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The 2010 Society for Academic Emergency Medicine’s annual meeting was held in June,  2010, in Phoenix, Arizona. The Research Forum featured 609 abstracts, including five plenary presentations and 20 innovations in emergency medicine education. Here are the 10 we felt had the most potential to impact the practice of emergency physicians.

* An interesting read but only practice changing for some physicians
** Abstract which has moderate impact and is practice changing for many
*** An abstract with high impact which is practice changing for most
**** A must-read abstract which is practice changing for all physicians
***** A landmark project which is practice changing for all

Abstract #4
The Likelihood of Acute Pulmonary Embolism in ED Patients is Not Lower Among Patients Taking Warfarin (independently selected by both authors as a Top Abstract)
rating *****
What were they looking for?

To correlate INRs in patients taking warfarin with the rule-in rate for PE.
Methods:
Prospective, observational study of 7,940 ED patients from 13 centers.
Results:
Overall rule-in rates were 6.1% for those not taking warfarin and 8.5% for patients taking warfarin.  The percentage was far higher (10%) in those with low INRs (2.5, 7.6%).
Practice Change Potential:
In patients presenting to the ED already taking warfarin with PE-possibility complaints, this study shows the importance of keeping PE on the differential.

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Abstract #1
Change in Acuity of Emergency Department Visits in Ten Massachusetts Hospitals After Implementation of Health Care Reform 
rating ****
What were they looking for?
To determine whether the passage of health care reform decreased the number of patients using the ED for low acuity visits.
Methods:
Before and-after study (325,664 and 336,915 patients respectively).
Results:
Low acuity visits for uninsured or government subsidized patients decreased from 38.0% to 36.3% while Medicare and privately insured patients increased from 30.1% to 31.2% of total visits.
Practice Change Potential:
In this statewide scenario, health care reform produced a relative decrease in uninsured patients utilizing the ED for lower acuity complaints.  If health care reform produces the same on a national level and encourages patients to seek their medical home for lower acuity complaints, this may have a significant financial impact for EDs.

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Abstract #29
Pregnancy Outcomes in Symptomatic 1st Trimester Pregnancies with Indeterminate Ultrasounds (US)  and Beta-HCG ≥1500 and ≤3000
rating ****
What were they looking for?
To determine fetal outcomes for symptomatic 1st trimester pregnancies in the ED with an indeterminate US (empty uterus or empty gestational sac) and quantitative HCG between 1500 and 3000.
Methods:
Retrospective analysis of 1164 consecutive ED patient encounters
Results:
53 (4.5%) patient encounters met inclusion criteria; 7 (13%) were lost to follow-up and 1 was excluded due to repeat ED visit, resulting in 45 patient encounters. 8 patients had a normal delivery and the rest had poor outcomes including: 1 molar pregnancy, 7 ectopic pregnancies, and 29 spontaneous abortions.
Practice Change Potential:
This study suggests that we should counsel our patients regarding the high likelihood (82%) of a poor pregnancy outcome when faced with this scenario. Of note, a subgroup analysis of the 7 ectopic pregnancies resulted in only one patient with no classic risk factors or adnexal mass or free fluid. The other 6 patients had at least one of these three findings.

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Abstract #131
Urinalysis is an Inadequate Screen for Rhabdomyolysis (independently selected by both authors as a Top Abstract)
rating ****
What were they looking for?
To determine the sensitivity of the urinalysis (UA) in the diagnosis of rhabdomyolysis A positive UA was defined by a dip positive for trace or more blood with negative microscopy, implying the presence of myoglobinuria.
Methods:
Retrospective electronic chart review of 228 admitted patients that had discharge diagnosis of rhabdomyolysis, CK >1000 and UA within 24 hours of presentation
Results:
195 patients (86%) had urine dip positive for blood, but only 94 (41%) had combination of positive dip with negative microscopy. In the 66 patients with more severe rhabdomyolysis and initial CK >10,000, the sensitivity of the UA was 55%. Applying a more liberal definition of a negative microscopy (<10 RBC), the sensitivity increased to only 79%.
Practice Change Potential:
The combination of a positive urine dip for blood and negative microscopy is insensitive for screening for rhabdomyolysis.

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Abstract #205
A Clinical Decision Rule (CDR) to Identify Infants with ALTE who can be Safely Discharged from the Emergency Department
rating ***
What were they looking for?
To formulate a CDR to identify low risk infants with ALTE that can be safely discharged from the ED.
Methods:
Prospective cohort of 300 infants with ED diagnosis of ALTE.  Admission was considered warranted if any significant intervention (SI) was required during the hospital stay (e.g. parenteral antibiotics, airway management, ICU admit) or had ALTE recurrence leading to ED repeat visit within 72 hours.
Results:
228/300 (76%) were admitted; 37 (12%) required SI; no patients died during hospital stay or within 72 hours of discharge; no patients were diagnosed with a serious bacterial infection;
286 patients met complete data requirements for a logistic regression analysis.  35 (12%) met criteria for SI.  Factors which were identified as predictors of SI included: prematurity (OR 4.5), abnormal physical exam (OR 3.4), color change to blue (OR 3.2), absence of reported cough or runny nose (OR 2.9), and absence of history of choking (OR 2.3).
Practice Change Potential:
These variables were used to create a CDR that could have decreased the admission rate from 76% to 36%. A larger multi-center study would likely be needed to validate this well-designed study before this rule can be safely applied to the general emergency department evaluation of the ALTE patient.

