Friday, July 13, 2012

Lit Bits: July 13, 2012

From the recent medical literature...

1. Complications Drive Post-MI Readmissions 

Dunlay SM, et al. Thirty-day rehospitalizations after acute myocardial infarction: A cohort study. Ann Intern Med 2012;157: 11-18. 

By Crystal Phend, Senior Staff Writer, MedPage Today. Published: July 05, 2012 

A return to the hospital soon after an admission for myocardial infarction (MI) often relates more to complications and comorbidities than to the heart attack itself, researchers found. 

Over 30% of rehospitalizations within 30 days of an MI were deemed unrelated to the incident event, according to an observational study by Véronique L. Roger, MD, MPH, of the Mayo Clinic in Rochester, Minn., and colleagues. 

Comorbidities and complications of treatment weighed heavily among the risk factors for readmission, the group reported in the July 3 issue of the Annals of Internal Medicine. 

The rate of repeat admission reached 35.3% among patients with an angiography complication during their initial stay and 31.6% among those with a reperfusion or revascularization complication. 

That was nearly double the 16.8% rate of 30-day readmission among patients who were reperfused or revascularized without complications.

"Prevention of complications and close follow-up for patients who have had a complication may be of particular importance for preventing rehospitalizations," Roger's group noted. 

Another implication is for coordination of care, as comorbidities are so common in MI patients. 

With an aging population and 30-day rehospitalization now used as a quality of care marker, "these data underscore the importance of implementing a comprehensive management strategy in patients after incident MI to help prevent rehospitalizations," the researchers wrote. 

Their study included 3,010 incident MIs from 1987 to 2010 within the population-based registry of Olmsted County, Minn., where the Mayo Clinic is located. 

Retrospective analysis showed 643 rehospitalizations within 30 days in 561 patients (18.6%). 

Among these cases, 42.6% were rehospitalized related to the incident MI or its treatment, for reasons such as sternal wound infection, heart failure, acute renal failure, or pleural effusion. 

The 30.2% deemed unrelated to the initial MI were for reasons such as cancer, fracture, aspiration pneumonia, and end-stage renal disease in patients on dialysis prior to MI. 

The remaining 27.2% of rehospitalizations didn't clearly fit into either category and were most commonly for atypical chest pain. 

Significant, independent risk factors for readmission within 30 days of the initial MI were:  

·         A complication of angiography during the index hospitalization (hazard ratio 2.40)
·         A complication of reperfusion or revascularization during the index hospitalization (HR 2.12)
·         Diabetes mellitus (HR 1.34)
·         Chronic obstructive pulmonary disease (HR 1.43)
·         Anemia (HR 1.25)
·         Worse heart failure as marked by a higher Killip class at presentation (HR 1.22 for class 2 to 4)
·         A longer initial hospitalization (HR 1.34 for 4 to 7 days and 1.65 for more than 7 days compared with 3 or less) 

Acute kidney injury after percutaneous coronary intervention during the index MI hospitalization, which occurred in 5% of patients, boosted risk of readmission 92% after adjustment for baseline kidney problems. But it wasn't often a primary reason for rehospitalization. 

Rehospitalization after MI showed no trends over time during the 24-year study period. 

"Despite advances in therapies and improved inhospital outcomes after MI, rehospitalizations remain a serious problem and have shown no signs of abating," Roger's group concluded. 

Limitations of the study included that missed MIs that did not result in hospitalizations, and hospitalizations that occurred outside of the county studied as well. 

The largely white population of the county might have limited generalizability too. 

The study was funded by grants from the National Institutes of Health and the Rochester Epidemiology Project. 

Roger reported grant funds to her institution from the National Heart, Lung and Blood Institute. 

2. Heart Risk Seen with High-dose IV Zofran 

By John Gever, Senior Editor, MedPage Today. Published: June 29, 2012 

The nausea drug ondansetron (Zofran) may cause QT prolongation after a single 32-mg intravenous dose, the FDA warned. 

Patients could therefore be at risk for torsades de pointes, a life-threatening arrhythmia, the agency said, adding that the drug's manufacturer is removing the single 32-mg dose from its label. 

Ondansetron is indicated for chemotherapy-induced nausea and vomiting and, at lower doses, for postoperative nausea and vomiting. 

The FDA had previously indicated that it was investigating the arrhythmogenic potential of ondansetron in collaboration with the drug's maker, GlaxoSmithKline. 

Preliminary results of a study ordered by the FDA found a maximum mean difference in QTcF of 20 msec after the 32-mg IV dose. 

An IV dose of 8 mg, on the other hand, led to a mean maximum QTcF difference of 6 msec. 

The drug's new label will indicate that ondansetron can be used in adults and children at doses of 0.15 mg/kg every 4 hours for up to three doses, but no single dose should exceed 16 mg. 

No changes are contemplated at this point for instructions on oral dosing. Currently, oral doses of up to 24 mg are approved. 

3. Unsustainable ED crowding grows twice as fast as visits 

FierceHealthcare. By Karen M. Cheung 

Emergency department crowding is growing twice as fast as visits and will rise to unsustainable proportions, according to Jesse Pines, director of the Center for Healthcare Quality at George Washington University and associate professor of emergency medicine and health policy in Washington, D.C. 

ED visits increased 60 percent faster than population growth over an eight-year period. Crowding, or occupancy, as it's called, grew even faster, according to an Annals of Emergency Medicine study published online Tuesday. While ED visits increased by 1.9 percent annually from 2001 to 2008, crowding grew by 3.1 percent. 

"Visit volume is going up, which is outpacing population group, and patients are staying longer and longer within the ED getting more intense work-ups and treatments," Pines said in a statement to FierceHealthcare. "Together, the 'occupancy,' which is the number of patients in our nation's emergency care system at one time, is rising at a very rapid, unsustainable rate." 

Although advanced imaging often receives much of the blame for delays in the ED, researchers found that it had more to do with practice intensity, that is, blood work and x-rays at triage, that's really bogging down the ED. 

Patients are getting more tests, fluids and procedures for a number of reasons, Pines explained. Some providers are practicing defensive medicine, but patients and providers also expect high-technology care, such as requiring CT scans or other advanced test before admitting the patient to the hospital. 

"As technology outside the ED improves, such as organ transplantation and cancer care, when patients have complications--and they do--they end up coming in and are sicker and need more ED resources to take care of them," Pines said about the older, sicker population. 

Even more, EDs have become rapid diagnostic centers. For example, patients who need X-rays will go to the ED because it's the fastest place to do it, especially when their physicians refer them there, Pines said. 

