Disposition Time Research Articles

Comparison of Emergency Department Disposition Times in Adult Level I and Level II Trauma Centers

Introduction: The efficient utilization of resources is a crucial aspect of healthcare, particularly in both Level I and Level II American College of Surgeons (ACS)-verified trauma centers. The effect of resource allocation on emergency department length of stay (ED-LOS) of trauma patients has remained under-investigated. As ED crowding has become more prevalent, especially at quaternary care centers, an evaluation of the potential disparities in ED-LOS between Level I and Level II trauma centers is warranted. We hypothesized a longer ED-LOS at Level I centers compared to Level II centers. Methods: We queried the 2017–2021 Trauma Quality Improvement Process (TQIP) database for trauma patients ≥18 years of age presenting to either a Level-I or -II center. The TQIP defines ED-LOS as the time from arrival until the time an ED disposition (admission or discharge) order is written. We excluded transferred patients and those with missing data regarding ACS trauma center verification level. We performed bivariate analyses, as well as subgroup analyses based on location of disposition. Results: Of 2,225,067 trauma patients, 59.3% (1,318,497) received treatment at Level I centers. No significant differences were found in Injury Severity Scores between patients admitted to the operating room or non-intensive care unit (ICU) locations, or discharged home from Level-I and -II centers (all P < 0.05). The ED-LOS for trauma patients was longer at Level-I centers for all patient categories: overall (198 vs 145 minutes [min], P < 0.001), discharged home (286 vs 160 min, P < 0.001), non-ICU admissions (234 vs 164 min, P < 0.001), and those requiring surgery (126 vs 101 min, P < 0.001). Conclusion: Even when treating patients with similar injury severity, trauma patients at Level I trauma centers had longer ED-LOS compared to Level II centers, irrespective of the patients’ final disposition (surgery, non-ICU admission, or discharge). To optimize resource utilization and alleviate ED saturation, further research must delve into the underlying causes of these discrepancies to identify best practices and solutions.

Great expectations: A multisite, randomized controlled open-label trial of a novel patient expectations communication tool.

In emergency medicine (EM), discerning patient expectations to inform patient-centered care poses unique challenges. We devised a novel questionnaire to facilitate clinicians' understanding of patients' expectations for their visit. We conducted a multisite, randomized controlled trial. A brief questionnaire soliciting patient expectations was developed through feedback from clinicians and patients. At the beginning of their visit, the intervention group patients completed the questionnaire and provided it to their treating clinician. The control group patients received standard care. Participants in both groups completed a survey at time of disposition assessing five satisfaction domains. The primary ordinal logistic regression analysis modeled the extent to which the intervention led to patient-reported improvement in clinician understanding of expectations with adjustment for demographic factors and site. Among the 308 participants, 141 intervention and 123 control exit surveys were collected. In the primary analysis, the intervention group had 2.1 times greater odds of strongly agreeing that their clinician understood their expectations (odds ratio: 2.1, 95% confidence interval: 1.2, 3.7, p-value: 0.01), roughly equivalent to a net number needed to treat of 11 for one more improved satisfaction rating. Although the secondary outcome results were not significantly different between groups, all results tended toward the intervention group having more favorable answers. While more patients reported that their expectations were addressed when the novel tool was used, no significant difference was found for conventional satisfaction measures. Future studies may examine whether a tool to elicit patient expectations can lead to other improved outcomes.

Intravenous diltiazem infusions for rapid atrial fibrillation or flutter in the emergency department: A retrospective, exploratory analysis.

