ED Deaths Research Articles

Using machine learning and natural language processing in triage for prediction of clinical disposition in the emergency department

BackgroundAccurate triage is required for efficient allocation of resources and to decrease patients’ length of stay. Triage decisions are often subjective and vary by provider, leading to patients being over-triaged or under-triaged. This study developed machine learning models that incorporated natural language processing (NLP) to predict patient disposition. The models were assessed by comparing their performance with the judgements of emergency physicians (EPs).MethodThis retrospective study obtained data from patients visiting EDs between January 2018 and December 2019. Internal validation data came from China Medical University Hospital (CMUH), while external validation data were obtained from Asia University Hospital (AUH). Nontrauma patients aged ≥ 20 years were included. The models were trained using structured data and unstructured data (free-text notes) processed by NLP. The primary outcome was death in the ED or admission to the intensive care unit, and the secondary outcome was either admission to a general ward or transferal to another hospital. Six machine learning models (CatBoost, Light Gradient Boosting Machine, Logistic Regression, Random Forest, Extremely Randomized Trees, and Gradient Boosting) and one Logistic Regression derived from triage level were developed and evaluated using EPs’ predictions as reference.ResultA total of 17,2101 and 41,883 patients were enrolled from CMUH and AUH, respectively. EPs achieved F1 core of 0.361 and 0.498 for the primary and secondary outcomes, respectively. All machine learning models achieved higher F1 scores compared to EPs and Logistic Regression derived from triage level. Random Forest was selected for further evaluation and fine-tuning, because of its robust calibration and predictive performance. In internal validation, it achieved Brier scores of 0.072 and 0.089 for the primary and secondary outcomes, respectively, and 0.076 and 0.095 in external validation. Further analysis revealed that incorporating unstructured data significantly enhanced the model’s performance. Threshold adjustments were applied to improve clinical applicability, aiming to balance the trade-off between sensitivity and positive predictive value.ConclusionThis study developed and validated machine learning models that integrate structured and unstructured triage data to predict patient dispositions, distinguishing between general ward and critical conditions like ICU admissions and ED deaths. Integrating both structured and unstructured data significantly improved model performance.

Role of Transcranial Doppler Ultrasound in Early Assessment of Acute Post Traumatic Brain Injury

Abstract Introduction Traumatic brain injury (TBI) is a global health and socioeconomic problem. It is responsible of millions of ED visits, hospitalizations, and deaths with lifelong disability among survivors. Immediately after TBI, cerebral blood flow (CBF) is extremely low approaching the ischemic thresholds. Concurrently, CBF velocities become strongly correlated to CBF itself. Identification of such disturbances can predict outcome in TBI when assessed early post- injury using Transcranial Doppler (TCD). TCD provides non-invasive real time measurements of CBF velocities as well as pulsatility index (PI). Design Observational prospective cohort study. Setting Helwan university hospital. Aim to assess the accuracy of transcranial Doppler ultrasound as an early predictor of secondary neurological deterioration after acute post traumatic brain injury Patients and Methods 55 patients of acute post traumatic brain injury underwent TCD within 8 hours post trauma. Middle cerebral artery (MCA) velocities and pulsatility index, as well as GCS and initial CT findings, were recorded. The primary end point was the development of secondary neurological deterioration (SND) at day 7 after injury. Secondary outcome measures were the in-hospital mortality and hospital length of stay. Results There was a significant relation between end diastolic velocity (EVD) as well as PI with SND at day 7 as well as GOSE at day 28 post-trauma. There was also significant correlation between PI and hospital mortality. Conclusion TCD, when done early after admission, is useful in identifying patients at risk for developing neurological deterioration after TBI. EDV and PI are good predictors of SND at one week.as well as in-hospital mortality.

Retired nurse’s ED death tells us what we already know

Retired nurse’s ED death tells us what we already know

Racial and Ethnic Disparities in Intensity of Care at the End of Life for Patients With Lung Cancer: A 13-Year Population-Based Study.

Lung cancer is the leading cause of cancer death in the United States. Disparities in lung cancer mortality among racial and ethnic minorities are well documented. Less is known as to whether racial and ethnic minority patients with lung cancer experience higher rates of intensity of care at the end of life (EOL) compared with non-Hispanic White (NHW) patients. We conducted a population-based analysis of patients 18 years and older with a lung cancer diagnosis who died between 2005 and 2018 using the California Cancer Registry linked to patient discharge data abstracts. Our primary outcome was intensity of care in the last 14 days before death (defined as any hospital admission or emergency department [ED] visit, intensive care unit [ICU] admission, intubation, cardiopulmonary resuscitation [CPR], hemodialysis, and death in an acute care setting). We used multivariable logistic regression models to evaluate associations between race and ethnicity and intensity of EOL care. Among 207,429 patients with lung cancer who died from 2005 to 2018, the median age was 74 years (range, 18-107) and 106,821 (51%) were male, 146,872 (70.8%) were NHW, 1,045 (0.5%) were American Indian, 21,697 (10.5%) were Asian Pacific Islander (API), 15,490 (7.5%) were Black, and 22,325 (10.8%) were Hispanic. Compared with NHW patients, in the last 14 days before death, API, Black, and Hispanic patients had greater odds of a hospital admission, an ICU admission, intubation, CPR, and hemodialysis and greater odds of a hospital or ED death. Compared with NHW patients, API, Black, and Hispanic patients who died with lung cancer experienced higher intensity of EOL care. Future studies should develop approaches to eliminate such racial and ethnic disparities in care delivery at the EOL.