"Lengthy work-ups in the emergency department are not always a bad thing if they prevent a costly hospitalization. The problem is that more and more demands are being placed on emergency departments and the mood in the health policy community is to shrink emergency departments, not grow them," Pines said in a research announcement. 

Providers can help patients early in the care process, trimming off wasted time in the waiting room. For instance, hospitals can place a physician at triage or eliminate triage altogether when there are empty rooms. 

In addition, facilities can use space better to meet patient demands. When the ED is full, patients can wait in the ED, as opposed to outside of it in the waiting room, for tests to be completed. 

And lastly, much of the way that ED crowding should be avoided is pinching it off at the source and preventing ED visits altogether with public health measures so patients don't get sick or allowing patients to get "sick visits" at their doctor's office, Pines noted. 

Bryan Sloane
Deputy Editor, CAL/AAEM News Service 

Brian Potts MD, MBA
Managing Editor, CAL/AAEM News Service 

4. On the (Over) Diagnosis of PE 

A. Excerpt from “Right-sizing testing for PE: recognizing the risks of detecting any clot.” 

Green SM, Yealy DM. Ann Emerg Med. 2012 Jun;59(6):524-6.  

Seven-Step Program for Reducing Testing for Pulmonary Embolism  

Step 1: Accept That You Cannot Identify All Pulmonary Emboli  

As amply displayed by the case report in this issue,[4] emergency physicians must abandon any pretense that they can identify all pulmonary emboli on a first visit. Each of us will miss pulmonary emboli, and on rare occasions the outcome will be poor despite the well appearance. Resign yourself to a more pragmatic and utilitarian approach. 

Step 2: Recognize That Any Strategy That Seeks to Detect All Pulmonary Emboli Does More Harm Than Good  

As discussed, aggressive testing is not beneficial overall but simply shifts the net risks from the few patients with disease to the many without. [3] , [6]  

Step 3: Risk-Stratify and Reduce Your Testing  

Identify low-risk patients and don't initiate a diagnostic evaluation for pulmonary embolism. PERC is a well-validated tool for this purpose.[1] PERC-negative patients aren't just low risk but also ultralow risk. Identifying true zero risk is not achievable, even with testing. 

Don't like the validated decision aids? No problem. Because PERC simply mimics unstructured clinical judgment, there is every reason to believe that the gestalt of a skilled emergency physician will similarly identify patients whose lower risk of pulmonary embolism does not warrant the risks of a diagnostic evaluation. [11] , [12]  

Step 4: Try “Watchful Waiting”  

In the ED, our mindset is to make correct diagnoses on the spot, whereas most other physicians assess the likelihood of disease longitudinally. Emergency physicians need to gain more comfort delaying evaluations for pulmonary embolism and other diagnoses, a strategy sometimes nicknamed “watchful waiting”[13] or “masterful inactivity.”[14]  

To avoid unnecessary risks of testing, a feasible alternative for “on-the-fence” patients might simply be a 24-hour recheck either in the ED or with their regular physician. By then, the lack of disease may have become obvious, and if the patient is unimproved you can always test at this second visit. Patient satisfaction with watchful waiting can be just as high as with immediate testing.[13] We currently do this safely in low-risk venous thrombosis, the common pulmonary embolism companion. 

Step 5: Document Your Medical Decisionmaking  

The no-testing strategy can be readily documented on the medical record: “Given the known potential harms of a diagnostic evaluation for pulmonary embolism, my clinical judgment for this patient is that those risks currently outweigh the likely benefits.” If using watchful waiting, then add: “Instead, I have asked the patient to be rechecked in 24 hours (or earlier if worse) to reassess this risk, either in the ED or with his or her regular physician.” 

Step 6: Be Less Afraid of Litigation  

Adverse malpractice verdicts occur commonly when physicians fail to meet a reasonably well-defined standard of care and when more than a single opportunity is lost. Our recommendations resolve both of these directly. When that standard is murky, when the diagnosis is inapparent, and when the risks of testing are very real (as with pulmonary embolism), those judging our care will likely understand and support the physician who is attempting to act in the patient's best interests. Moreover, our patients will know we cared for them, especially if we share our knowledge and concern for their immediate and long-term safety and well-being. 

Step 7: Spread the Word  

Educate your trainees, partners, and colleagues about tailored decisionmaking and the pitfalls of testing “at any cost.” Track such testing in your continuous quality improvement programs. Ensure that your local ED logistics effectively facilitate return visits for watchful waiting. 

So that's the news, both bad and good. That we cannot consistently diagnose this protean disease safely is bad news. However, it is good news that the current scientific evidence supports a strategy of using clinical judgment to substantially reduce testing for pulmonary embolism. We will not always be right with individual patients, but aggressive testing for all only shifts who receives what bad event; it does not decrease harm universally. 

B. Overdiagnosis of Disease: A Modern Epidemic: 

Hoffman JR, Cooper RJ. Arch Intern Med. 2012 Jun 25:1-2. Archives, full-text (free):  

C. The Diagnosis and Treatment of Pulmonary Embolism: A Metaphor for Medicine in the Evidence-Based Medicine Era.  

Prasad V, Rho J, Cifu A. Arch Intern Med. 2012;172(12):955-958. Archives, full-text (free):  

5. Risks of Intracranial Hemorrhage among Patients with Acute Ischemic Stroke Receiving Warfarin and Treated With Intravenous Tissue Plasminogen Activator 

Xian Y, et al. JAMA. 2012;307(24):2600-2608. 

In an earlier Lit Bits prelim results from a conference presentation were posted. The full article now is available in press and online.   

Context  Intravenous tissue plasminogen activator (tPA) is known to improve outcomes in ischemic stroke; however, patients receiving long-term chronic warfarin therapy may face an increased risk for intracranial hemorrhage when treated with tPA. Although current guidelines endorse administering intravenous tPA to warfarin-treated patients if their international normalized ratio (INR) is 1.7 or lower, there are few data on safety of intravenous tPA in warfarin-treated patients in clinical practice. 

Objectives  To determine the risk of symptomatic intracranial hemorrhage (sICH) among patients with ischemic stroke treated with intravenous tPA who were receiving warfarin vs those who were not and to determine this risk as a function of INR. 

Design, Setting, and Patients  Observational study, using data from the American Heart Association Get With The Guidelines–Stroke Registry, of 23 437 patients with ischemic stroke and with INR of 1.7 or lower, treated with intravenous tPA in 1203 registry hospitals from April 2009 through June 2011. 

Main Outcome Measure  Symptomatic intracranial hemorrhage. Secondary end points include life-threatening/serious systemic hemorrhage, any tPA complications, and in-hospital mortality. 

