patients identified as Hispanic/Latino. The RPM group had higher body mass index (BMI) (29 (25-35) vs. 27 (25-31) p-value 0.020) and rates of hypertension (50.7% (76) vs. 35.8% (54) p-value 0.009). There were no statistically significant differences in rates of ED revisit between the RPM group (8% (12)) and control group (9.3% (14)) (OR: 0.863; 95% CI:0.413-1. 803; p- 0.695). DISCUSSION AND CONCLUSION: Our study explored the impact of continuous monitoring versus intermittent monitoring for reducing ED revisits in a largely underrepresented population of the Bronx. Our study demonstrated that continuous remote patient monitoring showed no significant difference in preventing ED revisits compared to non-standardized intermittent monitoring. However, potential other acute care settings where RPM may be useful for identifying high-risk patients for early interventions warrant further study.

Should COVID-19 symptoms be used to cohort patients in the emergency department? A retrospective analysis.

OBJECTIVE: To determine how cohorting patients based on presenting complaints affects risk of nosocomial infection in crowded Emergency Departments (EDs) under conditions of high and low prevalence of COVID-19. METHODS: This was a retrospective analysis of presenting complaints and PCR tests collected during the COVID-19 epidemic from 4 EDs from a large hospital system in Bronx County, NY, from May 1, 2020 to April 30, 2021. Sensitivity, specificity, positive and negative predictive value (PPV, NPV) were calculated for a symptom screen based on the CDC list of COVID-19 symptoms: fever/chills, shortness of breath/dyspnea, cough, muscle or body ache, fatigue, headache, loss of taste or smell, sore throat, nasal congestion/runny nose, nausea, vomiting, and diarrhea. PPV was calculated for varying values of prevalence. RESULTS: There were 80,078 visits with PCR tests. The sensitivity of the symptom screen was 64.7% (95% CI: 63.6, 65.8), specificity 65.4% (65.1, 65.8). PPV was 16.8% (16.5, 17.0) and NPV was 94.5% (94.4, 94.7) when the observed prevalence of COVID-19 in the ED over the year was 9.7%. The PPV of fever/chills, cough, body and muscle aches and nasal congestion/runny nose were each approximately 25% across the year, while diarrhea, nausea, vomiting and headache were less predictive, (PPV 4.7%-9.6%) The combinations of fever/chills, cough, muscle/body aches, and shortness of breath had PPVs of 40-50%. The PPV of the screen varied from 3.7% (3.6, 3.8) at 2% prevalence of COVID-19 to 44.3% (44.0, 44.7) at 30% prevalence. CONCLUSION: The proportion of patients with a chief complaint of COVID-19 symptoms and confirmed COVID-19 infection was exceeded by the proportion without actual infection. This was true when prevalence in the ED was as high as 30%. Cohorting of patients based on the CDC's list of COVID-19 symptoms will expose many patients who do not have COVID-19 to risk of nosocomially acquired COVID-19. EDs should not use the CDC list of COVID-19 symptoms as the only strategy to minimize exposure.

Post-severe Acute Respiratory Syndrome Coronavirus 2 Monoclonal Antibody Treatment Hospitalizations as a Sentinel for Emergence of Viral Variants in New York City.

We partnered with the US Department of Health and Human Services to treat high-risk, nonadmitted coronavirus disease 2019 (COVID-19) patients with bamlanivimab in the Bronx, New York per Emergency Use Authorization criteria. Increasing posttreatment hospitalizations were observed monthly between December 2020 and March 2021 in parallel to the emergence of severe acute respiratory syndrome coronavirus 2 variants in New York City.

Implementation of an aortic dissection CT protocol with clinical decision support aimed at decreasing radiation exposure by reducing routine abdominopelvic imaging.

Patients suspected of having an acute aortic syndrome in the ED typically undergo CT of the chest/abdomen/pelvis. However, the overwhelming majority of these exams are negative. With the help of clinical decision support, we implemented a new radiologist monitored 'aortic dissection screening protocol' that forgoes routine abdominopelvic imaging in order to reduce radiation dose without compromising diagnostic accuracy. The purpose of the present study is to assess the performance of this protocol. A retrospective analysis was performed to study the effect of the dissection screening protocol on the diagnostic yield, radiation and contrast dose on a total of 835 ED patients who underwent CT scans for suspected aortic dissection over a 48-week study period immediately before and after implementation of the protocol. 3.4% (28/835) of examinations were positive for an acute aortic syndrome over the 48-week study period with no difference in positivity before and after implementation of the 'aortic dissection screening' protocol, 3.0% vs. 3.7%, respectively (p = 0.57). There was a 14.6% reduction in median radiation dose and a 16% decrease in contrast volume utilization for the total ED population who underwent CT for aortic dissection using any protocol in the period after implementation of the 'aortic dissection screening' protocol. Aortic dissection CT in the ED is negative in the overwhelming majority of cases. A monitored 'aortic dissection screening' protocol that initially images the chest only significantly reduced contrast and radiation dose without reducing diagnostic accuracy for ED patients who underwent CT for aortic dissection.

