Journal of Emergencies, Trauma, and Shock

: 2021  |  Volume : 14  |  Issue : 3  |  Page : 180--183

Abstracts for the 39th emergencies in medicine conference

Sukaina Ali Alali1, Tinh Le2, M DeVogelaere3, Richard Nowak4, S Scott Sutton5, Kerri Coakley6, Zubaid Rafique7, Frank Peacock7,  
1 Central Michigan University, Mount Pleasant, Michigan, USA
2 Case Western Reserve University School of Medicine, Cleveland, OH, USA
3 Legacy Health Emergency Medicine, USA
4 Henry Ford Health System, Detroit, MI, USA
5 Department of Clinical Pharmacy and Outcomes Sciences, College of Pharmacy, University of South Carolina, Columbia, SC, USA
6 Baylor St. Luke's Medical Center, Houston, Texas, USA
7 Baylor College of Medicine, Houston, Texas, USA

Correspondence Address:
Sukaina Ali Alali
1000 Houghton Avenue, Saginaw, MI 48602

How to cite this article:
Alali SA, Le T, DeVogelaere M, Nowak R, Sutton S S, Coakley K, Rafique Z, Peacock F. Abstracts for the 39th emergencies in medicine conference.J Emerg Trauma Shock 2021;14:180-183

How to cite this URL:
Alali SA, Le T, DeVogelaere M, Nowak R, Sutton S S, Coakley K, Rafique Z, Peacock F. Abstracts for the 39th emergencies in medicine conference. J Emerg Trauma Shock [serial online] 2021 [cited 2022 Jan 18 ];14:180-183
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 Health-care System Use Following Buprenorphine Initiation by Emergency Physicians: Initial Results

Tinh Le, Ankur Parekh1, Hana Le1, Parker Cordial2, Mackenzie Sankoe1, Brian Hiestand3, W. F. Peacock4, James Neuenschwander5

Case Western Reserve University School of Medicine, Cleveland, 1The Ohio State University, 2The Ohio State University College of Medicine, Columbus, 5Genesis Healthcare System. Zanesville, OH, 3Wake Forest School of Medicine, Winston Salem, NC, 4Baylor College of Medicine, Houston, TX, USA

Background: In 2018, there were nearly 50,000 opioid-related deaths in the United States. The emergency department (ED) is a critical source of care for opioid-addicted patients, and emergency physicians are in a unique position to treat addiction. Medication-assisted treatment (MAT) with buprenorphine, a partial opioid agonist, may provide benefit. We investigated whether ED initiated buprenorphine decreased subsequent health-care system use for patients with opioid use disorder. Methods: A retrospective chart review was performed of patients who presented to a community hospital ED in southeastern Ohio between 6-1-18 and 12-20-18 and were prescribed buprenorphine. Demographic data were recorded using the electronic medical record, and the opioid-related International Classification of Disease (ICD)-10 codes patients received during their visits. These data were used to create a case-matched control group of demographically matched patients who presented in a similar time frame with similar ICD-10 codes without receiving buprenorphine. Outcomes were recorded for both groups, including the 12-month rates of ED visits, all-cause hospitalizations, and opioid overdoses. Differences in event occurrences between groups were assessed with Poisson regression. Results: A total of 85 patients were included; 43 MAT versus 42 controls. The groups were well matched on age, race, and sex, with one-third of each group being female. Overall, there were 55 males (65% of the cohort), with a median age of 33 years (interquartile range: 29-38). White patients were 79/85 (93%) of the total cohort. Patients in the control group had a median 2 ED revisits (range 0-9), 0 rehospitalizations (0-8), and 0 overdoses (0-2), versus median 2 ED revisits (0-8), 0 rehospitalizations (0-4), and 0 overdoses (0-6). The incidence rate ratio (IRR) for counts of ED revisits was 0.80, 95% CI: 0.61-1.05 favoring MAT. For hospitalizations, IRR was 0.46, 95%CI 0.28-0.76 favoring MAT, and for overdose 1.05, 95% CI 0.48-2.31. No mortalities were recorded in either group. Conclusion: The use of ED buprenorphine is associated with a lower 12-month hospitalization rate and a nonsignificant trend toward fewer ED visits, suggesting the potential of emergency physician-initiated buprenorphine as a means of decreasing health-care system utilization.