Results  Overall, 1802 (7.7%) patients with stroke treated with tPA were receiving warfarin (median INR, 1.20; interquartile range [IQR], 1.07-1.40). Warfarin-treated patients were older, had more comorbid conditions, and had more severe strokes. The unadjusted sICH rate in warfarin-treated patients was higher than in non–warfarin-treated patients (5.7% vs 4.6%, P < .001), but these differences were not significantly different after adjustment for baseline clinical factors (adjusted odds ratio [OR], 1.01 [95% CI, 0.82-1.25]). Similarly, there were no significant differences between warfarin-treated and non–warfarin-treated patients for serious systemic hemorrhage (0.9% vs 0.9%; adjusted OR, 0.78 [95% CI, 0.49-1.24]), any tPA complications (10.6% vs 8.4%; adjusted OR, 1.09 [95% CI, 0.93-1.29]), or in-hospital mortality (11.4% vs 7.9%; adjusted OR, 0.94 [95% CI, 0.79-1.13]). Among warfarin-treated patients with INRs of 1.7 or lower, the degree of anticoagulation was not statistically significantly associated with sICH risk (adjusted OR, 1.10 per 0.1-unit increase in INR [95% CI, 1.00-1.20]; P = .06). 

Conclusion  Among patients with ischemic stroke, the use of intravenous tPA among warfarin-treated patients (INR ≤1.7) was not associated with increased sICH risk compared with non–warfarin-treated patients. 

Associated editorial: Alberts MJ, et al. Cerebral Hemorrhage, Warfarin, and Intravenous tPA: The Real Risk Is Not Treating. JAMA. 2012;307(24):2637-2639.  

6. Age Is an Inverse Predictor of Propofol Dose for Procedural Sedation in Children 

But age accounted for only 7% of variability in induction doses.  

To determine if age predicts dosing of propofol in children, investigators retrospectively reviewed records of 88 patients aged <18 years (mean age, 11 years) who received only propofol for procedural sedation at a single emergency department between 2005 and 2009. 

Indications for sedation included fracture manipulation (60%), dislocation manipulation (17%), imaging (7%), and lumbar puncture (5%). The mean cumulative propofol dose was 2.1 mg/kg administered in a median of 3 boluses, with mean consecutive doses of 0.94, 0.49, and 0.40 mg/kg. Mean time to adequate sedation was 3.9 minutes. In linear regression analyses, age was inversely predictive of propofol dose; procedure type, opioid administration, and preprocedural pain scores were not predictors. Respiratory depression (oxygen saturation <90%, end tidal carbon dioxide >50 mm Hg or increase of >10 mm Hg from baseline, or apnea) occurred in 12 patients (14%); only 1 patient required temporary bag-mask ventilation. Transient hypotension occurred in 7 patients (8%) and required no intervention. Of note, although age was significantly inversely related to propofol dose, age accounted for only 7% of variability in doses. 

Comment: The aim in propofol dosing is to select an initial dose that achieves prompt and adequate sedation while minimizing adverse events. Younger patients are more likely to require higher doses of propofol, but the initial dose requirement for any one patient cannot be perfectly predicted. 

— Katherine Bakes, MD. Published in Journal Watch Emergency Medicine June 15, 2012. Citation: Jasiak KD et al. Induction dose of propofol for pediatric patients undergoing procedural sedation in the emergency department. Pediatr Emerg Care 2012 May; 28:440. 

7. The Debate Surrounding the EGDT Bundle (courtesy of EP Monthly)                                  

A. Sepsis: Unbundling the Bundle by Kevin Klauer, DO, EJD on May 24, 2012. 

Years after its debut, studies continue to question the efficacy of EGDT  

Two years ago I called into question the use of the sepsis bundle of therapies defined by the “Surviving Sepsis” campaign (EPM, March 2010) Although aggressively managing sepsis is a good thing, and the mere focus on the rapid identification and application of appropriate management strategies for sepsis is essential to good patient outcomes, it appears that EGDT and the research it was based on may have promised more than it could deliver. 

As it is with many modalities that are rapidly and widely accepted based on a few sentinel studies, years later we often find that our early adoption was premature and ill advised. With all due respect to the authors of the study, I respectfully submit that the sepsis bundle described in EGDT fits squarely into that category… 

B. Sepsis: EGDT Continues to Deliver by Emanuel Rivers, MD, MPH on July 10, 2012. 

The concept and components of early goal directed therapy (EGDT) for sepsis management has been part of the emergency medicine (EM) literature for over 40 years.1-3 Eleven years after the original publication of EGDT, the literature reflects the opposite position to that of Dr. Klauer, as put forth in last month’s Op/Ed. EGDT has been validated and proven effective in over 54 publications comprising over 23,000 patients (shown in the table at right).4 Because of these robust finding, the emergency department (ED) has had the most influential impact on sepsis outcomes in the last decade.5 EGDT remains one of the most important components of the Surviving Sepsis Campaign (SSC) recommendations.6 EGDT has not “failed to deliver,” as Dr. Klauer suggests… 

8. Images in Clinical Medicine 

Whooping Cough in an Adult

Obstructive Parotitis

Bladder Stone

Porcelain Aorta

Necrobiosis Lipoidica Diabeticorum

Steeple Sign of Croup

Dynamic Extrathoracic Airway Obstruction

Yellow Urticaria

ECG Diagnosis: Hypokalemia

Image diagnosis: abdominal wall hematoma

9. Catheter Not Required for Shock Diagnosis 

By Chris Kaiser, Cardiology Editor, MedPage Today. Published: July 02, 2012. 

NATIONAL HARBOR, Md. -- It may be possible for internists and emergency room physicians to diagnose cardiogenic shock using a model of clinical and echocardiographic variables, researchers suggested. 

A retrospective derivation cohort of 122 acute myocardial infarction (MI) patients used to test the noninvasive model had an overall accuracy of 83%, with good sensitivity (83%) and specificity (82%), according to Amir H. Najafi, MD, a cardiology fellow at Washington Hospital Center in Washington, D.C., and colleagues. 

When the model was validated in an all-comers cohort of 90 consecutive patients undergoing pulmonary artery catheterization, the overall accuracy was 81%, while the sensitivity dropped to 71%, which Najafi deemed "still respectable," during his report at American Society of Echocardiography annual meeting. In addition, the specificity came in at 86%. 

Patients identified as having cardiogenic shock using the echocardiography-based criteria had the same inhospital mortality rate as those identified using the invasive criteria (both 29%). 

