Emergency Medicine Department Research Articles

STUDY OF RATE, CAUSE AND PATTERN OF HOSPITAL READMISSIONS IN EMERGENCY MEDICINE OF A TERTIARY CARE HOSPITAL IN NORTH INDIA

Introduction: Hospital readmission rates serve as crucial indicators of healthcare quality, with significant implications for patient outcomes and financial costs. This study aims to investigate the rates, causes, and patterns of hospital readmissions in the emergency medicine department of a tertiary care hospital in North India. Methodology: A prospective study spanning one year was conducted, involving 4116 patients admitted through emergency medicine. The study analyzed readmission rates at different intervals (7 days, 30 days, 90 days, and 1 year) and considered demographic factors, primary diagnoses, and comorbidities. Data were collected through systematic random sampling and reinforced with semi-structured interviews and administrative records. Results & Observations: The study revealed varying readmission rates across different time intervals and diagnoses. Gastrointestinal disorders and respiratory diseases consistently exhibited elevated readmission rates. Age, gender, and Charlson Comorbidity Index were identified as significant factors influencing readmission patterns. Patients aged 50-59 years and males demonstrated higher readmission rates. The severity of comorbidities, as measuredbytheCharlson Comorbidity Index, was positivelycorrelated with increased readmission rates. Discussion: The findings underscore the importance of targeted post-discharge care, disease-specific interventions, and tailored strategies for specific demographics. The study emphasizes the need for enhanced monitoring and interventions, especially in the later stages post-discharge. Patient-centric insights highlight the role of discharge readiness and patient perceptions in influencing readmission dynamics. Conclusion: This study provides comprehensive insights into the complex factors influencing hospital readmissions in the emergency medicine setting. It emphasizes the necessity for focused interventions, customized care strategies, and all-encompassing approaches to reduce readmission risks. Healthcare institutions are encouraged to prioritize transitional care, interdisciplinary collaboration, evidence-based interventions, and patient-centered care models to optimize patient outcomes and alleviate the economic burden associated with avoidable readmissions.

Implementation of an education session on buprenorphine induction in the emergency department, a resident-led initiative

IntroductionMany physicians including emergency medicine physicians report insufficient training and education on prescribing buprenorphine for opioid use disorder. As emergency departments implement buprenorphine induction protocols, educational sessions can provide physicians with further familiarity with the treatment of opioid use disorder. This quality improvement project aimed to address the barrier of physician education in the implementation of buprenorphine initiation in the emergency department and presents a model for resident-led education sessions of emergency medicine physicians.MethodsThe project was a resident-led educational quality improvement project on educating members of the Department of Emergency Medicine on buprenorphine induction. The thirty-minute educational session included a pre-test survey, lecture, practice case workshop, questions, post-test survey, and a discussion. The survey questions were designed for physicians including residents and faculty, but medical students were invited to complete the session.ResultsPhysicians including faculty and resident physicians responded positively to the educational survey, with an increase from 42.5 to 100% responding that they understood the risks and benefits of prescribing buprenorphine in the emergency department pre and post-survey respectively. Based on post-survey results, 88.5% of physicians responded that they planned to prescribe buprenorphine in the emergency department for patients meeting clinical criteria after completing the educational session.ConclusionThe results suggest that a resident-led training session can encourage peer involvement in buprenorphine induction to treat opioid use disorder in the emergency department.

Family presence during in-hospital cardiopulmonary resuscitation: effects of an educational online intervention on self-confidence and attitudes of healthcare professionals.

Guidelines support family-witnessed resuscitation (FWR) during cardiopulmonary resuscitation in hospital if deemed to be safe, yet barriers amongst healthcare professionals (HCPs) still exist. This study aimed to evaluate the effects of an educational online video intervention on nurses' and physicians' attitudes towards in-hospital FWR and their self-confidence in managing such situations. A pre- and post-test quasi-experimental study was conducted October 2022 to March 2023 at six Swedish hospitals involving the departments of emergency care, medicine, and surgery. The 10 min educational video intervention was based on previous research covering the prevalence and outcome of FWR, attitudes of HCP, patient and family experiences, and practical and ethical guidelines about FWR.In total, 193 accepted participation, whereof 91 answered the post-test survey (47.2%) with complete data available for 78 and 61 participants for self-confidence and attitudes, respectively. The self-confidence total mean scores increased from 3.83 to 4.02 (P < 0.001) as did the total mean scores for attitudes towards FWR (3.38 to 3.62, P < 0.001). The majority (71.0%) had positive views of FWR at baseline and had experiences of in-hospital FWR (58.0%). Self-confidence was highest amongst participants for the delivery of chest compressions (91.2%), defibrillation (88.6%), and drug administration (83.3%) during FWR. Self-confidence was lowest (58.1%) for encouraging and attending to the family during resuscitation. This study suggests that a short online educational video can be an effective way to improve HCP's self-confidence and attitudes towards the inclusion of family members during resuscitation and can support HCP in making informed decisions about FWR.