Keywords: Buprenorphine, emergency department visits, health-care system utilization

 Getting to the Heart of Pericarditis in the Emergency Department

M. DeVogelaere, A. Fobi, R. Jhooty1

Legacy Health Emergency Medicine, 1Legacy Health Cardiology

Background: Pericarditis is the most common form of pericardial disease worldwide, and acute pericarditis has been reported in literature to be responsible for 5% of admissions to the emergency department (ED) due to cardiac chest pain. We wanted to better understand the gaps regarding the epidemiology of pericarditis, which currently limit the ability to manage and diagnose patients appropriately. Methods: We performed a comprehensive, multicentered, retrospective chart review on patients who had been diagnosed with pericarditis according to electronic health records after presenting to legacy health EDs from 2012 to 2019. Each chart was analyzed to evaluate the patient workup in the ED including biomarkers, imaging, procedures, medications given and prescribed, and specialist consults. For those admitted beyond the ED, their subsequent diagnostic workups were analyzed to determine how these influenced the next steps in the diagnosis and management of nonischemic chest pain. Results: Of 84,567 patients visiting the ED with the chief complaint of chest pain, 8169 (9.7%) were seen for cardiac chest pain, and 168 (0.20%) were diagnosed with pericarditis; of those, 29 (17.3%) were found to have recurrent pericarditis. A troponin level was drawn for 154 patients (91.7%) during their visit to the ED, and C-reactive protein (CRP) was drawn for 35 (20.8%) of whom 33 (88.6%) had elevated CRP. Of all pericarditis patients, 131 (78.0%) were treated with nonsteroidal anti-inflammatory drugs (NSAIDs), 68 (40.5%) with colchicine, and 45 (26.8%) with opiates; 38 (22.6%) were admitted to the hospital from the ED for further evaluation, with an average hospital stay of 3 days. Conclusion: Our finding that pericarditis accounts for 2.1% of ED cardiac chest pain visits is not consistent with previous reports that acute pericarditis accounts for 5% of ED cardiac chest pain visits. By conducting a large analysis of the presentation of pericarditis in the setting of chest pain in the ED, we will be able to create more accurate clinical guidelines for the diagnosis modalities and treatment of pericarditis. To achieve a more detailed understanding of the progression and management of pericarditis, data should be obtained from patients who were diagnosed with pericarditis after having a further workup during their hospital stay.

Keywords: Chest pain, emergency department, pericarditis

 Rapid High Sensitivity Troponin in Myocardial Infarction Allowing Discharge versus Admission

Richard Nowak, Robert Christenson1, Gordon Jacobsen2, Fred Apple3, James McCord2, Alexander Limkakeng4, Adam Singer5, W. Frank Peacock6, Chris deFilippi7

Emergency Medicine, Henry Ford Health System, Detroit, MI, 1University of Maryland, Baltimore, 2Henry Ford Health System, Detroit, MI, 3Hennepin County Medical Center, Minneapolis, MN, 4Duke University School of Medicine, Durham, NC, 5SUNY, Stony Brook, NY, 6Baylor College of Medicine, Houston, TX, 7Inova Heart and Vascular Institute, Church Falls, VA, USA