The current protocol for diagnosing cardiogenic shock requires the insertion of a catheter into the pulmonary artery. However, some expert cardiologists often make the assessment without pulmonary artery catheterization. 

"We hypothesized that learning the thought process of these experts who utilize clinical and echocardiographic data to make their diagnosis might help us develop a model for other noncardiologists to use," Najafi told MedPage Today. 

There were three sets of clinical criteria and one set of echocardiographic variables that Najafi and colleagues determined patients should have as part of the noninvasive model. 

The first set consists of any of these predisposing conditions:  

·         Anterior STEMI (ST-segment elevation myocardial infarction) or any acute MI with an ejection fraction less than 40%
·         Right ventricular MI
·         Acute myocarditis
·         Stress cardiomyopathy
·         Severe mitral or aortic regurgitation or stenosis
·         Ventricular septal rupture or free wall rupture
·         Severe left ventricular dysfunction

Next is evidence of hypotension:

·         Systolic blood pressure less than 90 mmHg for 30 minutes or longer
·         Need for supportive measures such as intra-aortic balloon pump, vasopressor, or inotrope to maintain systolic blood pressure greater than 90 mmHg 

Then evidence of hypoperfusion:  

·         Urine output of 25 mL/hour
·         CO2 less than 18 mmol/L
·         Lactate greater than 2 mmol/L 

Finally, echocardiographic evidence of elevated filling pressures such as:  

·         Mitral pulse Doppler E/A wave ratio greater than 0.9 (or if this is not measurable due to E/A fusion or the absence of A)
·         Minimum inferior vena cava diameter during full respiratory cycle greater than 15 mm 

"A patient may fulfill all three clinical criteria, but we still need evidence of elevated filling pressures for a definitive diagnosis of cardiogenic shock," Najafi said. "There are different types of shock and we want to be sure these patients are triaged properly and quickly." 

In the E/A ratio, E is the early diastolic filling of the left ventricle, which should be greater than A, the late atrial systolic push into the left ventricle. "An E/A ratio greater than 1 is suggestive of elevated filling pressures," Najafi said. "We believe 0.9 is the best cutoff value for this." 

In cases of tachycardia, the E/A can become fused, or difficult to separate, and in cases of atrial fibrillation, the A will sometimes be absent. That is why Najafi and colleagues allow for a second echocardiographic measurement of the inferior vena cava diameter. 

They also are testing other echocardiographic parameters, particularly tissue Doppler, in an ongoing prospective evaluation. For this ongoing study, nurses in the critical care unit at Washington Hospital Center have been asked to record the pulmonary artery catheterization data simultaneously with the echo parameters. 

They have more than 100 patients in the prospective study and intend to enroll several hundred. The interim analysis shows the trend is heading in the right direction, Najafi told MedPage Today. 

The researchers reported no conflicts of interest. 

Najafi A, et al "Accurate, noninvasive diagnosis of cardiogenic shock based on echocardiography rather than invasive hemodynamic assessment" American Society of Echocardiography 2012; Abstract P1-13. 

10. Rapid Rule-Out Protocol for Patients with Suspected Cardiac Chest Pain 

The combination of TIMI score of zero at presentation, no new ischemic changes on initial electrocardiogram, and negative troponin results at zero and 2 hours had a sensitivity of 99.7%. 

In a prospective observational study of 1975 patients who presented to two hospitals in Australia and New Zealand with chest pain suggestive of acute coronary syndrome, researchers assessed whether or not an accelerated diagnostic protocol could identify patients at low risk for major adverse cardiac events within 30 days. Patients with ST segment elevation on initial electrocardiogram (ECG) were excluded. Patients received usual care, including serial troponin testing, in accordance with international guidelines; each hospital used its standard troponin test. 

The protocol consisted of a Thrombolysis in Myocardial Infarction (TIMI) score at presentation, initial ECG results, and troponin I concentrations at zero and 2 hours; patients with a TIMI score of zero, no new ischemic changes on initial ECG, and negative troponin results at zero and 2 hours were deemed low risk. 

Major adverse cardiac events (acute myocardial infarction, death, cardiac arrest, cardiogenic shock, emergency revascularization, and ventricular dysrhythmia requiring intervention) occurred in 302 patients (15%), usually within 10 days. The protocol identified 392 patients (20%) as being low risk; one of these patients (0.25%) had a major cardiac event (myocardial infarction diagnosed on the basis of an elevated troponin result at 12 hours). The sensitivity and negative predictive value of the protocol for identifying patients with major adverse cardiac events were both 99.7%, and the specificity was 23.4%. 

Comment: This study begs for a randomized trial in which low-risk patients are actually sent home, but such a study is unlikely to ever be conducted. The study's strength is its use of current (i.e., not highly sensitive) troponin assays from two different manufacturers. These findings support institutions developing internal protocols to efficiently evaluate patients with low-risk chest pain. Developers of such protocols should recognize that most patients will require further testing, such as exercise tolerance testing, to exclude ischemia. 

— J. Stephen Bohan, MD, MS, FACP, FACEP. Published in Journal Watch Emergency Medicine June 29, 2012 

Citation(s): Than M et al. 2-hour accelerated diagnostic protocol to assess patients with chest pain symptoms using contemporary troponins as the only biomarker: The ADAPT trial. J Am Coll Cardiol 2012 Jun 5; 59:2091. Abstract:  

11. Heart Size Skews MI Biomarker 

By Charles Bankhead, Staff Writer, MedPage Today. Published: June 29, 2012. 

Levels of troponin I significantly overestimated infarct size after ST-elevation myocardial infarction (STEMI) in patients with left ventricular hypertrophy (LVH), a retrospective review of 500 cases showed. 

Patients with mild LVH had a mean troponin I level that was 13.7% higher than patients with no hypertrophy. The difference increased to 17.8% for patients with moderate to severe LVH. 

In contrast, creatinine kinase (CK) levels remained stable across the range from no hypertrophy to moderate/severe LVH, as reported online in the Journal of the American College of Cardiology. 

"After our findings, it may be speculated that LVH can act as a confounding factor when troponins are used as infarct size estimators," Borja Ibañez, MD, PhD, of the Carlos III National Center for Cardiovascular Studies in Madrid, and co-authors wrote. "Here we show that STEMI patients with LVH had significantly greater troponin I release than patients with normal left ventricle thickness at a given CK value. 

"According to the incidence of LVH in our nonselected STEMI patient population and others, myocardial infarction size calculated according to peak troponin release can be overestimated in 30% of patients, something that should be taken into consideration in studies evaluating the effect of therapies in infarct size." 