An expanded HIV screening strategy in the Emergency Department fails to identify most patients with undiagnosed infection: insights from a blinded serosurvey.

Screening for HIV in Emergency Departments (EDs) is recommended to address the problem of undiagnosed HIV. Serosurveys are an important method for estimating the prevalence of undiagnosed HIV and can provide insight into the effectiveness of an HIV screening strategy. We performed a blinded serosurvey in an ED offering non-targeted HIV screening to determine the proportion of patients with undiagnosed HIV who were diagnosed during their visit. The study was conducted in a high-volume, urban ED and included patients who had blood drawn for clinical purposes and had sufficient remnant specimen to undergo deidentified HIV testing. Among 4752 patients not previously diagnosed with HIV, 1403 (29.5%) were offered HIV screening and 543 (38.7% of those offered) consented. Overall, undiagnosed HIV was present in 12 patients (0.25%): six among those offered screening (0.4%), and six among those not offered screening (0.2%). Among those with undiagnosed HIV, two (16.7%) consented to screening and were diagnosed during their visit. Despite efforts to increase HIV screening, more than 80% of patients with undiagnosed HIV were not tested during their ED visit. Although half of those with undiagnosed HIV were missed because they were not offered screening, the yield was further diminished because a substantial proportion of patients declined screening. To avoid missed opportunities for diagnosis in the ED, strategies to further improve implementation of HIV screening and optimize rates of consent are needed.

Effect of a Single Dose of Oral Opioid and Nonopioid Analgesics on Acute Extremity Pain in the Emergency Department: A Randomized Clinical Trial.

Importance: The choice of analgesic to treat acute pain in the emergency department (ED) lacks a clear evidence base. The combination of ibuprofen and acetaminophen (paracetamol) may represent a viable nonopioid alternative. Objectives: To compare the efficacy of 4 oral analgesics. Design, Settings, and Participants: Randomized clinical trial conducted at 2 urban EDs in the Bronx, New York, that included 416 patients aged 21 to 64 years with moderate to severe acute extremity pain enrolled from July 2015 to August 2016. Interventions: Participants (104 per each combination analgesic group) received 400 mg of ibuprofen and 1000 mg of acetaminophen; 5 mg of oxycodone and 325 mg of acetaminophen; 5 mg of hydrocodone and 300 mg of acetaminophen; or 30 mg of codeine and 300 mg of acetaminophen. Main Outcomes and Measures: The primary outcome was the between-group difference in decline in pain 2 hours after ingestion. Pain intensity was assessed using an 11-point numerical rating scale (NRS), in which 0 indicates no pain and 10 indicates the worst possible pain. The predefined minimum clinically important difference was 1.3 on the NRS. Analysis of variance was used to test the overall between-group difference at P = .05 and 99.2% CIs adjusted for multiple pairwise comparisons. Results: Of 416 patients randomized, 411 were analyzed (mean [SD] age, 37 [12] years; 199 [48%] women; 247 [60%] Latino). The baseline mean NRS pain score was 8.7 (SD, 1.3). At 2 hours, the mean NRS pain score decreased by 4.3 (95% CI, 3.6 to 4.9) in the ibuprofen and acetaminophen group; by 4.4 (95% CI, 3.7 to 5.0) in the oxycodone and acetaminophen group; by 3.5 (95% CI, 2.9 to 4.2) in the hydrocodone and acetaminophen group; and by 3.9 (95% CI, 3.2 to 4.5) in the codeine and acetaminophen group (P = .053). The largest difference in decline in the NRS pain score from baseline to 2 hours was between the oxycodone and acetaminophen group and the hydrocodone and acetaminophen group (0.9; 99.2% CI, -0.1 to 1.8), which was less than the minimum clinically important difference in NRS pain score of 1.3. Adverse events were not assessed. Conclusions and Relevance: For patients presenting to the ED with acute extremity pain, there were no statistically significant or clinically important differences in pain reduction at 2 hours among single-dose treatment with ibuprofen and acetaminophen or with 3 different opioid and acetaminophen combination analgesics. Further research to assess adverse events and other dosing may be warranted. Trial Registration: clinicaltrials.gov Identifier: NCT02455518.

