Publications by authors named "Nicklaus P Ashburn"

10 Publications

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EMS blood collection from patients with acute chest pain reduces emergency department length of stay.

Am J Emerg Med 2021 Apr 26;47:248-252. Epub 2021 Apr 26.

Department of Emergency Medicine, Wake Forest School of Medicine, USA.

Background: Expediting the measurement of serum troponin by leveraging EMS blood collection could reduce the diagnostic time for patients with acute chest pain and help address Emergency Department (ED) overcrowding. However, this practice has not been examined among an ED chest pain patient population in the United States.

Methods: A prospective observational cohort study of adults with non-traumatic chest pain without ST-segment elevation myocardial infarction was conducted in three EMS agencies between 12/2016-4/2018. During transport, paramedics obtained a patient blood sample that was sent directly to the hospital core lab for troponin measurement. On ED arrival HEART Pathway assessments were completed by ED providers as part of standard care. ED providers were blinded to troponin results from EMS blood samples. To evaluate the potential impact on length of stay (LOS), the time difference between EMS blood draw and first clinical ED draw was calculated. To determine the safety of using troponin measures from EMS blood samples, the diagnostic performance of the HEART Pathway for 30-day major adverse cardiac events (MACE: composite of cardiac death, myocardial infarction (MI), coronary revascularization) was determined using EMS troponin plus arrival ED troponin and EMS troponin plus a serial 3-h ED troponin.

Results: The use of EMS blood samples for troponin measures among 401 patients presenting with acute chest pain resulted in a mean potential reduction in LOS of 72.5 ± SD 35.7 min. MACE at 30 days occurred in 21.0% (84/401), with 1 cardiac death, 78 MIs, and 5 revascularizations without MI. Use of the HEART Pathway with EMS and ED arrival troponin measures yielded a NPV of 98.0% (95% CI: 89.6-100). NPV improved to 100% (95% CI: 92.9-100) when using the EMS and 3-h ED troponin measures.

Conclusions: EMS blood collection used for core lab ED troponin measures could significantly reduce ED LOS and appears safe when integrated into the HEART Pathway.
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http://dx.doi.org/10.1016/j.ajem.2021.04.073DOI Listing
April 2021

The ethical dilemma of emergency department patients with low-risk chest pain.

Emerg Med J 2021 Mar 9. Epub 2021 Mar 9.

Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.

Millions of patients present to US EDs each year with symptoms concerning for acute coronary syndrome (ACS), but fewer than 10% are ultimately diagnosed with ACS. Well-tested and externally validated accelerated diagnostic protocols were developed to aid providers in risk stratifying patients with possible ACS and have become central components of current ED practice guidelines. Nevertheless, the fear of missing ACS continues to be a strong motivator for ED providers to pursue further testing for their patients. An ethical dilemma arises when the provider must balance the risk of ACS if the patient is discharged compared with the potential harms caused by a cardiac workup. Providers should be familiar with the ethical principles relevant to this dilemma in order to determine what is in the best interests of the patient.
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http://dx.doi.org/10.1136/emermed-2020-209900DOI Listing
March 2021

The disutility of stress testing in low-risk HEART Pathway patients.

Am J Emerg Med 2020 Aug 15. Epub 2020 Aug 15.

Department of Emergency Medicine, Wake Forest School of Medicine, Winston Salem, NC, United States.

Background: The HEART Pathway identifies low-risk chest pain patients for discharge from the Emergency Department without stress testing. However, HEART Pathway recommendations are not always followed. The objective of this study is to determine the frequency and diagnostic yield of stress testing among low-risk patients.

Methods: An academic hospital's chest pain registry was analyzed for low-risk HEART Pathway patients (HEAR score ≤ 3 with non-elevated troponins) from 1/2017 to 7/2018. Stress tests were reviewed for inducible ischemia. Diagnostic yield was defined as the rate of obstructive CAD among patients with positive stress testing. T-test or Fisher's exact test was used to test the univariate association of age, sex, race/ethnicity, and HEAR score with stress testing. Multivariate logistic regression was used to determine the association of age, sex, race/ethnicity, and HEAR score with stress testing.