Studies have shown that peak and area under the curve of circulating CK and troponins correlate with infarct size after STEMI. Moreover, measurement of troponin concentration at a single point in time has good correlation with infarct size. As a result, measurement of circulating biomarkers has become widespread in clinical practice and trials. 

Hypertrophied myocardium has elevated troponin concentrations as opposed to normal myocardial tissue, but CK levels are similar. Ibañez and co-authors hypothesized that troponin release following STEMI will be increased relative to CK in patients with LVH. Consequently, prediction of infarct size by troponin levels might be confounded by the presence of LVH. 

Investigators studied 504 patients treated for STEMI during 2004 to 2009. The group consisted of 331 patients with no LVH, 107 patients with mild LVH, and 66 patients with moderate to severe LVH. Biomarker release was compared in patients with and without LVH. 

Peak CK values did not differ significantly across categories of LVH. However, compared with patients with no LVH, patients who had mild or moderate to severe LVH had 13.7% (95% CI 2.5% to 26.1%, P<0.02) and 17.8% higher troponin levels (95% CI 3.3% to 34%, P<0.02), respectively. 

"In the presence of LVH, the discrepancy between total CK and troponin I can be as much as 34%," the authors wrote. "Such a variation in infarct size is of great biological impact in clinical trials testing the effect of cardioprotective interventions, and therefore the current results have a significant impact." 

The study is limited by its retrospective nature and researchers said that more studies need to be performed to confirm their results. 

12. FDA: Teething Pain Remedies Dangerous 

By Peggy Peck, Executive Editor, MedPage Today. May 31, 2012 

WASHINGTON -- Rubbing topical anesthetics such as Anbesol or Orajel on the throbbing gums of a teething baby can lead to methemoglobinemia, a serious condition that leads to oxygen deprivation and -- in extreme cases -- death, the FDA warned today. 

Products sold over-the-counter for teething and toothache pain contain benzocaine, and that is the source of the FDA's concern, said FDA pharmacist Mary Ghods, RPH, in a statement. 

The risk is greatest among children younger than 2, the age range at which most children experience teething pain. 

The FDA first warned about the products -- a list that includes Hurricaine, Baby Orajel and Orabase, as well as Orajel and Anbesol -- in 2006, and since then the agency has received "29 reports of benzocaine gel-related cases of methemoglobinemia. Nineteen of those cases occurred in children, and 15 of the 19 cases occurred in children under 2 years of age," FDA pharmacist Kellie Taylor, PharmD, MPH, said in a statement. 

The FDA issued a second warning a year ago, but, Taylor said, the agency remains concerned about "the difficulty parents may have recognizing the signs and symptoms of methemoglobinemia when using these products at home." 

Moreover, the symptoms can occur within minutes of use or may not manifest until hours after the drug is applied, and a child can become symptomatic with first use or only after several uses. 

Symptoms of methemoglobinemia include:  

·         Pale, gray, or blue-colored skin, lips and nail beds
·         Shortness of breath
·         Fatigue
·         Confusion
·         Headache
·         Light-headedness
·         Rapid heart rate 

As an alternative to using numbing drugs on gums, the American Academy of Pediatrics recommends giving the baby a chilled teething ring or gently massaging the baby's gums with a finger. 

If those remedies fail, the AAP recommends contacting a health professional for advice. 

The FDA noted that in addition to OTC sales of benzocaine products, physicians and dentists use benzocaine sprays to numb areas of the mouth and throat for procedures such as transesophageal echocardiograms, endoscopy, and feeding tube placements. 

Adults -- especially those with heart disease, asthma, bronchitis, or emphysema, as well as smokers -- are also at risk from benzocaine products, and Taylor recommended that adults with those conditions have a preprocedure consult to discuss the risks. 

13. Answering the myth: use of emergency services on Friday the 13th 

Lo BM, et al. Amer J Emerg Med. 2012;30:886-889. 

Objective: The aim of the study was to evaluate the risk of Friday the 13th on hospital admission rates and emergency department (ED) visits. 

Methods: This was a retrospective chart review of all ED visits on Friday the 13th from November 13, 2002, to December 13, 2009, from 6 hospital-based EDs. Thirteen unlikely conditions were evaluated as well as total ED volumes. As a control, the Friday before and after and the month before and after were used. χ2 Analysis and Wilcoxon rank sum tests were used for each variable, as appropriate. 

Results: A total of 49 094 patient encounters were evaluated. Average ED visits for Friday the 13th were not increased compared with the Friday before and after and the month before. However, compared with the month after, there were fewer ED visits on Friday the 13th (150.1 vs 134.7, P = .011). Of the 13 categories evaluated, only penetrating trauma was noted to have an increase risk associated with Friday the 13th (odds ratio, 1.65; 95% confidence interval, 1.04-2.61). No other category was noted to have an increase risk on Friday the 13th compared with the control dates. 

Conclusions: Although the fear of Friday the 13th may exist, there is no worry that an increase in volume occurs on Friday the 13th compared with the other days studies. Of 13 different conditions evaluated, only penetrating traumas were seen more often on Friday the 13th. For those providers who work in the ED, working on Friday the 13th should not be any different than any other day. 

14. If pre-procedure hydration is standard protocol in high-risk patients with stage 3 or 4 chronic kidney disease, what is the incidence of contrast-induced nephropathy (CIN)? 

A review from “Keeping Up”  at Vanderbilt Emergency Medicine  

Study Design: Prospective Cohort 

Level of Evidence: 2 

Synopsis: Adult patients in the Netherlands who were to undergo a procedure requiring IV contrast were divided into two cohorts based on high or low risk for CIN, and all had a creatinine measured 3-5 days after the procedure.  Those in the high risk group (eGFR <60mL/min + DM, eGFR 45-60 mL/min and at least 2 risk factors, or eGFR <45 mL/min) were hydrated with 250mL/hr of NS for four hours before and after the procedure (over 10 hours pre and post if eGFR <30mL/min, CHF, or on diuretics).  Low risk patients did not receive hydration.  The rate of CIN was about 2.4% in each cohort and 2.4% overall.  CHF, low BMI, and prior contrast within the past year were all independent risk factors for CIN. 

Upshot: If your patient is at high risk for CIN, give 1L of NS before and after the administration of IV contrast if at all possible.  Interesting how much lower the incidence of CIN was in this study than in the study Madji reviewed this week regarding CIN in patients getting CT pulmonary angiography.  It looks like hydration may have made a big difference. 

15. High Rate of Positive CT Scans in Older Patients with Minor Head Trauma 

Head computed tomography was positive in two thirds of patients aged >65 with Glasgow Coma Scale scores of 15 and no loss of consciousness. 

