Reducing Variation in Hospitalization and Processes of Care in Emergency Department Patients with Atrial Fibrillation: A Stepped Wedge Cluster Randomized Trial
This stepped-wedge cluster randomized trial will stagger implementation of a clinical decision support system (CDSS) across 13 KPNC emergency departments to assist emergency physicians and hospitalists in the comprehensive management of patients with atrial fibrillation/flutter. We will compare hospitalization rates,…
Potential accuracy of prehospital NIHSS-based triage for selection of candidates for acute endovascular stroke therapy
Whether patients with acute stroke and large vessel occlusion (LVO) benefit from prehospital identification and diversion by emergency medical services (EMS) to an endovascular stroke therapy (EST)-capable center is controversial. We sought to estimate the accuracy of field-based identification of…
Prospective Validation and Comparative Analysis of Coronary Risk Stratification Strategies Among Emergency Department Patients With Chest Pain
Background Coronary risk stratification is recommended for emergency department patients with chest pain. Many protocols are designed as "rule-out" binary classification strategies, while others use graded-risk stratification. The comparative performance of competing approaches at varying levels of risk tolerance has…
The Presentation, Pace, and Profile of Infection and Sepsis Patients Hospitalized Through the Emergency Department: An Exploratory Analysis
To characterize the signs and symptoms of sepsis, compare them with those from simple infection and other emergent conditions and evaluate their association with hospital outcomes. A multicenter, retrospective cohort study of 408,377 patients hospitalized through the emergency department from…
Tools for Outpatient and Population Management of SARS-COV-2 Infection (TOPS2)
This project aims to improve The Permanente Medical Group's capability for outpatient and population management of adults with COVID-19. It will identify the spatial, temporal, and racial distribution of coronavirus infections; characterize the clinical progression of coronavirus infection; and synthesize…
Automated retrospective calculation of the EDACS and HEART scores in a multicenter prospective cohort of emergency department chest pain patients
Coronary risk scores are commonly applied to emergency department patients with undifferentiated chest pain. Two prominent risk score-based protocols are the Emergency Department Assessment of Chest pain Score Accelerated Diagnostic Protocol (EDACS-ADP) and the History, ECG, Age, Risk factors, and…
Informatics approaches to assessing patient frailty in surgical care
Patient frailty increases the risk for surgical complications, which are common, costly, and deadly, especially for older Americans. To improve surgical care for older adults, we will investigate whether electronic measures of frailty can help reduce complications by identifying which…
Diagnostic Performance of Emergency Physician Gestalt for Predicting Acute Appendicitis in Patients Age 5 to 20 Years
Pediatric appendicitis remains a challenging diagnosis in the emergency department (ED). Available risk prediction algorithms may contribute to excessive ED imaging studies. Incorporation of physician gestalt assessment could help refine predictive tools and improve diagnostic imaging decisions. This study was…
The Impact of Step-Down Unit Care on Patient Outcomes After ICU Discharge
To examine whether and how step-down unit admission after ICU discharge affects patient outcomes. Retrospective study using an instrumental variable approach to remove potential biases from unobserved differences in illness severity for patients admitted to the step-down unit after ICU…
Red blood cell transfusions for emergency department patients with gastrointestinal bleeding within an integrated health system
To assess trends over time in red blood cell (RBC) transfusion practice among emergency department (ED) patients with gastrointestinal (GI) bleeding within an integrated healthcare system, inclusive of 21 EDs. Retrospective cohort of ED patients diagnosed with GI bleeding between…
ICU Utilization for Patients With Acute Exacerbation of Chronic Obstructive Pulmonary Disease Receiving Noninvasive Ventilation.
