Validation of a Simulation-Based Resuscitation Curriculum for Maternal Cardiac Arrest.

OBJECTIVE: To assess the knowledge, skills, and self-efficacy of health care participants completing a simulation-based blended learning training curriculum on managing maternal medical emergencies and maternal cardiac arrest (Obstetric Life Support). METHODS: A formative assessment of the Obstetric Life Support curriculum was performed with a prehospital cohort comprising emergency medical services professionals and a hospital-based cohort comprising health care professionals who work primarily in hospital or urgent care settings and respond to maternal medical emergencies. The training consisted of self-guided precourse work and an instructor-led simulation course using a customized low-fidelity simulator. Baseline and postcourse assessments included multiple-choice cognitive test, self-efficacy questionnaire, and graded Megacode assessment of the team leader. Megacode scores and pass rates were analyzed descriptively. Pre- and post-self-confidence assessments were compared with an exact binomial test, and cognitive scores were compared with generalized linear mixed models. RESULTS: The training was offered to 88 participants between December 2019 and November 2021. Eighty-five participants consented to participation; 77 participants completed the training over eight sessions. At baseline, fewer than half of participants were able to achieve a passing score on the cognitive assessment as determined by the expert panel. After the course, mean cognitive assessment scores improved by 13 points, from 69.4% at baseline to 82.4% after the course (95% CI 10.9-15.1, P <.001). Megacode scores averaged 90.7±6.4%. The Megacode pass rate was 96.1%. There were significant improvements in participant self-efficacy, and the majority of participants (92.6%) agreed or strongly agreed that the course met its educational objectives. CONCLUSION: After completing a simulation-based blended learning program focused on managing maternal cardiac arrest using a customized low-fidelity simulator, most participants achieved a defensible passing Megacode score and significantly improved their knowledge, skills, and self-efficacy.

Interrater agreement of the HEART score history component: A chart review study.

Study objectives: This study investigated the interrater reliability of the history component of the HEART (history, electrocardiogram, age, risk, troponin) score between physicians in emergency medicine (EM) and internal medicine (IM) at 1 tertiary-care center. Methods: We conducted a retrospective, secondary analysis of 60 encounters selected randomly from a database of 417 patients with chest pain presenting from January to June 2016 to an urban tertiary-care center. A total of 4 raters (1 EM attending, 1 EM resident, 1 IM attending, and 1 IM resident) scored the previously abstracted history data from these encounters.The primary outcome was the interrater agreement of HEART score history components, as measured by kappa coefficient, between EM and IM attending physicians. Secondary outcomes included the agreement between attending and resident physicians, overall agreement, pairwise percent agreement, and differences in scores assigned. Results: The kappa value for the EM attending physician and IM attending physician was 0.33 with 55% agreement. Interrater agreement of the other pairs was substantial between EM attending and resident but was otherwise fair to moderate. Percent agreement between the other pairs ranged from 48.3% to 80%. There was a significant difference in scores assigned and the subgroup in which there was disagreement between the raters demonstrated significantly higher scores by the EM attending and resident when compared to the IM attending. Conclusion: This study demonstrates fair agreement between EM and IM attending physicians in the history component of the HEART score with significantly higher scores by the EM attending physician in cases of disagreement at 1 tertiary-care center.

Are Patients Discharged on the HEART Pathway Following Up?

INTRODUCTION: The HEART (history, electrocardiogram [ECG], age, risk factors, troponin) pathway is a useful tool in the emergency department to identify patients that are safe for outpatient evaluation of chest pain. A dedicated HEART Clinic to follow-up versus primary care remains a topic that requires further delineation. We sought to identify how many patients discharged on the HEART pathway specifically followed up with the established HEART Clinic. MATERIALS AND METHODS: This is a secondary analysis of a previously published dataset. In an initial validation study of the HEART Pathway, 625 consecutive subjects were identified via chart review, 449 of which were included. We identified subjects for inclusion in this study if they were found to have a HEART score of 3 or less. Subjects were excluded if they were admitted or if their follow-up was beyond 6 weeks. RESULTS: Of the 449 subjects, 185 met criteria for study inclusion. 125 (67.6%) had follow-up with an average time of 7.94 days (95% CI: 6.54-9.34). Of those, half had additional testing such as ECG, cardiac computed tomography angiography, and treadmill stress testing. The most common clinics for follow-up were the Family Medicine, Internal Medicine, and HEART Clinic representing 35.8, 29, and 18% of the follow-ups, respectively. No subject died, had a myocardial infarction, or required reperfusion. CONCLUSIONS: Of the subjects discharged on the HEART Pathway, 67.6% followed up. Of those subjects that followed up, 18% did so at the HEART Clinic.

HEART Score of Four for Age and Risk Factors: A Case Series.