Prospective study of a non-restrictive decision rule for acute aortic syndrome.

OBJECTIVES: To determine the impact of a non-restrictive clinical decision rule on CT utilization for Emergency Department patients suspected of having an acute aortic syndrome (AAS). METHODS: We prospectively assessed the performance of a previously described, collaboratively designed, non-restrictive clinical decision rule for AAS. Emergency Department patients with suspected AAS were stratified into low and high-risk groups based on decision rule results, from July 2013-August 2014. Patients with acute trauma, prior AAS or aortic surgery were excluded. CT dose reduction protocols were concurrently implemented as a quality improvement measure. Bivariate analysis was performed to compare the prospective cohort with the historical derivation cohort for CT utilization rates, results of CT, AAS incidence and radiation exposure. The performance of the clinical decision rule was evaluated. RESULTS: Compared with the historic cohort, the study cohort demonstrated a lower CT utilization rate [0.344% (427/124,093) versus 0.477% (1465/306,961), (p<0.001)], a trend toward higher CT diagnostic yield [4.4% (19/427) versus 2.7% (40/1465), (p=0.08)]. AAS incidence was similar [0.015% (19/124,093) versus 0.013% (40/306,961), (p=0.57)]. The mean effective radiation dose was markedly lower [12±5.5mSv versus 43±20mSv, (p<0.0001)]. The clinical decision rule correctly stratified only 56% (10/18) of patients with AAS as high-risk. CONCLUSIONS: A non-restrictive, collaboratively designed, clinical decision rule for Emergency Department patients with suspected AAS performed poorly in risk-stratifying patients for AAS. However, its implementation was associated with a significant and safe decrease in CT utilization.

Temperature measurement in the adult emergency department: oral, tympanic membrane and temporal artery temperatures versus rectal temperature.

OBJECTIVE: The objective was to compare agreement between three non-invasive measures of temperature and rectal temperatures and to estimate the sensitivity and specificity of these measures to detect a rectal temperature of 38°C or higher. METHODS: We conducted a study of the diagnostic accuracy of oral, tympanic membrane (TM) and temporal artery (TA) thermometry to measure fever in an urban emergency department (ED). Data were collected from adult patients who received rectal temperature measurement. Bland-Altman analysis was performed; sensitivity, specificity and 95% CIs were calculated. RESULTS: 987 patients were enrolled. 36% of the TM and TA readings differed by 0.5°C or more from rectal temperatures, 50% of oral temperatures. TM measures were most precise-the SD of the difference from rectal was 0.4°C TM, and 0.6°C for oral and TA (p<0.001). The sensitivities of a 38°C cutpoint on oral, TM and TA measures to detect a rectal temperature of 38°C or higher were: 37.0%, 68.3% and 71.1%, respectively (oral vs TM and TA p<0.001). The corresponding specificities were 99.4%, 98.2% and 92.3% (oral, TM and TA) with oral specificity significantly higher than the other two methods (p<0.01). TM and TA cutpoints of 37.5°C provided greater than 90% sensitivity to detect fever with specificity of 90% and 72%, respectively. CONCLUSIONS: None of the non-invasive methods met benchmarks for diagnostic accuracy using the criterion of 38°C to detect rectal temperature of 38°C. A TM cutpoint of 37.5°C provides maximum diagnostic accuracy of the three non-invasive measures.

Diphenhydramine as Adjuvant Therapy for Acute Migraine: An Emergency Department-Based Randomized Clinical Trial.