Emergency physicians commonly treat patients with atrial fibrillation (AF) or atrial flutter (AFL) with rapid ventricular response, and intravenous (IV) diltiazem is the most commonly used medication for rate control of such patients. We sought to compare rate control success and safety outcomes for emergency department (ED) patients with AF or AFL who, after a diltiazem bolus, received a diltiazem drip compared to those who did not receive a drip. We performed a retrospective cohort study comparing outcomes of ED patients from a single hospital system with AF and AFL and a heart rate (HR) > 100 beats/min who received a diltiazem drip after an IV diltiazem bolus to those who received no drip. The primary outcome was a HR < 100 beats/min at the time of ED disposition. Secondary outcomes were hospital length of stay and safety (hypotension, electrical cardioversion, vasopressor use, and death). We compared groups using propensity score matching. Between January 1, 2020, and November 8, 2022, there were 746 AF or AFL patients eligible for analysis. Of those, 382 (51.2%) received a diltiazem drip and 364 (48.8%) did not. In the unadjusted analysis, the last recorded ED HR was <100 beats/min in 55.2% of patients in the drip group compared to 65.9% in the no-drip group (difference 10.7%, 95% confidence interval [CI] 3.7 to 17.7). After propensity matching, diltiazem drip use was associated with lower likelihood of rate control in the ED (OR 0.69, 95% CI 0.48-0.99) and 22.5 h (95% CI 12.2-36.8) longer hospital stay. For patients with AF or AFL, the use of a diltiazem drip after an IV diltiazem bolus was associated with less rate control in the ED.

The inefficiency of courts of justice: industry structure, capacity and misallocation

In this paper, we introduce an optimization model to quantify the trade-off between resource capacity utilization and disposition time for the caseload of courts of justice. The optimization model takes into account the impact of an increase in demand that may arise when disposition time is reduced. We employ the model to measure the impact of various policy reform scenarios on the length of trials, both at the court and system level. We do so by taking into account the potential reallocation of resources, using the population of Italian courts of justice over the 2005–2012 period. Our results show that if all policy scenarios we discuss were to be implemented, the average length of trials for civil cases would be more than halved, from the current 15.5 months to about 7 months. Implementing best practices, the single most effective policy would be equivalent to a 25% increase in the number of judges (which would otherwise cost around 100 million euros per year).

Individualized throughput metric reports for emergency medicine residents: Impact on time to disposition and resident perceptions.

Research suggests that quantitative metric reports can improve the clinical performance of emergency physicians; however, few studies have examined their effects on physicians in training. The primary study objective was to assess the effects of providing emergency medicine (EM) residents with individualized throughput metrics with regard to emergency department (ED) disposition times. We performed a single-center, retrospective, observational study from January 2021 to December 2022 examining ED disposition times before and after providing upper-level EM residents individualized throughput metrics. Residents received monthly reports of three specific metrics averaged over the preceding 6 months: (1) median time from room to discharge order (Rm2Dc), (2) median time from return of all results to discharge order (Rlts2Dc), and (3) median time from room and to consult order for hospitalization (Rm2Hosp). Overall mean values of the three metrics before and during metric sharing were compared via independent t-test and stratified by level of training and time of year. Adjusted analysis was performed to control for temporal differences between study periods. Testing was conducted at α = 0.05 level of significance. A total of 35 unique residents were included in the analysis. Overall, mean disposition times were not significantly different before and during reporting of metrics: Rm2Dc (154.8 min vs. 148.9 min, p = 0.109), Rslt2Dc (46.5 min vs. 45.1 min, p = 0.522), and Rm2Hosp (141.7 min vs. 135.7 min, p = 0.257). Subgroup analysis yielded similar results, aside from a significant decrease in mean Rm2Hosp in the postgraduate year-3 (PGY-3) group (145.8 min vs. 124.1 min, p = 0.004). Analysis with adjusted means yielded results similar to those observed with unadjusted data. Overall, individualized throughput metrics were not correlated with decreased average times to ED disposition for upper-level EM residents; however, in the subset of hospitalized patients seen by PGY-3 residents, we observed a mean decrease of 21.7 min to consultation.

Two days before Friday versus 2 days from today: How future (vs. present) anchors in deadlines increase goal achievement

AbstractWhile deadlines are routinely used as a strategy to achieve goals, the way these deadlines are described has been relatively overlooked in terms of their influence on decision‐making. We examined the unique effect of future (vs. present) anchors in deadlines on ones' goal achievement. A field study shows that a deadline with a future anchor encourages people to complete a task more effectively within the deadline than a deadline with a present anchor (Study 1). In Study 2, we further demonstrated the positive effect of future (vs. present) anchors on individuals' goal achievement in a more controlled lab setting. Study 3 provided support for our mechanism by examining individuals' perceived time availability until the deadline underlies this effect. Studies 4 and 5 delved deeper, investigating our mechanism by examining individuals' dispositional time value as an important moderator. This research enriches our understanding of time perception and decision‐making, and offers valuable insights on how to strategically deal with deadlines to enhance one's goal achievement.