OBJECTIVES: We investigated whether patients with chronic obstructive pulmonary disease could safely receive noninvasive ventilation outside of the ICU.DESIGN: Retrospective cohort study.SETTING: Twelve states with ICU utilization flag from the State Inpatient Database from 2014.PATIENTS: Patients greater than or equal…
Text message alerts to emergency physicians identifying potential study candidates increase clinical trial enrollment
Prospective enrollment of research subjects in the fast-paced emergency department (ED) is challenging. We sought to develop a software application to increase real-time clinical trial enrollment during an ED visit. The Prospective Intelligence System for Clinical Emergency Services (PISCES) scans…
Validation of the Pediatric Appendicitis Risk Calculator (pARC) in a Community Emergency Department Setting
The pediatric Appendicitis Risk Calculator (pARC) is a validated clinical tool for assessing a child's probability of appendicitis. Our objective was to assess the performance of the pARC in community emergency departments (EDs) and to compare its performance with that…
Statistical Modeling and Aggregate-Weighted Scoring Systems in Prediction of Mortality and ICU Transfer: A Systematic Review
The clinical deterioration of patientsin general hospital wards is an important safety issue. Aggregate-weighted early warning systems (EWSs) may not detect risk until patients present with acute decline. We aimed to compare the prognostic test accuracy and clinical workloads generated…
Assessing and Optimizing the Impact of an Electronic Clinical Decision Support Tool for Chest Pain Risk Stratification in the Emergency Department STEWARD Project (Phase 3)
Conducted with co-investigator Dustin G. Mark, MD, this study helps emergency physicians with estimates of individual patient risk for patients with chest pain. The research team will evaluate impacts on guideline-supported acute coronary syndrome evaluations.
Patient characteristics associated with treatment initiation and engagement among individuals diagnosed with alcohol and other drug use disorders in emergency department and primary care settings
Background: Treatment initiation and engagement rates for alcohol and other drug (AOD) use disorders differ depending on where the AOD use disorder was identified. Emergency department (ED) and primary care (PC) are 2 common settings where patients are identified; however,…
How competent are people who use opioids at responding to overdoses? Qualitative analyses of actions and decisions taken during overdose emergencies.
BACKGROUND AND AIMS: Providing take-home naloxone (THN) to people who use opioids is an increasingly common strategy for reversing opioid overdose. However, implementation is hindered by doubts regarding the ability of people who use opioids to administer naloxone and respond…
Increasing Safe Outpatient Management of Emergency Department Patients With Pulmonary Embolism: A Controlled Pragmatic Trial
Many low-risk patients with acute pulmonary embolism (PE) in the emergency department (ED) are eligible for outpatient care but are hospitalized nonetheless. One impediment to home discharge is the difficulty of identifying which patients can safely forgo hospitalization. To evaluate…
Associations of ICU Capacity Strain with Disposition and Outcomes of Patients with Sepsis Presenting to the Emergency Department
Intensive care unit (ICU) capacity strain refers to the potential limits placed on an ICU's ability to provide high-quality care for all patients who may need it at a given time. Few studies have investigated how fluctuations in ICU capacity…
Optimal Anticoagulation Strategies for Acute Atrial Fibrillation
The purpose of this project is to assess the variation and impact of oral anticoagulant prescribing in the emergency department in order to inform development of interventions to improve acute atrial fibrillation and flutter management. A longitudinal database will be…
Outpatient Management of Emergency Department Patients With Acute Pulmonary Embolism: Variation, Patient Characteristics, and Outcomes
Outpatient management of emergency department (ED) patients with acute pulmonary embolism is uncommon. We seek to evaluate the facility-level variation of outpatient pulmonary embolism management and to describe patient characteristics and outcomes associated with home discharge. The Management of Acute…
The Impact of Acute Organ Dysfunction on Long-Term Survival in Sepsis
To estimate the impact of each of six types of acute organ dysfunction (hepatic, renal, coagulation, neurologic, cardiac, and respiratory) on long-term mortality after surviving sepsis hospitalization. Multicenter, retrospective study. Twenty-one hospitals within an integrated healthcare delivery system in Northern…
Characterizing and Predicting Adverse Drug Events Outside the Hospital
This study aims to employ machine learning methods to develop predictive models for adverse drug events, or ADEs, that result in patients using the emergency department and/or being hospitalized (non-nosocomial ADEs, NNADEs). Based on work with a pharmacist expert panel…
Acute Pulmonary Embolism in Emergency Department Patients Despite Therapeutic Anticoagulation
Emergency department (ED) patients with acute pulmonary embolism (PE) despite therapeutic anticoagulation at the time of diagnosis are uncommonly encountered and present a diagnostic and management challenge. Their characterization and outcomes are poorly described. We sought to describe the prevalence…
