Course of Untreated High Blood Pressure in the Emergency Department

<p>Introduction: No clear understanding exists about the course of a patient’s blood pressure (BP) during an emergency department (ED) visit. Prior investigations have demonstrated that BP can be reduced by removing patients from treatment areas or by placing patients supine and observing them for several hours. However, modern EDs are chaotic and noisy places where patients and their families wait for long periods in an unfamiliar environment. We sought to determine the stability of repeated BP measurements in the ED environment.</p> <p>Methods: A prospective study was performed at an urban ED. Research assistants trained and certified in BP measurement obtained sequential manual BPs and heart rates on a convenience sample of 76 patients, beginning with the patient arrival in the ED. Patients were observed through their stay for up to 2 hours, and BP was measured at 10-minute intervals. Data analysis with SAS PROC MIXED (SAS Institute, Cary, North Carolina) for regression models with correlated data determined the shape of the curve as BP changed over time. Patients were grouped on the basis of their presenting BP as normal (less than 140/90), elevated (140–160/90–100), or severely elevated (greater than 160/100) for the regression analysis.</p> <p>Results: A statistically significant downward trend in systolic and diastolic BP was observed only for those patients presenting with severely elevated BPs (ie, greater than 160/100).</p> <p>Conclusion: We demonstrate a statistically significant decline in systolic and diastolic BP over time spent in the ED only for patients with severely elevated presenting BPs. [West J Emerg Med. 2011;12(4):421–425.]</p

Provider Self-Report and Practice: Reassessment and Referral of Emergency Department Patients With Elevated Blood Pressure

Background We attempted to identify patient factors associated with blood pressure (BP) reassessment and to compare health-care provider self-reported reassessment and referral to actual practice in an emergency department (ED) setting. Methods Provider reassessment and referral practices were determined through systematic review of 1,250 medical records at five EDs. Medical records were included if patients were ≥18 years, nonpregnant, presented with a systolic (SBP) ≥140 or diastolic BP (DBP) ≥90 mm Hg, and discharged. A separate questionnaire obtained self-reported practice patterns of health-care providers. Multivariate logistic regression identified factors associated with patient BP reassessment and referral. Results Of 1,250 patients, only 57% underwent BP reassessment and 9% received a referral for outpatient management. The most significant independent variables related to a reassessment were as follows: treatment of elevated BP in the ED (odds ratio (OR): 6.05; 95% confidence interval (CI): 1.80-20.31), chest pain (OR: 3.90; 95% CI: 2.37-6.42), and presence of an ED reassessment protocol (OR: 2.49; 95% CI: 1.77-3.50). The most significant factors associated with a referral included treatment of elevated BP in the ED (OR: 5.55; 95% CI: 2.72-11.32), presence of a reassessment protocol (OR: 2.58; 95% CI: 1.32-5.05), and a BP reassessment (OR: 2.56; 95% CI: 1.34-4.89). For self-reported practice patterns, 379 (72%) health-care providers completed questionnaires. Providers consistently overestimated their referral practices, yet the mean referral threshold values reported (SBP, 150 mm Hg; DBP, 93 mm Hg) were lower than the mean BP values of patients who actually received a directed referral (SBP, 170 mm Hg; DBP, 97 mm Hg, P < 0.0001). Conclusions Reassessment and referral of discharged ED patients with elevated BP was infrequent and health-care providers overestimate their reassessment and referral effort

Emergency Medicine Research Directors and Research Programs: Characteristics and Factors Associated with Productivity

: Background: Periodic surveys of research directors (RDs) in emergency medicine (EM) are useful to assess the specialty's development and evolution of the RD role. Objectives: To assess associations between characteristics and research productivity of RDs and EM programs. Methods: A survey of EM RDs was developed using the nominal group technique and pilot tested. RDs or surrogate respondents at programs certified by the Accreditation Council for Graduate Medical Education were contacted by e-mail in early 2005. The survey assessed programs' research infrastructure and productivity, as well as RD characteristics, responsibilities, and career satisfaction. Three measures of research productivity were empirically defined: research publications, grant awards, and grant revenue. Results: Responses were received from 86% of 123 EM programs. Productivity was associated with the presence of nonclinical faculty, dedicated research coordinators, and reduced clinical hours for research faculty. Programs with an RD did not have greater research productivity, using any measure, than those without an RD. The majority of RDs cited pursuing their own studies, obtaining funding, research mentoring, and research administration to be major responsibilities. The majority characterized internal research funding, grant development support, and support from other faculty as inadequate. Most RDs are satisfied with their careers and expect to remain in the position for three or more years. Conclusions: Research productivity of EM residency programs is associated with the presence of dedicated research faculty and staff and with reduced clinical demands for research faculty. Despite perceiving deficiencies in important resources, most RDs are professionally satisfied.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/72908/1/j.aem.2006.01.027.pd

