Faculty Bibliography

BACKGROUND:The Veterans Health Administration COVID-19 (VACO) Index predicts 30-day all-cause mortality in patients with COVID-19 using age, sex and pre-existing comorbidity diagnoses. The VACO Index was initially developed and validated in a nationwide cohort of US veterans-we now assess its accuracy in an academic medical centre and a nationwide US Medicare cohort. METHODS:With measures and weights previously derived and validated in US national Veterans Health Administration (VA) inpatients and outpatients (n=13 323), we evaluated the accuracy of the VACO Index for estimating 30-day all-cause mortality using area under the receiver operating characteristic curve (AUC) and calibration plots of predicted versus observed mortality in inpatients at a single US academic medical centre (n=1307) and in Medicare inpatients and outpatients aged 65+ (n=427 224). RESULTS:30-day mortality varied by data source: VA 8.5%, academic medical centre 17.5%, Medicare 16.0%. The VACO Index demonstrated similar discrimination in VA (AUC=0.82) and academic medical centre inpatient population (AUC=0.80), and when restricted to patients aged 65+ in VA (AUC=0.69) and Medicare inpatient and outpatient data (AUC=0.67). The Index modestly overestimated risk in VA and Medicare data and underestimated risk in Yale New Haven Hospital data. CONCLUSIONS:The VACO Index estimates risk of short-term mortality across a wide variety of patients with COVID-19 using data available prior to or at the time of diagnosis. The VACO Index could help inform primary and booster vaccination prioritisation, and indicate who among outpatients testing positive for SARS-CoV-2 should receive greater clinical attention or scarce treatments.

BACKGROUND:Myocarditis is a rare sequelae of acute myeloid leukemia (AML) and typically presents after the initial diagnosis of AML has been made. CASE REPORT/METHODS:We present the case of a 37-year-old female who came to the emergency department with chest pain, ST elevations on electrocardiogram, and a positive point-of-care troponin. She was brought emergently to the cardiac catheterization laboratory. After a negative catheterization, blasts were noted on the complete blood count, ultimately leading to the diagnosis of AML, with myopericarditis as the presenting manifestation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case highlights the need for emergency physicians to consider a broad differential for chest pain, especially in those who do not fit into the prototypical patient with acute coronary syndrome.

INTRODUCTION/BACKGROUND:It is difficult to determine illness severity for coronavirus disease 2019 (COVID-19) patients, especially among stable-appearing emergency department (ED) patients. We evaluated patient outcomes among ED patients with a documented ambulatory oxygen saturation measurement. METHODS:This was a retrospective chart review of ED patients seen at New York University Langone Health during the peak of the COVID-19 pandemic in New York City. We identified ED patients who had a documented ambulatory oxygen saturation. We studied the outcomes of high oxygen requirement (defined as >4 liters per minute) and mechanical ventilation among admitted patients and bounceback admissions among discharged patients. We also performed logistic regression and compared the performance of different ambulatory oxygen saturation cutoffs in predicting these outcomes. RESULTS:Between March 15-April 14, 2020, 6194 patients presented with fever, cough, or shortness of breath at our EDs. Of these patients, 648 (11%) had a documented ambulatory oxygen saturation, of which 165 (24%) were admitted. Notably, admitted and discharged patients had similar initial vital signs. However, the average ambulatory oxygen saturation among admitted patients was significantly lower at 89% compared to 96% among discharged patients (p<0.01). Among admitted patients with an ambulatory oxygen saturation, 30% had high oxygen requirements and 8% required mechanical ventilation. These rates were predicted by low ambulatory oxygen saturation (p<0.01). Among discharged patients, 50 (10%) had a subsequent ED visit resulting in admission. Although bounceback admissions were predicted by ambulatory oxygen saturation at the first ED visit (p<0.01), our analysis of cutoffs suggested that this association may not be clinically useful. CONCLUSION/CONCLUSIONS:Measuring ambulatory oxygen saturation can help ED clinicians identify patients who may require high levels of oxygen or mechanical ventilation during admission. However, it is less useful for identifying which patients may deteriorate clinically in the days after ED discharge and require subsequent hospitalization.