Comparison of qSOFA, MEDS, and APACHE II Scores in Early Identification of Sepsis for Patients with 28 days Mortality and ICU Admission: A cross-sectional Study

Introduction: Sepsis is a life-threatening infection that results in organ dysfunction due to an increased pathogen load, necessitating urgent intervention. There is a gap in clinicians’ ability to identify septic patients at high-risk with poor outcomes, highlighting the need for validated predictive scores for early intervention, favourable outcomes, and prompt recovery. Aim: To validate the predictive capacity of the Sequential Organ Failure Assessment (qSOFA), Mortality in Emergency Department Sepsis (MEDS), and Acute Physiology and Chronic Health Evaluation (APACHE 2) scores in patients with 28- day mortality and in Intensive Care Unit (ICU) patients due to sepsis. Materials and Methods: This cross-sectional study was conducted on 150 septic patients at the Department of Emergency Medicine, Sri Ramachandra Institute of Higher Education and Research in Chennai, India, between June and December 2022. Parameters assessed included Respiratory Rate (RR), Systolic Blood Pressure (SBP), Mean Arterial Pressure (MAP), temperature, White Blood Cell (WBC) count, platelet count, bilirubin, and creatinine. Descriptive analysis of age, gender, source, RR, GCS, SBP, qSOFA, MEDS, APACHE 2 in 28-day mortality, and ICU patients. Positive correlation and good predictivity of predictive scores (qSOFA, MEDS, APACHE 2) were analysed using Spearman’s Rank Correlation Coefficient (SRCCRs) statistical test in 28-day mortality and ICU patients. Results: A total of 150 septic patients (male: female-93:57) with an average age of 57.07±14.4 years were included. Urosepsis was the most common (n=51), followed by respiratory sepsis (n=48). Of these, 96 patients were admitted to the ICU, and 54 patients experienced 28-day mortality. The average and median values of RR were 27.1±7.64 breaths/minute (b/m) and 26 b/m, respectively. SBP values were 106.13±30.47 mmHg and 110 mmHg, respectively. Diastolic Blood Pressure (DBP) values were 66±16.51 mmHg and 60 mmHg, respectively. The average and median values of GCS were 12.75±3.92 and 15, respectively. The average for qSOFA was 29.1±0.025, with a median of 28; for MEDS, the average was 7.99±5.89, with a median of 7; and for APACHE 2, the average was 16.74±9.64, with a median of 15. Spearman’s Rank Correlation Coefficient (SRCCRs) demonstrated a strong positive correlation and good predictive validity between qSOFA, MEDS, and APACHE 2 scores in 28- day mortality and ICU patients (&lt;0.001). Receiver Operating Characteristic Curve (ROC) analysis indicated good predictive validity for qSOFA in 28-day mortality and ICU patients. Conclusion: qSOFA exhibited a positive correlation and good predictive validity compared to MEDS and APACHE 2 in both 28-day mortality and ICU patients (&lt;0.001). This study highlights the utility and applicability of qSOFA at the bedside for initial triage, as it can be quickly employed with minimal information.

MANAGEMENT OF A PATIENT PRESENTED WITH AMITRIPTILINE POISONING- A RARE CASE REPORT

Abstract Tricyclic Antidepressant overdose for suicidal poisoning purpose is not frequent but still possible in patient and his near relative due to its availability at home. On susception laboratory testing is required for many poisons but availability is limited and any delay in diagnosis and starting management may worsen the patient&amp;apos;s condition. Amongst all TCAs, Amitriptyline is classic having sedative and anticholinergic properties. Its self-poisoning is not that much common in general population. Here we are reporting a case of Amitriptyline poisoning in a healthy women aged 30 years brought by relatives with drowsiness and giddiness to our Emergency Medicine Department, LG Hospital, Narendra Modi Medical College, Ahmedabad. Her relatives had given history of self-ingestion of 30 Tab of Amitriptyline Hydrochloride. Each Tablet contained 25 mg of drug molecule. On examination in ED, patient was in drowsy but arousable state. Patient had tachycardia (130/min), high blood pressure (140/90 mm of Hg) and tachypnoea (RR 24/min). Except tachycardia her ECG did not show any significant findings. She was taking Tab. Amitriptyline for her psychiatric problems. Urine sample for toxicology was sent and the reports were normal. Other blood investigations were normal. In emergency room, Ryle&amp;apos;s tube inserted, gastric sample was collected and she was given activated charcoal lavage and force alkaline diuresis with Inj. Furosemide with saline. She was shifted to emergency ICU for further management. After 12 hours patient was conscious and oriented with stable hemodynamic. She was referred to psychiatry department and then transferred to Medicine department for further care. She remained stable there and discharged after 2 days.

