COVID-19: challenges and opportunities

Adam J. Singer,Bettina C Fries 대한응급의학회 2020 Clinical and Experimental Emergency Medicine Vol.7 No.3

A paper in this Journal by Choi et al. demonstrates how the technologically advanced Korean healthcare system has responded to the COVID-19 pandemic by creation of novel drive through and walk through facilities that allow rapid and safe viral testing helping to identify and isolate patients with the disease as well a track contacts to help reduce the pandemic spread. Another paper in this issue by Rola et al.4 highlights how much the traditional approach to hypoxemic respiratory failure has changed with COVID-19. While invasive mechanical ventilation has generally been used early in refractory hypoxemia, we now recognize that many patients present with profound hypoxemia (even with oxygen levels previously thought to be incompatible with life) with little distress. This phenotype has been called the L phenotype or the so-called “happy hypoxemic” patient.5 In these cases, use of oxygen by high flow nasal cannula or noninvasive ventilation together with proning may help avoid invasive mechanical ventilation or delay the need for, and duration of, subsequent invasive ventilation thus helping to preserve scarce and vital resources.

Admission rates for emergency department patients with venous thromboembolism and estimation of the proportion of low risk pulmonary embolism patients: a US perspective

Adam J. Singer,Henry C. Thode,W. Frank Peacock IV 대한응급의학회 2016 Clinical and Experimental Emergency Medicine Vol.3 No.3

Objective Introduction of target specific anticoagulants and recent guidelines encourage outpatient management of low risk patients with venous thromboembolism. We describe hospital admission rates over time for patients presenting to US emergency departments (EDs) with deep vein thrombosis (DVT) and pulmonary embolism (PE) and estimate the proportion of low-risk PE patients who could potentially be managed as outpatients. Methods We performed a structured analysis of the National Hospital Ambulatory Medical Care Survey (a nationally representative weighted sampling of US ED visits) database for the years 2006–2010 including all adult patients with a primary diagnosis of DVT or PE. Simplified pulmonary embolus scoring index (sPESI) scores were determined in patients with PE to identify low risk patients. Results There were an estimated 652,000 and 394,000 ED visits for DVT and PE over the 5-year period (0.17%). Mean (SE) age was 59 (1.3), 50% were female, and 40% were > 65 years. Admission rates for DVT and PE were 52% and 90% respectively with no significant changes over time. In patients with DVT, predictors for admission were age (odds ratio, 1.03 per year of age [95% confidence interval, 1.01 to 1.05]) and race (odds ratio, 4.1 [95% confidence interval, 0.9 to 19.8] for Hispanics and 2.9 [1.2 to 7.4] for Blacks). Of all ED patients with PE, 51% were low risk based on sPESI scores. Conclusion Admission rates for DVT and PE have remained high and unchanged, especially with PE, minorities, and in older patients. Based on sPESI scores, up to half of PE patients might be eligible for early discharge or outpatient therapy.

What’s on tablet PC: an introduction to FOAM at home

Adam J. Singer,Eric J Morley,Haney Mallemat 대한응급의학회 2016 Clinical and Experimental Emergency Medicine Vol.3 No.3

A retrospective study of emergency department potassium disturbances: severity, treatment, and outcomes

Adam J. Singer,Henry C. Thode,W. Frank Peacock IV 대한응급의학회 2017 Clinical and Experimental Emergency Medicine Vol.4 No.2

Objective: Disturbances in potassium (K) levels are relatively common and may be associated with significant morbidity and mortality; however, treatments vary. Our purpose was to determine the incidence, treatments, and outcomes associated with hyperkalemia and hypokalemia in emergency department (ED) patients. Methods: We performed a structured, retrospective review of electronic medical records of consecutive adult ED patients with K measured while in the ED. Demographic, clinical, and laboratory data as well as treatments, disposition, and in-hospital complications were collected. Univariate and multivariate analyses, presented as adjusted odds ratios, were used to compare outcomes by K levels. Results: Of 100,260 visits in 2014, an ED K level was ordered in 48,827 (49%). A total of 1,738 patients (3.6%) were excluded because of sample hemolysis. The K was low (<3.5 mEq/L) in 5.5%, normal (3.5 to 5.0 mEq/L) in 90.9%, and elevated (>5.0 mEq/L) in 3.6% of patients. Patients with hyperkalemia were older (64 vs. 49 years, P<0.001) and more likely male (58% vs. 40%, P<0.001). Treatment for hyperkalemia varied greatly. After adjusting for confounders, both hyperkalemia and hypokalemia were associated with inpatient hospitalization and death. At least one medication was used to manage hyperkalemia in 11.5% of patients with a K of 5.1 to 5.4 mEq/L, 36.4% of those with a K 5.5 to 6 mEq/L and 77.0% of the cohort with K >6 mEq/L. Conclusion: Hyperkalemia or hypokalemia occur in 1 of 11 ED patients and are associated with inpatient admission and mortality. Treatment of hyperkalemia varies greatly suggesting the need for evidence-based treatment guidelines.