Thromboprophylaxis for Patients with High-risk Atrial Fibrillation and Flutter Discharged from the Emergency Department
Many patients with atrial fibrillation or atrial flutter (AF/FL) who are high risk for ischemic stroke are not receiving evidence-based thromboprophylaxis. We examined anticoagulant prescribing within 30 days of receiving dysrhythmia care for non-valvular AF/FL in the emergency department (ED).…
Performance of Coronary Risk Scores Among Patients With Chest Pain in the Emergency Department
Both the modified History, Electrocardiogram, Age, Risk factors and Troponin (HEART) score and the Emergency Department Assessment of Chest pain Score (EDACS) can identify patients with possible acute coronary syndrome (ACS) at low risk (
Alcohol, Marijuana, and Opioid Use Disorders: 5-Year Patterns and Characteristics of Emergency Department Encounters
Changes in substance use patterns stemming from opioid misuse, ongoing drinking problems, and marijuana legalization may result in new populations of patients with substance use disorders (SUDs) using emergency department (ED) resources. This study examined ED admission trends in a…
Novel Telestroke Program Improves Thrombolysis for Acute Stroke Across 21 Hospitals of an Integrated Healthcare System
Faster treatment with intravenous alteplase in acute ischemic stroke is associated with better outcomes. Starting in 2015, Kaiser Permanente Northern California redesigned its acute stroke workflow across all 21 Kaiser Permanente Northern California stroke centers to (1) follow a single…
The Bidirectional Association Between Depression and Severe Hypoglycemic and Hyperglycemic Events in Type 1 Diabetes
Severe hyperglycemia and hypoglycemia ("severe dysglycemia") are serious complications of type 1 diabetes (T1D). Depression has been associated with severe dysglycemia in type 2 diabetes but has not been thoroughly examined specifically in T1D. We evaluated bidirectional associations between depression…
Short-Term Outcomes and Factors Associated With Adverse Events Among Adults Discharged From the Emergency Department After Treatment for Acute Heart Failure
Although 80% of patients with heart failure seen in the emergency department (ED) are admitted, less is known about short-term outcomes and demand for services among discharged patients. We examined adult members of a large integrated delivery system who visited…
Development and Validation of a Tool to Identify Patients With Type 2 Diabetes at High Risk of Hypoglycemia-Related Emergency Department or Hospital Use
Hypoglycemia-related emergency department (ED) or hospital use among patients with type 2 diabetes (T2D) is clinically significant and possibly preventable. To develop and validate a tool to categorize risk of hypoglycemic-related utilization in patients with T2D. Using recursive partitioning with…
The association between physician turnover (the “July Effect”) and survival after in-hospital cardiac arrest.
IMPORTANCE: The July Effect refers to adverse outcomes that occur as a result of turnover of the physician workforce in teaching hospitals during the month of June.OBJECTIVE: As a surrogate for physician turnover, we used a multivariable difference-in-difference approach to…
Development and Validation of a Novel Coding Algorithm for Identification of Severe Hypoglycemic Events in Ambulance Records
Severe hypoglycemia (SH) is one of the most prevalent diabetes complications and a critical public health concern; 25% of hospitalizations for adverse drug events is due to SH. Existing surveillance does not capture SH occurring in pre-emergency settings (e.g., treat…
Accelerating Access through Call Centers (AACC) Study
To examine the association between patient calls to a provider-led call center and emergency department visits.
Risk stratifying emergency department patients with acute pulmonary embolism: Does the simplified Pulmonary Embolism Severity Index perform as well as the original?
The Pulmonary Embolism Severity Index (PESI) is a validated prognostic score to estimate the 30-day mortality of emergency department (ED) patients with acute pulmonary embolism (PE). A simplified version (sPESI) was derived but has not been as well studied in…
Optimizing Clinical Decision Support in the Electronic Health Record. Clinical Characteristics Associated with the Use of a Decision Tool for Disposition of ED Patients with Pulmonary Embolism
Adoption of clinical decision support (CDS) tools by clinicians is often limited by workflow barriers. We sought to assess characteristics associated with clinician use of an electronic health record-embedded clinical decision support system (CDSS). In a prospective study on emergency…
Emergency Department Management of Atrial Fibrillation and Flutter and Patient Quality of Life at One Month Postvisit
We identify characteristics of patients with atrial fibrillation or flutter associated with favorable assessments of emergency department (ED) effectiveness and 30-day quality of life. As part of a prospective observational study of ED management and short-term outcomes of patients with…
Implementation of Computerized Physician Order Entry Is Associated With Increased Thrombolytic Administration for Emergency Department Patients With Acute Ischemic Stroke
Electronic health record systems with computerized physician order entry and condition-specific order sets are intended to standardize patient management and minimize errors of omission. However, the effect of these systems on disease-specific process measures and patient outcomes is not well…
Pulmonary Oedema-Therapeutic Targets.