Clinical Associated Factors of Tile B/C Type of Pelvic Ring Fractures; a Retrospective Cross-sectional study.

Pelvic ring fractures categorized under Tile Categories B and C denote partially and fully unstable fractures, respectively. This study aimed to identify the clinically associated factors of Tile B/C pelvic ring fractures. This retrospective cross-sectional study reviewed medical records from the Emergency Medicine department at Ramathibodi Hospital in Bangkok, Thailand. The study included individuals aged ≥ 15 who experienced accidents from 2012 to 2021. To investigate the associations between the clinical variables and three critical outcomes, including Tile B/C pelvic ring fractures, major vascular injuries, and the necessity for surgical or radiological interventions, multivariable logistic regression analysis was employed. A total of 198 patients were included in the study, among whom 34.8% were diagnosed with Tile B/C pelvic ring fractures. The analysis revealed several significant predictors of Tile B/C fractures, including the presence of pelvic tenderness (adjusted odds ratio [aOR] = 15.25, 95% confidence interval [CI] = 5.86-39.66, p < 0.001), and a shock index (SI) ≥1 (aOR = 4.2, 95% CI = 1.24-14.22, p = 0.021). Moreover, Tile B/C pelvic ring fractures were associated with an increased incidence of major vascular events and the imperative requirement for surgical or radiological interventions. Clinical findings of pelvic tenderness and an SI ≥1 are strong predictive clinical factors associated with Tile B/C pelvic fractures. Early diagnosis, application of an pelvic binder, provision of initial resuscitation, and prompt transportation to a definitive care facility are crucial components of management.

Classification of trauma-related preventable death; protocol of a Delphi procedure.

Trauma-related (preventable) death is used to evaluate the management and quality of trauma care worldwide. Therefore, it is necessary to identify fatalities in the trauma care population and assess them on preventability. However, the definition on trauma-related preventable death lacks validity due to differences in terminology and classifications. This study aims to reach consensus on the definition of trauma-related preventable death by performing a Delphi procedure, thereby, improving the assessment of trauma-related preventable death and thereby enhancing the quality of trauma care. Based on the results of a recently performed systematic review Hakkenbrak (2021). The definitions used to describe trauma-related preventable death could be divided into four categories: 1) Clinical definition based on panel review or expert opinion, 2) Trauma prediction algorithm, 3) Clinical definition with an additional trauma prediction algorithm and 4) Others (e.g., errors in care or detailed clinical definition). A three round, electronic Delphi study will be performed in the Netherlands to reach consensus. Experts from the department of Trauma surgery, Neurosurgery, Forensic medicine, Anaesthesiology and Emergency medicine, of the designated Level 1 trauma centres in the Netherlands, will be invited to participate. In the first round the panel will comment on the composed categories and trauma prediction algorithms. In the second and third round a feedback report will be presented and the questions with disagreement will be retested. The identification and assessment of trauma-related preventable death is necessary to evaluate and improve trauma care. Therefore, a valid, fair, and applicable definition of trauma-related preventable death is required. The Delphi technique is utilized to reach group consensus to obtain a scientifically valid definition of trauma-related preventable death.

Utilization of a multidisciplinary hospital-based approach to reduce readmission rates.