493. ENDURANCE - EffectiveNess of Evusheld for COVID-19 Pre-exposUre PRophylAxis iN ImmunoCompromised PatiEnts – A Pilot Study

Abstract Background In December 2021, Evusheld, a cocktail of 2 monoclonal antibodies (mAB), was granted EUA for COVID-19 pre-exposure prophylaxis (PrEP) of immunocompromised patients (Table 1). The EUA was updated June 2022 to recommend repeating a dose every 6 months for patients needing ongoing protection. However, EUA was revoked in January 2023 due to identified resistance of Omicron lineage. Clinical trials about a new mAB for PrEP are continuing. Real-world data on the effectiveness of Evusheld may help develop strategies for the administration of new mAB. ENDURANCE is a complex retrospective study to assess Evusheld's effectiveness by evaluating and comparing treatment outcomes among 4 groups of patients classified based on the timing of treatment and the number of repeated Evusheld treatments (Figure 1). This pilot study describes treatment outcomes in the first analyzed group (gr. A) treated before Omicron development. Table 1 EUA criteria for Evusheld use, used as inclusion criteria for our study. * Patients with moderate to severe immunosuppression due to a medical condition or receipt of immunosuppressive medications and may not mount an adequate immune response to COVID-19 vaccination. Figure 1 ENDURANCE Study design. 459 patients who received the initial dose of Evusheld were followed for 180 days (group A, n=151, and group B, n=308). Patients who received repeated treatment (group A’, n=151) were followed for 180 days following an additional dose while patients who did not receive repeated treatment (group B’, n=308) were followed for an additional 180 days (181 till 360 days after the initial dose). Primary outcome is defined as confirmed symptomatic COVID-19 infection. We hypothesize a significantly lower rate of COVID-19 infections in the period before Omicron emergence (Groups A and B), disregarding if patients received repeated doses of Evusheld (Group A’) or not (Group B’). A Pilot Study describes the treatment outcomes in group A. Methods We conducted a retrospective chart review of patients treated with Evusheld under EUA between January 18 and June 21, 2022, to assess their response to treatment by evaluating outcomes listed in Figure 2. Patients were classified in tiers based on the degree of underlying immunosuppression (Table 2). In addition, COVID-19 anti-Spike antibodies were requisitioned before treatment. Figure 2 Evaluated outcomes. Primary outcome was positive COVID test at any point during the study period. Secondary outcomes were measured through the number of all-cause ED visits, hospitalizations, ICU admissions and deaths within 30 days from the positive COVID-19 test. Table 2 Tiered system for prioritizing patients based on severity of immunosuppression should resources be scarce. Results From 151 patients, the majority were vaccinated (95%), seropositive (66%), and classified as Tier 1 at the time of treatment (58%) (Table 3). All seronegative patients (39) were vaccinated (Figure 3). 16/159 (11%) developed symptomatic COVID-19 infection within 180 days from treatment (mean 119.8 days); 10/16 patients received antiviral treatment outpatient (Table 4). None visited ED, were hospitalized, or died. Table 3 Patients’ vaccination status and anti-Spike antibody (serology) results per tiers. *All seronegative patients were vaccinated; unvaccinated patients (8) were either seropositive (5) or with unknown serology (3). Figure 3 Serum anti-Spike antibody results in vaccinated and unvaccinated patients. All seronegative patients (n=39) were vaccinated. Unvaccinated patients were either seropositive (n=5) or with unknown serology results. Table 4 Characteristics of COVID-19 positive patients, compared to patients not diagnosed with COVID-19. Conclusion Our pilot data suggests that Evusheld may be effective against susceptible strains, as demonstrated by the low number of symptomatic infections, which all were mild and did not require ED or hospital utilization (Figure 4). A tier system may help prioritize patients in scarce resource conditions. Further studies are needed to identify risk factors for severe COVID in immunocompromised patients and understand their immunological response to vaccines and natural infection to create the most helpful tier system. Figure 4 Treatment outcomes. 10% (16/151) of Evusheld recipients developed mild symptomatic COVID-19. Number of all cause ED visits, hospitalizations, and deaths within 30 days from testing positive for COVID-19 was 0, suggesting possible beneficial effect of Evusheld use in immunocompromised population. Disclosures All Authors: No reported disclosures

Impact of the MEESSI-AHF tool to guide disposition decision-making in patients with acute heart failure in the emergency department: a before-and-after study

ObjectivesTo determine the impact of risk stratification using the MEESSI-AHF (Multiple Estimation of risk based on the Emergency department Spanish Score In patients with acute heart failure) scale to guide...