STUDY OBJECTIVE: More than 1 million patients present to US emergency departments (EDs) annually seeking care for acute migraine. Parenteral antihistamines have long been used in combination with antidopaminergics such as metoclopramide to treat acute migraine in the ED. High-quality data supporting this practice do not exist. We determine whether administration of diphenhydramine 50 mg intravenously+metoclopramide 10 mg intravenously results in greater rates of sustained headache relief than placebo+metoclopramide 10 mg intravenously. METHODS: This was a randomized, double-blind, clinical trial comparing 2 active treatments for acute migraine in an ED. Eligible patients were adults younger than 65 years presenting with an acute moderate or severe headache meeting International Classification of Headache Disorders-2 migraine criteria. Patients were stratified according to presence or absence of allergic symptoms. The primary outcome was sustained headache relief, defined as achieving a headache level of mild or none within 2 hours of medication administration and maintaining this level of relief without use of any additional headache medication for 48 hours. Secondary efficacy outcomes included mean improvement on a 0 to 10 verbal scale between baseline and 1 hour, the frequency with which subjects indicated they would want the same medication the next time they present to the ED with migraine, and the ED throughput time. Sample size calculation using a 2-sided α of .05, a ß of .20, and a 15% difference between study arms determined the need for 374 patients. An interim analysis was conducted when data were available for 200 subjects. RESULTS: Four hundred twenty patients were approached for participation. Two hundred eight eligible patients consented to participate and were randomized. At the planned interim analysis, the data and safety monitoring board recommended that the study be halted for futility. Baseline characteristics were comparable between the groups. Fourteen percent (29/208) of the sample reported allergic symptoms. Of patients randomized to diphenhydramine, 40% (40/100) reported sustained relief at 48 hours, as did 37% (38/103) of patients randomized to placebo (95% confidence interval [CI] for difference of 3%: -10% to 16%). One hour after medication administration, patients randomized to diphenhydramine improved by a mean of 5.1 on the 0 to 10 scale versus 4.8 for those randomized to placebo (95% CI for difference of 0.3: -0.6 to 1.1). Eighty-five percent (84/99) of the patients in the diphenhydramine arm reported they would want the same medication combination during a subsequent ED visit, as did 76% (77/102) of those who received placebo (95% CI for difference of 9%: -2% to 20%). Median ED length of stay was 122 minutes (interquartile range 84 to 180 minutes) in the diphenhydramine group and 139 minutes (interquartile range 90 to 235 minutes) in the placebo arm. Rates of adverse effects, including akathisia, were comparable between the groups. CONCLUSION: Intravenous diphenhydramine, when administered as adjuvant therapy with metoclopramide, does not improve migraine outcomes.

Naproxen With Cyclobenzaprine, Oxycodone/Acetaminophen, or Placebo for Treating Acute Low Back Pain: A Randomized Clinical Trial.

IMPORTANCE: Low back pain (LBP) is responsible for more than 2.5 million visits to US emergency departments (EDs) annually. These patients are usually treated with nonsteroidal anti-inflammatory drugs, acetaminophen, opioids, or skeletal muscle relaxants, often in combination. OBJECTIVE: To compare functional outcomes and pain at 1 week and 3 months after an ED visit for acute LBP among patients randomized to a 10-day course of (1) naproxen + placebo; (2) naproxen + cyclobenzaprine; or (3) naproxen + oxycodone/acetaminophen. DESIGN, SETTING, AND PARTICIPANTS: This randomized, double-blind, 3-group study was conducted at one urban ED in the Bronx, New York City. Patients who presented with nontraumatic, nonradicular LBP of 2 weeks' duration or less were eligible for enrollment upon ED discharge if they had a score greater than 5 on the Roland-Morris Disability Questionnaire (RMDQ). The RMDQ is a 24-item questionnaire commonly used to measure LBP and related functional impairment on which 0 indicates no functional impairment and 24 indicates maximum impairment. Beginning in April 2012, a total of 2588 patients were approached for enrollment. Of the 323 deemed eligible for participation, 107 were randomized to receive placebo and 108 each to cyclobenzaprine and to oxycodone/acetaminophen. Follow-up was completed in December 2014. INTERVENTIONS: All participants were given 20 tablets of naproxen, 500 mg, to be taken twice a day. They were randomized to receive either 60 tablets of placebo; cyclobenzaprine, 5 mg; or oxycodone, 5 mg/acetaminophen, 325 mg. Participants were instructed to take 1 or 2 of these tablets every 8 hours, as needed for LBP. They also received a standardized 10-minute LBP educational session prior to discharge. MAIN OUTCOMES AND MEASURES: The primary outcome was improvement in RMDQ between ED discharge and 1 week later. RESULTS: Demographic characteristics were comparable among the 3 groups. At baseline, median RMDQ score in the placebo group was 20 (interquartile range [IQR],17-21), in the cyclobenzaprine group 19 (IQR,17-21), and in the oxycodone/acetaminophen group 20 (IQR,17-22). At 1-week follow-up, the mean RMDQ improvement was 9.8 in the placebo group, 10.1 in the cyclobenzaprine group, and 11.1 in the oxycodone/acetaminophen group. Between-group difference in mean RMDQ improvement for cyclobenzaprine vs placebo was 0.3 (98.3% CI, -2.6 to 3.2; P = .77), for oxycodone/acetaminophen vs placebo, 1.3 (98.3% CI, -1.5 to 4.1; P = .28), and for oxycodone/acetaminophen vs cyclobenzaprine, 0.9 (98.3% CI, -2.1 to 3.9; P = .45). CONCLUSIONS AND RELEVANCE: Among patients with acute, nontraumatic, nonradicular LBP presenting to the ED, adding cyclobenzaprine or oxycodone/acetaminophen to naproxen alone did not improve functional outcomes or pain at 1-week follow-up. These findings do not support use of these additional medications in this setting. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01587274.