Background: The multicenter high sensitivity cardiac troponin I (hs cTnI) study (HIGH US) reported a 0/1-hour hs cTnI algorithm in the emergency department (ED) rule out rate of 50.4% for acute myocardial infarction (AMI) with a negative predictive value of 99.7% (95% CI: 99.2 99.9), sensitivity of 98.7% (95% confidence interval [CI]: 96.3 99.7) and a 30-day incidence of AMI/death rate of 0.2% (1 death, 1 AMI). Our objective was to determine which available clinical parameters were associated with ED discharge versus observation/inpatient placements (OBS/ADM) for these rapidly AMI rule-out patients. Methods: The HIGH US study enrolled patients (April 2015 to April 2016) with symptoms suspicious for AMI. Inclusion criteria were 21 years of age or older and the ability to consent. No exclusion criteria. Patients underwent routine clinical assessment by ED physicians including history, physical exam, electrocardiogram (ECG) and other needed tests. Baseline and 1 h (±30 min) blood samples were drawn and later analyzed in 3 different core laboratories using the Siemens Atellica hs cTnI assay (99th %45.0 ng/L). AMI diagnoses were independently adjudicated after review of all available data. Diagnoses were made according to the 3rd Universal Definition of AMI. Clinical variables affecting disposition were compared. Results: 1020 (48.3%) patients were ruled out for AMI in 1 h. Of these, 584 (57.3%) were discharged home while 436 (42.7%) placed in OBS/ADM beds. The patients placed in OBS/ADM were significantly (P value < 0.05) older (55 vs. 52 years old), with more individuals having a history of hypertension (71.8 vs. 54.4%), diabetes (30 vs. 19.1%), former smoking (32.3 vs. 22.9%), heart failure (11.4 vs. 7%), coronary artery disease (CAD) (41 vs. 16.1%), family history of CAD (52.8 vs. 42.8%), prior AMI (23 vs. 7.2%) or revascularization (31.1 vs. 10,5), or did not have a normal ECG (36.5 vs. 51.7%). Conclusion: ED physicians were less likely to discharge home patients rapidly ruled out for AMI if they had traditional risk factors for CAD. However, considering the excellent prognosis in this population and recent evidence showing that revascularization in the absence of AMI does not reduce adverse clinical outcomes compared to medical therapy, reliance on clinical variables should be judiciously considered and systems developed to reduce extended stay for such patients.

Keywords: Disposition, high-sensitivity troponin, myocardial infarction

 Peripherally Acting Mu-opioid Receptor Antagonist Emergency Department Use in Opioid Induced Constipation

Peacock Frank, Slatkin Neal1, Gagnon-Sanschagrin Patrick2, Maitland Jessica2, Guârin Annie2, Joseph George3

Henry JN Taub Department of Emergency Medicine, Houston, TX, 1Salix Pharmaceuticals, Bridgewater, 3Bausch Health US, LLC, Bridgewater, NJ, USA, 2Analysis Group, Inc., Montrâal, QC, Canada

Background Peripherally acting mu-opioid receptor antagonist (PAMORA) treatments are shown to be effective for patients with opioid-induced constipation (OIC). Yet, there is little evidence on the real-world impact of PAMORA use in the emergency department (ED). This study aimed to compare health-care resource utilization (HRU) and costs between patients in the ED who did/did not receive PAMORA for OIC. Methods: Adult ED OIC patients were evaluated retrospectively (4/2016-9/2019) and classified into cohorts based on if they received PAMORA in the ED. Cohorts were reweighted using entropy balancing—a reweighing technique to reduce selection bias—which balanced cohorts based on demographics, hospital characteristics, and OIC-related procedures/comorbidities. HRU was assessed during the ED encounter and costs were compared using weighted regressions with random effects at the hospital level. Outcomes were also assessed among a subgroup of patients with cancer. Results: Overall, 11,135 and 21,474 patients were identified in the PAMORA (93% given methylnaltrexone subcutaneous injection) and no-PAMORA cohorts, respectively. After balancing, overall characteristics were: Mean age 59 years, 60% female, 82% Caucasian, and 52% Medicare-insured. Most patients were from nonteaching, 300+ beds, or 10,000+ quarterly ED encounter hospitals, serving an urban population. PAMORA patients were 2.4 times more likely to be discharged home (odds ratio [OR] [95% confidence interval (CI)] = 2.44 [2.14, 2.78]; P < 0.001), 64% less likely to be admitted as an inpatient (OR [95% CI] = 0.36 [0.31–0.41];P < 0.001)– of which 83% had a primary diagnosis for constipation. Inpatient average length of stay was 1 day shorter ([0.84–1.22]; P < 0.001). Accounting for PAMORA drug costs, PAMORA patients had a mean of $1152 less in total health-care costs per ED encounter. The results were consistent among the cancer subgroup where PAMORA patients had a mean of $922 ([$432–$1412]; P < 0.001) less in total health-care costs per ED encounter. Conclusion: Patients receiving PAMORA (mostly methylnaltrexone SC) in the ED are more likely to be discharged home, less likely to be hospitalized, have a shorter stay, cost $1152 less (cancer subgroup: $922 less) and save 0.7 inpatient days (cancer subgroup: Save 1.0 inpatient days) per ED encounter than when patients do not receive PAMORA in the ED setting.