Play the Game by Charlene Allen (review)

Reviewed by: Play the Game by Charlene Allen Wesley Jacques Allen, Charlene Play the Game. Tegen/HarperCollins [304p] Trade ed. ISBN 9780063212794 $19.99 E-book ed. ISBN 9780063212817 $10.99 Reviewed from digital galleys R Gr. 7-12 Seventeen-year-old Brooklynite Victor "VZ" Zemblist has been struggling to mourn his best friend Ed, who was fatally shot by a white man last year; he couldn't bring himself to attend the protests and memorials, and his other relationships, with parents, school, but especially with Jack, another long-time friend, have suffered. When the body of the man responsible for Ed's death is found in the same place Ed was killed, Jack becomes the primary suspect, meaning VZ must both grieve one friend and vindicate another, all while crushing hard on Diamond, who's flirty but taken. For nerdy game designer Ed, VZ is determined to finish and make public his late friend's point-and-click mystery game imbued with Ed's unique (read: corny) [End Page 248] sense of humor and theatrics. For Jack, VZ must gather clues and navigate his complicated relationships as well as an obviously illegitimate police investigation. Despite the contemporary themes of police brutality and racialized violence at the forefront, this is ultimately an old school hard-boiled detective story delivered skillfully in a rich contemporary context by debut author Allen. The multiple story threads inform a sometimes frustratingly paced but immersively realistic whodunit, in which the cynicism of classic noir and pulp stories is replaced with the promising optimism of restorative justice circles and a tough protagonist that's nonetheless willing to take the help that's offered. Teens will find VZ's story a rewarding read with undeniably difficult lessons to teach. Copyright © 2023 The Board of Trustees of the University of Illinois

Predicting Early Versus Late In-Hospital Mortality in the Trauma Population.

This study aimed to evaluate non-survivors who were admitted to a level I trauma center but later died, in terms of predicting who would expire early vs late. This is a single-center study of Trauma Registry data, from July 3, 2016, to February 24, 2022. The inclusion criteria were based upon age (≥18years) and in-hospital mortality. 546 patients (mean age 58) were included in the analysis. Trauma patients who may experience an earlier death were those with increasing injury severity scores, activation of massive transfusion protocol, comorbid advanced directive limiting care, COPD, personality disorder, and ED death location. Patients were more likely to experience later in-hospital mortality, including those with increasing ICU stays, and comorbid dementia.

Examining the effect of interventions in emergency care for older people using a system dynamics decision support tool.

Rising demand for Emergency and Urgent Care is a major international issue and outcomes for older people remain sub-optimal. Embarking upon large-scale service development is costly in terms of time, energy and resources with no guarantee of improved outcomes; computer simulation modelling offers an alternative, low risk and lower cost approach to explore possible interventions. A system dynamics computer simulation model was developed as a decision support tool for service planners. The model represents patient flow through the emergency care process from the point of calling for help through ED attendance, possible admission, and discharge or death. The model was validated against five different evidence-based interventions (geriatric emergency medicine, front door frailty, hospital at home, proactive care and acute frailty units) on patient outcomes such as hospital-related mortality, readmission and length of stay. The model output estimations are consistent with empirical evidence. Each intervention has different levels of effect on patient outcomes. Most of the interventions show potential reductions in hospital admissions, readmissions and hospital-related deaths. System dynamics modelling can be used to support decisions on which emergency care interventions to implement to improve outcomes for older people.