Chest pain is a frequent chief complaint in the ED. Identifying acute coronary syndrome (ACS) and establishing proper disposition for further risk assessment for major adverse cardiac events are paramount. The HEART Score is a key decision-making tool used to determine patient risk and disposition. One scenario with a potential drawback of the HEART Score is found in patients with a score of four based solely on age and risk factors. The HEART Score categorizes a score of three or less as low risk, and patients with scores above this threshold are typically admitted. We present six cases of chest pain presenting to a military emergency department with a score of four based solely on age and risk factors. They represent every such case found in a previously created database used to validate the HEART Score. We followed each case forward one year in electronic medical records to identify major adverse cardiac events. With the exception of one case that was placed on hospice for non-cardiac reasons and subsequently lost to follow up, there were no adverse events. There is a rising concern for increasing hospital admission rates, overuse of resources, and cost. We highlight that this subset of HEART Score patients requires a more nuanced risk stratification in the ED. It may be worth the time and effort to risk stratify this subset with coronary computed tomography angiography. This additional effort may help reduce admission at such a patient's current and future presentations to the ED for chest pain.

The HEART score as a prognostic tool for revascularization.

The History, Electrocardiogram, Age, Risk Factors, Troponin (HEART) score is a useful tool in the Emergency Department setting to identify those patients safe for outpatient evaluation of chest pain. Its utility for predicting cardiac interventions is unclear. Our objective was to evaluate the prognostic accuracy of the HEART score to predict the need for cardiac stent or coronary artery bypass grafting (CABG). We conducted a retrospective chart review of 625 consecutive subjects with chest pain presenting to an Emergency Department (ED) with a HEART pathway protocol in place. We also reviewed each subject's record for evidence of major adverse cardiac events within 6 weeks following their ED visit. We double-abstracted 10% of the charts for quality assurance. We included subjects if they were ≥ 18 at the time of presentation and had a chief complaint of chest pain. We excluded subjects if they did not have an electrocardiogram or troponin, or if their chart lacked sufficient information to calculate the history portion of their HEART score. Of 625 charts, 449 subjects met criteria for study inclusion. The area under the receiver operator curve reported as c-statistics was 0.877 [95% confidence interval (CI) 0.806-0.949] for the HEART score's ability to predict cardiac stent and 0.921 (95% CI 0.858-0.984) for CABG. There is a strong association between increasing HEART scores and the need for revascularization which may provide emergency physicians justification for expedited cardiology consultation and admission for these patients. These findings require further prospective validation.

More Than a Lymph Node in the Neck: A Rare Synovial Cell Sarcoma with Carotid Artery Mass Effect.

The authors discuss a case of a previously healthy 33-year-old man who presented with a subacute neck mass, found to be a rare synovial cell sarcoma with mass effect on the carotid vessels. This report demonstrates the utility of point of care ultrasound and computed tomography (CT) in the workup of the patient's neck mass. Additionally, we synthesize findings from previous studies that recommend approaching neck masses in adults with a high index of suspicion for malignancy.

Evaluation of an Electronic Dosing Calculator to Reduce Pediatric Medication Errors.

INTRODUCTION: Adverse medication events are a potential source of significant morbidity and mortality in pediatric patients, where dosages frequently rely on weight-based formulas. The most frequent occurrence of medication errors occurs during the ordering phase. METHODS: Through a prospective cohort analysis, we followed medication errors through patient safety reports (PSRs) to determine if the use of a medication dosage calculator would reduce the number of PSRs per patient visits. RESULTS: The number of PSRs for medication errors per patient visit occurring due to errors in ordering decreased from 10/28 417 to 1/17 940, a decrease by a factor of 6.31, with a χ2 value of 4.063, P = .0463. CONCLUSION: We conclude that the use of an electronic dosing calculator is able to reduce the number of medication errors, thereby reducing the potential for serious pediatric adverse medication events.

A HEART Pathway pitfall in an admitted patient.

This paper discusses a possible weakness of the HEART Pathway specific to patients identified as high risk, requiring admission for inpatient risk stratification. Emergency Department (ED) crowding is at an all-time high and the possibility that many of these patients will board in the ED for a period of time before they are transported to an inpatient ward is becoming more likely. Given troponins peak at 6 h after the initial cardiac injury, it is plausible an initial troponin could still remain negative upon arrival. Extending the HEART Pathway to include a 3-hour delta troponin for admitted patients boarded in the emergency department may help alert the patient's inpatient team of those requiring more aggressive evaluations or more timely interventions. The case discussed herein highlights the course of a patient who was admitted to a medicine floor for chest pain along the HEART Pathway. After remaining in the ED for 3 h following admission a second troponin was drawn that resulted in the diagnosis of a non-ST segment myocardial infarction. The patient then received further management in the ED and a change in admission to the Cardiac Care Unit instead of the medicine floor. The patient ultimately received a Coronary Artery Bypass Graft during admission. If the patient had not had the second troponin while in the ED this care would have been delayed.