Randomized trial of IV valproate vs metoclopramide vs ketorolac for acute migraine.

OBJECTIVE: We compared the efficacy of IV valproate with metoclopramide and with ketorolac in patients presenting to an emergency department (ED) with acute migraine. METHODS: This was a double-blind comparative efficacy trial. Patients were randomized to 1,000 mg sodium valproate, 10 mg metoclopramide, or 30 mg ketorolac, each administered as an IV drip over 15 minutes. The primary outcome was improvement in headache by 1 hour, measured on a verbal 0 to 10 scale, at baseline and 60 minutes later. Important secondary outcomes included (1) need for rescue medication in the ED, and (2) sustained headache freedom. RESULTS: Three hundred thirty patients were enrolled over 30 months beginning in October 2010. Baseline characteristics were comparable among the 3 arms. On the primary outcome, patients receiving IV valproate improved by a mean of 2.8 (95% confidence interval [CI]: 2.3, 3.3) on the 0 to 10 scale; those receiving IV metoclopramide improved by 4.7 (95% CI: 4.2, 5.2); and those receiving IV ketorolac improved by 3.9 (95% CI: 3.3, 4.5). On the secondary endpoints, 69% (95% CI: 60%, 78%) of patients receiving valproate required rescue medication, compared with 33% (95% CI: 24%, 42%) of metoclopramide patients and 52% (95% CI: 42%, 63%) of those assigned to ketorolac. Sustained headache freedom was achieved in 4% (95% CI: 0%, 7%) of those randomized to valproate, 11% (95% CI: 5%, 17%) of metoclopramide patients, and 16% (95% CI: 9%, 23%) receiving ketorolac. In the metoclopramide arm, 6% (95% CI: 3%, 12%) of patients reported feeling "very restless" after investigational medication administration. CONCLUSIONS: Valproate was less efficacious than either metoclopramide or ketorolac. Metoclopramide demonstrated superiority to ketorolac on several endpoints. CLASSIFICATION OF EVIDENCE: This study provides Class I evidence that in ED patients with acute migraine, IV valproate is inferior to metoclopramide or ketorolac in improving headache outcomes.

Use of butterfly needles to draw blood is independently associated with marked reduction in hemolysis compared to intravenous catheter.

OBJECTIVES: Hemolysis of blood samples drawn in the emergency department (ED) is a common problem that can interfere with timely diagnosis and appropriate treatment. The objective of this study was to identify the smallest number of remediable factors that independently increases the risk of hemolysis to design an effective strategy to address this issue. METHODS: This was a prospective, observational, cross-sectional study of blood specimens obtained by ED staff in an urban, academic, adult ED in a tertiary care center. The staff member who drew the specimen recorded data on a standardized data collection instrument about device (intravenous [IV] catheter or butterfly needle), needle size, anatomic site, fullness of collection tube, tourniquet time, and difficulty of venipuncture. Specimens were sent to the laboratory by a vacuum-powered tube system. A standard automated process that measures free hemoglobin was used to identify hemolysis. A multivariable logistic regression and a tabular analysis stratified by device were performed. Ninety-five percent confidence intervals (CIs) were calculated around the odds ratios (ORs) and around the difference between hemolysis rates. RESULTS: Data were collected on 5,118 blood specimens. There were 4,513 specimens with complete data on all characteristics of the blood draw included in the analyses. The overall hemolysis rate was 12.5% (95% CI = 11.6% to 13.5%), 14.6% in blood drawn from IV catheters and 2.7% from butterfly needles (difference = 11.9%; 95% CI = 10.2% to 13.4%). Device was the strongest independent predictor of hemolysis (OR = 7.7; 95% CI = 4.9 to 12.0). In specimens drawn by IV catheter, hemolysis was significantly higher when blood was drawn from locations other than the antecubital fossa, with small-gauge catheters, collection tubes ≤ half full, tourniquet time ≥ 1 minute, and difficult venipuncture. In contrast, none of these factors was associated with hemolysis when blood was drawn by butterfly needle. CONCLUSIONS: The device used to collect blood was the strongest independent predictor of hemolysis in blood samples drawn in the ED in this study. This finding suggests that the most effective strategy to reduce the rate of hemolysis in the ED is to use butterfly needles for phlebotomy rather than IV catheters.

Derivation of an abbreviated instrument for use in emergency department low back pain research: the five-item Roland Morris Questionnaire.