Maternal Vaccination Protects Infants Against Flu and Pertussis

Source: Rowe SL, Leder K, Perrett KP, et al. Maternal vaccination and infant influenza and pertussis. Pediatrics. 2021;148(3): e2021051076; doi.10.1542/peds.2021-051076Investigators from multiple institutions in Australia conducted a population-level inception cohort study to assess the effectiveness of maternal influenza and pertussis vaccination during pregnancy in preventing these diseases in their children during the first 6 months of life. For the study, they abstracted data from the Victorian Perinatal Data Collection (VPDC) on women whose pregnancies ended between September 2015 and December 2017. The VPDC includes information on all live births and stillbirths in Victoria, Australia, including demographic and clinical data related to pregnancy and birth. In addition, whether the mother received influenza and/or pertussis vaccine at any time during pregnancy is recorded. Data from multiple databases were reviewed to identify laboratory-confirmed cases of influenza and pertussis in infants <6 months old during the study period and record ED visits, hospital admissions, and deaths from influenza and pertussis. Information from these databases and VPDC were linked to identify mother-infant dyads.The primary study outcomes were laboratory-confirmed cases of influenza and pertussis in infants born to mothers included in the study, and secondary outcomes included cases of severe disease, defined as ED visit, hospitalization, or death from influenza or pertussis in study infants. Poisson regression was used to calculate the relative risk (RR) for influenza and pertussis in infants of mothers vaccinated during pregnancy vs not vaccinated, after adjusting for multiple confounders. Results were stratified in infants <2 months old, and those 2 to <6 months of age. Vaccine effectiveness (VE) of maternal immunization in preventing childhood illness was estimated as (1-RR) × 100.Data were analyzed on 186,962 mother-infant dyads. Overall, 45.9% of study women were vaccinated against influenza during pregnancy and 68.5% against pertussis. There were 185,404 and 184,194 infants, respectively, included in influenza and pertussis vaccination analyzes. The risk of influenza was significantly reduced in children whose mothers were vaccinated, both among children <2 months old (RR, 0.44; 95% CI, 0.25, 0.77), and in those 2 to <6 months of age (RR, 0.64; 95% CI, 0.42, 0.98), with VE estimated as 56.1% (95% CI, 23.3%, 74.9%) and 35.7% (95% CI, 2.2%, 57.7%), respectively. Maternal vaccination reduced the risk of pertussis in infants <2 months old (RR, 0.20; 95% CI, 0.06, 0.63), with an estimated VE of 80.1% (95% CI, 37.1%, 93.7%), but no significant effect was noted among infants 2 to <6 months old (RR, 0.68; 95% CI, 0.33, 1.39). Maternal pertussis immunization reduced the risk of severe pertussis in infants <2 months old (RR, 0.38; 95% CI, 0.16, 0.94). There were no significant effects from maternal vaccination on severe cases of pertussis in children 2 to <6 months old or on influenza among children <6 months old.The authors conclude that maternal vaccination during pregnancy reduces the risk of influenza and pertussis in infants <2 months old.Dr Brady has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.The goal of maternal immunization is to provide infants with passive antibodies prior to their first dose of vaccines. In a previous study, Baxter et al1 noted that maternal Tdap during pregnancy significantly reduced pertussis risk during the entire first year of life (See AAP Grand Rounds. 2017;38[2]:15.)1 In the current study, which included infants born at ≥30 weeks’ gestation, this benefit was most notable only in infants <2 months. In contrast, Baxter et al1 enrolled only infants born at ≥37 weeks’ gestation, allowing more time for antibody transfer after maternal Tdap receipt (usually between 27–36 weeks’ gestation).2As demonstrated by the results of the current study, maternal vaccination during pregnancy also reduces the infant’s risk for influenza during the first 6 months of life. Tdap and influenza vaccination rates during pregnancy, however, remain suboptimal.3 To assess influenza and Tdap vaccination coverage among women pregnant during the 2020–21 influenza season, the Centers for Disease Control and Prevention (CDC) conducted a survey during April 2021.4 Among 1,795 survey respondents who were pregnant anytime during October 2020–January 2021, 54.5% reported receiving an influenza vaccine before or during pregnancy. Among 729 respondents, 53.5% reported receiving Tdap during pregnancy. Unfortunately, receipt of both influenza and Tdap vaccines was reported by only 30.7% of women.COVID-19 vaccines also are recommended for all pregnant women.5 Providers need to take every opportunity to recommend these vaccines for their pregnant patients.Vaccination of pregnant women with Tdap, influenza, and COVID-19 vaccines is safe and protects the mother and her young infant.As influenza vaccines are approved only for infants ≥6 months of age, the 6-month duration of immunity conferred by maternal influenza vaccination provides further support for maternal immunization.

Determinants of Early Death and Outcomes for Acute Promyelocytic Leukemia in the Arsenic Era: A Real World Study

ObjectiveEarly death (ED) persists as the main obstacle to cure all the patients with acute promyelocytic leukemia (APL) in all-trans retinoic acid (ATRA) era. Uncertainty remains as to whether ED rate can reduce and which markers are independent predictors for ED and outcomes in arsenic era. We conducted a real world study of APL patients to assess ED, outcomes and predictors in arsenic era.MethodsThis study includes consecutive 309 APL patients in our center between 2005 and 2013. Three treatment protocols using arsenic and ATRA as first-line treatment were adopted in our center. Protocol A was used from 2005 to 2007.Patients received oral tetra-arsenic tetra-sulfide (As4S4) (60mg/kg/day) or intravenous ATO (10 mg/day) daily with ATRA (25 mg/m2/day), until complete remission (CR) for induction therapy, whereas additional minimal chemotherapy was administered to control hyperleukocytosis (mitoxantrone 1.4 mg/m2/day for 5-10 days or daunorubicin 40 mg/m2/day for 2-3 days was added if peripheral WBC was greater than 10 × 109/L or on the second day in patients with high risk). After achieving CR, most patients were administered 3 courses of consolidation chemotherapy including mitoxantrone (6-8 mg/m2/day for 3 days), daunorubicin (40mg/m2 for 3 days) ,idarubicin (6-8 mg/m2 for 3 days). Maintenance treatment included inter-mittent oral As4S4 and ATRA for 2-3 years. Protocol B was used from 2008 to 2012, which is described in our previous report (Zhu HH, et al. JCO 2013; 31:4215-4221 ).Protocol C was used since 2013, which only included non high-risk patients and was described in our previous report (Zhu HH, et al. NEJM 2014; 371:2239-41).ResultsThe ED (death within 30 days of diagnosis) rate was 4.8% (n=15) and showed a trend of decrease after 2008 (3.8% vs, 8.5% p=0.053). Using multivariate Cox proportional hazards regression, the hazard ratio of ED was 19.89 (95% CI, 4.49-88) for white blood cell (WBC) count of >10×109/L vs ≤10×109/L (P<0.0001) and 8.70 (95% CI, 1.15-66.67) for platelet count of ≤40×109/L vs >40×109/L(P=0.037). Estimated 10 year cumulative incidence of relapse (CIR), disease-free survival and overall survival (OS) was 6.32% (95% CI: 3.03%-9.61%), 93.0% (95% CI: 88.7%-95.7%) and 92.0% (95% CI: 88.3%-94.6%). WBC count was only independent predictor for OS (HR 5.34, 95% CI, 2.36-12 for >10×109/L vs ≤10×109/L, P<0.0001) in multivariate analysis.ConclusionsIn this large cohort of APL patients under a ‘real world’ setting, a relative low ED and high OS could be achieved and high WBC count emerged as an independent predictor of ED and OS in arsenic era. DisclosuresNo relevant conflicts of interest to declare.