Sex Differences in Neurological Emergencies Presenting to Multiple Urban Level 1 Trauma Centers

Previous studies have suggested that there are sex differences in the treatment and outcome of neurological emergencies; however, research identifying the role these sex differences play in the management of neurological emergencies is lacking. More knowledge of the way sex factors into the pathophysiology of neurological emergencies will be helpful in improving outcomes for these patients. The aim of this cross-sectional study was to assess the prevalence and management of neurological emergencies while evaluating sex differences in the diagnosis and treatment of these emergencies. We analyzed a cohort of 530 adult patients from four level 1 trauma centers over a period of 4 weeks who had a chief complaint of a neurological emergency, including seizures, cerebrovascular events, headache disorders, traumatic brain injuries, and central nervous system infections. Among patients with neurological emergencies, a significantly lower proportion of female patients underwent neurosurgery and were admitted to the intensive care unit compared to male patients, but there were no significant differences between sexes in the time of symptom onset, type of hospital transportation, amount of neuroimaging performed, admission rates, hospital length of stay, and disposition from the emergency department. Although female patients were more likely to have a chief complaint of headache compared to traumatic injuries in male patients, this was not statistically significant. A significantly higher proportion of female patients had health insurance coverage than male patients

Emergency Medicine Research Directors and Research Programs: Characteristics and Factors Associated with Productivity

: Background: Periodic surveys of research directors (RDs) in emergency medicine (EM) are useful to assess the specialty's development and evolution of the RD role. Objectives: To assess associations between characteristics and research productivity of RDs and EM programs. Methods: A survey of EM RDs was developed using the nominal group technique and pilot tested. RDs or surrogate respondents at programs certified by the Accreditation Council for Graduate Medical Education were contacted by e-mail in early 2005. The survey assessed programs' research infrastructure and productivity, as well as RD characteristics, responsibilities, and career satisfaction. Three measures of research productivity were empirically defined: research publications, grant awards, and grant revenue. Results: Responses were received from 86% of 123 EM programs. Productivity was associated with the presence of nonclinical faculty, dedicated research coordinators, and reduced clinical hours for research faculty. Programs with an RD did not have greater research productivity, using any measure, than those without an RD. The majority of RDs cited pursuing their own studies, obtaining funding, research mentoring, and research administration to be major responsibilities. The majority characterized internal research funding, grant development support, and support from other faculty as inadequate. Most RDs are satisfied with their careers and expect to remain in the position for three or more years. Conclusions: Research productivity of EM residency programs is associated with the presence of dedicated research faculty and staff and with reduced clinical demands for research faculty. Despite perceiving deficiencies in important resources, most RDs are professionally satisfied.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/72908/1/j.aem.2006.01.027.pd

Course of Untreated High Blood Pressure in the Emergency Department

Introduction: No clear understanding exists about the course of a patient’s blood pressure (BP) during an emergency department (ED) visit. Prior investigations have demonstrated that BP can be reduced by removing patients from treatment areas or by placing patients supine and observing them for several hours. However, modern EDs are chaotic and noisy places where patients and their families wait for long periods in an unfamiliar environment. We sought to determine the stability of repeated BP measurements in the ED environment.Methods: A prospective study was performed at an urban ED. Research assistants trained and certified in BP measurement obtained sequential manual BPs and heart rates on a convenience sample of 76 patients, beginning with the patient arrival in the ED. Patients were observed through their stay for up to 2 hours, and BP was measured at 10-minute intervals. Data analysis with SAS PROC MIXED (SAS Institute, Cary, North Carolina) for regression models with correlated data determined the shape of the curve as BP changed over time. Patients were grouped on the basis of their presenting BP as normal (less than 140/90), elevated (140–160/90–100), or severely elevated (greater than 160/100) for the regression analysis.Results: A statistically significant downward trend in systolic and diastolic BP was observed only for those patients presenting with severely elevated BPs (ie, greater than 160/100).Conclusion: We demonstrate a statistically significant decline in systolic and diastolic BP over time spent in the ED only for patients with severely elevated presenting BPs. [West J Emerg Med. 2011;12(4):421–425.