Hospital readmissions remain a significant and pressing issue in our healthcare system. In 2010, the Affordable Care Act helped establish the Hospital Readmissions Reduction Program, which incentivized reducing readmission rates by instituting penalties. Hospital readmission, specifically unplanned, refers to a patient returning to the hospital shortly after discharge due to the same or a related medical condition, signaling potential issues in initial care, discharge processes, or post-hospitalization management. For this study, we defined readmission as a return to the hospital within 30 days. In 2018, Staten Island University Hospital started a multidisciplinary and coordinated initiative to reduce patient readmissions. The approach involved the departments of emergency medicine, medicine, cardiology, case management, nursing, pharmacy, and transitional care management. This study aimed to determine if this approach reduced 30-day readmissions. This case-control retrospective study reviewed electronic health records between January 2018 and November 2019. Readmission rates within 30 days of index discharge were compared between patients who received transitional care management before and after establishing a multidisciplinary communication of transitional care. Readmission rates were unadjusted and adjusted for patient demographics and predisposed risk for readmission and compared across demographics and select clinical characteristics. A total of 772 patients were included in the analyses; 323 were in the control group (41.8%), and 449 were in the intervention group (58.2%). After the hospital adopted the workflow for multidisciplinary communication of transitional care, there was 45.2% less adjusted incidence of readmission, or approximately seven fewer overall readmissions per 100 patients (16.4% readmission vs 9.0% readmission; incident rate ratio, 0.55; 95% CI: 0.34-0.88). Multidisciplinary communication approaches led by emergency medicine can help reduce readmissions significantly. Adopting a structured communication workflow can enhance co-managing patients with a high risk of readmission between the emergency department and hospital medicine teams.

Developing an early warning system for detecting sepsis in patients with trauma.

The purpose of this study was to analyse the risk factors for sepsis in patients with trauma and develop a new scoring system for predicting sepsis in patients with trauma based on these risk factors. This will provide a simple and effective early warning method for the rapid and accurate detection and evaluation of the probability of sepsis in patients with trauma to assist in planning timely clinical interventions. We undertook a retrospective analysis of the clinical data of 216 patients with trauma who were admitted to the emergency intensive care unit of the emergency medicine department of the Hebei Medical University Third Hospital, China, between November 2017 and October 2022. We conducted a preliminary screening of the relevant factors using univariate logistic regression analysis and included those factors with a p value of <0.075 in the multivariate logistic regression analysis, from which the risk factors were screened and assigned, and obtained a total score, which was the sepsis early warning score. The incidence of sepsis in patients in the intensive care unit with trauma was 36.9%, and the mortality rate due to sepsis was 19.4%. We found statistically significant differences in several factors for patients with sepsis. The risk factors for sepsis in patients with trauma were the activated partial thromboplastin time, the New Injury Severity Score, growth differentiation factor-15 levels, shock, mechanical ventilation and the Acute Physiology and Chronic Health Evaluation II score. The area under the receiver operating characteristic curve of the sepsis early warning score for predicting sepsis in patients with trauma was 0.725. When the cutoff value of the early warning score was set at 5.0 points, the sensitivity was 69.9% and the specificity was 60.3%. The incidence of sepsis in patients with trauma can be reduced by closely monitoring patients' hemodynamics, implementing adequate fluid resuscitation promptly and by early removal of the catheter to minimize the duration of unnecessary invasive mechanical ventilation. In this study, we found that the use of the sepsis early warning score helped in a more accurate and effective evaluation of the prognosis of patients with trauma.

Endocrinology Consultations Evaluated in the Emergency Department over the Last Five Years: A Single Center Experience

Purpose:&#x0D; The increasing trend of metabolic diseases causes endocrine emergencies to be encountered more frequently in emergency services. This trend increases the importance of endocrinology consultations from emergency services. Examining the features of these consultations will allow the process to be concluded more quickly and effectively.&#x0D; Materials and Method:&#x0D; Patients who applied to Manisa Celal Bayar University Faculty of Medicine Emergency Department between March 1, 2017 and March 1, 2022, and were consulted with the Department of Endocrinology were included. The patients' age, gender, diagnoses, the day, the duration and the results of the consultations were evaluated.&#x0D; Results:&#x0D; The mean age of the 326 patients included in the study was 51.56 ± 19.4 years. 53.4% (n=174) were female, 46.6% (n=152) were male. Of the patients, 29.4% (n=96) were diagnosed as diabetic ketoacidosis, 21.5% (n=70) hyperglycemia, and 10.7% (n=35) diabetic ketosis. The mean consultation duration was 65.21 ± 46.23 minutes. 32.2% of the patients (n=105) were discharged from the emergency department. This was followed by endocrinology service admission (23.9%; n=78) and intensive care unit admission (17.8%; n=58).&#x0D; Conclusion:&#x0D; In the sample group with homogeneous gender and age distribution, it was observed that the majority of the patients applied to the emergency service with diabetes-related emergencies. The diagnosis spectrum of the patients was quite wide, and the consultations were concluded within an average of about one hour. A further investigation of the emergency department endocrinology consultations in detail will contribute to detecting the problems in this process and; therefore, its improvement.

