Articles of Interest in Annals of Emergency Medicine - August 2019

Sam Shahid, MBBS, MPH
Practice Management Manager, ACEP

ACEP would like to provide you with very brief synopses of the latest articles and articles coming soon to Annals of Emergency Medicine. Some of these have not appeared in print. These synopses are not meant to be thorough analyses of the articles, simply brief introductions. Before incorporating into your practice, you should read the entire articles and interpret them for your specific patient population.

Chang BP, Rostanski S, Willey J, Miller EC, Shapiro S, Mehendale R, Kummer B, Navi BB, Elkind MSV. Safety and Feasibility of a Rapid Outpatient Management Strategy for Transient Ischemic Attack and Minor Stroke: The Rapid Access Vascular Evaluation-Neurology (RAVEN) Approach.
While most transient ischemic attack and minor stroke (TIAMS) patients in U.S. emergency departments (EDs) are admitted, experience in other countries suggests that timely outpatient evaluation of TIAMS can be safe. This study assessed the feasibility and safety of a rapid outpatient stroke clinic for TIAMS: Rapid Access Vascular Evaluation-Neurology (RAVEN), and found that rapid outpatient management appears a feasible and safe strategy for TIAMS patients evaluated in the ED, with recurrent stroke and TIA rates comparable to historical published data. Between December 2016 and June 2018, 162 TIAMS patients were discharged to RAVEN. Of these 154 (95. 1%) appeared as scheduled and 101 (66%) had a final diagnosis of TIAMS. Among the 101 patients with confirmed TIAMS, 18 patients (19.1%) had returned to an ED or been admitted at 90 days. Five were noted to have had recurrent neurological symptoms diagnosed as TIA (4.9%), while one had a recurrent stroke (0.9%). No TIAMS individuals died, and none received thrombolytics or thrombectomy, during the interval period.
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PMID: 31326206

Boniface KS, King JB, LeSaux MA, Haciski SC, Shokoohi H. Diagnostic Accuracy and Time-Saving Effects of Point-of-Care Ultrasonography in Patients With Small Bowel Obstruction: A Prospective Study.
The study evaluated the accuracy of point-of-care ultrasonography compared with computed tomographic (CT) scan and assess the potential time-saving effect of point-of-care ultrasonography in diagnosing small bowel obstruction. They included 125 patients of whom 32 (25.6%) had small bowel obstruction, and 9 (7.2%) underwent surgery for it. Overall, the sensitivity of point-of-care ultrasonography for small bowel obstruction was 87.5%, and specificity was 75.3%. Results were similar across evaluated subgroups, including physician training level. The average time to obtain a CT scan report was 3 hours, 42 minutes; obtaining an abdominal radiograph took 1 hour, 38 minutes; and the mean elapsed time to complete point-of-care ultrasonography was 11 minutes. The authors concluded that in ED patients with suspected small bowel obstruction, point-of-care ultrasonography has a reasonably high accuracy in diagnosing small bowel obstruction compared with CT scan, and may substantially decrease the time to diagnosis.
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PMID: 31350094

Krawczyk N, Eisenberg M, Schneider KE, Richards TM, B. Casey Lyons BC, Jackson K, Ferris L, Weiner JP, Saloner B. Predictors of Overdose Death among High-Risk Emergency Department Patients with Substance-Related Encounters: A Data Linkage Cohort Study
This study linked hospital ED and medical examiner mortality databases in one state to identify individual-level risk factors associated with overdose death among ED patients with substance-related encounters. During 2014-2015, 139,252 patients had substance-related ED encounters. Of these, 963 later experienced an opioid overdose death, indicating a case fatality rate of 69.2/10,000 patients, six times higher than patients who used the ED for any other cause. Factors most strongly associated with death included having both an opioid and another substance use disorder, having 3+ previous non-fatal overdoses, and having a previous non-fatal overdose involving heroin. These results highlight important differences in overdose risk among patients receiving care in EDs for substance-related conditions and demonstrate the potential utility of incorporating routine-data from patient records to assess risk of future negative outcomes and identify primary targets for initiation and linkage to life-saving care.

Zachrison KS, Boggs KM, Hayden EM, Espinol JA and Camargo Jr. CA. Understanding Barriers to Telemedicine Implementation in Rural Emergency Departments.
Telemedicine has potential to add value to the delivery of emergency care in rural emergency departments (EDs), however prior work suggests that it may be under-utilized and the authors sought to understand barriers to telemedicine implementation in rural EDs, and to describe characteristics of rural EDs that do and do not use telemedicine. The authors identified 977 rural EDs responding to the 2016 NEDI-USA survey, 453 did not use telemedicine. Among rural EDs not using telemedicine, 235 EDs (67%) reported that their ED, hospital, or health system leadership had considered it, and that cost was the most commonly cited reason for lack of adoption (n=86, 37%). 

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