Pulmonary oedema (PO) is a common manifestation of acute heart failure (AHF) and is associated with a high-acuity presentation and with poor in-hospital outcomes. The clinical picture of PO is dominated by signs of pulmonary congestion, and its pathogenesis has…
Impact of Relative Contraindications to Home Management in Emergency Department Patients with Low-Risk Pulmonary Embolism
Studies of adults presenting to the emergency department (ED) with acute pulmonary embolism (PE) suggest that those who are low risk on the PE Severity Index (classes I and II) can be managed safely without hospitalization. However, the impact of…
Timing of Discharge Follow-up for Acute Pulmonary Embolism: Retrospective Cohort Study
Historically, emergency department (ED) patients with pulmonary embolism (PE) have been admitted for several days of inpatient care. Growing evidence suggests that selected ED patients with PE can be safely discharged home after a short length of stay. However, the…
Pneumothorax is a rare complication of thoracic central venous catheterization in community EDs
The rate of iatrogenic pneumothorax associated with thoracic central venous catheterization in community emergency departments (EDs) is poorly described, although such information is vital to inform the procedure's risk/benefit analysis. We undertook this multicenter study to estimate the incidence of…
The Accuracy of an Electronic Pulmonary Embolism Severity Index Auto-Populated from the Electronic Health Record: Setting the stage for computerized clinical decision support
The Pulmonary Embolism (PE) Severity Index identifies emergency department (ED) patients with acute PE that can be safely managed without hospitalization. However, the Index comprises 11 weighted variables, complexity that can impede its integration into contextual workflow. We designed a…
Bleeding complications of central venous catheterization in septic patients with abnormal hemostasis
Central venous catheterization (CVC) is thought to be relatively contraindicated in patients with thrombocytopenia or coagulopathy. We measured the 24-hour incidence of bleeding in septic emergency department (ED) patients undergoing CVC. This multicenter, retrospective cohort study included septic ED patients…
Emergency Physician Perspectives on Central Venous Catheterization in the Emergency Department: A Survey-based Study
The objective was to assess clinician experience, training, and attitudes toward central venous catheterization (CVC) in adult emergency department (ED) patients in a health system promoting increased utilization of CVC for severely septic ED patients. The authors surveyed all emergency…
Patterns of intensive care unit admissions in patients hospitalized for heart failure: insights from the RO-AHFS registry.
AIM: The present study aims to describe the epidemiology, baseline clinical characteristics, in-hospital management, and outcome of patients hospitalized for heart failure admitted directly or transferred to the ICU.METHODS AND RESULTS: The Romanian Acute Heart Failure Syndromes (RO-AHFS) registry prospectively…
Predictors of Unattempted Central Venous Catheterization in Septic Patients Eligible for Early Goal-directed Therapy
Central venous catheterization (CVC) can be an important component of the management of patients with severe sepsis and septic shock. CVC, however, is a time- and resource-intensive procedure associated with serious complications. The effects of the absence of shock or…
Fluid Volume, Lactate Values, and Mortality in Sepsis Patients with Intermediate Lactate Values
Patients with severe sepsis without shock or tissue hypoperfusion face substantial mortality; however, treatment guidelines are lacking. To evaluate the association between intravenous fluid resuscitation, lactate clearance, and mortality in patients with "intermediate" lactate values of 2 mmol/L or greater…
Nontraumatic Subarachnoid Hemorrhage in the Setting of Negative Cranial Computed Tomography Results: External Validation of a Clinical and Imaging Prediction Rule
STUDY OBJECTIVE: Clinical variables can reliably exclude a diagnosis of nontraumatic subarachnoid hemorrhage in patients with negative cranial computed tomography (CT) results. We externally validated 2 decision rules with 100% reported sensitivity for a diagnosis of subarachnoid hemorrhage, among patients…
Emergency Physicians’ Knowledge and Attitudes of Clinical Decision Support in the Electronic Health Record: A Survey-based Study
OBJECTIVES: The objective was to investigate clinician knowledge of and attitudes toward clinical decision support (CDS) and its incorporation into the electronic health record (EHR). METHODS: This was an electronic survey of emergency physicians (EPs) within an integrated health care…
Risk of traumatic intracranial hemorrhage in patients with head injury and preinjury warfarin or clopidogrel use
OBJECTIVES: Appropriate use of cranial computed tomography (CT) scanning in patients with mild blunt head trauma and preinjury anticoagulant or antiplatelet use is unknown. The objectives of this study were: 1) to identify risk factors for immediate traumatic intracranial hemorrhage…
Risk factors for unplanned transfer to intensive care within 24 hours of admission from the emergency department in an integrated healthcare system
BACKGROUND: Emergency department (ED) ward admissions subsequently transferred to the intensive care unit (ICU) within 24 hours have higher mortality than direct ICU admissions. DESIGN, SETTING, PATIENTS: Describe risk factors for unplanned ICU transfer within 24 hours of ward arrival…
Does primary stroke center certification change ED diagnosis, utilization, and disposition of patients with acute stroke?