Comparision Between Provisional Diagnosis made in Emergency Department vs Final Discharge Diagnosis at Ramkrishna Care Hospital, Raipur C.G

Objective/Hypothesis: Objective of this study was to find out the diagnostic accuracy made by emergency physician, this will ensure improvement in patients care and will help to implement better accuracy in determining diagnostic accuracy. Background: Department of emergency medicine is a specialized care facility in tertiary health care centre whose main function is to take care of patients with immediate and emergent health issues. In view limited literature in EM in India a study between PD vs FD was performed for future reference in continuous quality improvement. Methods: A prospective, observational study was done among 200 patients between provisonal diagnosis made in emergency department vs final discharge diagnosis. Results: Majority of the patients (n=153, 76.5%) were from the age group of patients between 15-64 followed by (n=40, 20%) in the age group with patients of &gt;65 years age, followed by (n= 7, 3.5%) in the age group of 1-14 years. Most matched diagnosis were from department of internal medicine (18.5%) followed by department of cardiology (16%), followed by department of neuromedicine (13%). It was found that 81% (n=162) cases were accurately matched) diagnosed during Emergency department admission, while there was unmatched diagnosis of 19% cases (n=38). Conclusion: Result obtained suggests that the provisional diagnosis was made by the emergency physicians were mostly matched with final discharge diagnosis that was made by the concerned specialist doctors. This shows that the choice of treatment done in the ER were a prompt and accurate treatment. This has a positive effect on the prognosis, mortality and outcome in patients. Department of internal medicine had more diagnostic errors. Improving history taking of patients with proper clinical evaluation correct diagnosis in the ER. Early availability in blood reports during emergency stay will help as a better diagnostic interpretation of disease. it is required to upgrade clinical skills of emergency physicians in diagnosing pediatric age group.

Family caregiver perspectives on strengths and challenges in the care of pediatric injury patients at a tertiary referral hospital in Northern Tanzania.

Pediatric injuries are a leading cause of morbidity and mortality in low- and middle-income countries (LMICs). It is important that injured children get quality care in order to improve their outcomes. Injured children are nearly always accompanied by family member caregivers invested in their outcome, and who will be responsible for their recovery and rehabilitation after discharge. The purpose of this study was to identify family member caregiver perspectives on strengths and challenges in pediatric injury care throughout hospitalization at a tertiary hospital in Northern Tanzania. This study was conducted at a zonal referral hospital in Northern Tanzania. Qualitative semi-structured in-depth interviews (IDIs) were conducted by trained interviewers who were fluent in English and Swahili in order to examine the strengths and challenges in pediatric injury care. IDIs were completed from November 2020 to October 2021 with 30 family member caregivers of admitted pediatric injured patients. De-identified transcripts were synthesized in memos and analyzed through a team-based, thematic approach informed by applied thematic analysis. Strengths and challenges were identified throughout the hospital experience, including emergency medicine department (EMD) care, inpatient wards care, and discharge. Across the three phases, strengths were identified such as how quickly patients were evaluated and treated, professionalism and communication between healthcare providers, attentive nursing care, frequent re-evaluation of a patient's condition, and open discussion with caregivers about readiness for discharge. Challenges identified related to lack of communication with caregivers, perceived inability of caregivers to ask questions, healthcare providers speaking in English during rounds with lack of interpretation into the caregivers' preferred language, and being sent home without instructions for rehabilitation, ongoing care, or guidance for follow-up. Caregiver perspectives highlighted strengths and challenges throughout the hospital experience that could lead to interventions to improve the care of pediatric injury patients in Northern Tanzania. These interventions include prioritizing communication with caregivers about patient status and care plan, ensuring all direct communication is in the caregivers' preferred language, and standardizing instructions regarding discharge and follow-up.

A comparative study of etomidate and propofol as induction agent for intubation in patients coming to emergency medicine department

Background &amp; Aims: An ideal induction agent for intubation in the emergency department should have hemodynamic stability, minimal respiratory side effects and rapid clearance. Etomidate and Propofol are popular rapid-acting inducing agents; our aim is to compare hemodynamic changes and adverse effects occurring between them when used as induction agents in the emergency department. Material and Methods: A study sample of 200 patients who required intubation in the emergency department were enrolled after satisfying the inclusion and exclusion criteria and were divided into two equal groups. After assessing the primary survey of airway, baseline hemodynamic parameters, Group A was given Inj. Etomidate 0.3–0.5 mg/kg iv and Group B was given Inj. Propofol 0.5–1.5 mg/kg iv as an induction agent, followed by that Heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), respiratory rate (RR), oxygen saturation, myoclonus, nausea, and vomiting were monitored after induction and intubation at one, five and fifteen minutes. Result: The mean changes in HR, SBP, DBP, and MAP of groups A and B were compared, there was significant reduction in all three parameters in Propofol compared to Etomidate. In group A, out of 100 patients, 25 had myoclonus, 15 had vomiting, and no side effect was observed in the other 60 patients. In group B, out of 100 patients, 22 had apnea,14 had vomiting, and no side effect was observed in the remaining 64 patients. Conclusion: This study concludes that Etomidate is a better agent for induction than Propofol in view of hemodynamic stability. The incidence of apnea was higher with Propofol, and myoclonus more with Etomidate. Keywords:-Etomidate, Propofol, Intubation