Updates in emergency department laceration management

Karalynn Otterness,Adam J. Singer 대한응급의학회 2019 Clinical and Experimental Emergency Medicine Vol.6 No.2

Lacerations are a common reason for patients to seek medical attention, and are often acutely managed in the emergency department. Recent studies pertaining to closure techniques, sedation and analgesia, advances in wound care, and various other topics have been published, which may enhance our understanding of this injury and improve our management practices. This article will review pertinent studies published in the past few years relevant to laceration management. Understanding the current literature and appreciating which areas warrant further investigation will help us optimize outcomes for patients who sustain laceration injuries.

Hyponatremia and hypernatremia in the emergency department: severity and outcomes

Otterness Karalynn,Singer Adam J,Thode Henry C,Peacock W. Frank 대한응급의학회 2023 Clinical and Experimental Emergency Medicine Vol.10 No.2

Objective: Hyponatremia and hypernatremia are common electrolyte disorders. Few studies to date have focused on patients presenting to the emergency department (ED) with sodium (Na) disorders. Our objective was to determine the incidence and outcomes of hyponatremia and hypernatremia in ED patients. Methods: This study was a retrospective, single-center review of electronic medical records at an academic suburban ED with approximately 100,000 annual visits. Subjects included consecutive adult ED patients with Na levels measured while in the ED in 2019. Demographic, clinical, and laboratory data were recorded. Outcomes data, including hospital admission, intensive care unit (ICU) admission, mortality, and length of stay (LOS), were recorded. The primary outcome was inhospital death. Secondary outcomes were hospital admission, ICU admission, ED LOS, and hospital LOS. Univariable and multivariable linear and logistic regression analyses were performed to explore the association of candidate predictor variables and outcomes. Results: Na was measured in 57,427 adults (54%) among a total of 106,764 assessed ED visits in 2019. The mean±standard deviation age was 54±21 years, and 47% of participants were male. Mild, moderate, and severe hyponatremia and hypernatremia occurred in 8%, 2%, and 0.1% of patients and 1%, 0.2%, and <0.1% of patients, respectively. Hospital and ICU admission and mortality rates increased as Na levels increased or decreased further from normal. Adjusted odds ratio (95% confidence interval) values for hospital mortality were 2.39 (1.97–2.90) for mild hyponatremia, 3.93 (2.95–5.24) for moderate hyponatremia, 6.98 (2.87–16.40) for severe hyponatremia, 3.65 (2.47–5.40) for mild hypernatremia, 8.58 (4.92–14.94) for moderate hypernatremia, and 55.75 (11.37–273.30) for severe hypernatremia. Hypernatremia was associated with a greater risk of death than hyponatremia. Patients with hyponatremia and hypernatremia had increased LOS times compared to those with normal Na levels. Conclusion: Hyponatremia and hypernatremia were associated with greater rates of hospital admission, ICU admission, mortality, and prolonged hospital LOS times.

The Long-Term Effect of an Independent Capacity Protocol on Emergency Department Length of Stay: A before and after Study

차원철,신상도,송경준,조진성,Adam J. Singer 연세대학교의과대학 2015 Yonsei medical journal Vol.56 No.5

Purpose: In this study, we determined the long-term effects of the Independent Capacity Protocol (ICP), in which the emergency department (ED) is temporarily used to stabilize patients, followed by transfer of patients to other facilities when necessary, on crowding metrics. Materials and Methods: A before and after study design was used to determine the effects of the ICP on patient outcomes in an academic, urban, tertiary care hospital. The ICP was introduced on July 1, 2007 and the before period included patients presentingto the ED from January 1, 2005 to June 31, 2007. The after period began three months after implementing the ICP from October1, 2007 to December 31, 2010. The main outcomes were the ED length of stay (LOS) and the total hospital LOS of admitted patients. The mean number of monthly ED visits and the rate of inter-facility transfers between emergency departments were also determined. A piecewise regression analysis, according to observation time intervals, was used to determine the effect of the ICP on the outcomes. Results: During the study period the number of ED visits significantly increased. The intercept for overall ED LOS after interventionfrom the before-period decreased from 8.51 to 7.98 hours [difference 0.52, 95% confidence interval (CI): 0.04 to 1.01] (p=0.03), and the slope decreased from -0.0110 to -0.0179 hour/week (difference 0.0069, 95% CI: 0.0012 to 0.0125) (p=0.02). Conclusion: Implementation of the ICP was associated with a sustainable reduction in ED LOS and time to admission over a six-year period.

