Original language | English (US) |
---|---|
Pages (from-to) | 161-164 |
Number of pages | 4 |
Journal | Academic Emergency Medicine |
Volume | 27 |
Issue number | 2 |
DOIs | |
State | Published - Feb 1 2020 |
ASJC Scopus subject areas
- Emergency Medicine
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In: Academic Emergency Medicine, Vol. 27, No. 2, 01.02.2020, p. 161-164.
Research output: Contribution to journal › Letter › peer-review
}
TY - JOUR
T1 - Frequency of Abnormal and Critical Laboratory Results in Older Patients Presenting to the Emergency Department With Syncope
AU - Moore, Andrew B.
AU - Su, Erica
AU - Weiss, Robert E.
AU - Yagapen, Annick N.
AU - Malveau, Susan E.
AU - Adler, David H.
AU - Bastani, Aveh
AU - Baugh, Christopher W.
AU - Caterino, Jeffrey M.
AU - Clark, Carol L.
AU - Diercks, Deborah B.
AU - Hollander, Judd E.
AU - Nicks, Bret A.
AU - Nishijima, Daniel K.
AU - Shah, Manish N.
AU - Stiffler, Kirk A.
AU - Storrow, Alan B.
AU - Wilber, Scott T.
AU - Sun, Benjamin C.
N1 - Funding Information: Andrew B. Moore MD Erica Su Robert E. Weiss PhD Annick N. Yagapen MPH Susan E. Malveau MSBE David H. Adler MD, MPH Aveh Bastani MD Christopher W. Baugh MD, MBA Jeffrey M. Caterino MD, MPH Carol L. Clark MD, MBA Deborah B. Diercks MD, MPH Judd E. Hollander MD Bret A. Nicks MD, MHA Daniel K. Nishijima MD, MAS Manish N. Shah MD, MPH Kirk A. Stiffler MD Alan B. Storrow MD Scott T. Wilber MD Benjamin C. Sun MD, MPP Erik P. Hess MD From the Center for Policy and Research in Emergency Medicine Department of Emergency Medicine Oregon Heath & Science University Portland OR the Department of Biostatistics University of California Los Angeles CA the Department of Emergency Medicine University of Rochester Rochester NY the Department of Emergency Medicine William Beaumont Hospital–Troy Troy MI the Department of Emergency Medicine Brigham & Women’s Hospital Boston MA the Department of Emergency Medicine The Ohio State University Wexner Medical Center Columbus OH the Department of Emergency Medicine William Beaumont Hospital–Royal Oak Royal Oak MI the Department of Emergency Medicine University of Texas‐Southwestern Dallas TX the Department of Emergency Medicine Thomas Jefferson University Hospital Philadelphia PA the Department of Emergency Medicine Wake Forest School of Medicine Winston Salem NC the Department of Emergency Medicine UC Davis School of Medicine Sacramento CA the Department of Emergency Medicine University of Wisconsin–Madison Madison WI the Department of Emergency Medicine Northeast Ohio Medical University Rootstown OH the Department of Emergency Medicine Vanderbilt University Medical Center Nashville TN and the Department of Emergency Medicine University of Pennsylvania Philadelphia PA National Heart, Lung, and Blood Institute R01HL111033 Data Supplement S1 . Differences in Characteristics of Cohort. Presented at the Society for Academic Emergency Medicine Western Regional Meeting, Napa, CA, March 2019; and the Society for Academic Emergency Medicine Annual Meeting, Las Vegas, NV, May 2019. Research reported in this publication was supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under award R01HL111033. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. DHA has received research funding from Roche. AB has received research funding from Radiometer and Portola and has been a consultant for Portola. CWB has received advisory board and speaker’s fees from Roche, research funding from Janssen and Boehringer Ingelheim, and consulting and advisory board fees from Janssen. JMC has received research funding from Astra Zeneca and Entegrion and consulting fees from Wellstat Therapeutics. CLC has received institutional research funding from Radiometer, Ortho Clinical Trials, Janssen, Pfizer, NIH, Portola, Biocryst, Glaxo Smith Klein, Hospital Quality Foundation, and Abbott; she is a consultant for Portola, Janssen, and Hospital Quality Foundation. DBD is a consultant for Janssen and Roche; has received institutional research support from Novartis, Ortho Scientific, and Roche; and is on the editorial board for AEM and Circulation . JEH has received research funding from Alere, Echosense, Siemens, Roche, Portola and Trinity. BAN has no conflicts to report. DKN has received honorarium for Pfizer. MNS has received funding from Roche and Omron, Inc. KAS has no conflicts to report. ABS is a consultant for Quidel. BCS is a consultant for Medtronic. The other authors have no potential conflicts to disclose. Syncope is a common and costly chief complaint among patients presenting to the emergency department (ED), accounting for 740,000 ED visits annually with an estimated annual cost of $2.4 billion per year in the United States. Syncope presents a diagnostic dilemma for clinicians in the ED since differentiating serious and benign causes of syncope can be challenging, particularly in the older adult. Routine laboratory testing with complete blood count (CBC) and basic metabolic panel (BMP) is commonly ordered for patients presenting to the ED with syncope. Despite these guidelines, it is common practice to obtain broad panel laboratory testing such as CBC or BMP for ED evaluation of patients with syncope regardless of level of suspicion