Risk Stratification in Primary Care: Value-Based Contributions of Provider Adjudication.

In primary care risk stratification, automated algorithms do not consider the same factors as providers. The process of adjudication, in which providers review and adjust algorithm-derived risk scores, may improve the prediction of adverse outcomes. We assessed the patient factors that influenced provider adjudication behavior and evaluated the performance of an adjudicated risk model against a commercial algorithm. (1) Structured interviews with primary care providers (PCP) and multivariable regression analysis and (2) receiver operating characteristic curves (ROC) with sensitivity analyses. Primary care patients aged 18years and older with an adjudicated risk score. APPROACH AND MAIN MEASURES: (1) Themes from structured interviews and discrete variables associated with provider adjudication behavior; (2) comparison of concordance statistics and sensitivities between risk models. 47,940 patients were adjudicated by PCPs in 2018. Interviews revealed that, in adjudication, providers consider disease severity, presence of self-management skills, behavioral health, and whether a risk score is actionable. Provider up-scoring from the algorithmic risk score was significantly associated with patient male sex (OR 1.24, CI 1.15-1.34), age > 65 (OR 2.55, CI 2.24-2.91), Black race (1.26, CI 1.02-1.55), polypharmacy >10 medications (OR 4.87, CI 4.27-5.56), a positive depression screen (OR 1.57, CI 1.43-1.72), and hemoglobin A1c >9 (OR 1.89, CI 1.52-2.33). Overall, the adjudicated risk model performed better than the commercial algorithm for all outcomes: ED visits (c-statistic 0.689 vs. 0.684, p < 0.01), hospital admissions (c-statistic 0.663 vs. 0.649, p < 0.01), and death (c-statistic 0.753 vs. 0.721, p < 0.01). When limited to males or seniors, the adjudicated models displayed either improved or non-inferior performance compared to the commercial model. Provider adjudication of risk stratification improves model performance because providers have a personal understanding of their patients and are able to apply their training to clinical decision-making.

Adverse outcomes associated with inappropriate direct oral anticoagulant starter pack prescription among patients with atrial fibrillation: a retrospective claims-based study.

Direct oral anticoagulant (DOAC) starter packs are designed for unique treatment dosing for acute venous thromboembolism (VTE). Inappropriate use of 30-day DOAC starter packs in patients with atrial fibrillation (AF) may increase the risk for bleeding events given higher dosing in the first 1-3weeks of treatment. A retrospective analysis of medical and outpatient pharmacy claims data from 2015 to 2018 in Optum's De-identified Clinformatics® Data Mart was performed.Patients greater than 18years of age with AF and a new prescription of apixaban or rivaroxaban were included. Patients with an acute VTE were excluded. The main outcome of interest was adverse events (emergency department [ED] visits, hospitalizations, and deaths within 90days after prescription fill date) associated with inappropriate DOAC starter pack prescription. A total of 90,950 DOAC-treated patients with AF were identified. The mean age was 74.5years (SD 10.0) and 42,717 (47.0%) were female. Inappropriate starter packs were used by 117 (0.1%) patients, who were younger than non-starter pack patients (71.3years vs. 74.5years). Patients who received an inappropriate DOAC prescription were more likely to identify as Black (12.0% vs. 8.8%). Rates of ED visits, hospitalizations, and deaths overall were numerically lower in patients with starter pack compared to non-starter pack DOAC prescriptions. In contrast, rates ofED visits and hospitalizationsrelated to significant bleeding were numerically higherin patients with starter pack compared to non-starter pack DOAC prescriptions. Among patients with AF but no VTE, those who received an inappropriate DOAC starter pack had numerically higher rates of severe bleeding leading to ED visits and hospitalizations compared to those prescribed an appropriate non-starter pack DOAC anticoagulant.