Study design of Real World Evidence for Treatment of Hyperkalemia in the Emergency Department (REVEAL-ED): a multicenter, prospective, observational study

Zubaid Rafique,Mikhail Kosiborod,Carol L. Clark,Adam J. Singer,Stewart Turner,Joseph Miller,Douglas Char,W. Frank Peacock IV 대한응급의학회 2017 Clinical and Experimental Emergency Medicine Vol.4 No.3

Objective Hyperkalemia affects up to 10% of hospitalized patients and, if left untreated, can lead to serious cardiac arrhythmias or death. Although hyperkalemia is frequently encountered in the emergency department (ED), and is potentially life-threatening, standard of care for the treatment is poorly defined, with little supporting evidence. The main objectives of this observational study are to define the overall burden of hyperkalemia in the ED setting, describe its causes, the variability in treatment patterns and characterize the effectiveness and safety of ED standard of care therapies used in the United States. Methods This is an observational study evaluating the management of hyperkalemia in the ED. Two hundred and three patients who presented to the ED with a potassium value ≥5.5 mmol/L were enrolled in the study at 14 sites across the United States. Patients were treated per standard of care practices at the discretion of the patient’s physician. In patients who received a treatment for hyperkalemia, blood samples were drawn at pre-specified time points and serum potassium values were recorded. The change in potassium over 4 hours and the adverse events after standard of care treatment were analyzed. Results and Conclusion This article describes the background, rationale, study design, and methodology of the REVEAL-ED (Real World Evidence for Treatment of Hyperkalemia in the Emergency Department) trial, a multicenter, prospective, observational study evaluating contemporary management of patients admitted to the ED with hyperkalemia.

Can a Point-of-Care Troponin I Assay be as Good as a Central Laboratory Assay? A MIDAS Investigation

W. Frank Peacock,Deborah Diercks,Robert Birkhahn,Adam J. Singer,Judd E. Hollander,Richard Nowak,Basmah Safdar,Chadwick D. Miller,Mary Peberdy,Francis Counselman,Abhinav Chandra,Joshua Kosowsky,James N 대한진단검사의학회 2016 Annals of Laboratory Medicine Vol.36 No.5

Background: We aimed to compare the diagnostic accuracy of the Alere Triage Cardio3 Tropinin I (TnI) assay (Alere, Inc., USA) and the PathFast cTnI-II (Mitsubishi Chemical Medience Corporation, Japan) against the central laboratory assay Singulex Erenna TnI assay (Singulex, USA). Methods: Using the Markers in the Diagnosis of Acute Coronary Syndromes (MIDAS) study population, we evaluated the ability of three different assays to identify patients with acute myocardial infarction (AMI). The MIDAS dataset, described elsewhere, is a prospective multicenter dataset of emergency department (ED) patients with suspected acute coronary syndrome (ACS) and a planned objective myocardial perfusion evaluation. Myocardial infarction (MI) was diagnosed by central adjudication. Results: The C-statistic with 95% confidence intervals (CI) for diagnosing MI by using a common population (n=241) was 0.95 (0.91-0.99), 0.95 (0.91-0.99), and 0.93 (0.89-0.97) for the Triage, Singulex, and PathFast assays, respectively. Of samples with detectable troponin, the absolute values had high Pearson (RP) and Spearman (RS) correlations and were RP =0.94 and RS=0.94 for Triage vs Singulex, RP =0.93 and RS=0.85 for Triage vs PathFast, and RP =0.89 and RS=0.73 for PathFast vs Singulex. Conclusions: In a single comparative population of ED patients with suspected ACS, the Triage Cardio3 TnI, PathFast, and Singulex TnI assays provided similar diagnostic performance for MI.

Emergency medicine physicians infrequently perform pediatric critical procedures: a national perspective

Shadd N. Cabalatungan,Henry C. Thode Jr.,Adam J. Singer 대한응급의학회 2020 Clinical and Experimental Emergency Medicine Vol.7 No.1

Objective To our knowledge, this is the first comprehensive study using a nationally representative database to estimate the frequency of critical procedures (endotracheal tube intubation [ETI], cardiopulmonary resuscitation [CPR], and central line insertion [CLI]) in children and adults. Methods The study was based on the secondary analysis of the 2010-2014 National Hospital Ambulatory Medical Care Survey. We included adult and pediatric patients undergoing critical procedures in the emergency department. We extracted demographic and clinical information, including the performance of critical procedures. For frequent procedures (≥1 per year), we estimated the annual number of critical procedures per emergency physician (EP) by dividing the total number of annual critical procedures by the total number of EPs (estimated at 40,000). For infrequent procedures, we calculated the average interval between procedures. We summarized the data with descriptive statistics and 95% confidence intervals (CIs). Results There were an estimated 668 million total emergency department visits (24% pediatric). On average, a single EP performed 8.6 (95% CI, 5.5 to 11.7) CLIs, 3.7 (95% CI, 2.4 to 5.0) CPRs, and 6.3 (95% CI, 5.3 to 7.4) ETIs per year in adults. In comparison, a single EP performed one pediatric CLI, CPR, and ETI every 3.2 (95% CI, 1.9 to 9.8), 5.2 (95% CI, 2.8 to 33.5), and 2.8 (95% CI, 1.6 to 8.9) years, respectively. Conclusion Our nationwide findings confirm those of previous smaller studies that critical procedures are significantly fewer in children than adults. We suggest that methods to retain skills in pediatric critical procedures should be developed for general EPs to ensure that they deliver the highest level of care across the entire age spectrum.