for abnormalities. Broad panel laboratory testing with CBC and BMP could identify potentially reversible causes of syncope in the older adult including anemia, dehydration, and electrolyte abnormalities. It is not known how frequently routine laboratory testing identifies normal, abnormal, and critical laboratory values in older patients with syncope. The objective of this study was to evaluate the frequency of normal, abnormal, and critical laboratory results from CBC and BMP ordered in older patients presenting to the ED with syncope or near syncope. The 2017 American Heart Association (AHA), American College of Cardiology (ACC), and Heart Rhythm Society (HRS) guidelines on the evaluation of syncope in the ED recommend targeted laboratory testing based on history and physical examination, such as prior history of peptic ulcer disease or dark tarry stools. We conducted a secondary analysis of a large, multicenter, prospective cohort study (ClinicalTrials.gov identifier NCT01802398) to determine the frequency of abnormal and critical routine laboratory testing at the primary ED visit. The study was approved by the institutional review boards at all sites, and written informed consent was obtained from all participating subjects. Eligible patients were ≥60 years of age with a complaint of syncope or near syncope at 11 academic EDs across the United States. Exclusion criteria were intoxication, medical or electrical intervention to restore consciousness, or inability or unwillingness to provide informed consent or follow‐up information. Patients with a presumptive cause of loss of consciousness due to seizure, stroke, or transient ischemic attack or hypoglycemia were also excluded. For this analysis, we also excluded patients who did not have a CBC or BMP performed. All patients underwent history and physical examination, laboratory testing at the discretion of the treating physician, and 12‐lead EKG testing. Patient disposition was directed by the treating clinical providers. We determined abnormal hematocrit ranges based on preexisting syncope literature. We determined critical values by an institutional laboratory protocol. The primary outcome is the proportion of abnormal and critical laboratory values obtained from CBC and BMP laboratory testing. We evaluated the following routine laboratory tests: hematocrit, glucose, sodium, potassium, bicarbonate, blood urea nitrogen, and creatinine. We defined abnormal ranges for the BMP using standard reference ranges. We present data as means with standard deviations (SD) or medians with interquartile ranges. We tested independence between categorical variables with chi‐square or Fisher’s exact test. We performed statistical analyses using the R package. All p‐values are two‐sided and we considered those ≤ 0.05 to be significant. S1 There were 6,930 subjects that met eligibility criteria, of whom 3,686 (53.2%) consented and were enrolled into the primary study. Of the 3,686 enrolled subjects, 105 subjects had no serious outcome and were lost to follow‐up or withdrawn from the study, resulting in a base cohort of 3,581 subjects. There were 3,557 patients (99.3%) who had CBC or BMP laboratory testing performed in the ED, representing the cohort for this study. Twenty‐four subjects (0.7%) with a mean (±SD) age of 68.4 (±6.8) years (p = 0.015), but otherwise similar baseline demographics to the study cohort, had missing laboratory values and were excluded from the analysis (Data Supplement , available as supporting information in the online version of this paper, which is available at http://onlinelibrary.wiley.com/doi/10.1111/acem.13096/full ) . Study subjects had a mean (±SD) age of 72.8 (±9) years, 1,835 (51.6%) were male, and 1,722 (48.4%) female. Compared to patients who had normal laboratory testing, those who had abnormal laboratory testing or critical laboratory testing were more likely to have a history of congestive heart failure, coronary artery disease, or arrhythmia; be on diuretics, beta blockers, or calcium channel blockers; and have an abnormal ECG or hypotension on initial vital signs and to be hospitalized. ). We found 323 patients (9.1%) had entirely normal laboratory results, 3,080 patients (86.6%) had at least one abnormal, but no critical, laboratory results, and 154 patients (4.3%) had at least one critical laboratory result (Table ). Abnormal laboratory values were most commonly elevated blood glucose (72.9%), elevated blood urea nitrogen (44.4%), hyponatremia (21.7%), hypokalemia (16.7%), and anemia (8.4%; Table ). The most common critical laboratory results were serum creatinine (2.5%), elevated serum potassium (0.7%), elevated blood urea nitrogen (0.6%), and low hematocrit (0.4%; Table ). Of all laboratory results collected, 69.9% were normal, 29.9% were abnormal, and 0.7% were in the critical range (Table
PY - 2020/2/1
Y1 - 2020/2/1
UR - http://www.scopus.com/inward/record.url?scp=85077911875&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=85077911875&partnerID=8YFLogxK
U2 - 10.1111/acem.13906
DO - 10.1111/acem.13906
M3 - Letter
C2 - 31837233
AN - SCOPUS:85077911875
SN - 1069-6563
VL - 27
SP - 161
EP - 164
JO - Academic Emergency Medicine
JF - Academic Emergency Medicine
IS - 2
ER -