OBJECTIVES: Low back pain (LBP) is a common reason for emergency department (ED) visits in the United States. Pain and functional outcomes after ED visits for LBP tend to be poor. ED-based clinical LBP research is hampered by complexity of available outcome instruments, which can be time-consuming to administer. The purpose of this investigation was to determine if a shorter version of the well-validated and commonly used Roland Morris Disability Questionnaire (RMDQ) would retain the original 24-item instrument's ability to assess functional outcomes accurately in ED patients with LBP. METHODS: The authors used deidentified data obtained from a prospective LBP cohort study, which enrolled 674 patients during index ED visits for LBP, and followed them by telephone 1 week and 3 months later. Five items were selected from the original 24 items of the RMDQ using regression techniques. Internal consistency of the abbreviated scale was measured using Cronbach's alpha. The strength of association between the five-item scale (RM5) and the parent scale was determined at baseline, 1 week, and 3 months. The association between change in the parent scale and change in the RM5 and the change in RM5 that was most closely associated with a minimum clinically significant difference on the RMDQ were also determined. RESULTS: The Cronbach's alpha for the RM5 was 0.88 (95% confidence interval [CI] = 0.87 to 0.89) at baseline, 0.96 (95% CI = 0.96 to 0.96) at 7 days, and 0.97 (95% CI = 0.97 to 0.97) at 3 months. The Pearson correlation coefficient for the RM5 versus the parent scale was 0.93 (R(2)  = 0.86) at baseline, 0.98 (R(2)  = 0.96) at 1 week, and 0.98 (R(2)  = 0.96) at 3 months. The correlations between change from baseline in the abbreviated scale and the parent scale were 0.95 (R(2)  = 0.90) and 0.96 (R(2)  = 0.92) at 7 days and 3 months, respectively. A one-point change in the RM5 has a sensitivity of 96% (95% CI = 93% to 98%) and a specificity of 92% (95% CI = 89% to 94%) for the minimum clinically significant change on the RMDQ. CONCLUSIONS: An abbreviated five-item version of the RMDQ was developed. Pending independent validation, this shortened instrument should streamline ED-based low back pain research.

Preliminary development of a clinical decision rule for acute aortic syndromes.

OBJECTIVE: Patients with suspected acute aortic syndromes (AAS) often undergo computed tomography (CT) with negative results. We sought clinical and diagnostic criteria to identify low-risk patients, an initial step in developing a clinical decision rule. METHODS: We retrospectively identified all adults presenting to our emergency department (ED) from January 1, 2006, to August 1, 2010, who underwent CT angiography for suspected AAS without prior trauma or AAS. A total of 1465 patients met inclusion criteria; a retrospective case-controlled review (ratio 1:4) was conducted. Cases were diagnosed with aortic dissection, intramural hematoma, penetrating atherosclerotic ulcer, or ruptured aneurysm. RESULTS: Of the patients who underwent CT, 2.7% (40/1465) had an AAS; 2 additional cases were diagnosed after admission (ED miss rate, 5% [2/42]). Patients with AAS were significantly older than controls (66 vs 59 years; P = .008). Risk factors included abnormal chest radiograph (sensitivity, 79% [26/33]; specificity, 82% [113/137]) and acute chest pain (sensitivity, 83% [29/35]; specificity, 71% [111/157]). None of the 19 patients with resolved pain upon ED presentation had AAS. These data support a 2-step rule: first screen for ongoing pain; if present, screen for acute chest pain or an abnormal chest radiograph. This approach achieves a 54% (84/155) reduction in CT usage with a sensitivity for AAS of 96% (95% confidence interval, 89%-100%), negative predictive value of 99.8% (99.4%-100%), and a false-negative rate of 1.7% (1/84). CONCLUSIONS: Our results demonstrate a need to safely identify patients at low risk for AAS who can forgo CT. We developed a preliminary 2-step clinical decision rule, which requires validation.

A randomized trial of intravenous ketorolac versus intravenous metoclopramide plus diphenhydramine for tension-type and all nonmigraine, noncluster recurrent headaches.

