Differences in initial severity of illness between black and white emergency department patients hospitalized with heart failure.

Background: Black patients hospitalized for heart failure have better reported short-term survival than white patients for unknown reasons. We sought to determine if initial severity of illness differed between black and white emergency department (ED) patients hospitalized for heart failure.

Methods: We analyzed 1,408 black and 7,260 white randomly selected patients in one state hospitalized from an ED during 2003 and 2004 and with a discharge diagnosis of heart failure.

Validation of the Acute Heart Failure Index.

Study Objective: Validate a clinical prediction rule prognostic of short-term fatal and inpatient nonfatal outcomes for heart failure patients admitted through the emergency department.

Methods: We retrospectively studied a random cohort of 8,384 adult patients admitted to Pennsylvania hospitals in 2003 and 2004 with a diagnosis of heart failure as defined by primary discharge diagnosis codes. We reported the proportions of inpatient death, serious medical complications before discharge, and 30-day death in the patients identified as low risk by the prediction rule.

Comparison of four clinical prediction rules for estimating risk in heart failure.

Study Objective: We examine the performance of 4 clinical prediction rules prognostic of short-term fatal and hospital-based nonfatal outcomes in heart failure patients.

Methods: We used a retrospective cohort of 33,533 adult patients admitted to Pennsylvania hospitals in 1999 with a diagnosis of heart failure. We stratified patients into risk categories defined by each clinical prediction rule.

Factors associated with the hospitalization of low-risk patients with community-acquired pneumonia in a cluster-randomized trial.

Background: Many low-risk patients with pneumonia are hospitalized despite recommendations to treat such patients in the outpatient setting.

Objective: To identify the factors associated with the hospitalization of low-risk patients with pneumonia.

Methods: We analyzed data collected by retrospective chart review for 1,889 low-risk patients (Pneumonia Severity Index [PSI] risk classes I to III without evidence of arterial oxygen desaturation) enrolled in a cluster-randomized trial conducted in 32 emergency departments.

A prediction rule to identify low-risk patients with pulmonary embolism.

Background: A simple prognostic model could help identify patients with pulmonary embolism who are at low risk of death and are candidates for outpatient treatment.

Methods: We randomly allocated 15,531 retrospectively identified inpatients who had a discharge diagnosis of pulmonary embolism from 186 Pennsylvania hospitals to derivation (67%) and internal validation (33%) samples. We derived our rule to predict 30-day mortality using classification tree analysis and patient data routinely available at initial examination as potential predictor variables.

Effect of increasing the intensity of implementing pneumonia guidelines: a randomized, controlled trial.

Background: Despite the development of evidence-based pneumonia guidelines, limited data exist on the most effective means to implement guideline recommendations into clinical practice.

Objective: To compare the effectiveness and safety of 3 guideline implementation strategies.

Design: Cluster-randomized, controlled trial.

Derivation and validation of a prognostic model for pulmonary embolism.

Rationale: An objective and simple prognostic model for patients with pulmonary embolism could be helpful in guiding initial intensity of treatment.

Objectives: To develop a clinical prediction rule that accurately classifies patients with pulmonary embolism into categories of increasing risk of mortality and other adverse medical outcomes.

Methods: We randomly allocated 15,531 inpatient discharges with pulmonary embolism from 186 Pennsylvania hospitals to derivation (67%) and internal validation (33%) samples.

A prediction rule to identify low-risk patients with heart failure.

Objectives: To derive a prediction rule using data available in the emergency department (ED) to identify a group of patients hospitalized for the treatment of heart failure who are at low risk of death and serious complications.

Methods: The authors analyzed data for all 33,533 patients with a primary hospital discharge diagnosis of heart failure in 1999 who were admitted from EDs in Pennsylvania. Candidate predictors were demographic and medical history variables and the most abnormal examination or diagnostic test values measured in the ED (vital signs only) or on the first day of hospitalization.

Using randomized controlled trial data, the agreement between retrospectively and prospectively collected data comprising the pneumonia severity index was substantial.

Objective: To assess the agreement between prospectively and retrospectively determined variables comprising the Pneumonia Severity Index (PSI), assignment to PSI risk class, and designation as low risk, based on these two methods of data collection.

Study Design And Setting: We analyzed data from a randomized trial of patients with community-acquired pneumonia managed in 32 hospital emergency departments (EDs). For all enrolled patients, the 20 PSI variables were collected prospectively by ED providers and retrospectively by medical record abstractors.