Funding: This study was funded by Bausch Health US, LLC

Keywords: Methylnaltrexone, opioid-induced constipation, PAMORA

 Initial Effects of Methylnaltrexone in Severe Medical Illness and Impaired Functional Status

W. Frank Peacock, Neal E. Slatkin1,2, Robert J. Israel3, Nancy Stambler4

Baylor College of Medicine, Houston, TX, 1University of California Riverside, School of Medicine, Riverside, CA, 2Salix Pharmaceuticals, 3Bausch Health US, LLC, Bridgewater, NJ, 4Progenics Pharmaceuticals, Inc., New York, NY, USA

Background: Opioid-induced constipation (OIC) is common in opioid therapy for pain. Traditional laxatives target different mechanisms and are ineffective. Methylnaltrexone (MNTX) is a selective, peripherally acting μ-opioid receptor antagonist that decreases OIC without attenuating its analgesia. This study assesses the efficacy and safety of a single MNTX dose for OIC patients with severe medical illness and varying degrees of baseline functional status. Methods: This was a post hoc analysis of pooled data from 3 multicenter, double-blind, randomized, placebo-controlled clinical trials. Each of the 3 studies provided a different dose of MNTX and timeframe. Inclusion criteria were adults aged ≥18 years with OIC and a diagnosis of advanced Illness with a life expectancy of months, chronic opioid use with a recent stable regimen. Exclusion criteria were history of MNTX use, suspected gastrointestinal obstruction and others. Baseline functional levels were described through mapping World Health Organization (WHO) performance status. Efficacy assessed the percentage of patients who achieved a rescue-free laxation (RFL, defined as laxation without the use of other laxatives). Intent-to-treat analysis was used. Safety assessments included treatment-emergent adverse events (TEAEs). Results: Five hundred and eighteen patients received ≥1 dose of either MNTX, n = 281 or placebo, n = 237. Significantly more patients treated with MNTX compared with placebo had an RFL within 4 and 24 h after the first dose. Similar findings resulted after stratification by baseline WHO performance status. Time to first RFL was shorter in the MNTX (>50% of MNTX-group in <2 h vs. < 50% of placebo-group by 24 h). There are no significant differences in pain scores. The percentage of patients with at least 1 TEAE declined from day 1 (placebo = 20.7%; MNTX = 41.6%) to day 2 (placebo = 14.1%; MNTX = 22.5%). Conclusion: A single dose of MNTX produced RFL responses within 4 and 24 h regardless of baseline functional status in significantly higher number of severely ill patients with OIC compared with placebo. The time to first RFL was shorter after MNTX with most MNTX group achieving an RFL within 2 h. MNTX did not alter opioid analgesic efficacy. Most TEAEs were GI related. MNTX provides effective, safe, and rapid relief of OIC in patients with various forms of advanced illnesses and OIC.