Time Delay in Motor Vehicle Accident Arrival: A Critical Analysis of Trauma Team Activation.

Introduction This research aims to investigate the role of time since trauma (TST) in refining trauma team activation (TTA) criteria within a level I trauma center. We analyze the association between TST and post-emergency department (ED) disposition, proposing new insights for the enhancement of TTA criteria. Methods A retrospective analysis was conducted on a dataset comprising 3,693 patients presenting to a level I trauma center following motor vehicle accidents (MVAs) from 2016 to 2021. Data from a trauma registry, encompassing time of injury, time of ED arrival, TTA status, and post-ED disposition, were utilized. TST was calculated as the difference between the time of injury and the time of ED arrival. Patients that received TTA, full or partial, were categorized based on TST (less than one hour, one to two hours, and two or more hours). Statistical analyses, including chi-square tests, were performed using the Statistical Analysis System (SAS) (version 3.8, SAS Institute Inc., Cary, NC). Results Of the 1,261 patients meeting the criteria, 98.3% received TTA, with decreasing TTA rates observed with increasing TST (p = 0.0076). A significant association was found between TST and post-ED disposition for patients who received TTA (p = 0.0007). Compared to the other TST groups, a higher proportion of patients with a TST of two or more hours were admitted,sent to the intensive care unit (ICU), and sent to the operating room (OR). Conclusion The study indicates a statistically significant relationship between TST and TTA rates, challenging our assumptions about the decreased need for TTA over time. While a longer TST was associated with a lower percentageof TTA, patients with a TST of two or more hours demonstrated increased rates of admission, ICU utilization, and surgical interventions. This suggests that TTA criteria may benefit from refinement to include patients with longer TST. Acknowledging study limitations, such as a small sample size and retrospective design, this research contributes valuable insights into potential considerations for optimizing trauma care protocols.

Factors increasing case disposition time in Brazil

Resumo A morosidade judicial no Brasil é um problema grave e persistente. Este trabalho ajuda a compreender as causas desse problema, na medida em que identifica e discute 12 fatores que aumentam o tempo do processo judicial no país, os quais foram identificados com base na análise de conteúdo de entrevistas com 15 atores-chave do sistema brasileiro de Justiça, entre juízes, promotores e advogados. Cada um dos fatores foi discutido segundo a literatura acadêmica, relatórios oficiais e indicadores de desempenho. Os achados da pesquisa mostram que fatores como o baixo custo do ajuizamento, a ausência de punição a litigantes repetitivos e o ajuizamento de execuções fiscais promovem uma sobrecarga de processos nos tribunais. O Judiciário também parece sobrecarregado por atribuições que extrapolam a função jurisdicional, como coletar evidências e localizar devedores e bens. O excesso de disputas e atribuições teria tornado a máquina judiciária brasileira grande e lenta, além de cara. Políticas públicas de redução da morosidade judicial no país são sugeridas.

Retrospective review of non-ST segment elevation acute coronary syndrome presenting to the emergency department of a major tertiary center in Saudi Arabia.

Acute coronary syndrome (ACS) comprises a spectrum of diseases ranging from unstable angina (UA), non-ST elevation myocardial infarction (non-STEMI) and ST elevation myocardial infarction (STEMI). Treatment of ACS without STEMI (NSTEMI-ACS) can vary, depending on the severity of presentation and multiple other factors. Analyze the NSTEMI-ACS patients in our institution. Retrospective observational. A tertiary care institution with accredited chest pain center. The travel time from ED booking to the final disposition for patients presenting with chest pain was retrieved over a period of 6 months. The duration of each phase of management was measured with a view to identify the factors that influence their management and time from the ED to their final destination. The data was analyzed using descriptive statistics. Travel time from ED to final destination. 300 patients. The majority of patients were males (64%) between 61 and 80 years of age (45%). The median disposition time (from ED booking to admission order by the cardiology team) was 5 hours and 19 minutes. Cardiology admissions took 10 hours and 20 minutes from ED booking to the inpatient bed. UA was diagnosed in 153 (51%) patients and non-STEMI in 52 (17%). Coronary catheterization was required in 79 (26%) patients, 24 (8%) had coronary artery bypass grafting (CABG) and 8 (3%) had both catheterization and CABG. The time from ED booking to final destination for NSTEMI-ACS patients is delayed due to multiple factors, which caused significant delays in overall management. Additional interventional steps can help improve the travel times, diagnosis, management and disposition of these patients. Single center study done in a tertiary care center so the results from this study may not be extrapolated to other centers.