Analysis of Blood Cultures of Patients Presenting to the Emergency Department in a Tertiary Healthcare Hospital in Mumbai

Aim and objectives: Analysis of blood cultures taken from patients attending emergency departments is an important exercise in determining the common pathogens prevalent in the region. The distribution of these infective pathogens keeps changing over time, and the rise in antimicrobial-resistant pathogens makes it difficult to routinely conduct effective empirical broad-spectrum antimicrobial therapy. This study aimed to analyse the results of blood cultures obtained from patients presenting to the Emergency Department of a Tertiary Healthcare Hospital in Mumbai and provide updated and detailed information on the distribution of causative pathogens in adult sepsis and study their antibiotic-susceptibility pattern. Materials and methods: A hospital-based prospective cross-sectional study of 121 positive blood culture reports was conducted at the Department of Emergency Medicine, Fortis Hospital Mulund, Mumbai, which included all adult (age &gt; 18 yrs) suspected sepsis patients arriving to the Emergency Department whose blood cultures were sent from the Emergency Department from January 2021 to December 2021. Results: The study showed that mean age of the study cases was 59.3 years with 59.5% cases that belonged to the elderly age group with a male predominance (56.2% males–43.8% females). Overall, Gram-negative isolates were seen in 95% cases, while Gram-positive isolates were seen in only 1.7% cases. The most common organism isolated from cases with sepsis was Escherichia coli (45.5%) followed by Klebsiella (13.2%), Salmonella (10.7%), Stenotrophomonas (7.4%) and Pseudomonas (5%). Among Gram-positive organisms, Staphylococcus aureus was the most common organism isolated (1.7%). Escherichia coli isolates showed poor sensitivity towards fluoroquinolones and cephalosporins while good sensitivity towards aminoglycosides, carbapenems and combination drugs like Cefoperazone and Sulbactam and Piperacillin and Tazobactam. These findings suggest that Gram-negative organisms are the most common isolates observed in this study, with E. coli being the predominant pathogen followed by Klebsiella. High-level antimicrobial resistance was observed in sepsis cases for commonly used antimicrobials like fluoroquinolones and cephalosporins.

Effect of Comorbid Diseases on Hospitalization and In-Hospital Mortality of Elderly Patients Who Reapplied to the Emergency Department Within 72 Hours.

This study aimed to determine the effects of comorbidities on hospitalization and in-hospital mortality in patients aged 65 years and older who returned to the emergency department within 24, 48, and 72 hours of an initial visit. This study was conducted at the Department of Emergency Medicine, Firat University Faculty of Medicine, Elâzığ, Turkey. It has a retrospective design and received local ethics committee approval from the university. Patients aged 65 years and older who presented to the emergency department within a one-year period (2022) were examined to identify those who returned to the emergency department within 24, 48, and 72 hours of an initial visit. A total of 763 (3.2%) patients >65 years of age returned to the emergency department within the first three days of their initial visit. Of these returning patients, 349 returned within 24 hours (Group 1), 227 within 48 hours (Group 2), and 187 within 72 hours (Group 3). Being female, polypharmacy, the presence of at least one comorbidity, cancer, and chronic renal failure were found to be independent predictors of hospitalization, whereas polypharmacy was found to be an independent predictor of in-hospital mortality. Patients returning to the emergency department shortly after an initial visit should be assessed more diligently due to the risk of mortality.

Medical Admission Prediction Score (MAPS); a simple tool to predict medical admissions in the emergency department.

