Objectives: The authors sought to describe the demographic and clinical characteristics of interhospital transfers from U.S. emergency departments (EDs) along with the primary reasons for transfers.Methods: This was a retrospective, cross-sectional analysis of the 1997 through 2009 National Hospital Ambulatory Medical Care Survey (NHAMCS). Visit-level characteristics were compared for patients who were transferred, admitted, or discharged. Additionally, data on primary reason for transfer for available years (2005 through 2008) were reviewed. Weighted analyses produced nationally representative estimates.Results: During this time period, 1.8% (95% confidence interval [CI] = 1.7% to 2.0%) of ED patients were transferred to other hospitals. Compared to visits resulting in admission, those resulting in transfer were more likely to involve patients who were <18 years old (18% vs. 7.9%), male (53% vs. 46%), with Medicaid (22% vs. 16%) or self-payment (15% vs. 8.2%) as a primary expected source of payment, having a visit related to injury (40% vs. 19%), and from a nonurban ED (29% vs. 15%). Among transferred patients, 28% (95% CI = 27% to 30%) received four to six diagnostic tests, and 31% (95% CI = 29% to 34%) received more than six diagnostic tests prior to transfer; 52% (95% CI = 50% to 54%) had diagnostic imaging, and 17% (95% CI = 16% to 19%) had cross-sectional imaging. Of the patients transferred from 2005 through 2008, 47% (95% CI = 43% to 53%) were transferred for a higher level of care, and 29% (95% CI = 26% to 35%) were transferred for psychiatric care. Conclusions:Transfer of ED patients was relatively rare, but was more common among specific, potentially high-risk populations. Diagnostic testing, including advanced imaging, was common prior to transfer. A majority of transfers were for reasons indicating limited resources or expertise at the referring facility.ACADEMIC EMERGENCY MEDICINE 2013; 20:888-893

Background Since the 2001 “black box” warning on droperidol, its use in the prehospital setting has decreased substantially in favor of haloperidol. There are no studies comparing the prehospital use of either drug. The goal of this study was to compare QTc prolongation, adverse events, and effectiveness of droperidol and haloperidol among a cohort of agitated patients in the prehospital setting. Methods In this institutional review board-approved before and after study, we collected data on 532 patients receiving haloperidol (n = 314) or droperidol (n = 218) between 2007 and 2010. We reviewed emergency department (ED) electrocardiograms when available (haloperidol, n = 78, 25%; droperidol, n = 178, 76%) for QTc length (in milliseconds), medical records for clinically relevant adverse events (defined a priori as systolic blood pressure (SBP) <90 mmHg, seizure, administration of anti-dysrhythmic medications, cardioversion or defibrillation, bag–valve–mask ventilation, intubation, cardiopulmonary arrest, and prehospital or in-hospital death). We also compared effectiveness of the medications, using administration of additional sedating medications within 30 minutes of ED arrival as a proxy for effectiveness. Results The mean haloperidol dose was 7.9 mg (median 10 mg, range 4–20 mg). The mean droperidol dose was 2.9 mg (median 2.5 mg, range 1.25–10 mg.) Haloperidol was given IM in 289 cases (92%), and droperidol was given IM in 132 cases (61%); in all other cases, the medication was given IV. There was no statistically significant difference in median QTc after medication administration (haloperidol 447 ms, 95% CI: 440–454 ms; droperidol 454 ms, 95% CI: 450–457). There were no statistically significant differences in adverse events in the droperidol group as compared to the haloperidol group. One patient in the droperidol group with a history of congenital heart disease suffered a cardiopulmonary arrest and was resuscitated with neurologically intact survival. There was no significant difference in the use of additional sedating medications within 30 minutes of ED arrival after receiving droperidol (2.9%, 95% CI: −2.5–8.4%). Conclusions In this cohort of agitated patients treated with haloperidol or droperidol in the prehospital setting, there was no significant difference found in QTc prolongation, adverse events, or need for repeat sedation between haloperidol and droperidol.

Paramedics do not use ASA optimally and may choose therapies with less proven benefit.