Effect of oral clonidine on pain reduction in patients with opioid use disorder in the emergency department: A randomized clinical trial.

Pain can create physical and psychosocial discomfort. Pain management of patients with opioid misuse history can be challenging, in part due to their tolerance to opioids. Clonidine is an alpha-2 agonist that has been used for the reduction of anxiety and pain. The aim of this study was to investigate the effect of oral clonidine on pain outcomes in patients with a history of opioid use disorder presenting with orthopaedic fractures in the emergency room. In this blinded clinical trial in the emergency department, 70 opioid-dependent patients with orthopaedic fractures were divided into a control group of 35 and an intervention group of 35 subjects. Initially, 0.2 mg of oral clonidine was given to the intervention group and the control group received placebo tablets. Pain levels were recorded based on the Numerical Rating Scale rating before intervention, at 30 min, 1h after intervention and at disposition from the emergency room (3-6h after intervention). The total morphine requirement was also recorded. The pain score of the clonidine group was significantly lower than that of the control group at 1h and at disposition time. The amount of morphine required was significantly reduced in the clonidine group (P < 0.05). Oral clonidine had no significant effect on pulse rate. Oral clonidine was more effective for pain reduction in lower limb injuries. Oral clonidine significantly reduced pain and the need for morphine in opioid-dependent patients with orthopaedic fractures.

Racial Differences in Triage for Emergency Department Patients with Subjective Chief Complaints.

Introduction: Black and Hispanic patients are frequently assigned lower acuity triage scores than White patients. This can lead to longer wait times, less aggressive care, and worse outcomes. In this study we aimed to determine whether these effects are more pronounced for patients with subjective complaints. Methods: We performed a retrospective analysis for all adult visits between 2016-2019 at an urban academic emergency department (ED) with acuity-based pods. We determined rates of initial high-acuity triage both across all patients and among the subset located in the high-acuity pod at time of disposition (either through initial assignment or subsequent up-triage). Analysis was performed for common chief complaints categorized as subjective (chest pain, dyspnea, any pain); observed (altered mental status); numeric (fever, hypotension); or protocolized (stroke, ST-elevation myocardial infarction). We constructed logistic regression models to control for age, race, gender, method of arrival, and final disposition. Results: We analyzed 297,355 adult ED visits. Black and Hispanic patients were less likely to be triaged to high-acuity beds (adjusted odds ratio [aOR] 0.76, 95% confidence interval [CI] 0.73-0.79 for Black, and aOR 0.87, 95% CI 0.84-0.90 for Hispanic patients). This effect was more pronounced for those with subjective chief complaints, including chest pain (aOR 0.76, 95% CI 0.73-0.79 for Black and 0.88, 95% CI 0.78-0.99 for Hispanic patients), dyspnea (aOR 0.79, 95% CI 0.68-0.92 and 0.8, 95% CI 0.72-0.99), and any pain (aOR 0.83, 95% CI 0.75-0.92 and 0.89, 95% CI 0.82-0.97, respectively). Among patients in the high-acuity pod at time of disposition, Black and Hispanic patients were disproportionately triaged to lower acuity pods on arrival (aOR 1.47, 95% CI 1.33-1.63 for Black and aOR 1.27, 95% CI 1.15-1.40 for Hispanic adults), with significant differences observed only for subjective chief complaints. No differences were observed for observed, objective, or protocolized complaints in either analysis. Conclusion: Black and Hispanic adults, including those who ultimately required high-acuity resources, were disproportionately triaged to lower acuity pods. This effect was more pronounced for patients with subjective chief complaints. Additional work is needed to identify and overcome potential bias in the assessment of patients with subjective chief complaints in ED triage.