Abstract 309: Outcomes of Depressed Patients With and Without Antidepressant Prescription

Background: Many studies have shown a relationship between depression and an increased risk of rehospitalization, suggesting assessment and management, potentially including antidepressants, should remain an important part of inpatient treatment. However, studies analyzing the outcomes associated with antidepressant use among cardiac patients have shown mixed results. This study aims to describe the long-term outcomes (ED visits, readmissions, and death) of a cohort of cardiac patients with concomitant depression treated with antidepressants. Methods: A total of 151 patients with a medical history of depression were randomly selected between 2008-2017 from a cardiac transitional care clinic registry. A retrospective chart review was conducted to determine the frequency of antidepressant prescription at discharge following a cardiac hospital admission. Demographics and outcomes were compared between those prescribed and those not prescribed antidepressants at discharge. Results: Of 4,298 patients, 1,067 (24.8%) had a diagnosis of depression recorded in their medical record. Of the 151 randomly selected depression patients, 106 (70.2%) were on at least one antidepressant at discharge. Significantly more females were prescribed antidepressants at discharge than males (78.0% v. 58.3%, p=0.010). No significant differences were seen in race, socioeconomic status, or outcomes at 30, 60, 90, or 180 days post-discharge between those prescribed and those not prescribed antidepressants at discharge. However, when compared to patients without depression (n=3,231), those on at least one antidepressant had significantly more 30-day ED visits (25.5% vs 17%, p=0.026), 180-day ED visits (52.9% vs 38.1%, p=0.002), and 180-day readmissions (55.8% vs 40.1%, p=0.001). Conclusions: Patients with depression had worse outcomes than those without depression, despite the majority (70.2%) being treated with antidepressants. These results suggest efforts should be made post-discharge to closely monitor patients with depression, even if they are prescribed antidepressants, and additional treatment modalities should be researched.

The Extremity/Mechanism/Shock Index/GCS (EMS-G) score: A novel pre-hospital scoring system for early and appropriate MTP activation

BackgroundNumerous in-hospital scoring systems to activate massive transfusion protocols (MTP) have been proposed; however, to date, pre-hospital scoring systems have not been robustly validated. Many trauma centers do not have blood or pre-thawed plasma available in the trauma bay, leading to delays in balanced transfusion. This study aims to assess pre-hospital injury and physiologic parameters to develop a pre-hospital scoring system predictive of need for massive transfusion (MT) prior to patient arrival. MethodsA retrospective review of all adult full and partial trauma team activations from July 2014–July 2018 from an urban level 2 trauma center was performed utilizing our trauma registry. Stepwise logistic regression analysis was performed to develop a new scoring system, with point totals assigned proportional to the odds ratios of requiring MT for each variable. Internal validation of the EMS-G score was performed using a subset of the data which was not utilized for development of the scoring system, and sensitivity and specificity were compared to previously validated in-hospital scoring systems applied in the pre-hospital setting. Results763 patients were included with 94 patients (12.3%) receiving early MT, defined as 4 units pRBC in 4 h or ED death. In-hospital models for predicting MT such as Assessment of Blood Consumption (ABC) or Shock Index (SI) have sensitivities and specificities of 46/85% and 94/79% respectively for early MTP utilization based on pre-hospital data. Pre-hospital variables found to be predictive of MT were used to develop the EMS-G (Extremity, Mechanism, Shock Index, GCS) score. This system assigns obvious extremity injury–1-point, penetrating mechanism −2 points, shock index ≥0.9–2 points, GCS ≤8–3 points. A score of 3 or greater was chosen to maximize sensitivity and specificity for pre-hospital MT activation. EMS-G score based on pre-hospital report is 89% sensitive, 84% specific, with a PPV of 44% and NPV of 98% for early MT. Using this system, 25% of full and partial trauma team activations met criteria for pre-hospital MTP activation. ConclusionThe EMS-G Score has increased sensitivity and specificity compared to the ABC Score in the pre-hospital setting and appears more appropriate than shock index alone at predicting massive transfusion. This scoring system allows trauma centers to activate MTP prior to patient arrival to ensure early and appropriate blood product administration without blood product wastage.

When is It Safe to Start VTE Prophylaxis After Blunt Solid Organ Injury? A Prospective Study from a Level I Trauma Center

The optimal timing of VTE prophylaxis initiation after blunt solid organ injury is controversial. Retrospective studies suggest initiation ≤48h is safe. This prospective study examined the safety and efficacy of early VTE prophylaxis initiation after nonoperative blunt solid organ injury. All patients >15years of age presenting after blunt trauma (12/01/16-11/30/17) were prospectively screened. Patients were included if solid organ injury (liver, spleen, kidney) was diagnosed on admission CT scan and nonoperative management was planned. ED deaths, transfers, patients with pre-existing bleeding disorders or home antiplatelet/anticoagulant medications, and those who did not receive VTE prophylaxis were excluded. Demographics, injury/clinical data, type/timing of VTE prophylaxis initiation, and outcomes were collected. Patients were dichotomized into study groups based on VTE prophylaxis initiation time: Early (≤48h) vs Late (>48h after admission). Prophylaxis initiation was at the discretion of the attending trauma surgeon. The primary study outcome was VTE event rate. Secondary outcomes included hospital length of stay (LOS), intensive care unit (ICU) LOS, need for and volume of post-prophylaxis blood transfusion, need for delayed (post-prophylaxis) interventional radiology (IR) or operative intervention, failure of nonoperative management, and mortality. Outcomes were compared with univariate analysis. Multivariate analysis with logistic regression determined independent predictors of late VTE prophylaxis initiation. After exclusions, 118 patients were identified. Median ISS was 22 [IQR 14-26]. Median AAST grade of injury was 2 [IQR 2-3] for liver, 2 [IQR 1-3] for spleen, and 3 [IQR 2-3] for kidney. Compared to late prophylaxis patients (n = 57, 48%), early prophylaxis patients (n = 61, 52%) had significantly fewer DVTs (n = 0, 0% vs n = 5, 9%, p = 0.024) but similar rates of PE (n = 2, 3% vs n = 3, 5%, p = 0.672). TBI was the only significant risk factor for late prophylaxis (OR 0.22, p = 0.015). No patient in either group required delayed intervention (operative or IR) for bleeding. There was no difference in volume of post-prophylaxis blood transfusion. In this prospective study of patients with nonoperative blunt solid organ injuries, early (≤48h) initiation of VTE prophylaxis resulted in a lower incidence of DVTs without an associated increase in bleeding or need for intervention. Early initiation of VTE prophylaxis is likely to be safe and beneficial for patients with blunt solid organ injury.