Results: There were 4743 HEART Pathway assessments, with 43.7% (2074/4743) being low-risk. Stress testing was performed on 4.1% (84/2074). Of the 84 low-risk patients who underwent testing, 8.3% (7/84) had non-diagnostic studies and 2.6% (2/84) had positive studies. Among the 2 patients with positive studies, angiography revealed that 1 had widely patent coronary arteries and the other had multivessel obstructive coronary artery disease, making the diagnostic yield of stress testing 1.2% (1/84). Each one-point increase in HEAR score (aOR 2.17, 95% CI 1.45-3.24) and being male (aOR 1.59, 95% CI 1.02-2.49) were associated with testing.

Conclusions: Stress testing among low-risk HEART Pathway patients was uncommon, low yield, and more likely in males and those with a higher HEAR score.
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http://dx.doi.org/10.1016/j.ajem.2020.08.032DOI Listing
August 2020

Identification of very low-risk acute chest pain patients without troponin testing.

Emerg Med J 2020 Nov 4;37(11):690-695. Epub 2020 Aug 4.

Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.

Background: The HEART Pathway combines a History ECG Age Risk factor (HEAR) score and serial troponins to risk stratify patients with acute chest pain. However, it is unclear whether patients with HEAR scores of 1 require troponin testing. The objective of this study is to measure the major adverse cardiac event (MACE) rate among patients with 1 HEAR scores and determine whether serial troponin testing is needed to achieve a miss rate <1%.

Methods: A secondary analysis of the HEART Pathway Implementation Study was conducted. HEART Pathway risk assessments (HEAR scores and serial troponin testing at 0 and 3 hours) were completed by the providers on adult patients with chest pain from three US sites between November 2014 and January 2016. MACE (composite of death, myocardial infarction (MI) and coronary revascularisation) at 30 days was determined. The proportion of patients with HEAR scores of 1 diagnosed with MACE within 30 days was calculated. The impact of troponin testing on patients with HEAR scores of 1 was determined using Net Reclassification Improvement Index (NRI).

Results: Providers completed HEAR assessments on 4979 patients and HEAR scores<1 occurred in 9.0% (447/4979) of patients. Among these patients, MACE at 30 days occurred in 0.9% (4/447; 95% CI 0.2% to 2.3%) with two deaths, two MIs and 0 revascularisations. The sensitivity and negative predictive value for MACE in the HEAR 1 was 97.8% (95%CI 94.5% to 99.4%) and 99.1% (95% CI 97.7% to 99.8%), respectively, and were not improved by troponin testing. Troponin testing in patients with HEAR 1 correctly reclassified two patients diagnosed with MACE, and was elevated among seven patients without MACE yielding an NRI of 0.9% (95%CI -0.7 to 2.4%).

Conclusion: These data suggest that patients with HEAR scores of 0 and 1 represent a very low-risk group that may not require troponin testing to achieve a missed MACE rate <1%. NCT02056964.
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http://dx.doi.org/10.1136/emermed-2020-209698DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7952041PMC
November 2020

Comparison of accelerated diagnostic pathways for acute chest pain risk stratification.

Heart 2020 07 8;106(13):977-984. Epub 2020 Apr 8.

Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA.

Background: The History Electrocardiogram Age Risk factor Troponin (HEART) Pathway and Emergency Department Assessment of Chest pain Score (EDACS) are validated accelerated diagnostic pathways designed to risk stratify patients presenting to the emergency department with chest pain. Data from large multisite prospective studies comparing these accelerated diagnostic pathways are limited.

Methods: The HEART Pathway Implementation is a prospective three-site cohort study, which accrued adults with symptoms concerning for acute coronary syndrome. Physicians completed electronic health record HEART Pathway and EDACS risk assessments on participants. Major adverse cardiac events (death, myocardial infarction and coronary revascularisation) at 30 days were determined using electronic health record, insurance claims and death index data. Test characteristics for detection of major adverse cardiac events were calculated for both accelerated diagnostic pathways and McNemar's tests were used for comparisons.

