The ACEP Research Forum, held at our annual scientific meeting, focuses on cutting edge research. In 2017, the forum included outstanding expert state-of-the-art talks on how research is incorporated into clinical practice guidelines and how landmark articles come into being. There was also a session including legislators and researchers discussing the opioid crisis. This article highlights just a few of the research abstracts that may help your practice.
You can find all the abstracts presented at the ACEP17 Research Forum in Annals of Emergency Medicine’s October 2017 supplement.
Multicenter Trial of Rivaroxaban for Early Discharge of Pulmonary Embolism From the Emergency Department (MERCURY-PE)
Peacock W, Diercks D, Francis S, et al
This multicenter, prospective, open label, randomized clinical trial sought to determine what happens to low risk pulmonary embolism (PE) patients who are discharged home straight from the emergency department with rivaroxaban compared to standard care (SC; observation unit stay or inpatient admission). Not surprisingly, mean total hospital days (for any reason) at 90 days after randomization were significantly less for rivaroxaban than SC; 0.8 versus 1.8 days. The composite safety endpoint was similar in both groups. This industry-funded study suggests that carefully selected patients with PE can be managed as outpatients from the emergency department.
Trends in Site of Care for Low-Acuity Conditions Among Those with Commercial Insurance, 2008–2015
Poon SJ, Schuur JD, Mehrotra A
This study examined an insurance database for visits related to three low-acuity complaints. They found not only that emergency departments were seeing a decreasing proportion of these types of visits, but also that this decrease was due to an increase in “new” visits to urgent care and retail clinics (additive visits, not substitution). Thus, these clinics did not “steal” visits from the emergency department, but “created” visits through supply-induced demand.
Association of State Gun Laws with Pediatric Mortality from Firearms
Patel SJ, Badolato G, Parikh K, et al
In this politically timely abstract, the authors analyzed Centers for Disease Control and Prevention (CDC) data for firearm-related mortality in children 0–21 years of age and measured whether there was a relationship to state-specific Brady Campaign Gun Law Scores for 2015. The CDC noted that 4,528 children died from firearm-related injuries in 2015. Higher pediatric mortality rates were associated with lower (less strict) state-specific gun law scores. More specifically, median mortality rates were lower among the 12 states requiring universal background checks for firearm purchase (3.8 versus 5.7 per 100,000 children) and ammunition (2.3 versus 5.6 per 100,000 children). Although observational, these data provide the best available evidence to guide policy development.
Effect of SEP-1 Core Measure Compliance on Mortality and Hospital Length of Stay
E.A. Gross, G. McGlynn
Fluid Resuscitation of Septic Patients at Risk for Fluid Overload
M. Akhter, M. Hallare, A. Roontiva, et al
We’ve all seen this patient: past medical history of congestive heart failure (CHF) and creatinine of 5.6 who presents in septic shock. The much-discussed SEP-1 quality metric mandates an intravenous fluid bolus (30 ml/kg), but clinicians fear causing pulmonary edema, leading to a need for intubation. These two abstracts look at institutional databases and found that even in patients with CHF and end-stage renal disease (ESRD), following SEP-1 decreased mortality. Furthermore, there was no increase in intubation in septic patients with CHF and ESRD when clinicians followed SEP-1.
While noting, once again, the caveat of observational data and likely inclusion bias, this still provides some reassurance to providers caring for septic patients with CHF or ESRD.
A Randomized Study of Naproxen Plus Placebo, Orphenadrine, or Methocarbamol for Acute Low Back Pain
Friedman BW, Irizarry, E, Solorzano, C, et al
Back pain continues to be a common reason for ED visits, and Dr. Friedman and colleagues continue to search for effective treatments. This double-blind trial randomized patients to receive naproxen plus a one-week supply of either orphenadrine (Norflex) 100mg, methocarbamol (Robaxin) 750mg, or placebo. Unfortunately, 34 percent of naproxen+placebo patients reported moderate or severe low back pain versus 33 percent of naproxen+orphenadrine and 39 percent of naproxen+ methocarbamol patients. This study reinforces an approach that emphasizes nonsteroidal anti-inflammatory drugs and education for patients with musculoskeletal back pain.
Do Intranasal Vasoconstrictors Increase Blood Pressure?
Bellew SD, Johnson KL, Kummer T
This study calls to mind another common ED scenario: the epistaxis patient with severe hypertension. In this elegant randomized, double-blinded, placebo-controlled trial, a convenience sample of patients was assigned to one of four arms: phenylephrine 0.25%, oxymetazoline 0.05%, lidocaine 1% with epinephrine 1:100,000, or bacteriostatic 0.9% sodium chloride in cotton soaked nasal pledgets. They did not find any changes in blood pressure over the 30 minutes after drug administration between any of the arms. This suggests that vasoconstrictors cause minimal acute blood pressure changes when applied nasally via soaked pledgets.
High Sensitivity Troponin T (hsTnT) Identifies Patients at Very Low Risk of Adverse Events
Peacock WF, Baumann B.M, Bruton D, et al
There has been much literature published on the utility of high-sensitivity troponin assays. This study reports on their use in an American cohort. This Roche-funded study examined a three-hour protocol in 1,264 ED patients suspected of having acute coronary syndrome, finding that in the 974 (77.1 percent) patients with both a zero- and three-hour hsTnT<19 ng/L a 30-day adverse cardiac event occurred in seven patients for a negative predictive value of 99.3 percent (95 percent CI, 99.05–99.55).
Telehealth for Low-acuity EMS: One Fire-based System Experience with 10,000 Patients
Gonzalez MG, Persse DE, Gleisberg GR, et al
Telemedicine in the Emergency Department: A Novel, Academic Approach to Optimizing Operational Metrics and Patient Experience
Sharma R, Clark S, Torres-Lavoro J, et al
Finally, we would be remiss if we did not highlight the latest cutting-edge work from our first ever session of abstracts devoted to telemedicine. Both of these abstracts demonstrated the ability of emergency physicians to care for patients via remote communication, the first in the pre-hospital environment, and the second in a fast track scenario. Both abstracts demonstrated that patients could be cared for efficiently and safely while reducing ED visits or time in the emergency department.
Congratulations are also in order to award winners Brett Schuchardt and Rebecca Kowalski, who were awarded Best Medical Student abstract for “The Ability of Heparin-Binding Protein to Identify Delayed Shock in Emergency Department Sepsis Patients is Impacted by Age and Source of Infection,” and Sumit Patel, MD, who was awarded Best Resident Abstract for “A Comparison of Three Sobering Center Screens Using a Prospective Cohort of Intoxicated Emergency Department Patients,” at the first–ever live award finalists presentation. Congratulations also to Best Young Investigator Naveen Poonai, MD, for “Intranasal Ketamine for Procedural Sedation in Children: A Randomized Controlled Pilot Study” and to Michael Gonzalez, MD, for Best Overall Abstract on his telehealth EMS abstract above.
Find out what’s next for emergency medicine this October at the ACEP18 Research Forum in San Diego!
Dr. Limkakeng is director of the ACEP Research Forum and associate professor and director of acute care research in the division of emergency medicine at Duke University School of Medicine in Durham, North Carolina.
Dr. Piktel is assistant professor of emergency medicine at Case Western Reserve University School of Medicine in Cleveland, Ohio.