Moore MM, et al. Impact of age and anticoagulation: Need for neurosurgical intervention in trauma patients with mild traumatic brain injury. J Trauma Acute Care Surg. 2012 May 2. [Epub ahead of print] 

BACKGROUND: Of the 500,000 brain injuries in the United States annually, 80% are considered mild (mild traumatic brain injury). Unfortunately, 2% to 3% of them will subsequently deteriorate and result in severe neurologic dysfunction. Intracerebral changes in the elderly, chronic oral anticoagulation, and platelet inhibition may contribute to the development of intracranial bleeding after minor head injury. We sought to investigate the association of age and the use of anticoagulation and antiplatelet therapy with neurologic deterioration and the need for neurosurgical intervention in patients presenting with mild traumatic brain injury. 

METHODS: A retrospective review of all adult (>14 years) patients admitted to our Level I trauma service with a Glasgow Coma Scale (GCS) score of 14 to 15 who underwent neurosurgical intervention during their hospital stay was performed. Patients were stratified into two groups, age <65 years and age ≥65 years. Each group was then further stratified by the use of anticoagulants: warfarin, aspirin, clopidogrel, or a combination. Mechanism of injury, prehospital complaints, admission GCS, type of neurosurgical intervention, intensive care unit length of stay, hospital length of stay, and discharge disposition were evaluated. Z test and logistic regression were used to compare proportions or percentages from different groups. 

RESULTS: Of the 7,678 patients evaluated during the study period, 101 (1.3%) required neurosurgical intervention. The ≥65 years population underwent significantly more interventions as did those patients on anticoagulants. 

CONCLUSION: All patients aged 65 years or older who present with a GCS score of >13 after head trauma should undergo a screening computed tomography of the head regardless of prehospital use of anticoagulation. Patients younger than 65 years can be selectively screened based on presenting complaints and mechanism of injury provided they are not on anticoagulation. 

16. Good News About Antibiotic Use in Children, but Judicious Use Is Still Needed 

From 2000–2005, the decline in antibiotic dispensing rates for children in Massachusetts was largely attributable to lower rates of otitis media diagnoses, but the decline has stalled. 

Researchers obtained antibiotic dispensing and diagnosis data for children from two health insurers in 16 Massachusetts communities from 2000 to 2009 and analyzed the data according to three age groups: 3 to 24 months, 24 to 48 months, and 48 to 72 months. 

Annual population-based antibiotic dispensing rates (number of antibiotic dispensings divided by number of person-years) declined in all three age groups. The decline was greatest (24%) in the 3- to 24-month-old group (from 2.3 to 1.8 antibiotic dispensings per person-year). The downward trend leveled off after 2005 in the two youngest groups and after 2001 in the older group, with no further significant change through 2009. The decline was primarily attributable to a lower rate of otitis media diagnoses. Lower rates of antibiotic dispensing unrelated to office visits in each age group also contributed to the decline. The authors were unable to determine if use of the pneumococcal vaccine, changes in the threshold for diagnosis of otitis media, or both contributed to the downward trend. Although overall use of second-generation macrolides was relatively low, use increased among children aged 48 to 72 months during the study period. 

Comment: The downward trend in the use of antibiotics in children during the last decade is a positive development. The message concerning the need for judicious use of antibiotics is being heard. However, the decline has stalled. We now need to reduce improper use of antibiotics — such as second-generation macrolides (e.g., azithromycin) — instead of less expensive and more effective first-line treatment with penicillin (e.g., amoxicillin). 

— Louis M. Bell, MD. Published in Journal Watch Pediatrics and Adolescent Medicine July 11, 2012. Citation: Greene SK et al. Trends in antibiotic use in Massachusetts children, 2000–2009. Pediatrics 2012 Jul; 130:15. 

17. Dehydration in children with diabetic ketoacidosis: a prospective study. 

Sottosanti M, et al. Arch Dis Child. 2012 Feb;97(2):96-100. 

OBJECTIVES: To investigate the association between the degree of patient dehydration on presentation with diabetic ketoacidosis (DKA) and clinical and laboratory parameters obtained on admission. 

DESIGN: Prospective descriptive study. 

SETTING: A tertiary care children's hospital. 

PATIENTS: Thirty-nine paediatric patients (1 month-16 years) presenting with 42 episodes of DKA. 

INTERVENTION: Clinical and biochemical variables were collected on admission. Dehydration was calculated by measuring acute changes in body weight during the period of illness. All patients were treated according to a previously established protocol. 

MAIN OUTCOME MEASURES: Magnitude of dehydration, defined as % loss of body weight (LBW), was determined by the difference in body weight obtained at presentation and at discharge. The relationship between the magnitude of dehydration and the clinical assessment and biochemical parameters was examined. 

RESULTS: The median (25th-75th centiles) magnitude of dehydration at presentation was 5.7% (3.8-8.3%) (mean ± SD 6.8 ± 5%). Neither the initial clinical assessment nor the comprehensive biochemical profile at admission correlated with the magnitude of dehydration. Despite considerable variation in the degree of dehydration and biochemical disequilibrium, all patients recovered from DKA within 24 h with a standardised therapeutic approach. Furthermore, the rapidity of patient recovery did not correlate with the magnitude of dehydration on presentation or the amount of fluid administered (median (25th-75th centiles) 48.8 ml/kg (38.5-60.3)) in the first 12 h. 

CONCLUSION: The magnitude of dehydration in DKA is not reflected by either clinical or biochemical parameters. These findings need confirmation in larger studies. 

18. Comprehensive pain management protocol reduces children's memory of pain at discharge from the pediatric ED.  

Crocker PJ, et al. Amer J Emerg Med. 30:861-871. 

Background: Historically, pain has been poorly managed in the pediatric emergency department (ED) (PED), resulting in measurable psychosocial issues both acute and delayed. 

Objective: The aim of the study was to measure the impact of protocolized pain management on patients with painful conditions or undergoing painful procedures in the PED. 

Methods: We performed an analysis before and after the implementation of the protocol, dubbed the “Comfort Zone.” Validated, age-appropriate pain scales were performed. Validation (using Cronbach α, confirmatory factor analysis) was followed by comparison of responses between the pre- and posttests collected (χ2 and Wilcoxon rank sum tests). Pain scores were collected at triage and at discharge. At triage, patients were asked to report pain levels. At discharge, they were asked to report their current pain and recall the level of pain during their stay. At triage, parents were asked to report about their perception of the child's pain. At discharge, they were asked to report about their perception of the child's current pain and recall the level of pain during the stay and during procedures, if done. 