Prospective comparison of three validated prediction rules for prognosis in community-acquired pneumonia.

Purpose: We assessed the performance of 3 validated prognostic rules in predicting 30-day mortality in community-acquired pneumonia: the 20 variable Pneumonia Severity Index and the easier to calculate CURB (confusion, urea nitrogen, respiratory rate, blood pressure) and CURB-65 severity scores.

Subjects And Methods: We prospectively followed 3181 patients with community-acquired pneumonia from 32 hospital emergency departments (January-December 2001) and assessed mortality 30 days after initial presentation. Patients were stratified into Pneumonia Severity Index risk classes (I-V) and CURB (0-4) and CURB-65 (0-5) risk strata.

The emergency department community-acquired pneumonia trial: Methodology of a quality improvement intervention.

Community-acquired pneumonia causes more than 4 million episodes of illness each year and has high morbidity, mortality, and total cost of care. Nationwide, nearly 75% of community-acquired pneumonia patients are initially evaluated and treated in hospital-based emergency departments (EDs). Substantial variation exists in illness severity assessment, hospital admission decisions, and performance of recommended processes of care.

Influenza immunizations provided by EMS agencies: the MEDICVAX Project.

Objective: Emergency medical services (EMS) agencies may be an underutilized resource for provision of preventive health services. This study sought to demonstrate the feasibility for EMS agencies to provide influenza immunizations.

Methods: This prospective, observational cohort study was conducted with urban, suburban, and rural EMS agencies that volunteered to participate.

Evaluation of guidelines for ordering prothrombin and partial thromboplastin times.

Objectives: Existing clinical practice guidelines for ordering prothrombin time (PT) and partial thromboplastin time (PTT) tests in the emergency department (ED) include physician expectation of an invasive procedure as a criterion. This study sought to determine whether this criterion accurately identifies patients who undergo an invasive procedure and whether an amalgam of these guidelines identifies patients at low risk of an adverse medical outcome.

Methods: A prospective observational cohort study of adults treated in a university medical center ED between July 1997 and March 1998.

Two-thumb vs. two-finger chest compression in an infant model of prolonged cardiopulmonary resuscitation.

Objective: Previous experiments in the authors' swine lab have shown that cardiopulmonary resuscitation (CPR) using two-thumb chest compression with a thoracic squeeze (TT) produces higher blood and perfusion pressures when compared with the American Heart Association (AHA)-recommended two-finger (TF) technique. Previous studies were of short duration (1-2 minutes). The hypothesis was that TT would be superior to TF during prolonged CPR in an infant model.

The psychometric and cardiac effects of dimenhydrinate in the hyperbaric environment.

Study Objectives: To examine the psychometric and cardiac effects of dimenhydrinate at 1 and 3 atmospheres (atm) of pressure (0 and 66 feet of sea water, respectively), and to make recommendations about the drug's safety in the diving environment.

Design: Double-blind, placebo-controlled, crossover study

Setting: Monoplace hyperbaric chamber of a university hospital.

Subjects: Thirty active divers (mean age 38 yrs).

The psychometric and cardiac effects of pseudoephedrine in the hyperbaric environment.

Study Objectives: To examine the psychometric and cardiac effects of pseudoephedrine at 1 and 3 atmospheres (atm) of pressure (0 and 66 feet of sea water, respectively), and to make recommendations about the agent's safety in the diving environment.

Design: Double-blind, placebo-controlled, crossover study.

Setting: Monoplace hyperbaric chamber of a university hospital.

Current outpatient management of asthma shows poor compliance with International Consensus Guidelines.

Study Objective: This study aimed to establish whether the outpatient management of patients presenting with an asthma exacerbation to the emergency department (ED) was in compliance with the 1992 guidelines of the "International Consensus Report on the Diagnosis and Management of Asthma."

Design: Prospective, observational study using a researcher-administered questionnaire.

Setting: University tertiary referral ED.

Assessing prognosis and selecting an initial site of care for adults with community-acquired pneumonia.

Over the last 20 years, more than 15 medical practice guidelines and clinical prediction rules have emerged to assist physicians in assessing the prognosis of adult patients with community-acquired pneumonia (CAP) and selecting an appropriately matched initial site of care. Most of these guidelines and rules suffer from major methodological flaws. One, the Pneumonia Patient Outcomes Research Team (PORT) clinical prediction rule, has satisfied rigorous methodological standards for the derivation and validation of high-quality prediction rules.