Hospital Development of a Hybrid Emergency Department—Inpatient Care Observation Unit

IntroductionThis project aimed to design and implement an emergency department-managed observation unit that improves inpatient bed and emergency department stretcher capacity, decreases observation patient length of stay, earns high patient satisfaction scores, and generates a positive fiscal impact on the organization. MethodsThis quality improvement project followed a 1-group, pre- and postprogram implementation design. ResultsIn the first year of operations, 40% of the total observation patients treated in this hospital were managed in the new observation unit. Emergency department observation unit length of stay across all patient complaints was half of the average length of stay for observation patients located on hospital inpatient units. In most cases, the emergency department observation unit was in the top 25 percentile of hospital Press Ganey inpatient satisfaction categories. The hospital estimates a contribution margin of three-quarters of a million dollars in the first year. DiscussionThis effective and efficient hybrid observation unit possessed specific aspects of inpatient and emergency department patient care models. Placing providers and nurses at the workstation for faster communication expedited care. Prioritizing all observation patient testing, transportation, phlebotomy, and intravenous (IV) services shortened disposition times. Emergency nurses transitioning to the observation unit were challenged to acquire inpatient care knowledge. Observation unit management struggled to maintain staffing while under an inpatient productivity model managed by the inpatient house supervisor. Reducing patient disposition time required clear communication between observation unit and inpatient staffing managers, between physician consultants and advanced practice nursing providers, and among nurses, patients, and providers. Observation units are 1 solution to decrease observation patient length of stay and improve emergency department capacity.

Emergency Department Evaluation of Priapism: Etiology and Consultation

Introduction: Priapism is a time-critical condition requiring immediate evaluation and management to avoid significant sequela. Management of this condition is significantly variable, dependent upon the underlying cause, and often instituted by a consultant rather than the treating emergency physician. Objectives: To determine etiologic factors contributing to priapism treatment and determine if treatments initiated in the emergency department (ED) contribute to an improved disposition metric. Methods: We conducted a multi-center, retrospective study of patients with priapism caused by multiple different etiologies. Study subjected were located at 15 hospitals by chart review and conducted a computer-assisted chart review to locate patients with priapism for each hospital over a 2-year period. Results: We evaluated 236 patients during the study period; 8 excluded for chart unavailable and 6 with non-priapism diagnosis on review. Median age was 39 years (IQR 22-52). Pediatrics, defined as less than 21 years of age, comprised 4% of patients (N=9). Overall, 85% (N=188) were discharged. Erectile dysfunction medications (EDM) were the most common identifiable cause; involving 23% (N=52). The remaining were sickle cell 20% (N=45), antipsychotic medications 14% (N=30), cocaine 2% (N=4), the remainder without an identifiable etiology. Overall, intrapenile procedures occurred in 56% (N=125) of patients. EDM was associated with significantly less intrapenile procedures compared to other etiologies, 15% (N=58) (p = 0.009), and also had a 2% (N=1) admission rate, significantly less compared to other etiologies (p=0.009). Further, consulting urology did not significantly increase mean length of stay, with difference of 19 minutes (p=0.64) when compared to ED intervention alone. Conclusion: Priapism as a result of EDM, the most frequent etiology, was associated with less frequent emergent intrapenile procedures and significantly less admissions and urology consultation does not significantly lengthen disposition times.

Does electronic case-processing enhance court efficacy? New quantitative evidence

We empirically investigate the effect of electronic case-processing on court efficacy. We draw on monthly court-level panel data on adjudication and enforcement in Brazilian labor justice, a major pillar of the Brazilian justice system where electronic case-processing is a recent phenomenon and court inefficacy has been a pervasive concern. Using dynamic panel methods and multiple estimation approaches to address endogeneity, we show, first and foremost, that in both adjudication and enforcement a shift to electronic case-processing unequivocally increases judicial productivity and court clearance rate while reducing case disposition times. In adjudication, electronification exhibits diminishing marginal returns: additional electronification does not yield further efficacy gains once the share of electronically-processed court caseload is between 50% and 75%. We do not find similarly stark evidence of plateauing of the effect of electronification in enforcement, a key court activity domain where attaining fully electronic case-processing would thus be especially advantageous. Overall, our findings suggest that electronic case-processing provides one viable path to unclogging courts and enhancing administration of justice.

