Association of an Emergency Critical Care Program With Survival and Early Downgrade Among Critically Ill Medical Patients in the Emergency Department.

OBJECTIVES: To determine whether implementation of an Emergency Critical Care Program (ECCP) is associated with improved survival and early downgrade of critically ill medical patients in the emergency department (ED). DESIGN: Single-center, retrospective cohort study using ED-visit data between 2015 and 2019. SETTING: Tertiary academic medical center. PATIENTS: Adult medical patients presenting to the ED with a critical care admission order within 12 hours of arrival. INTERVENTIONS: Dedicated bedside critical care for medical ICU patients by an ED-based intensivist following initial resuscitation by the ED team. MEASUREMENTS AND MAIN RESULTS: Primary outcomes were inhospital mortality and the proportion of patients downgraded to non-ICU status while in the ED within 6 hours of the critical care admission order (ED downgrade <6 hr). A difference-in-differences (DiD) analysis compared the change in outcomes for patients arriving during ECCP hours (2 pm to midnight, weekdays) between the preintervention period (2015-2017) and the intervention period (2017-2019) to the change in outcomes for patients arriving during non-ECCP hours (all other hours). Adjustment for severity of illness was performed using the emergency critical care Sequential Organ Failure Assessment (eccSOFA) score. The primary cohort included 2,250 patients. The DiDs for the eccSOFA-adjusted inhospital mortality decreased by 6.0% (95% CI, -11.9 to -0.1) with largest difference in the intermediate illness severity group (DiD, -12.2%; 95% CI, -23.1 to -1.3). The increase in ED downgrade less than 6 hours was not statistically significant (DiD, 4.8%; 95% CI, -0.7 to 10.3%) except in the intermediate group (DiD, 8.8%; 95% CI, 0.2-17.4). CONCLUSIONS: The implementation of a novel ECCP was associated with a significant decrease in inhospital mortality among critically ill medical ED patients, with the greatest decrease observed in patients with intermediate severity of illness. Early ED downgrades also increased, but the difference was statistically significant only in the intermediate illness severity group.

An Ethical Anaylsis of the Arguments Both For and Against COVID-19 Vaccine Mandates for Healthcare Workers.

BACKGROUND: Since the development of the first U.S. Food and Drug Administration-approved vaccine for the prevention of serious disease and death associated with the SARS-CoV-2 virus, health care workers have been expected to comply with mandatory immunization requirements or face potential termination of employment and censure by their state medical boards. Although most accepted this mandate, there have been several who have felt this was an unnecessary intrusion and violation of their right to choose their own health care mitigation strategies, or an infringement on their autonomy and other civil liberties. Others have argued that being a health care professional places your duties above your own self-interests, so-called fiduciary duties. As a result of these duties, there is an expected obligation to do the best action to achieve the "most good" for society. A so-called "utilitarian argument." DISCUSSION: We explore arguments both for and against these mandatory vaccine requirements and conclude using duty- and consequence-based moral reasoning to weigh the merits of each. CONCLUSIONS: Although arguments for and against vaccine mandates are compelling, it is the opinion of the Ethics Committee of the American Academy of Emergency Medicine that vaccine mandates for health care workers are ethically just and appropriate, and the benefit to society far outweighs the minor inconvenience to an individual's personal liberties.

Call of Duty - What are Physicians' Obligations During Crises?

BACKGROUND: Society allows physicians the privilege and responsibility of caring for patients. Those responsibilities demand that their knowledge and technical expertise meet standards defined and policed by their colleagues, through medical societies or governmental entities. However, the fiduciary duty that patients' interests are held above those of the physicians' is an ethical precept that is tested when society is under threat. DISCUSSION: Disasters that stress society are a constant and can present themselves in a myriad of ways to include medical, meteorological, or political. Minimizing the potential damage to the quality and quantity of life of the population is dependent upon public safety personnel and health care professionals who may put their health and safety in harm's way to care for patients. These acts may be taken for granted or assumed to be part of the professional obligations of physicians and other health care workers who work at the bedside. The obligations of physicians to their patients and society may differ from those not in the medical field, and the level of risk deemed acceptable by the physician and by society should be clearly delineated. CONCLUSION: Despite the conflict between normative and descriptive ethics, in times of disaster, physicians must respond to the call of duty. This duty is contingent on the responsibility being shared with governmental agencies and health care facilities, to mitigate the risks borne by those who answer the call.