Results: 5799 patients presenting to the emergency department were accrued, of which HEART Pathway and EDACS assessments were completed on 4399. Major adverse cardiac events at 30 days occurred in 449/4399 (10.2%). The HEART Pathway identified 38.4% (95% CI 37.0% to 39.9%) of patients as low-risk compared with 58.1% (95% CI 56.6% to 59.6%) identified as low-risk by EDACS (p<0.001). Major adverse cardiac events occurred in 0.4% (95% CI 0.2% to 0.9%) of patients classified as low-risk by the HEART Pathway compared with 1.0% (95% CI 0.7% to 1.5%) of patients identified as low-risk by EDACS (p<0.001). Thus, the HEART Pathway had a negative predictive value of 99.6% (95% CI 99.1% to 99.8%) for major adverse cardiac events compared with a negative predictive value of 99.0% (95% CI 98.5% to 99.3%) for EDACS.

Conclusions: EDACS identifies a larger proportion of patients as low-risk than the HEART Pathway, but has a higher missed major adverse cardiac events rate at 30 days. Physicians will need to consider their risk tolerance when deciding whether to adopt the HEART Pathway or EDACS accelerated diagnostic pathway.

Trial Registration Number: NCT02056964.
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http://dx.doi.org/10.1136/heartjnl-2019-316426DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7962144PMC
July 2020

Prehospital Trauma Scene and Transport Times for Pediatric and Adult Patients.

West J Emerg Med 2020 Feb 21;21(2):455-462. Epub 2020 Feb 21.

Wake Forest School of Medicine, Department of Emergency Medicine, Winston-Salem, North Carolina.

Introduction: Increased out-of-hospital time is associated with worse outcomes in trauma. Sparse literature exists comparing prehospital scene and transport time management intervals between adult and pediatric trauma patients. National Emergency Medical Services guidelines recommend that trauma scene time be less than 10 minutes. The objective of this study was to examine prehospital time intervals in adult and pediatric trauma patients.

Methods: We performed a retrospective cohort study of blunt and penetrating trauma patients in a five-county region in North Carolina using prehospital records. We included patients who were transported emergency traffic directly from the scene by ground ambulance to a Level I or Level II trauma center between 2013-2018. We defined pediatric patients as those less than 16 years old. Urbanicity was controlled for using the Centers for Medicare and Medicaid's Ambulance Fee Schedule. We performed descriptive statistics and linear mixed-effects regression modeling.

Results: A total of 2179 records met the study criteria, of which 2077 were used in the analysis. Mean scene time was 14.2 minutes (95% confidence interval [CI], 13.9-14.5) and 35.3% (n = 733) of encounters had a scene time of 10 minutes or less. Mean transport time was 17.5 minutes (95% CI, 17.0-17.9). Linear mixed-effects regression revealed that scene times were shorter for pediatric patients (p<0.0001), males (p=0.0016), penetrating injury (p<0.0001), and patients with blunt trauma in rural settings (p=0.005), and that transport times were shorter for males (p = 0.02), non-White patients (p<0.0001), and patients in urban areas (p<0.0001).

Conclusion: This study population largely missed the 10-minute scene time goal. Demographic and patient factors were associated with scene and transport times. Shorter scene times occurred with pediatric patients, males, and among those with penetrating trauma. Additionally, suffering blunt trauma while in a rural environment was associated with shorter scene time. Males, non-White patients, and patients in urban environments tended to have shorter transport times. Future studies with outcomes data are needed to identify factors that prolong out-of-hospital time and to assess the impact of out-of-hospital time on patient outcomes.
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http://dx.doi.org/10.5811/westjem.2019.11.44597DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7081873PMC
February 2020

Point-of-Care Troponin Testing during Ambulance Transport to Detect Acute Myocardial Infarction.

Prehosp Emerg Care 2020 Nov-Dec;24(6):751-759. Epub 2020 Mar 3.