Anticoagulation Reversal.

Today a variety of anticoagulants and antiplatelet agents are available on the market. Given the propensity for bleeding among patients prescribed these medications, the emergency medicine physician must be equipped with a working knowledge of hemostasis, and anticoagulant and antiplatelet reversal. This article reviews strategies to address bleeding complications occurring secondary to warfarin, low-molecular-weight heparin, and direct oral anticoagulant therapy.

An external validation of the HEART pathway among Emergency Department patients with chest pain.

The impact of an outpatient disposition strategy for patients with HEART score 0-3 (HEART pathway) on HEART score prognostic accuracy is unclear. Our objective is to perform an external validation the HEART score in the setting of recent implementation of the HEART pathway. We conducted an external validation study of the HEART pathway among patients presenting to our ED with chest pain 6 weeks after institutional implementation of a HEART pathway outpatient disposition pathway. We reviewed the charts of 625 consecutive patients with chest pain. Data abstracted included all elements of the HEART score to include history, electrocardiogram (ECG) read, patient age, patient risk factors, and troponin levels. We also reviewed each patient's record for evidence of major adverse cardiac events (MACE) to include mortality, myocardial infarction, or coronary revascularization over 6 weeks following their initial ED visit. We double-abstracted 10% of the charts for quality assurance purposes. Of 625 charts, 449 patients met all criteria for study inclusion. Of these, 25 subjects (5.56%) experience 6-week MACE. No subject with a score of 3 or less has a MACE at 6 weeks (100% sensitivity, 38.7% specificity). The area under the receiver operator curve (AUROC) is 0.898 (95% confidence interval 0.847-0.950). Kappa coefficients for inter-rater reliability range from 0.62 for the history component of the HEART score to 1.0 for troponin. A low HEART score (0-3) maintains excellent sensitivity for predicting 6-week MACE in the setting of an outpatient disposition pathway for these patients.

Impact of the HEART Pathway on Admission Rates for Emergency Department Patients with Chest Pain: An External Clinical Validation Study.

BACKGROUND: Chest pain is a common emergency department (ED) chief complaint. Safe discharge mechanisms for low-risk chest pain patients would be useful. OBJECTIVE: To compare admission rates prior to and after implementation of an accelerated disposition pathway for ED patients with low-risk chest pain based upon the HEART (History, ECG, Age, Risk factors, Troponin) score (HEART pathway). METHODS: We conducted an impact analysis of the HEART pathway. Patients with a HEART score ≥ 4 underwent hospital admission for cardiac risk stratification and monitoring. Patients with a HEART score ≤ 3 could opt for discharge with 72-h follow-up in lieu of admission. We collected data on cohorts prior to and after implementation of the new disposition pathway. For each cohort, we screened the charts of 625 consecutive chest pain patients. We measured patient demographics, past medical history, vital signs, HEART score, disposition, and 6-week major adverse cardiac events (MACE) using chart review methodology. We compared our primary outcome of hospital admission between the two cohorts. RESULTS: The admission rate for the preintervention cohort was 63.5% (95% confidence interval [CI] 58.7-68.2%), vs. 48.3% (95% CI 43.7-53.0%) for the postintervention cohort. The absolute difference in admission rates was 15.3% (95% CI 8.7-21.8%). The odds ratio of admission for the postintervention cohort in a logistic regression model controlling for demographics, comorbidities, and vital signs was 0.48 (95% CI 0.33-0.66). One postintervention cohort patient leaving the ED against medical advice (HEART Score 4) experienced 6-week MACE. CONCLUSIONS: The HEART pathway may provide a safe mechanism to optimize resource allocation for risk-stratifying ED chest pain patients.

A retrospective external validation study of the HEART score among patients presenting to the emergency department with chest pain.

Emergency physicians must be able to effectively prognosticate outcomes for patients presenting to the Emergency Department (ED) with chest pain. The HEART score offers a prognostication tool, but external validation studies are limited. We conducted an external retrospective validation study of the HEART score among ED patients presenting to our ED with chest pain from 1 January 2014 to 9 June 2014. We utilized chart review methodology to abstract data from each patient's electronic medical record. We collected data relevant to each of the five elements of the HEART score: history, electrocardiogram (ECG) interpretation, patient age, patient risk factors, and troponin levels. We calculated the diagnostic accuracy of the HEART score (0-10) for predicting the primary outcome of major adverse cardiac events (MACE) over 6 weeks following the ED visit (coronary revascularization, myocardial infarction, or mortality). We randomly selected 10% of patient charts from which a second investigator abstracted all data to assess inter-rater reliability for all study variables. Of 625 charts reviewed, we abstracted data on 417 (66.7%) consecutive patients meeting study inclusion criteria. Thirty-one (7.4%) of these patients experienced 6-week MACE. We observed no instances of MACE within 6 weeks among subjects with a HEART score of 3 or less. The area under the receiver operator curve (AUROC) is 0.885 (95% confidence interval 0.838-0.931). Patients with a HEART score ≤3 are at low risk for 6-week MACE. Hence, these patients may be candidates for outpatient follow-up instead of inpatient admission for cardiac risk stratification.