In the near future, clinicians may face scenarios in which there are not have enough resources (ventilators, ECMO machines, etc) available for the number of critically sick COVID-19 patients. There may not be enough healthcare workers, as those who are positive for COVID-19 or those who have been exposed to the virus and need to be quarantined. During these worst-case scenarios, new crisis standards of care and thresholds for intensive care unit (ICU) admissions will be needed. Clinical decision scores may support the clinician's decision-making, especially if properly adapted for this unique pandemic and for the patient being treated. This review discusses the use of clinical prediction scores for pneumonia severity at 3 main decision points to examine which scores may provide value in this unique situation. Initial data from a cohort of over 44,000 COVID-19 patients in China, including risk factors for mortality, were compared with data from cohorts used to study the clinical scores, in order to estimate the potential appropriateness of each score and determine how to best adjust results at the bedside.

BACKGROUND:VASc scores in e-health, and the geographical and specialty uptake of these scores, using data gleaned from a popular online clinical decision tool and medical reference, MDCalc. We hypothesised that the change in use of the scores would reflect the changes in guidelines and trends in clinical practice. RESULTS:VASc scores were primary care physicians, with cardiologists being in the minority; the proportion of cardiologists was greater outside USA, compared to within USA. CONCLUSION/CONCLUSIONS:VASc score for stroke risk stratification.

Epidemiological data, including prevalence, for cannabinoid hyperemesis syndrome (CHS) remain largely unknown. Without these data, clinicians often describe CHS as "rare" or "very rare" without supporting information. We seek to estimate the prevalence of CHS in a population of patients presenting to a socioeconomically and racially diverse urban Emergency Department of a public hospital. This study consisted of a questionnaire administered to a convenience sample of patients presenting to the ED of the oldest public hospital in the United States. Trained Research Associates (RAs) administered the questionnaire to patients between the ages of 18-49 years who reported smoking marijuana at least 20 days per month. The survey included questions related to CHS symptoms (nausea and vomiting) and Likert scale rankings on eleven symptom relief methods, including "hot showers." Patients were classified as experiencing a phenomenon consistent with CHS if they reported smoking marijuana at least 20 days per month and also rated "hot showers" as five or more on the ten-point symptom relief method Likert scale for nausea and vomiting. Among 2,127 patients approached for participation, 155 met inclusion criteria as smoking 20 or more days per month. Among those surveyed, 32.9% (95% CI, 25.5% - 40.3%) met our criteria for having experienced CHS. If this is extractable to the general population, approximately 2.75 million (2.13 - 3.38 million) Americans may have suffered from a phenomenon similar to CHS.

Background: Emergency medicine professional reimbursement-in particular, the Evaluation and Management levels-is based on Medicare's rules defining the complexity of care. Services are only reimbursable if they are properly recorded. Therefore detailed documentation is essential for optimal compensation. Critical care follows a different set of rules than other Evaluation and Management levels and a lack of clinician awareness of these rules leads to incomplete documentation and under billing. Objectives: The goal of this study is to: 1. Identify gaps in critical care documentation knowledge among emergency physicians. 2. Determine if these gaps can be filled via a selfadministered online training module. 3. Determine whether improvement in knowledge can improve documentation and enhance reimbursement. Methods: Critical care charts were examined in an urban tertiary care center with approximately 68,000 ED visits per year. Pre-intervention, 1.2% of charts were coded as "critical care"; less than the national average of 2.5%. Physicians completed a pre-module assessment, followed by a 15-minute online educational module, followed by a post-module assessment. Critical care rates were measured during the months preceding and following module completion. Results: 1. Gaps in knowledge were defined when average correct pre-assessment response was < 75%, revealing deficiencies in specific aspects of critical care documentation, which may be reflected in the critical care rate. 2. Post-module assessments had an overall higher correct response rate (65.9% to 84.8%, p<0.001). Specifically for knowledge gap questions, the correct response rate increased from 53% to 86.5% (p<0.001). 3. After all clinicians completed the teaching module, ED critical care rates increased from 1.4% (Nov-Dec, 2015) to 3.22% (Mar-Apr, 2016), an increase of 129% that trended towards statistical significance (p=0.058). This extrapolates to an annual increase in reimbursement of $103,900, based on the ED's specific average collection rates. Conclusions: The training module was able to identify and correct gaps in critical care knowledge, likely leading to an increase in proper charting and coding and a subsequent increase in revenue. Additionally, the effectiveness of a short, easily distributed teaching module carries broad implications for future physician education initiatives