Overcrowding in the emergency departments (ED) is linked to adverse clinical outcomes, a negative impact on patient safety, patient satisfaction, and physician efficiency. We aimed to design a medical admission prediction scoring system based on readily available clinical data during ED presentation. In this retrospective cross-sectional study, data on ED presentations and medical admissions were extracted from the Emergency and Internal Medicine departments of a tertiary care facility in Qatar. Primary outcome was medical admission. Of 320299 ED presentations, 218772 were males (68.3%). A total of 11847 (3.7%) medical admissions occurred. Most patients were Asians (53.7%), followed by Arabs (38.7%). Patients who got admitted were older than those who did not (p <0.001). Admitted patients were predominantly males (56.8%), had a higher number of comorbid conditions and a higher frequency of recent discharge (within the last 30 days) (p <0.001). Age > 60 years, female gender, discharge within the last 30 days, and worse vital signs at presentations were independently associated with higher odds of admission (p<0.001). These factors generated the scoring system with a cut-off of >17, area under the curve (AUC) 0.831 (95% CI 0.827-0.836), and a predictive accuracy of 83.3% (95% CI 83.2-83.4). The model had a sensitivity of 69.1% (95% CI 68.2-69.9), specificity was 83.9% (95% CI 83.7-84.0), positive predictive value (PPV) 14.2% (95% CI 13.8-14.4), negative predictive value (NPV) 98.6% (95% CI 98.5-98.7) and positive likelihood ratio (LR+) 4.28% (95% CI 4.27-4.28). Medical admission prediction scoring system can be reliably applied to the regional population to predict medical admissions and may have better generalizability to other parts of the world owing to the diverse patient population in Qatar.

Low cardiac index and high total peripheral resistance are independent predictors of mortality for acutely admitted medical patients

Abstract Introduction Identification of critically ill and high-risk patients upon hospital admission represents a significant triage task in the emergency department. Rapid identification and treatment of these patients improves survival, reduces complications during admission, decrease hospitalization duration, and lower treatment cost. Hemodynamic variables such as cardiac index (CI) and total peripheral resistance (TPR) hold the potential to improve the diagnosis of critically ill patients by providing better prognostic value. Using arterial waveform and the model flow method, CI and TPR can be measured non-invasively. These methods are validated against thermodilution, which is the golden standard. Purpose The purpose of the study was to examine the association between CI, TPR, and all-cause mortality within 30 and 90-day among patients admitted to acutely the emergency department or cardiac care unit. Methods In this observational prospective cohort study, all patients were included from the emergency department and cardiac care unit. Patients of age 18 years or older admitted to the emergency department or cardiac care unit due to acute medical disease, were included. Patients with a life expectance of 3months or less and patients unable to give informed consent were excluded. Within the first 24 hours of admission, patients underwent a 10-minute non-invasive hemodynamic measurement using arterial waveform analysis and the model-flow method. Patients were followed up to 90 days after discharge. The endpoints 30- and 90-day mortality were obtained through electronic patient journals. Cox proportional-hazard models examined the association between CI, TPR, and outcomes. All hazard models were adjusted for age, sex, BMI, heart failure, early warning score, and Charlson comorbidity score. Results Between May 2019 and January 2023, we included 920 unselected patients from the department of emergency medicine (n=433) and cardiac care unit (n=487) from a metropolitan hospital. We observed a 3% 30-days mortality while 90-days mortality was 4.9%. The median value of CI was 3.3L, the lowest decile was 2L, and the highest decile was 4.7L. Patients with the lowest CI were older, had higher incidents of heart failure, and had more comorbidities according to Charlson’s comorbidity score (table 1). In Cox proportional hazard models, lowest decile of CI at admission was associated with a significantly higher risk of 30- and 90-days mortality. Total peripheral resistance was significantly associated with 90-day mortality (table 2). Conclusion Low CI ≤2.0 liter/min/m2, and high peripheral resistance measured non-invasively were associated with an increased risk of mortality among patients admitted to the emergency department or cardiac care unit. Non-invasive estimation of CI and TPR may assist in identifying high-risk patients.Table 1Table 2

Alcohol use among emergency medicine department patients in Tanzania: A comparative analysis of injury versus non-injury patients.