Keywords: Functional status, methylnaltrexone, opioid-induced constipation, severe illness

 Outcomes of Oral Factor Xa Inhibitor-Related Major Bleeding Treated with Antidote

S. Scott Sutton, Joe Magagnoli, Tammy H Cummings, Theresa Dettling1, James Hardin2

Department of Clinical Pharmacy and Outcomes Sciences, College of Pharmacy, University of South Carolina, 2Health Services Policy and Management, Epidemiology and Biostatistics, University of South Carolina, South Carolina, USA, 1US HEOR, Global Medical Affairs, Alexion Pharmaceuticals

Background: Major bleeding related to anticoagulant treatment is associated with high a mortality and morbidity burden. This study assesses real-world outcomes among the United States (US) veterans treated with factor replacement or reversal agents for the management of major bleeding in the presence of oral factor Xa inhibitors. Methods: The study evaluated andexanet alfa and four-factor prothrombin complex concentrate (4F-PCC) using Department of Veteran Affairs (VA) data within the VA informatics and computing infrastructure. Electronic medical records from March 2014 through May 2020 were included and evaluated demographic, comorbid, clinical, and mortality data. Differences among the groups were evaluated using t-tests, chi-square tests, and adjusted odds ratios (aORs) with 95% confidence intervals (CI), adjusted for age, sex, race, Charlson comorbidity index (CCI), bleed type (gastrointestinal [GI], intracranial [ICH], or other), intensive care unit stay, and ventilation. Study outcomes included in-hospital and 30-day mortality. Results: 169 patients were included (39 in the andexanet alfa cohort and 130 in the 4F-PCC cohort). The median age was 72 (IQR = 67–79) years old and the majority of patients were white males. Both study cohorts had a median CCI of 5. More patients in the andexanet alfa cohort than in the 4F-PCC cohort had ICH (33.3% and 25.4%, respectively) and fewer patients in the andexanet alfa cohort had GI (53.9% vs. 56.2% for 4FPCC) or other bleeds (12.8% vs. 18.5% for 4F-PCC). Median length of hospitalization was 8 (interquartile range [IQR]: 5.5–15.5) days for andexanet alfa and 10 (IQR: 5.0–19.8) days for 4FPCC. In-hospital mortality was significantly lower in the andexanet alfa cohort than in the 4F-PCC cohort (7.7% vs. 26.2%, respectively; aOR: 0.19 [95% CI: 0.04–0.70]; P = 0.02). The 30-day mortality rates were 15.4% for andexanet alfa compared to 28.5% for 4F-PCC (aOR: 0.42 [95% CI: 0.13-1.19]; P = 0.15;). Conclusion: Among 169 US veterans treated with andexanet alfa or 4F-PCC for major bleeding in the presence of oral factor Xa inhibitors, treatment with andexanet alfa was associated with lower in-hospital mortality.

Keywords: Andexanet alfa, four-factor prothrombin complex concentrate, major bleeding factor Xa inhibitor, in-hospital mortality

 Prone Positioning in Intubated COVID-19 Patients: Best Practices and Lessons Learned