BACKGROUND AND PURPOSE: We examined the impact of primary stroke center (PSC) certification on emergency department (ED) use and outcomes within an integrated delivery system in which EDs underwent staggered certification. METHODS: A retrospective cohort study of 30 461 patients…
Practice variation in neuroimaging to evaluate dizziness in the ED
BACKGROUND: The appropriate role of neuroimaging to evaluate emergency department (ED) patients with dizziness is not established by guidelines or evidence. METHODS: We identified all adults with a triage complaint of dizziness who were evaluated at 20 EDs of a…
Immediate and delayed traumatic intracranial hemorrhage in patients with head trauma and preinjury warfarin or clopidogrel use
STUDY OBJECTIVE: Patients receiving warfarin or clopidogrel are considered at increased risk for traumatic intracranial hemorrhage after blunt head trauma. The prevalence of immediate traumatic intracranial hemorrhage and the cumulative incidence of delayed traumatic intracranial hemorrhage in these patients, however,…
Urgent neurology consultation from the ED for transient ischemic attack
OBJECTIVE: The objective of this study was to evaluate the association between urgent neurology consultation and outcomes for patients with transient ischemic attack (TIA). METHODS: In a secondary analysis of data from 1707 emergency department patients with transient ischemic attack…
Validation of an algorithm for categorizing the severity of hospital emergency department visits
BACKGROUND: Differentiating between appropriate and inappropriate resource use represents a critical challenge in health services research. The New York University Emergency Department (NYU ED) visit severity algorithm attempts to classify visits to the ED based on diagnosis, but it has…
Influence of patient costs and requests on emergency physician decisionmaking
STUDY OBJECTIVES: We examine emergency physician knowledge of, attitudes about, and responses to patient cost-sharing in the emergency department (ED). METHODS: A convenience sample of emergency physicians from an integrated delivery system completed a questionnaire including self-report questions about knowledge…
Patient sex and quality of ED care for patients with myocardial infarction
OBJECTIVE: The aim of the study was to assess the quality of care between male and female emergency department (ED) patients with acute myocardial infarction (AMI). METHODS: A 2-year retrospective cohort study of 2215 patients with AMI presenting immediately to…
Cost-sharing for emergency care and unfavorable clinical events: findings from the safety and financial ramifications of ED copayments study
OBJECTIVE: To evaluate the effect of emergency department (ED) copayment levels on ED use and unfavorable clinical events. Data Source/Study Setting. Kaiser Permanente-Northern California (KPNC), a prepaid integrated delivery system. STUDY DESIGN: In a quasi-experimental longitudinal study with concurrent controls,…
Care-seeking behavior in response to emergency department copayments
BACKGROUND: Patients are increasingly paying for more of their medical care through cost-sharing, yet little is known about how patients change the ways that they seek care in response. OBJECTIVE: We sought to assess how patients change their care-seeking behavior…
Older emergency department patients with acute myocardial infarction receive lower quality of care than younger patients
STUDY OBJECTIVE: We assessed the independent relationship between age and the quality of medical care provided to patients presenting to the emergency department (ED) with acute myocardial infarction. METHODS: We conducted a 2-year retrospective cohort study of 2,216 acute myocardial…
Cost-sharing: patient knowledge and effects on seeking emergency department care
BACKGROUND: The use of cost-sharing to control healthcare expenditures is increasing, but there is scant information about patients' knowledge of cost-sharing or its influence on behavior. OBJECTIVE: The objective of this study was to evaluate what patients know about their…
Slow infusion for the prevention of akathisia induced by prochlorperazine: a randomized controlled trial
The utility of intravenous prochlorperazine (PCZ) in the treatment of nausea, vomiting, and headache may be limited by the akathisia that occurs frequently with the recommended 2-min infusion rate. We tested the hypothesis that decreasing the rate of PCZ infusion…