Sex differences in musculoskeletal injury epidemiology and subsequent loss of tactical readiness during Marine Corps Officer Candidates School

IntroductionThe US Marine Corps (USMC) Officer Candidates School (OCS) is a 10-week training course for Marine Officer Candidates (MOCs). OCS training is rigorous and demanding, which results in a high...

Regional Anesthesia as an Alternative to Procedural Sedation for Forearm Fracture Reductions in the Pediatric Emergency Department.

Pediatric forearm fractures are common injuries in the pediatric emergency department (PED). Pediatric procedural sedation (PPS) is often required for forearm fracture reductions and pain control for casting. Bier blocks and hematoma blocks are types of regional anesthesia (RA) procedures that can be performed as a potential alternative to PPS. The objective of this study is to compare the safety of RA with that of PPS. We hypothesized that RA has a safety profile that is equal or superior to PPS as well as a shorter duration of treatment in the PED. Pediatric emergency department encounters in patients presenting with a diagnosis of radius fracture, ulna fracture, distal "both-bone" fracture, Monteggia fracture, and/or Galeazzi fracture were included. Outcomes of interest included patient adverse events (AEs), sedation medications used, PED duration of treatment (arrival time to disposition time), sedation failures, and reduction failures. Propensity matching was performed resulting in 632 well-matched RA-PPS pairs. The PPS cohort had 13% of encounters with at least 1 AE compared with 0.2% in the RA cohort, P < 0.001. The most common AE in the PPS group was hypoxia (9.8%), and the only AE in the RA group was an intravenous infiltrate (0.16%). Within the matched cohorts, PPS required more medications than RA (100% vs 60%, P < 0.001). Ketamine alone was more commonly used in the PPS group than the RA group (86% vs 0.2%, P < 0.001). Propofol was used only in the PPS group. The average duration of treatment was 205 (SD, 81) minutes in the PPS group and 178 (SD, 75) minutes in the RA group ( P < 0.001). There were no reduction failures in either group. Bier blocks and hematoma blocks are an acceptable alternative to PPS for children requiring forearm reductions. The AE rate is low and the reduction success rate is high. Duration of treatment in the PED is shorter for patients receiving RA compared with PPS.

Point-of-care ultrasound: impact on emergency department length of stay for suspected lower extremity DVT.

Point-of-care ultrasound (POCUS) has demonstrated excellent sensitivity and specificity for the diagnosis of DVT in the emergency department (ED). Before POCUS became widespread, patients underwent radiology department comprehensive lower extremity venous duplex ultrasounds (RADUS) which may be associated witha prolonged length of stay. The goal of this study is to evaluate the impact of POCUS on ED arrival to disposition (ATD) time for patients presenting to the ED with suspected lower extremity DVT. This is a retrospective chart analysis of ED visits to an urban, university-affiliated community hospital from January 2019 to December 2020. This study compared ATD between patients who underwent POCUS by an emergency medicine physician and RADUS by the radiology department. In total, 1204 patients underwent POCUS, and 1582 patients were evaluated with RADUS. The POCUS mean ATD was 313 ± 16.8min compared to the RADUS arm average of 323 ± 57.9min (p = 0.56). Order to disposition time (OTD) was prolonged among the RADUS group relative to POCUS. ATD was significantly reduced in the POCUS subgroup of patients presenting during night shift when RADUS was not available, 326 ± 28.2min versus 630 ± 109min (p < 0.05). ED POCUS scans decrease the amount of time between order placement and disposition when compared to RADUS. POCUS significantly decreases length of stay in the ED when RADUS is not available.

TEMPO DO PROCESSO JUDICIAL NO BRASIL E EM PAÍSES EUROPEUS

Abstract The length of judicial proceedings is an important subject on the agenda of social researchers, policy-makers, politicians, legal practitioners, and court administrators in several countries. Whether the court disposition time in a country is reasonable or not is a matter of debate. Brazilian courts are usually perceived to be slow. This study investigates whether court delay is a real problem or merely a perception. The duration of civil cases in Brazil is measured by international standards and then compared to those in European courts. The disposition time in Brazilian first-instance courts takes 600 days, almost three times longer than the European average (232 days). In Brazilian second-instance courts, it takes 320 days, 50% longer than in Europe (215 days). However, the number of cases decided in those courts exceeds the number of new incoming cases, which means that the backlog and the disposition time in Brazilian courts are decreasing. These data are discussed in this paper and a research agenda and management recommendations are proposed later on this document.