Abstract 118: Impact of an Early HF Discharge Follow-up Intervention on 30-Day Outcomes in a Veterans Hospital

Objective: Rehospitalizations occur in 25% of HF patients. We implemented an intervention to improve HF outcomes by focusing on early post-discharge follow-up. We conducted a pre- and post-intervention analysis to determine if the intervention was associated with improved 30-day HF composite outcome, defined as 30-day all-cause ED visit, all-cause rehospitalization, or death. Methods: In 2011, we created an intervention in which the discharge team was asked to refer all HF patients to HF clinic follow-up within 14 days. Patients were given an appointment prior to hospital discharge and received contact information for a HF nurse. In the post-intervention period, patients were seen by a NP or HF cardiologist, whereas in the pre-intervention period patients were seen by any cardiology provider. The study sample consisted of patients with a discharge diagnosis of HF hospitalized within 6 months before (‘pre-intervention’) or within 6 months after the intervention (‘post-intervention’) began. Clinical variables were collected including demographics, vital signs, lab values, and LVEF. We censored hospice patients. Descriptive statistics and incidence of individual and composite outcomes were calculated. Hospital utilization at outside hospitals was not available. We created a Cox proportional hazards model to evaluate the effect of the intervention on the 30-day composite outcome, adjusted for clinical predictors associated with the outcome (p&lt;0.1). Findings: 261 patients were studied (pre-intervention, n=142; post-intervention, n=119). Patients were male (99%), white (71%), with a mean age of 70 years. 65% of patients had LVEF ≤ 40%. Only BNP was different between the pre- and post-groups, respectively ((median 1212 [IQR, (613-2752)] vs. 990 [IQR, (426-1726]), p=.04)). 40% of intervention group was referred for cardiology follow-up within 7 days versus 12% of the pre-intervention group (p&lt;.001), with medians of 6 days (IQR [5,9)] and14 days (IQR [8,20] p&lt;.001), respectively. There was a trend towards lower unadjusted 30-day composite outcome incidence in the intervention group (p=.15). After adjustment for clinical predictors, the post-intervention period was associated with a reduced hazard of the 30-day composite endpoint (HR 0.56, 95%CI [0.33,0.94], p=.03). Discussion: The transitional HF care intervention was associated with a reduced risk of all-cause ED visit, all-cause rehospitalization, or death. This analysis confirms the importance of establishing a systematic follow-up program for all HF patients that bridges the transition from hospital to home.

1935. Outpatient Parenteral Antimicrobial Therapy in Nonagenarians

BackgroundAlthough OPAT is widely accepted practice for adults in the USA, the safety of OPAT in very old patients has not been examined before.MethodsThe Cleveland Clinic OPAT Registry was screened to identify patients aged 90 and above discharged from hospital on OPAT. Control subjects (those aged 89 years and younger) were selected from the OPAT registry, matched to study subjects on sex, year of admission, OPAT site, vascular access, infection category, and antibiotic group. ED visits, readmissions, and deaths, for nonagenarians and controls, were described as competing outcomes. Patients were only included once. Events up to 90 days following initiation of OPAT were considered. OPAT-related ED visits, and separately OPAT-related readmissions, were compared across the two groups in subdistribution proportional hazards competing risks regression models. Adverse drug events were compared using logistic regression.ResultsThirty nonagenarians and 87 control subjects were identified for patients discharged on OPAT between January 1, 2013 and May 21, 2014. Mean (SD) of age for nonagenarians and controls were 92 (3) and 61 (16), respectively, and 67 (57%) were males. Cardiovascular and osteoarticular infections accounted for more than 50% of infections treated in each group, and the majority of patients received their OPAT in skilled nursing facilities. The cumulative incidences of OPAT-related ED visits and readmissions for nonagenarians and control patients, with death and non-OPAT-related readmissions accounted for as competing events, are shown in the figure. Compared with matched patients below 90 years of age, nonagenarians were not at increased risk of OPAT-related ED visits (HR 1.32, 95% CI 0.55–3.18, P = 0.54), OPAT-related readmissions (HR 1.2, 95% CI 0.23–6.19, P = 0.83), or adverse drug events from OPAT medications (OR 1.22, 95% CI 0.28–8.55, P = 0.81).ConclusionOPAT can be accomplished in nonagenarians as safely as in younger patients. Disclosures All authors: No reported disclosures.