Use of point-of-care (POC) troponin (cTn) testing in the Emergency Department (ED) is well established. However, data examining POC cTn measurement in the prehospital setting, during ambulance transport, are limited. The objective of this study was to prospectively test the performance of POC cTn measurement by paramedics to detect myocardial infarction (MI) among patients transported to the ED for acute chest pain. A prospective cohort study of adults with non-traumatic chest pain was conducted in three Emergency Medical Services agencies (December 2016 to January 2018). Patients with ST-elevation MI on ECG were excluded. During ambulance transport paramedics initiated intravenous access, collected blood, and used a POC device (i-STAT; Abbott Laboratories) to measure cTn. Following ED arrival, participants received standard evaluations including clinical blood draws for cTn measurement in the hospital central lab (AccuTnI +3 assay; Beckman Coulter, or cTnI-Ultra assay; Siemens). Blood collected during ambulance transport was also analyzed for cTn in the central lab. Index visit MI was adjudicated by 3 experts using central lab cTn measures from the patient's clinical blood draws. Test characteristics (sensitivity, specificity, and predictive values) for detection of MI were calculated for POC and central lab cTn measurement of prehospital blood and compared with McNemar's test. During the study period prehospital POC cTn results were obtained on 421 patients, of which 5.0% (21/421) had results >99th percentile upper reference limit. MI was adjudicated in 16.2% (68/421) during the index visit. The specificity and positive predictive value of the POC cTn measurement were 99.2% (95% CI 97.5-99.8%) and 85.7% (95% CI 63.7-97.0%) for MI. However, the sensitivity and NPV of prehospital POC cTn were 26.5% (95% CI 16.5-38.6%) and 87.5% (95% CI 83.9-90.6%). Compared to POC cTn, the central lab cTn measurement of prehospital blood resulted in a higher sensitivity of 67.9% (95% CI 53.7-80.1%,  < 0.0001), but lower specificity of 92.4% (95% CI 88.4-95.4%,  = 0.0001). Prehospital POC i-STAT cTn measurement in patients transported with acute chest pain was highly specific for MI but had low sensitivity. This suggests that prehospital i-STAT POC cTn could be useful to rule-in MI, but should not be used to exclude MI.
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http://dx.doi.org/10.1080/10903127.2020.1721740DOI Listing
May 2021

One-Year Mortality and Associated Factors in Patients Receiving Out-of-Hospital Naloxone for Presumed Opioid Overdose.

Ann Emerg Med 2020 05 23;75(5):559-567. Epub 2020 Jan 23.

Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC.

Study Objective: Out-of-hospital naloxone has been championed as a lifesaving solution during the opioid epidemic. However, the long-term outcomes of out-of-hospital naloxone recipients are unknown. The objectives of this study are to describe the 1-year mortality of presumed opioid overdose victims identified by receiving out-of-hospital naloxone and to determine which patient factors are associated with subsequent mortality.

Methods: This was a regional retrospective cohort study of out-of-hospital records from 7 North Carolina counties from January 1, 2015 to February 28, 2017. Patients who received out-of-hospital naloxone were included. Out-of-hospital providers subjectively assessed patients for improvement after administering naloxone. Naloxone recipients were cross-referenced with the North Carolina death index to examine mortality at days 0, 1, 30, and 365. Naloxone recipient mortality was compared with the age-adjusted, at-large population's mortality rate in 2017. Generalized estimating equations and Cox proportional hazards models were used to assess for mortality-associated factors.

Results: Of 3,085 out-of-hospital naloxone encounters, 72.7% of patients (n=2,244) improved, whereas 27.3% (n=841) had no improvement with naloxone. At day 365, 12.0% (n=269) of the improved subgroup, 22.6% (n=190) of the no improvement subgroup, and 14.9% (n=459) of the whole population were dead. Naloxone recipients who improved were 13.2 times (95% confidence interval 13.0 to 13.3) more likely to be dead at 1 year than a member of the general populace after age adjusting of the at-large population to match this study population. Older age and being black were associated with 1-year mortality, whereas sex and multiple overdoses were not.

Conclusion: Opioid overdose identified by receiving out-of-hospital naloxone with clinical improvement carries a 13-fold increase in mortality compared to the general population. This suggests that this is a high-risk population that deserves attention from public health officials, policymakers, and health care providers in regard to the development of long-term solutions.
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http://dx.doi.org/10.1016/j.annemergmed.2019.11.022DOI Listing
May 2020

News From Lake Wobegon … Clinician Gestalt Debunked?

Acad Emerg Med 2020 01 11;27(1):80-82. Epub 2019 Aug 11.

Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC.

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http://dx.doi.org/10.1111/acem.13837DOI Listing
January 2020