Alcohol is a leading behavioral risk factor for death and disability worldwide. Tanzania has few trained personnel and resources for treating unhealthy alcohol use. In Emergency Medicine Departments (EMDs), alcohol is a well-known risk factor for injury patients. At Kilimanjaro Christian Medical Center (KCMC) in Moshi, Tanzania, 30% of EMD injury patients (IP) test positive for alcohol upon arrival to the ED. While the IP population is prime for EMD-based interventions, there is limited data on if non-injury patients (NIP) have similar alcohol use behavior and potentially benefit from screening and intervention as well. This was a secondary analysis of a systematic random sampling of adult (≥18 years old), KiSwahili speaking, KCMC EMD patients surveyed between October 2021 and May 2022. When medically stable and clinically sober, participants provided informed consent. Information on demographics (sex, age, years of education, type of employment, income, marital status, tribe, and religion), injury status, self-reported alcohol use, and Alcohol Use Disorder (AUD) Identification Test (AUDIT) scores were collected. Descriptive statistics were analyzed in RStudio using frequencies and proportions. Of the 376 patients enrolled, 59 (15.7%) presented with an injury. The IP and NIP groups did not differ in any demographics except sex, an expected difference as females were intentionally oversampled in the original study design. The mean [SD] AUDIT score (IP: 5.8 [6.6]; NIP: 3.9 [6.1]), drinks per week, and proportion of AUDIT ≥8 was higher for IP (IP:37%; NIP: 21%). However, alcohol preferences, drinking quantity, weekly expenditure on alcohol, perceptions of unhealthy alcohol use, attempts and reasons to quit, and treatment seeking were comparable between IPs and NIPs. Our data suggests 37% of injury and 20% of non-injury patients screen positive for harmful or hazardous drinking in our setting. An EMD-based alcohol treatment and referral process could be beneficial to reduce this growing behavioral risk factor in non-injury as well as injury populations.

Abstract 228: Suboptimal Door‐to‐Puncture Times: Challenges Faced in the Stroke Alert Workflow

Introduction Advances in stroke care have led to more patients eligible for thrombectomy. With these advances, it has become imperative to create a seamless workflow for thrombectomy candidates to ensure rapid door‐to‐puncture times and, ultimately, improve patient outcomes. We sought to determine what barriers are causing delays in patients’ door‐to‐puncture time. Methods A survey was distributed to all members of the Neurology PGY2, PGY3, PGY4 classes and vascular fellows at our single‐center, Comprehensive Stroke Center. The survey allowed participants to freely respond to questions regarding obstacles they encountered that led to delays in door‐to‐puncture times. All survey responses were anonymized. Results The survey was sent to 32 participants, with 26 responses. Of the 26 responses, 11 respondents (42%) noted that obtaining IV access for CTA/CTP scans was a significant cause of delay. Other responses included lack of availability of family for collateral (23%), CT scanner availability (15%), and length of time to decide if the patient is a thrombectomy candidate (15%). Conclusion The goal of this study was to collect data from the individuals involved in the direct care of acute stroke patients who are thrombectomy candidates. We used their experience to determine which points in the stroke alert workflow led to delays in door‐to‐puncture time. Our survey showed the most consistent delay is obtaining proper IV access for CTA and CTP imaging. This information was valuable and has led to the creation of a coalition between the neurology and emergency medicine departments, nursing, and CT technologists to create a “CODE IV” protocol to be implemented into the stroke alert workflow. We aim to report the change in door‐to‐puncture time after the implementation of this new protocol.

Characteristics of children hospitalized through the pediatric emergency department and effects of pediatric emergency ward hospitalization

Purpose: To evaluate the efficiency of the pediatric emergency ward (PEW) through the outcomes of children hospitalized to the ward by the department of pediatric emergency medicine (PEM).Methods: A chart review was completed for children (&lt; 15 years) who were hospitalized to the PEW via the pediatric emergency center from March through May 2021. We compared the general characteristics and details regarding the outcomes depending on the departments they were hospitalized to, namely PEM, pediatrics (PED), and others.Results: We analyzed a total of 606 hospitalized children: PEM, 91; PED, 456; and others, 59. In the order listed above, their median ages were 2 years (interquartile range, 1-6), 1 year (0-4), and 9 years (7-14) (P &lt; 0.001). The numbers of children with Korean Triage and Acuity Scale of 1-3 were 71 (78.0%), 400 (87.7%), and 33 (55.9%) (P &lt; 0.001). Median length of stay (LOS) in the emergency department (ED) and hospital tended to be shorter in PEM (ED LOS: PEM, 4.3 hours vs. PED and others, 4.0-6.3 hours; hospital LOS: PEM, 19.0 hours vs. PED and others, 58.5-63.8 hours; all Ps &lt; 0.001). The differences in the LOS were prominent between others and PEM (ED LOS, 1.538 [95% confidence interval, 1.353-1.749]; hospital LOS, 3.375 [2.741-4.157]). Transfers to other departments occurred only in PEM (4.4%) and PED (3.9%) whereas intensive care was performed only in others (27.1%). Return visits showed no difference among the 3 departments. Top 5 chief complaints and primary diagnoses of the children hospitalized to PEM were vomiting, fever, abdominal pain, head injury, and poisoning, and gastroenteritis, concussion, syncope, poisoning, and upper respiratory infection, respectively.Conclusion: Hospitalization to PEWs for short-term treatment or observation may relieve overcrowding in EDs or in hospitals, with comparable frequency of return visits.