Results: Five hundred thirty-one patients were enrolled in the preprotocol group; 47% were women with a median age of 5 years (range, 30 days-18 years). Two hundred sixty-three patients were enrolled in the protocol group; 39% were women with a median age of 6 years (range, 30 days-18 years). Patient-recalled pain scores of the ED visit in the protocol group were significantly lower than those of the preprotocol group (Wong-Baker Faces Pain Scale, 5.07-4.01; P < .001); yet parent estimates of pain did not show a significant change at any point. Patient assessment of pain at ED discharge did not show a significant change either (Wong-Baker Faces Pain Scale, 1.99-1.56; P = .09). The Faces scale is not well validated for patients younger than 4, so that group had only parental assessment of pain and, consistent with the larger data set, showed no significant pain scale reduction at any point. 

Conclusion: Protocolized pain management reduces patients' memory of pain during PED visits but may not affect parental memory of perceived pain or parent- and patient-reported pain at discharge. 

19. A Simple Score Predicts Aortic Injury in Patients with Blunt Chest Trauma 

A score based on seven physical exam and chest x-ray findings had high sensitivity for aortic injury. 

Mosquera VX, et al. Traumatic aortic injury score (TRAINS): an easy and simple score for early detection of traumatic aortic injuries in major trauma patients with associated blunt chest trauma.

Intensive Care Med. 2012 May 23. [Epub ahead of print]. 

PURPOSE: To develop a risk score based on physical examination and chest X-ray findings to rapidly identify major trauma patients at risk of acute traumatic aortic injury (ATAI). 

METHODS: A multicenter retrospective study was conducted with 640 major trauma patients with associated blunt chest trauma classified into ATAI (aortic injury) and NATAI (no aortic injury) groups. The score data set included 76 consecutive ATAI and 304 NATAI patients from a single center, whereas the validation data set included 52 consecutive ATAI and 208 NATAI patients from three independent institutions. Bivariate analysis identified variables potentially influencing the presentation of aortic injury. Confirmed variables by logistic regression were assigned a score according to their corresponding beta coefficient which was rounded to the closest integer value (1-4). 

RESULTS: Predictors of aortic injury included widened mediastinum, hypotension less than 90 mmHg, long bone fracture, pulmonary contusion, left scapula fracture, hemothorax, and pelvic fracture. Area under receiver operating characteristic curve was 0.96. In the score data set, sensitivity was 93.42 %, specificity 85.85 %, Youden's index 0.79, positive likelihood ratio 6.60, and negative likelihood ratio 0.08. In the validation data set, sensitivity was 92.31 % and specificity 85.1 %. 

CONCLUSIONS: Given the relative infrequency of traumatic aortic injury, which often leads to missed or delayed diagnosis, application of our score has the potential to draw necessary clinical attention to the possibility of aortic injury, thus providing the chance of a prompt specific diagnostic and therapeutic management. 

20. CT without Oral Contrast Saves Time, Maintains Quality 

James Brice, Medscape Medical News. July 6, 2012 — An emergency department (ED) strategy that eliminates the routine use of oral contrast for abdominal-pelvic (AP) computed tomography (CT) for undifferentiated abdominal pain can reduce ED length of stay (LOS) without compromising diagnostic accuracy. 

Robin B. Levenson, MD, and colleagues from the Emergency Radiology Division of Beth Israel Deaconess Medical Center, Boston, Massachusetts, found the rescan rate with oral contrast was modest after the staff stopped routinely administering oral contrast for these procedures. Their findings were drawn from the clinical experience with a cohort of 1014 consecutive ED patients who underwent AP CT with oral contrast compared with that of a subsequent group of 987 patients who had AP CT without oral contrast. 

The study found additional CT scans with oral contrast rarely affected the results of the initial reading in any case. In patients admitted to the hospital, additional abdominal pelvic imaging during their stay did not alter their diagnosis. 

Dr. Levenson and colleagues found no statistically significant difference in the rate of return to the ED in the 72 hours after discharge for patients who underwent CT without oral contrast compared with those who had conventional AP CT with contrast. 

Oral CT contrast administration adds time to ED visits, noted Dr. Levenson and colleagues in the study, published online June 29 in Emergency Radiology. Multidetector CT is delayed 60 to 90 minutes to allow oral contrast to opacify the bowel. 

Several studies have demonstrated that AP CT without oral contrast leads to accurate evaluations of abdominal pain, especially for suspected acute appendicitis. The Beth Israel Deaconess group sought to assess the effect of AP CT without oral contrast on ED LOS. 

The current researchers showed, as hypothesized, that the routine use of oral contrast for AP CT was not necessary for patients with nontraumatic, undifferentiated abdominal pain. 

Oral contrast was still ordered, however, for patients with a known history of inflammatory bowel disease, gastrointestinal tract–altering surgery, or extremely lean body habitus, Dr. Levenson and colleagues write. 

The study did not consider patients with symptoms that have not traditionally led to oral contrast before AP CT. Indications excluding patients from the study were trauma, a suspected genitourinary stone, hemodynamic instability, suspected mesenteric ischemia, retroperitoneal hematoma, aortic rupture/dissection, and suspected pulmonary embolism. 

Before the protocol change, 95% of patients eligible for oral contrast received it before AP CT. Afterward, the proportion dropped to a statistically significant 42% (P < .001). ED LOS was cut by a mean of 97.7 minutes (P < .001), and the time between an order for CT and the actual procedure fell by 66.2 minutes (P < .001). 

"As our study demonstrates, elimination of routine oral contrast used in the ED for patients eligible for oral contrast may lead to decrease in patient time from CT ordered to CT performed and in mean ED LOS," the authors write. 

In terms of diagnostic quality, no patient had repeat CT with oral contrast during the initial ED episode or a 72-hour return visit to the ED that resulted in a change in CT diagnosis. 

Study limitations include the retrospective design, lack of follow-up to verify accuracy of diagnoses, inability to assess whether discharged patients presented to a different hospital, and radiologic assessment by only 1 attending radiologist. 

The authors note that Beth Israel Deaconess continues to administer oral contrast before AP CT for patients who have a history of gastrointestinal tract–altering surgery or inflammatory bowel disease or who are subjectively thin. More study and analysis are needed before CT without oral contrast can be justified for these patients, the authors write.

The published study did not include a statement that would have identified any potential conflicts of interests among the investigators.  