An end-user's guide to the HEART score and pathway.

BACKGROUND: Chest pain accounts for a significant percentage of emergency department (ED) presentations. The HEART score and pathway have demonstrated an ability to appropriately risk stratify and discharge from the ED a significant proportion of patients. OBJECTIVE: This review evaluates vital components of the HEART score and pathway, while discussing important considerations for current and future use. DISCUSSION: Chest pain is a common ED presentation, and several conditions associated with chest pain result in patient morbidity and mortality. One major disease is acute coronary syndrome (ACS). Despite the fear associated with this disease, it accounts for a minority of patients with chest pain in the ED. Emergency physicians rarely miss myocardial infarction (MI) or ACS, with miss rates<1%. Many have sought a score and pathway that allow physicians to safely and reliably risk stratify patients. The HEART score and pathway have revolutionized chest pain evaluation, as they can risk stratify a significant number of patients accurately into separate categories based on history, electrocardiogram (ECG), troponin, age, and risk factors while displaying high sensitivity for MACE. Several intricacies must be considered in the use of this score including risk factors, ECG, troponin, age, history, gestalt, follow up, borderline score, and shared decision making. The HEART pathway can supplement clinician decision making. CONCLUSIONS: Appropriate use of the HEART pathway reliably risk stratifies patients. Physicians must consider several key components when utilizing the HEART pathway, and future directions may incorporate other patient factors.

Patterns of cyanide antidote use since regulatory approval of hydroxocobalamin in the United States.

Sodium nitrite and sodium thiosulfate are common cyanide antidotes. Hydroxocobalamin was approved for use in the United States in 2006. Our objective was to determine the frequency of antidote use as reported to the US poison centers from 2005 to 2009 and describe which antidotes were used in critically ill cyanide toxic patients. We performed a retrospective review over 5 years (2005-2009) from 61 US poison centers. We identified all cyanide-exposed cases that received a cyanide antidote. Variables collected included demographics, gastric decontamination, antidote used, predefined serious clinical effects (hypotension, cardiac arrest, respiratory arrest, and coma), and predefined serious therapies (cardiopulmonary resuscitation, vasopressors, atropine, anticonvulsant, antidysrhythmic, and intubation/ventilation). One trained abstractor abstracted each chart to a standardized electronic form. Another investigator audited 20% of the charts. Kappa values were calculated. One hundred sixty-five exposures were identified. Mean age was 42 years (range, 3-93 years). Seventy-one percent were male. Exposures were 27% ingestion and 53% inhalation. Thirty-two percent of the ingestions were suicide attempts. Twenty percent (32 of 157) of all cases died. Over all years reported, hydroxocobalamin was administered to 29% (45 of 157) of patients, sodium nitrite to 25%, and sodium thiosulfate to 46%. Hydroxocobalamin use increased from 24% to 54% from 2007 to 2009, respectively (P = 0.024). Sodium thiosulfate use decreased from 73% to 31% (P = 0.002) and sodium nitrite use decreased from 26% to 14% (P = 0.39). The proportion of cases with serious clinical effects that received hydroxocobalamin increased each year, and the proportion that received other antidotes decreased. Hydroxocobalamin was also administered more often in cases that required serious therapies and increased each year. Hydroxocobalamin use for cyanide toxicity increased each year as reported to the US poison centers. Reported use of sodium thiosulfate and sodium nitrite decreased over the same years. In addition, hydroxocobalamin was used more often each year in critically ill cyanide toxic patients than were sodium nitrite or sodium thiosulfate.

Dengue and US military operations from the Spanish-American War through today.

Dengue is a major cause of illness among travelers and a threat to military troops operating in areas to which it is endemic. Before and during World War II, dengue frequently occurred in US military personnel in Asia and the South Pacific. From the 1960s into the 1990s, dengue often occurred in US troops in Vietnam, the Philippines, Somalia, and Haiti. We found attack rates as high as 80% and periods of convalescence up to 3-1/2 weeks beyond the acute illness. The increase in dengue throughout the world suggests that it will remain a problem for military personnel until an effective vaccine is licensed.