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Abstract #209
On-site Pharmacists in the Emergency Department Improve Errors (independently selected by both authors as a Top Abstract)
rating ***
What were they looking for?
To determine the impact of an ED pharmacist on medication errors and time delays.
Methods:
Retrospective review of data for 686 patients over a 3-month period.
Results:
There were 7 errors during the times pharmacists were present compared to 137 errors during non-pharmacist times.
Practice Change Potential:
If these robust results can be duplicated at other institutions, this may help EDs hire and retain pharmacists.

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Abstract #235
Management of Occult Pneumothorax (OP): An Evidence-based Emergency Medicine Review

rating ***
What were they looking for?
To evaluate the evidence in existing studies for the safety and efficacy of observation vs. thoracostomy tube (TT) for management of OP.
Methods:
Data base search including MEDLINE, EMBASE, Cochrane Library, and others for stable adult/pediatric trauma patients with OP (very small pneumothoraces seen on CT but not on X-ray).
Results:
248 articles were identified and 3 randomized trials were found to have acceptable quality standards (N=101 patients). No significant differences were found between observation vs. TT regarding progression of OP, pneumonia, mortality risk, and empyema rate.
Practice Change Potential:
Observation is at least as safe and effective as TT for the management of patients with OP. However, hospital and ICU length of stay may be increased with observation.

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Abstract #237
Prehospital Intubation and Traumatic Brain Injury: A Systematic Review
rating ***
What were they looking for?
To determine the effect of prehospital intubation on mortality and neurological outcome in patients with moderate to severe traumatic brain injury.
Methods:
Of 1,781 articles identified, 10 met the inclusion criteria.
Results:
The combined results of the available literature demonstrated that patients with moderate to severe TBI who undergo prehospital intubation have worse outcomes than those patients with matched injury severity scores who are intubated in the hospital.
Practice Change Potential:
While there isn’t definitive evidence that prehospital intubation is responsible for the outcomes presented in this abstract, this project demonstrates the need for EMS systems to closely examine the practice of prehospital intubation for patients with head injury.

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Abstract #399
Outcomes of Patients Following a Negative Coronary Computerized Tomographic Angiography (CTA) in the Emergency Department
(independently selected by both authors as a Top Abstract)
rating *****
What were they looking for?
To attempt to show whether patients with <50% maximal stenosis on coronary CTA have <1% rate of cardiovascular death or non-fatal MI over 1 year.
Methods:
Prospective cohort study of 1,194 patients presenting with chest pain who received coronary CTA in the ED.
Results:
Of patients with <50% maximal stenosis who were discharged home, there was possibly 1 cardiovascular death (0.2%), no AMI and no revascularization procedures.
Practice Change Potential:
In selected patients, coronary CTA is proving to be a highly effective means to rule out patients for AMI and cardiovascular death.

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Abstract #265
Emergency Department Medication Reconciliation: How Reliable are Patient-Completed Forms Compared to Pharmacy-generated Lists?
rating ***
What were they looking for?
To evaluate whether patient provided medication reconciliation (MR) forms agree with filled pharmacy prescriptions and to determine whether there is a difference in concordance when patients report their medications from memory compared to those who use a medication list or bring their pill bottles from home.
Methods:
Prospective convenience sample of 152 patients.  Pharmacies were contacted for list of drugs filled in prior 3 months which was compared with the MR.  Discrepancies were classified as “omissions” if pharmacy reported drugs not present on the patient’s list and “commissions” if that list contained drugs not reported by pharmacy.
Results:
49 (32%) omission rate, 18 (12%) commission rate, 30 (20%) with both, and 55 (36%) with no errors.  Patients with errors took more medications than those without errors (mean: 5.3 vs. 3.2).  More errors were made when MR was completed from a separate list than from memory or from pill bottles. Of note, increasing age had no effect on errors.
Practice Change Potential:
This is quite concerning, as in this study, the patient medication list often did not correlate with the medications that the patient was supposed to be taking. This could lead to errors involving duplication of medications or medication interaction problems.

Dr. Breyer is an Associate Program Director at Christiana Care Health System in Newark, Delaware.  His research interests include Medical Education and Ultrasound.

Dr. Valente is an Assistant Professor at the Alpert Medical School of Brown University in Providence, RI.  He is boarded in Emergency Medicine and Pediatric Emergency Medicine.  His interests include trauma, pediatrics, advanced airway education, wound care, and ultrasound.

 

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