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Open Access Publications from the University of California

Scholarly Works (35 results)

  • Article
  • Peer Reviewed
Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health, Volume 4, Issue 2 (2003)
    Cover page: Challenges in the Management of Acutely Decompensated Congestive Heat Failure: Disposition Decisions in the Emergency Department
    • Article
    • Peer Reviewed
    Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health, Volume 22, Issue 3 (2021)

    Introduction: Patients presenting to the emergency department (ED) with “low-risk” acute coronary syndrome (ACS) symptoms can be discharged with outpatient follow-up. However, follow-up compliance is low for unknown nonclinical reasons. We hypothesized that a patient’s social factors, health literacy, self-perceived risk, and trust in the emergency physician may impact follow-up compliance.

    Methods: This was a prospective study of a convenience sample of discharged ED patients presenting with chest pain and given a follow-up appointment prior to departing the ED. Patients were asked about social and demographic factors and to estimate their own risk for heart disease; they also completed the Short Assessment of Health Literacy-English (SAHL-E) and the Trust in Physician Scale (TiPS).

    Results: We enrolled146 patients with a follow-up rate of 36.3%. Patients who had a low self-perceived heart disease risk (10% or less) were significantly less likely to attend follow-up than those with a higher perceived risk (23% vs 44%, P = 0.01). Other factors did not significantly predict follow-up rates.

    Conclusion: In an urban county ED, in patients who were deemed low risk for ACS and discharged, only self-perception of risk was associated with compliance with a follow-up appointment.

      Cover page: Impact of Social Determinants of Health, Health Literacy, Self-perceived Risk, and Trust in the Emergency Physician on Compliance with Follow-upCreative Commons 'BY' version 4.0 license
      • Article
      • Peer Reviewed
      Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health, Volume 15, Issue 7 (2014)

      Introduction: The American Heart Association (AHA) recommends regionalized care following out-of-hospital cardiac arrest (OHCA) at cardiac resuscitation centers (CRCs). Key level 1 CRC criteria include 24/7 percutaneous coronary intervention (PCI) capability, therapeutic hypothermia capability, and annual volume of ≥40 patients resuscitated from OHCA. Our objective was to characterize the availability and utilization of resources relevant to post-cardiac arrest care, including level 1 CRCs in California.

      Methods: We combined data from the AHA, the California Office of Statewide Health Planning and Development (OSHPD), and surveys to identify CRCs. We surveyed emergency department directors and nurse managers at all 24/7 PCI centers identified by the AHA to determine their post-OHCA care capabilities. The survey included questions regarding therapeutic hypothermia use and specialist availability and was pilot-tested prior to distribution. Cases of OHCA were identified in the 2011 OSHPD Patient Discharge Database using a “present on admission” diagnosis of cardiac arrest (ICD-9-CM code 427.5). We defined key level 1 CRC criteria as 24/7 PCI capability, therapeutic hypothermia, and annual volume ≥40 patients admitted with a “present on admission” diagnosis of cardiac arrest. Our primary outcome was the proportion of hospitals meeting these criteria. Descriptive statistics and 95% CI are presented.

      Results: Of the 333 acute care hospitals in California, 31 (9.3%, 95% CI 6.4-13%) met level 1 CRC criteria. These hospitals treated 25% (1937/7780; 95% CI 24-26%) of all admitted OHCA patients in California in 2011. Of the 125 hospitals identified as 24/7 PCI centers by the AHA, 54 (43%, 95% CI 34-52%) admitted ≥40 patients following OHCA in 2011. Seventy (56%, 95% CI 47-65%) responded to the survey; 69/70 (99%, 95% CI 92-100%) reported having a therapeutic hypothermia protocol in effect by 2011. Five percent of admitted OHCA patients (402/7780; 95% CI 4.7-5.7%) received therapeutic hypothermia and 18% (1372/7780; 95% CI 17-19%) underwent cardiac catheterization.

      Conclusion: Approximately 10% of hospitals met key criteria for AHA level 1 CRCs. These hospitals treated one-quarter of patients resuscitated from OHCA in 2011. The feasibility of regionalized care for OHCA requires detailed evaluation prior to widespread implementation. [West J Emerg Med. 2014;15(7):–0.]