A Comparative Study on Predictive Validity of Modified Shock Index, Shock Index, and Age Shock Index in Predicting the Need for Mechanical Ventilation among Sepsis Patients in a Tertiary Care Hospital.

The shock index (SI), modified shock index (MSI), and age multiplied by SI (ASI) are used to assess the severity of shock. They are also used to predict the mortality of trauma patients, but their validity for sepsis patients is controversial. The aim of this study is to assess the predictive value of the SI, MSI, and ASI in predicting the need for mechanical ventilation after 24 h of admission among sepsis patients. A prospective observational study was conducted in a tertiary care teaching hospital. Patients with sepsis (235) diagnosed based on systemic inflammatory response syndrome criteria and quick sequential organ failure assessment were included in the study. The need for mechanical ventilation after 24 h is the outcome variables MSI, SI, and ASI were considered as predictor variables. The utility of MSI, SI, and ASI in predicting mechanical ventilation was assessed by receiver operative curve analysis. Data were analyzed using coGuide. Among the study population, the mean age was 56.12 ± 17.28 years. MSI value at the time of disposition from the emergency room had good predictive validity in predicting mechanical ventilation after 24 h, as indicated by the area under the curve (AUC) of 0.81 (P < 0.001), SI and ASI had fair predictive validity for mechanical ventilation as indicated by AUC (0.78, P < 0.001) and (0.802, P < 0.001), respectively. SI had better sensitivity (78.57%) and specificity (77.07%) compared to ASI and MSI in predicting the need for mechanical ventilation after 24 h in sepsis patients admitted to intensive care units.

924. Reducing Rates of Hospital Acquired Clostridium Difficile Infection by Switching to Two-Step Testing

Abstract Background Clostridium difficile infection (CDI) tests have various degrees of sensitivity, making diagnosis challenging. Polymerase chain reaction (PCR) positive tests in colonized patients can impact rates of hospital-acquired CDI (HACDI). A negative toxin A/B enzyme immunoassay (EIA) as a second step can help determine colonization but is not as sensitive. We aimed to study the impact of a two-step testing strategy on rates of HACDI and CDI treatment outcomes. Methods Two-step testing consisted of C. difficle DNA PCR, which if positive, was followed by toxin A/B EIA (Figure 1). We conducted a retrospective study in a 359-bed hospital from March 2020 to July 2021. Patients with positive PCR and negative EIA results were included and further classified based on CDI treatment status. The primary outcome was the number of HACDI cases avoided. Secondary outcomes included location at the time of testing, symptoms, leukocytosis, discharge disposition and readmission. Results Ninety-six patients were included. Sixty-five patients (68%) were treated while 31 (32%) were not. HACDI was avoided in 18 cases (18.8%). There were more HACDI avoided in the non-treated group compared to the treated group (32.3% vs 12.3%; p=0.026). Most non-treated patients were tested on medical-surgical units (77.4%), whereas 49.2 % of the treated patients were tested in more acute areas such as emergency or intensive care. Treated patients were more likely to have leukocytosis and/or fever (66.2%) compared to non-treated patients (29%; p= 0.0009), while there was no difference in abdominal pain, diarrhea, bloody stool, or constipation (Table 1). Most patients had an abdominal CT scan (70.8%). Of those that had a CT, colitis was found in 48.5%. Patients in the treated group were more likely to have had a CT completed that showed colitis vs the non-treated patients (43.1% vs 16.1%; p&amp;lt; 0.011). Finally, compared to the non-treated patients, treatment did not affect home disposition on discharge or 30-day readmission rate (80% vs 71%, P=0.436) and (25 % vs 29%, P= 0.63) respectively. Symptoms Associated with C. difficile infection. Schematic of C. difficile test interpretation. Conclusion CDI two-step testing led to decreased HACDI rates without affecting discharge disposition or readmission rates in patients with PCR positive and toxin EIA negative results regardless of treatment status. Disclosures All Authors: No reported disclosures.