Emerg Radiol. Published online June 29, 2012.  Abstract:

21. The Growing Role of EDs in Hospital Admissions 

Schuur JD, et al. New Engl J Med. July 11, 2012 (10.1056/NEJMp1204431)  

Growing use of U.S. emergency departments (EDs), cited as a key contributor to rising health care costs, has become a leading target of health care reform. ED visit rates increased by more than a third between 1997 and 2007, and EDs are increasingly the safety net for underserved patients, particularly adult Medicaid beneficiaries.1 Although much attention has been paid to increasing ED use, the ED's changing role in our health care system has been less thoroughly examined. EDs serve as a hub for prehospital emergency medical systems, an acute diagnostic and treatment center, a primary safety net, and a 24/7 portal for rapid inpatient admission. Approximately a quarter of all acute care outpatient visits in the United States occur in EDs, a proportion that has been growing since 2001.2 We examined the proportion of hospital admissions that come through the ED, hypothesizing that use of the ED as the admission portal had increased across conditions. 

We analyzed data from the Nationwide Inpatient Sample (NIS), the largest all-payer database of U.S. inpatient care, from 1993 to 2006 (the most recent year for which the ED admission data are available on HCUPnet, an interactive Web-based tool that uses data from the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality). The NIS contains data from approximately 8 million hospital stays each year and is weighted to produce national estimates. We used HCUPnet to query the NIS regarding trends in the 20 clinical conditions for which patients were most frequently admitted to the hospital in 2006. Clinical Classifications Software was used to group the conditions into clinically meaningful categories. We excluded two conditions for which patients are rarely admitted through the ED (osteoarthritis and back problems), one psychiatric condition that was not consistently coded in claims data (affective disorder), and four obstetrical diagnoses that are generally evaluated in other care settings, such as labor-and-delivery triage areas (liveborn infant, maternal birth trauma, other complications of birth, other complications of pregnancy). 

The number of hospital admissions increased by 15.0%, from 34.3 million in 1993 to 39.5 million in 2006; admissions from the ED increased by 50.4%, from 11.5 million to 17.3 million. The proportion of all inpatient stays involving admission from the ED increased from 33.5 to 43.8% (P<0.001). In 12 of the 13 conditions for which patients were most frequently admitted and that met our inclusion criteria, an increased proportion of admitted patients came through the ED (P<0.001), regardless of the trend in overall admissions; the exception was coronary atherosclerosis, for which rapid “rule-out” protocols and ED-based chest-pain observation units have reduced the need for inpatient admission. (For details on the 12 conditions, see the Supplementary Appendix, available with the full text of this article at The graphProportion of U.S. Hospitalizations in Which Patient Was Admitted through the Emergency Department, 1993–2006. shows the trend in admissions from the ED for conditions that the Centers for Medicare and Medicaid Services includes in assessments of 30-day readmission and mortality rates. 

Historically, clinically stable patients with acute problems who required hospital care for conditions such as community-acquired pneumonia would see an outpatient provider and be directly admitted from the physician's office. Our findings show that since 1993, EDs have played an increasing role in admissions for almost all conditions. 

There are several possible explanations of this growing role. One frequently cited hypothesis is that overuse of the ED for conditions that would more appropriately be treated in primary care providers' offices could lead to increased admission rates — either because reduced access to primary care leads to worsening of patients' conditions and greater need for emergency hospitalization or because emergency physicians are more likely than primary care providers to admit patients to the hospital. The latter theory is based in part on assumptions that emergency physicians are trained to assume the worst and are more likely to admit patients with uncertain diagnoses and with whom they don't have an ongoing relationship, and that they are unwilling to discharge patients when they cannot guarantee outpatient follow-up.3  

Alternatively, the trend could be driven by changes in the organization of medical services that favor the rapid diagnostic technologies and early treatment available in the ED. As diagnostic services have improved (with the introduction of such tools as computed tomographic scanning and troponin testing) and expectations of rapid and accurate diagnosis and treatment have become standard (e.g., percutaneous coronary intervention for ST-segment–elevation myocardial infarction), the evaluation of common symptoms such as chest pain, abdominal pain, and shortness of breath has become de facto reasons for ED referral. Public education campaigns emphasizing the importance of early emergency care for symptoms suggestive of heart attack or stroke have encouraged this approach. 

In addition, primary care providers are less likely than EDs to provide regular access for unscheduled acute care — and therefore less likely to admit patients to the hospital. A large national survey and observational studies have found that it is difficult for patients to arrange a sick visit with a primary care provider in a timely fashion, because schedules are often full, after-hours service is unavailable, and many acute problems are not well suited to office practices lacking basic laboratory and imaging capabilities.4 As hospitals strive for administrative efficiency by maximizing occupancy rates, it becomes more difficult for outpatient providers to admit patients directly to the hospital. Yet since such hospitals' practices have largely been reactive, it is unclear whether this trend reflects high-value use of limited emergency care resources and whether it has resulted in more or less appropriate use of scarce inpatient beds. 

This increasing use of EDs for inpatient admissions has important implications for the redesign of delivery systems. The need for more efficient use of inpatient resources is a clear focus of the Affordable Care Act (ACA), and the increased role of EDs in inpatient admissions will affect the implementation of central ACA principles, such as quality measurement, care coordination, and payment reform. Yet policymakers seem to view EDs as little more than a locus of inefficient or unnecessary care — the place where patients without access or insurance seek care at great expense to taxpayers. This popular view fails to address the ED's increasingly important role in hospital admissions, and it is not supported by the data.5  

EDs' growing role in hospital admissions is a clue to their critical role in the health care system. Rigorous research to identify drivers of this trend and determine the value or cost of emergency care is needed to inform health policy. For example, comparative effectiveness studies on admission from the ED versus direct admission can evaluate whether early access to diagnostic and therapeutic services improves outcomes while shortening lengths of stay. Similarly, studies of conditions that are ideally evaluated in the ED, such as chest pain, must demonstrate the ability of evidence-based rapid diagnostic pathways to safely stratify patients according to risk level and reduce admissions rates. 

Should we return to having primary care providers initiate and direct hospital admissions? Because of the increasingly specialized nature of patient care, our systems have evolved into separate arenas of hospital-based and ambulatory care provided by clinicians with different types of training. As reimbursement models shift from providing incentives for admissions as a hospital's revenue source to providing incentives for reducing admissions, EDs will probably reduce their use of hospital admission. Yet the ACA's expansion of insurance coverage, the reality of an aging population with complex conditions, and the expectation of timely, specialized, and coordinated care mean that the trend toward increasing percentages of ED admissions is unlikely to be reversed. New models of acute care delivery aiming to improve the use of scarce intensive, hospital-based services should take into account this change in patient and provider expectations.