        Cover page: Availability and Utilization of Cardiac Resuscitation CentersCreative Commons 'BY-NC' version 4.0 license
        • Article
        • Peer Reviewed
        UC Davis Previously Published Works (2017)
        When screening for acute myocardial infarction (AMI), troponin levels below the 99th percentile, including those below the limit of detection (LOD), are considered normal. We hypothesized that a low-risk HEART score (0-3) or ACS Pretest Probability Assessment <2% plus a single troponin below the LOD would rule out both AMI and 30-day major adverse cardiac events (MACE). We studied all patients who presented to a single academic emergency department and received a troponin I (Siemens Ultra Troponin I) from September 1, 2013, to November 13, 2013 (n=888). Demographic and clinical data were abstracted from the electronic medical record. Primary outcome was a final encounter diagnosis of myocardial infarction. Secondary outcome was 30-day MACE, defined as composite of myocardial infarction, revascularization, or death from a cardiac or uncertain etiology. Sensitivities of low-risk HEART score and ACS Pretest Probability <2% alone were 98% (95% confidence interval [CI], 89%-100%) and 96% (95% CI, 86%-100%) for AMI and 94% (95% CI, 86%-98%) and 95% (95% CI, 88%-99%), respectively, for 30-day MACE. When combined with troponin below the LOD, sensitivity for AMI was 100% (95% CI, 93%-100%; difference 2%; 95% CI, -2% to 6%) for low-risk HEART Score and 100% (95% CI, 93%-100%; difference 4%; 95% CI, -1.5% to 10%) for ACS Pretest Probability <2%. When combined with troponin below the LOD, sensitivity for 30-day MACE was 100% (95% CI, 95%-100%; difference 6%; 95% CI, 1%-12%) for low-risk HEART Score and 100% (95% CI, 95%-100%; difference 5%; 95% CI, 0.2%-10%) for ACS Pretest Probability <2%. Addition of a single troponin below the LOD to these scores improves sensitivity for 30-day MACE.
          Cover page: Troponin Limit of Detection Plus Cardiac Risk Stratification Scores to Rule Out Acute Myocardial Infarction and 30-Day Major Adverse Cardiac Events in ED Patients
          • Article
          • Peer Reviewed
          UC Davis Previously Published Works (2016)

          Background

          Current guidelines suggest a "door-in-door-out" (DIDO) time of 30 minutes or shorter for patients with ST-segment elevation myocardial infarction (STEMI) who arrive at a STEMI referral hospital and are transferred to a STEMI-receiving center for primary percutaneous coronary intervention. Experts previously identified 18 system practices as critical for reducing DIDO times. The objective of this study was to describe how frequently these critical practices are used and to determine whether their use was associated with shorter DIDO times.

          Methods

          We surveyed 18 STEMI referral hospitals for 4 STEMI-receiving centers regarding their use of these 18 practices. The median number used was 14 practices (interquartile range 12-15). We then evaluated their association with DIDO times in all patients (n = 93) transferred from these STEMI referral hospitals to the 4 STEMI-receiving centers for primary percutaneous coronary intervention.

          Results

          In univariate linear regression analyses, system-wide quality improvement programs with leaders in the emergency medical services agencies and STEMI referral hospitals were associated with shorter DIDO times (P < 0.001 for all). Overall use of system practices was not associated with DIDO times (P = 0.143). The majority (76%, 95% confidence interval: 66%-85%) of DIDO times did not meet the 30-minute goal.

          Conclusions

          These findings highlight the difficulty in achieving the 30-minute DIDO goal and the need for continued focus on strategies for reducing DIDO time, including system-wide quality improvement programs.
            Cover page: Association Between Hospital Practices and Door-in-door-out Time in ST-segment Elevation Myocardial Infarction
            • Article
            • Peer Reviewed
            UC Davis Previously Published Works (2014)

            Background

            Nitroglycerin ointment is commonly used in the treatment of emergency department (ED) patients with suspected acute heart failure (AHF) or suspected acute coronary syndrome (ACS), but its hemodynamic effects in this population are not well described.

            Objective

            Our objective was to assess the effect of nitroglycerin ointment on mean arterial pressure (MAP) and systemic vascular resistance (SVR) in ED patients receiving nitroglycerin. We hypothesized that nitroglycerin ointment would result in a reduction of MAP and SVR in the acute treatment of patients.