Cutting Edge Acute Ischemic Stroke Management.

Acute ischemic stroke (AIS) is a medical emergency that requires prompt recognition and streamlined work-up to ensure that time-dependent therapies are initiated to achieve the best outcomes. This article discusses frequently missed AIS in the emergency department, the role of various imagining modalities in the work-up of AIS, updates on the use of intravenous thrombolytics and endovascular therapy for AIS, pearls on supportive care management of AIS, and prehospital and hospital process improvements to shorten door-to-needle time.

Radiographic and Clinical Predictors of Cardiac Dysfunction Following Isolated Traumatic Brain Injury.

INTRODUCTION: Although cardiac dysfunction after traumatic brain injury (TBI) has been described, there is little data regarding the association of radiographic severity and particular lesions of TBI with the development of cardiac dysfunction. We hypothesize that the Rotterdam or Marshall scores and particular TBI lesions are associated with the development of cardiac dysfunction after isolated TBI. METHODS: We performed a retrospective cohort study. Adult patients with isolated TBI who underwent echocardiography between 2003 and 2010 were included. A board-certified neuroradiologist assessed the first computed tomography head, assigning the Rotterdam and Marshall scores and the type of TBI. Cardiac dysfunction was defined as either systolic or all cause based on the first echocardiogram after TBI. Demographic, radiological, and clinical variables were used in our analysis. RESULTS: A total of 139 patients were identified, with 20 having isolated systolic dysfunction. The Marshall and Rotterdam scores were not associated with the development of cardiac dysfunction. Only head Abbreviated Injury Scale was found to be an independent predictor of systolic cardiac dysfunction (relative risk: 2.70, 95% confidence interval: 1.19-6.13; P = .02). CONCLUSIONS: No specific radiographic variable was found to be an independent predictor of cardiac dysfunction. Further study into clinical or radiological features that would warrant an echocardiogram is warranted, as it may direct patient management.

Cervical spine injury: analysis and comparison of patients by mode of transportation.

BACKGROUND: Cervical spine injury (CSI) studies have identified different factors contributing to CSI, but none compares the incidence and pattern of injury of patients arriving at the Emergency Department (ED) by private vehicle (PV). OBJECTIVE: We compared the characteristics and injury patterns in CSI patients who were transported to the ED via Emergency Medical Services (EMS) versus PV. METHODS: We conducted a three-hospital retrospective review of patients with CSI from January 1, 2000 to December 31, 2007. We excluded transfers and follow-up visits. Using a standardized data collection form, we reviewed demographics, mode of transport, mechanism of injury, imaging results, injury type and level, and neurologic deficits. Means and proportions were compared using t-tests and chi-squared as appropriate. RESULTS: Of 1174 charts identified, 718 met all study criteria; 671 arrived by EMS and 47 by PV. There was no difference between groups in age or gender. Ground-level fall was more likely in PV patients (32%, 95% confidence interval [CI] 20-46% vs. 6%, 95% CI 4-9%), whereas motor vehicle collision was less likely (32%, 95% CI 20-46% vs. 67%, 95% CI 63-70%). PV patients more often sustained a stable injury (66%, 95% CI 52-78% vs. 40%, 95% CI 36-44%), and were more often triaged to a lower-acuity area (25%, 95% CI 15-40% vs. 4%, 95% CI 3-6%). The incidence of neurologic deficit was similar (32%, 95% CI 20-46% vs. 24%, 95% CI 21-28%), though more PV patients had spinal cord injury without radiographic abnormality (21%, 95% CI 12-35% vs. 5%, 95% CI 4-7%). CONCLUSION: A small proportion of patients with CSI present to the ED by PV. Although most had stable injuries, a surprising number had unstable injuries with neurologic deficits, and were triaged to lower-acuity areas in the ED.