P140: Risk factors for adverse outcomes in hyperglycemic patients presenting to the emergency department: a systematic review

Introduction: Hyperglycemia is a significant cause of morbidity and mortality, often resulting in adverse outcomes such as recurrent ED visits, hospitalization or death. The objective of this study was to perform a systematic review to identify predictors of these adverse outcomes among patients who present to the ED with hyperglycemia. Methods: Electronic searches of Medline and EMBASE were conducted for studies published in English between the years 1946 and June 2017. Studies with patients presenting to the ED with hyperglycemia were eligible for inclusion. Both adult and pediatric populations were included, as were diabetic and non-diabetic patients. Two reviewers independently screened all titles and abstracts for relevance to the research question. If consensus could not be reached, full-length manuscripts were reviewed. For any discrepancy, a third reviewer was consulted, and disagreement was resolved through discussion. Study quality was assessed using the Newcastle-Ottawa Quality Assessment Scale. Study- and patient-specific data were then extracted and presented descriptively in the systematic review. Results: Thirteen observational studies were included, with a combined total of 664,829 patients. The studies scored between 5 to 8 on the Quality Assessment Scale out of a possible total of 8. Predictors of adverse outcomes included patients in both older and younger (&lt; 25) age groups, history of diabetes, multiple comorbidities, patients requiring insulin, sepsis and hyperlactatemia, access to a family physician, a sentinel hyperglycemia visit in the past month, and triage glucose level &gt; 20 mmol/L. Protective factors included no admissions in the past year, care from a diabetes team while in hospital, systolic blood pressure between 90-150 mmHg and heart rate &gt; 110 bpm. Conclusion: This systematic review found eight predictors and four protective factors for adverse outcomes in patients presenting to the ED with hyperglycemia. These factors should be considered for easier identification of higher-risk patients for adverse outcomes in order to guide management and follow-up.

Endoplasmic Reticulum Stress Drives High Selenium‐Induced Endothelial Dysfunction

BackgroundSelenium is an essential trace element important to human health. Nonetheless, supra‐nutritional selenium intake is reported to be associated with insulin resistance and may therefore increase the risk of diabetes and disrupt endothelial function (ED), the initial step in atherosclerosis development. However, the underpinning molecular mechanisms are not clear. High selenium concentrations cause apoptosis in cancer cells through the induction of endoplasmic reticulum (ER) stress, a mechanism also involved in the pathogenesis of ED. Therefore, we hypothesised here that high selenium intake could cause ED through the activation of ER stress response.MethodsHuman Umbilical Vein Endothelial Cells (HUVECs) were cultured with selenite at either physiological (0.5μM) or supra‐nutritional concentrations (5–20μM) for 8 to 24 hours in the presence or absence of a chemical chaperone, 4‐phenylbutryic acid (PBA). Then, mRNA expression of key ER stress response markers was analysed by qPCR. To assess endothelial function, we evaluated NO (Griess assay) release and Reactive Oxygen Species (ROS, flow cytometry) production. Finally, apoptosis (flow cytometry) and caspases 3/7 activity were measured.ResultsHigh selenium concentrations (5–20μM of selenite) compared to physiological concentration (0.5μM) or control enhanced mRNA expression of several ER stress markers such as CAAA/enhanced‐binding homologous protein (CHOP) [control (2.25±0.88), 0.5 μM (3.9±0.85), 10μM (36.2±6); n=5]. The pre‐incubation of cells with PBA completely reversed high selenium‐mediated ER stress. High selenite (5–20μM) also reduced NO production [control (2.27±0.07), 0.5μM (2.4±0.04), 10μM (1.8±0.05); n=5] and enhanced ROS production [control (18.9±1.93), 0.5μM (21.7±2.14), 10μM (68±0.65); n=5] compared to physiological concentration of selenite while cells pre‐treated with PBA were fully protected. Finally, supra‐nutritional concentrations of selenite increased the percentage of apoptotic HUVECs [control (2.96%±0.94), 0.5μM (3.92%±0.85), 10μM (43.7%±5.1); n=7] and augmented caspases 3/7 activity [0.5μM (0.45±0.08), 5μM (1.92±0.3) fold of control; n=5] compared to physiological concentration. Importantly, pre‐treatment of cells with PBA completely reversed high selenium‐mediated cell death.ConclusionsWe show here that high selenium treatment causes ED and cell death through the activation of ER stress. These results highlight the importance of a balanced selenium intake in order to achieve maximal health benefits. These findings underscore the importance to monitor cardiovascular risk development in cancer patients supplemented with high amounts of selenium as part of their chemotherapeutic intervention.This abstract is from the Experimental Biology 2018 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.