            Methods

            We conducted a prospective, observational pilot study in a convenience sample of adult patients from a single ED who were treated with nitroglycerin ointment. Impedance cardiography was used to measure MAP, SVR, cardiac output (CO), stroke volume (SV), and thoracic fluid content (TFC) at baseline and at 30, 60, and 120 min after application of nitroglycerin ointment. Mixed effects regression models with random slope and random intercept were used to analyze changes in hemodynamic parameters from baseline to 30, 60, and 120 min after adjusting for age, sex, and final ED diagnosis of AHF.

            Results

            Sixty-four subjects with mean age of 55 years (interquartile range, 48-67 years) were enrolled; 59% were male. In the adjusted analysis, MAP and TFC decreased after application of nitroglycerin ointment (p=0.001 and p=0.043, respectively). Cardiac index, CO, SVR, and SV showed no change (p=0.113, p=0.085, p=0.570, and p=0.076, respectively) over time.

            Conclusions

            Among ED patients who are treated with nitroglycerin ointment, MAP and TFC decrease over time. However, other hemodynamic parameters do not change after application of nitroglycerin ointment in these patients.
              Cover page: Hemodynamic Effects of Nitroglycerin Ointment in Emergency Department Patients
              • Article
              • Peer Reviewed
              UC Davis Previously Published Works (2015)

              Objective

              Lack of longitudinal patient outcome data is an important barrier in emergency medical services (EMS) research. We aimed to demonstrate the feasibility of linking prehospital data from the California EMS Information Systems (CEMSIS) database to outcomes data from the California Office of Statewide Health Planning and Development (OSHPD) database for patients with out-of-hospital cardiac arrest (OHCA).

              Methods

              We included patients age 18 years or older who sustained nontraumatic OHCA and were included in the 2010-2011 CEMSIS databases. The CEMSIS database is a unified EMS data collection system for California. The OSHPD database is a comprehensive data collection system for patient-level inpatient and emergency department encounters in California. OHCA patients were identified in the CEMSIS database using cardiac rhythm, procedures, medications, and provider impression. Probabilistic linkage blocks were created using in-hospital death or one of the following primary or secondary diagnoses (ICD-9-CM) in the OSHPD databases: cardiac arrest (427.5), sudden death (798), ventricular tachycardia (427.1), ventricular fibrillation (427.4), and acute myocardial infarction (410.xx). Blocking variables included incident date, gender, date of birth, age, and/or destination facility. Due to the volume of cases, match thresholds were established based on clerical record review for each block individually. Match variables included incident date, destination facility, date of birth, sex, race, and ethnicity.

              Results

              Of the 14,603 cases of OHCA we identified in CEMSIS, 91 (0.6%) duplicate records were excluded. Overall, 46% of the data used in the linkage algorithm were missing in CEMSIS. We linked 4,961/14,512 (34.2%) records. Linkage rates varied significantly by local EMS agency, ranging from 1.4 to 61.1% (OR for linkage 0.009-0.76; p < 0.0001). After excluding the local EMS agency with the outlying low linkage rate, we linked 4,934/12,596 (39.2%) records.

              Conclusion

              Probabilistic linkage of CEMSIS prehospital data with OSHPD outcomes data was severely limited by the completeness of the EMS data. States and EMS agencies should aim to overcome data limitations so that more effective linkages are possible.
                Cover page: Probabilistic Linkage of Prehospital and Outcomes Data in Out-of-hospital Cardiac Arrest
                • Article
                • Peer Reviewed
                UC Davis Previously Published Works (2014)

                Background

                Current guidelines recommend ≤90 minutes from first medical contact to percutaneous coronary intervention (FMC2B) for ST-segment-elevation myocardial infarction (STEMI) patients. We evaluated the relationship between patient home distance from a percutaneous coronary intervention (PCI) center, prehospital electrocardiogram (ECG) use, and FMC2B time among patients with STEMI.

                Methods

                We performed a retrospective cohort study including all STEMI patients in the ACTION-Get With The Guidelines registry from July 1, 2008, to September 30, 2012, who were transported by ambulance to a PCI center. Patient home distance was defined as the driving distance from the patient's home zip code to the PCI center address. Distance was classified into tertiles, and linear regression was used to characterize the interaction between prehospital ECG use and patient home distance with respect to FMC2B time.