Kerri Coakley

Baylor St. Luke's Medical Center, Houston, Texas, USA

Background: Substantial research has shown prone positioning to improve outcomes and decrease mortality in patients with severe acute respiratory distress syndrome (ARDS), and recently these benefits have been demonstrated in the COVID-19 patient population. Pronation therapy improves oxygenation and alveolar recruitment and reduces ventilator-associated lung injury. As the staff was initially unfamiliar with the practice of prone positioning, there were several observed inadequacies, inefficiencies, and adverse events when initially instituted. Time delays, inadequate staff knowledge of the proning process, and pressure injuries were the most common challenges encountered by the staff. Methods: At an 850-bed academic medical center in Houston, Texas, a multidisciplinary proning team that included registered nurses, patient care associates, and exercise physiologists was formed in the COVID-19 intensive care unit. Following a review of the literature and assessment of current practices, inadequacies, and adverse events, a proning checklist, protocol, and kit were put into practice. Staff was in-serviced on the checklist and protocol, and a laminated copy was attached to the proning kit for off-shift just-in-time training. The proning kit contains items necessary for proning– silicone dressings, telemetry leads, proning pillows, tegaderms, pulse oximeter probes, and intravenous caps. Results: The process of proning intubated patients with COVID-19 became more safe, efficient, and streamlined following the institution of the proning checklist and kit. The new protocol resulted in a reduction in time delays and increased staff knowledge and competency. The unit also saw a decrease in facial pressure injuries following the practice changes, although complete data could not be collected as the hospital ceased its weekly pressure injury reports while in “crisis mode” during the pandemic. Conclusion: Prone positioning has proven beneficial in COVID-19 patients with severe ARDS, yet deficiencies were noted and work was needed to educate staff, improve the process, and decrease adverse events. The best practices and lessons learned here can be utilized by similar institutions caring for COVID-19 patients with the goal of process improvement.

Keywords: Acute respiratory distress syndrome, COVID-19, prone positioning

 Trends in Emergency Department Use in Patients Diagnosed with Hyperkalemia

Zubaid Rafique, Saurabh Aggarwal1, Ozlem Topaloglu1, Georgiana Cornea2, Ansgar Conrad3, Frank Peacock

Baylor College of Medicine, Ben Taub General Hospital, Houston, TX, 1Novel Health Strategies, Bethesda, MD, 3Relypsa Inc., Redwood City, CA, USA, 2Vifor Fresenius Medical Care Renal Pharma Ltd., St. Gallen, Switzerland

Background: Hyperkalemia (HK) is a common condition that refers to increased serum potassium (sK+) concentration (sK+ >5.0 mEq/L). HK is reported in 10% of hospitalized patients and is often comorbid with heart failure (HF), hypertension (HTN), chronic kidney disease (CKD), and diabetes mellitus (DM). HK is a common cause of emergency department (ED) admission and is associated with increased all-cause mortality. The effects of HK on health outcomes and resource utilization are unknown. This study evaluates trends in ED use in patients diagnosed with HK. Methods: The 2016 Nationwide Emergency Department Sample (NEDS) dataset from the Health-care Cost and Utilization Project was analyzed. NEDS contains data from around 31 million ED visits per year and provides a weighted estimate of roughly 143 million ED visits. Patients with an ICD-10 diagnosis code E87.5 or E87.8 were included. The rate of comorbidities was assessed using previously validated ICD-10 codes. Hospital length of stay (LOS) was estimated using the Agency for Healthcare Research and Quality's National Inpatient Sample. Sample analyzed separately for patients with any diagnosis of HK/electrolyte abnormalities, and primary diagnosis of HK. In all analyses, patients with any missing value involved in a particular analysis were excluded from that analysis. Results: Patient gender was approximately equal (52% male) and patients had a mean (standard error) age of 61.8 (0.21) years. With the diagnosis of HK, rate of ED visits was 409.1/100,000 persons; rate of same-hospital admission was 332.8/100,000 persons, mean LOS was 6.8 days, and median was 5 days, mean hospital charges was $ 71,643, and median was $ 40,309. Rate of comorbid conditions in these patients was 43.1% DM, 62%HTN, 44.4% CKD, 23.1% HF. With primary diagnosis of HK, rate of ED visits was 27.6/100,000 persons; rate of same-hospital admission was 11.7/100,000 persons, mean LOS was 3.2 days, and median was 2 days, mean hospital charges was $ 33,515, and median was $ 20,946. Conclusion: New treatments, able to extract and normalize sK + for 24 h or longer, with low risk of complications are needed. Patients with HK suffer high rates of comorbidities and ED visits and represent a significant healthcare burden. Our analysis suggests that a significant proportion of LOS and associated costs are related to HK and HK management.

Keywords: Emergency department visits, hyperkalemia, length of stay, resource utilization