STUDY OBJECTIVE: We compare metoclopramide 20 mg intravenously, combined with diphenhydramine 25 mg intravenously, with ketorolac 30 mg intravenously in adults with tension-type headache and all nonmigraine, noncluster recurrent headaches. METHODS: In this emergency department (ED)-based randomized, double-blind study, we enrolled adults with nonmigraine, noncluster recurrent headaches. Patients with tension-type headache were a subgroup of special interest. Our primary outcome was a comparison of the improvement in pain score between baseline and 1 hour later, assessed on a 0 to 10 verbal scale. We defined a between-group difference of 2.0 as the minimum clinically significant difference. Secondary endpoints included need for rescue medication in the ED, achieving headache freedom in the ED and sustaining it for 24 hours, and patient's desire to receive the same medication again. RESULTS: We included 120 patients in the analysis. The metoclopramide/diphenhydramine arm improved by a median of 5 (interquartile range 3, 7) scale units, whereas the ketorolac arm improved by a median of 3 (IQR 2, 6) (95% confidence interval [CI] for difference 0 to 3). Metoclopramide+diphenhydramine was superior to ketorolac for all 3 secondary outcomes: the number needed to treat for not requiring ED rescue medication was 3 (95% CI 2 to 6); for sustained headache freedom, 6 (95% CI 3 to 20); and for wish to receive the same medication again, 7 (95% CI 4 to 65). Tension-type headache subgroup results were similar. CONCLUSION: For adults who presented to an ED with tension-type headache or with nonmigraine, noncluster recurrent headache, intravenous metoclopramide+diphenhydramine provided more headache relief than intravenous ketorolac.

A randomized controlled trial of a comprehensive migraine intervention prior to discharge from an emergency department.

OBJECTIVES: Patients who use an emergency department (ED) for acute migraine headaches have higher migraine disability scores, lower socioeconomic status, and are unlikely to have used a migraine-specific medication prior to presentation to the ED. The objective was to determine if a comprehensive migraine intervention, delivered just prior to ED discharge, could improve migraine impact scores 1 month after the ED visit. METHODS: This was a randomized controlled trial of a comprehensive migraine intervention versus typical care among patients who presented to an ED for management of acute migraine. At the time of discharge, for patients randomized to comprehensive care, the research team reinforced their diagnosis, shared a migraine education presentation from the National Library of Medicine, provided them with six tablets of sumatriptan 100 mg and 14 tablets of naproxen 500 mg, and if they wished, provided them with an expedited free appointment to the institution's headache clinic. Patients randomized to typical care received the care their attending emergency physicians (EPs) felt was appropriate. The primary outcome was a between-group comparison of the Headache Impact Test (HIT-6) score, a validated headache assessment instrument, 1 month after ED discharge. Secondary outcomes included an assessment of satisfaction with headache care and use of migraine-specific medication within that 1-month period. RESULTS: Over a 19-month period, 50 migraine patients were enrolled. One-month follow-up was successfully obtained in 92% of patients. Baseline characteristics were comparable. One-month HIT-6 scores in the two groups were nearly identical (59 vs. 56, 95% confidence interval [CI] for difference of 3 = -5 to 11), as was dissatisfaction with overall headache care (17% vs. 18%, 95% CI for difference of 1% = -22% to 24%). Patients randomized to the comprehensive intervention were more likely to be using triptans or migraine-specific therapy (43% vs. 0%, 95% CI for difference of 43% = 20 to 63%) 1 month later. CONCLUSIONS: A comprehensive migraine intervention, when compared to typical care, did not improve HIT-6 scores (a validated measure of the effect of migraine on one's daily life) 1 month after ED discharge. Future work is needed to define a migraine intervention that is practical and useful in an ED, where many underserved patients, of necessity, present for care.

Predicting 7-day and 3-month functional outcomes after an ED visit for acute nontraumatic low back pain.

BACKGROUND: Recent work has shown that two-thirds of patients report functional disability 1 week after an emergency department (ED) visit for nontraumatic musculoskeletal low back pain (LBP). Nearly half of these patients report functional disability 3 months later. Identifying high-risk predictors of functional disability at each of these 2 time points will allow emergency clinicians to provide individual patients with an evidence-based understanding of their risk of protracted symptoms. OBJECT: The aim of the present study was to determine whether 5 high-risk features previously identified in various primary care settings predict poor functional outcomes among patients in the ED. The hypothesized predictors are as follows: LBP-related functional disability at baseline, radicular signs, depression, a work-related injury, or a history of chronic or recurrent LBP before the index episode. METHODS: We conducted a prospective observational cohort study of patients in the ED with a chief complaint of nontraumatic LBP, which the ED attending physician classified as musculoskeletal. We interviewed patients in the ED before discharge and performed a baseline assessment of functional disability using the 24-item Roland-Morris questionnaire. We also trichotomized the patient's baseline history of LBP into chronic (defined as 30 straight days with continuous LBP or a history of acute exacerbations more frequently than once per week); episodic (acute exacerbations more frequently than once per year but less frequently than once per week), or rarely/never (less frequently than once per year or no history of LBP). We performed telephone follow-up 1 week and 3 months after ED discharge using a scripted closed-question data collection instrument. The primary outcome was any functional limitation attributable to LBP at 1 week and 3 months, defined as a score greater than zero on the Roland-Morris questionnaire. We used logistic regression, adjusted for age, sex, and educational level, to assess the independent association between functional disability and each of the 5 hypothesized predictors listed above. RESULTS: We approached 894 patients for participation and included 556. We obtained follow-up on 97% and 92% of our sample at 1 week and 3 months, respectively. Two of the 5 hypothesized variables predicted functional disability at both time points: higher baseline Roland-Morris score (odds ratio [OR], 4.3; 95% confidence interval [CI], 2.6-6.9) and chronic LBP (OR, 2.3; 95% CI, 1.1-4.8) were associated with 7-day functional disability. These same 2 variables predicted functional disability 3 months after ED discharge-higher baseline Roland-Morris score (OR, 2.3; 95% CI, 1.4-3.9) and chronic LBP (OR, 2.8; 95% CI, 1.5-5.2). The remaining 3 hypothesized predictors (depression, radicular signs, and on-the-job injury) did not predict functional outcome at either time point. CONCLUSIONS: Patients in the ED with worse baseline functional impairment and a history of chronic LBP are 2 to 4 times most likely to have poor short- and longer-term outcomes.