                Results

                Of the 29,506 STEMI patients, 19,690 (67%) received a prehospital ECG. The median patient home distance to the PCI center was 11.0 miles among patients with and 9.9 miles among those without a prehospital ECG. Prehospital ECGs were associated with a 10-minute reduction in the FMC2B time (P < .0001), which was consistent across distance tertiles (11 vs 11 vs 10 minutes). The association between prehospital ECGs and shorter FMC2B was attenuated by 0.8 minute for every 10-mile increase in distance (interaction P = .0002).

                Conclusions

                Prehospital ECGs are associated with a 10-minute reduction in the FMC2B time. However, patient home distance from a PCI center does not substantially change this association.
                  Cover page: Association between prehospital electrocardiogram use and patient home distance from the percutaneous coronary intervention center on total reperfusion time in ST-segment–elevation myocardial infarction patients: A retrospective analysis from the National Cardiovascular Data Registry
                  • Article
                  • Peer Reviewed
                  UC Davis Previously Published Works (2015)

                  Background

                  For patients resuscitated from out-of-hospital cardiac arrest (OHCA), the American Heart Association recommends regionalized care at cardiac resuscitation centers that are aligned with ST-segment elevation myocardial infarction (STEMI) centers. The effectiveness of treatment at STEMI centers remains unknown.

                  Objective

                  To evaluate whether good neurologic recovery after OHCA is associated with treatment at an STEMI center and if volume of admitted OHCA patients is associated with good neurologic recovery.

                  Methods

                  We included patients in the 2011 California Office of Statewide Health Planning and Development database with a "present on admission" diagnosis of cardiac arrest. Primary outcome was good neurologic recovery at hospital discharge. Hierarchical multiple logistic regression models were used to determine the association between treating hospital and good neurologic recovery after adjusting for patient factors (age, sex, race, ethnicity, insurance type, and ventricular arrest rhythm) and hospital factors (hospital size, intensive care unit bed days, trauma center designation, and teaching status).

                  Results

                  We included 7,725 patients; two-thirds (5,202) were treated at an STEMI center and 1,869 (24%, 95% CI 23%-25%) had good neurologic recovery. After adjustment, treatment at an STEMI center with ≥40 and <40 OHCA cases/year were associated with good neurologic recovery (odds ratio 1.32 [95% CI 1.06-1.64] and 1.63 [95% CI 1.35-1.97], respectively). Higher volume of admitted OHCA patients was associated with decreased odds of good neurologic recovery (adjusted odds ratio per 10 patients 0.96, 95% CI 0.92-1.00), but this association was not statistically significant after excluding the highest-volume outlier.

                  Conclusions

                  Treatment at an STEMI center-regardless of its annual OHCA volume-after resuscitation from OHCA is associated with good neurologic recovery. Regionalized systems of care should prioritize STEMI centers as destinations for resuscitated OHCA patients.
                    Cover page: Association between treatment at an ST-segment elevation myocardial infarction center and neurologic recovery after out-of-hospital cardiac arrest
                    • Article
                    • Peer Reviewed
                    UC Davis Previously Published Works (2014)
                    Of patients with ST segment elevation myocardial infarction (STEMI), approximately two thirds present to a hospital not capable of percutaneous coronary intervention. Transfer to a STEMI-receiving center delays time to reperfusion in patients with STEMI, but factors that affect this delay have not been well studied. We performed a 3-round modified Delphi study to identify system practices that minimize transfer time to a STEMI-receiving center. A comprehensive literature review was used to identify candidate system practices. Emergency medical services, emergency medicine, and cardiology experts were invited to participate. Consensus was defined as 80% agreement that a variable was "very important (5)" or "important (4)" with a mean score ≥ 4.25 or 80% agreement that a variable was "not important (1)" or "somewhat important (2)" with a mean score ≤ 1.75. In round 1, participants rated the candidate items and suggested additional items. Individual feedback was provided, and participants discussed items via conference calls before rating them again in round 2. In round 3, participants ranked the consensus items from rounds 1-2 from most to least important, and the mean score for each item was calculated. Of the 98 experts invited, 29 participated in round 1, 22 in round 2, and 14 in round 3. Participants identified 18 system practices that they agree are critical in minimizing transfer time to STEMI-receiving centers, with the most important being performance of a prehospital electrocardiogram and having established transfer protocols. These factors should be considered in the development of STEMI systems of care.
                      Cover page: Minimizing Transfer Time to an ST Segment Elevation Myocardial Infarction-Receiving Center
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