One-week and 3-month outcomes after an emergency department visit for undifferentiated musculoskeletal low back pain.

STUDY OBJECTIVE: Nearly 3 million patients present to US emergency departments (EDs) annually with undifferentiated musculoskeletal low back pain. Little is known about short- and longer-term outcomes in this group. We seek to describe the pain and functional outcomes 1 week and 3 months after discharge in a sample of ED patients presenting with undifferentiated musculoskeletal low back pain. METHODS: We used a prospective observational descriptive cohort design, enrolling ED patients with a chief complaint of low back pain classified as musculoskeletal in origin by the ED attending physician. We defined low back pain as pain originating in the posterior back between the tips of the scapulae and upper buttocks and excluded any patient with a traumatic back injury occurring within the previous month. We interviewed patients in the ED and then by telephone follow-up 1 week and 3 months after ED discharge, using a scripted closed-question data collection instrument. Our primary outcome was functional limitation attributable to low back pain assessed with a validated scale. Secondary outcomes included pain and analgesic use during the 24 hours before each follow-up telephone call. RESULTS: During a 9-month period beginning in July 2009, we approached 894 patients, of whom 556 were enrolled. We obtained follow-up on 97% of our sample at 1 week and 92% at 3 months. One week after ED discharge, 70% (95% confidence interval [CI] 66% to 74%) of patients reported back pain-related functional impairment, 59% (95% CI 55% to 63%) reported moderate or severe low back pain, and 69% (95% CI 65% to 73%) reported analgesic use within the previous 24 hours. Three months after ED discharge, 48% (95% CI 44% to 52%) of patients reported functional impairment, 42% (95% CI 38% to 46%) reported moderate or severe pain, and 46% (95% CI 44% to 50%) reported analgesic use within the previous 24 hours. CONCLUSION: There is substantial short- and longer-term morbidity and ongoing analgesic use among patients who present to an ED with undifferentiated musculoskeletal low back pain.

Dosing and titration of intravenous opioid analgesics administered to ED patients in acute severe pain.

OBJECTIVES: The objectives were to describe the dose of opioids and incidence of titration for management of acute pain in emergency department patients and, secondarily, to assess the association between change in pain and dose. METHODS: Data from control groups of 2 randomized clinical trials were analyzed. Patients 21 to 64 years with acute pain judged to warrant intravenous (i.v.) opioids were eligible. We calculated the mean weight-based dose of i.v. opioids, distribution of dose, proportion of patients receiving additional i.v. opioids, and 95% confidence intervals. We compared these statistics to 3 recommendations: 0.1 mg/kg morphine, 10 mg morphine, and titration to analgesic effect. We used multiple linear regression to assess the association between change in pain measured on a numerical rating scale and dose. RESULTS: There were 281 patients with an initial median pain score of 10 (interquartile range: 8, 10). Mean weight-based dose of i.v. opioids was 0.08 mg/kg (0.07, 0.08 mg/kg). A total of 268 patients (95.4% [92.2%, 97.5%]) received less than 10 mg i.v. morphine equivalents; 7 patients (2.5% [1.0%, 5.0%]) received additional opioids. There was a weak association between change in pain in the 15, 30, and 60 minutes after the initial bolus and dose: b = 0.22 (0.07, 0.37), b = 0.17 (0.02, 0.32), and b = 0.12 (-0.03, 0.28), respectively, after adjustment for baseline pain. CONCLUSION: Analgesic practice did not conform to recommended doses or regimens. There was only a weak association between change of pain and dose in the range of doses given. These findings suggest that oligoanalgesia continues to be a problem despite improvements over the past 20 years.