Emergency Department Assessment Research Articles

Airway, breathing, cellphone: a new vital sign?

IntroductionIn emergency medicine, triage encompasses more than the initial prioritization of treatment; it also includes decisions about the most suitable level of care and disposition for each patient. However, the increasing use of mobile technology by patients in the emergency department (ED) introduces a new factor. This study aims to explore the relationship between patients’ cellphone use at the time of initial assessment and final disposition in the ED.MethodsA prospective, cross-sectional study was conducted on 292 patients who presented to the ED between 9/1/2021 and 8/9/2022. Patients were stratified into two cohorts based on their behavior during the initial assessment: actively using a cell phone (n = 32) or not using a cell phone (n = 259). Final disposition was dichotomously recorded as admission or discharge. Hospital admission, hospital observation, and admission to the ED observation unit were consolidated into the combined category of admission.ResultsPatients not actively using their cell phone on initial assessment exhibited a discharge rate of 64%, while those engaged with their cellphones displayed notably higher dismissal rates at 94%. The calculated odds ratio (OR) of 8.4 (95% confidence interval: 1.96-36.0, p = 0.004) underscores a significantly heightened likelihood of dismissal among individuals actively using their cellphones, suggesting a potential association between cellphone use and a reduced probability of hospital admission.ConclusionThe study suggests an association between cellphone use during initial ED assessment and higher discharge rates. While this introduces a novel concept, the study’s potential contribution to more informed and efficient triage decisions warrants careful consideration in future research and clinical applications.

Risk-stratification tools for emergency department patients with syncope: A systematic review and meta-analysis of direct evidence for SAEM GRACE.

Approximately 10% of patients with syncope have serious or life-threatening causes that may not be apparent during the initial emergency department (ED) assessment. Consequently, researchers have developed clinical decision rules (CDRs) to predict adverse outcomes and risk stratify ED syncope patients. This systematic review and meta-analysis (SRMA) aims to cohere and synthesize the best current evidence regarding the methodological quality and predictive accuracy of CDRs for developing an evidence-based ED syncope management guideline. We conducted a systematic literature search according to the patient-intervention-control-outcome question: In patients 16 years of age or older who present to the ED with syncope for whom no underlying serious/life-threatening condition was found during the index ED visit (population), are risk stratification tools (intervention), better than unstructured clinical judgment (i.e., usual care; comparison), for providing accurate prognosis and aiding disposition decision for outcomes within 30 days (outcome)? Two reviewers independently assessed articles for inclusion and methodological quality. We performed statistical analysis using Meta-DiSc. We used GRADEPro GDT software to determine the certainty of the evidence and create a summary of the findings (SoF) tables. Of 2047 publications obtained through the search strategy, 31 comprising 13 CDRs met the inclusion criteria. There were 13 derivation studies (17,578 participants) and 24 validation studies (14,845 participants). Only three CDRs were validated in more than two studies. The San Francisco Syncope Rule (SFSR) was validated in 12 studies: positive likelihood ratio (LR+) 1.15-4.70 and negative likelihood ratio (LR-) 0.03-0.64. The Canadian Syncope Risk Score (CSRS) was validated in five studies: LR+ 1.15-2.58 and LR- 0.05-0.50. The Osservatorio Epidemiologico sulla Sincope nel Lazio (OESIL) risk score was validated in five studies: LR+ 1.16-3.32 and LR- 0.14-0.46. Most CDRs for ED adult syncope management have low-quality evidence for routine clinical practice use. Only three CDRs (SFSR, CSRS, OESIL) are validated by more than two studies, with significant overlap in operating characteristics.

Online Mental Health Assessment in a psychiatry emergency department in adults using touchscreen mobile devices: A randomised controlled trial.

To determine whether completion of an online mental health self-assessment by patients who are waiting in the emergency department can save clinician time taken to complete clinical assessment and documentation. Patients presenting to a psychiatric emergency department for a period of 6 months were allocated by week of presentation to either the intervention arm (online mental health self-assessment, followed by a clinical interview) or the control arm (usual assessment) arm on a random basis. Time at the beginning and end of the interview was recorded and used to derive interview time. Similarly, time at the beginning and end of the clinical documentation was recorded and used to derive the time to complete clinical documentation. Of 168 patients who presented during the study period, 69 (38.55%) agreed to participate, 33 completed the usual assessment and 30 completed the online mental health self-assessment followed by a clinical interview. Patients receiving usual care had a statistically significant, t(61) = 2.15, p = 0.035, longer interview duration (M = 48.7 minutes, SD = 19.8) compared with those in the online mental health self-assessment arm (M = 38.9 minutes, SD = 15.9). There was no statistically significant difference between groups for documentation time, t(61) = -0.64, p = 0.52. Online mental health self-assessment was associated with a statistically significant reduction in interview time by approximately 10 minutes without increasing documentation time. While online mental health self-assessment is not appropriate for all patients in the emergency department setting, it is likely to yield greater benefits in less acute settings.

An Audit of Time to Inpatient Bed In Patients With A Suspected Delirium

Abstract Background Our local Dementia/Delirium Combined Pathway and Care Bundle for Emergency Department (ED) and Acute Medical Assessment Unit sets a target door to ward admission in patients aged over 65 years with a suspected delirium at less than 6 hours. This audit assessed if this target is being met in patients with a suspected delirium. Methods Retrospective point prevalence audit of 240 randomly selected patients who were assessed by the Frailty Intervention Team (FIT) in the Mater Misericordiae University Hospital ED in 2022, aged ≥ 65 years with a suspected delirium (4AT ≥4) and no delirium (4AT=0). Time of presentation to ED, time of admission to ward bed, ward name and length of hospital stay were recorded. Results The median age in patient's with a 4AT ≥4 was 86 years (range 65-99). There was an equal spread across gender groups in patient's with a 4AT ≥4; 55.3% (n=52) females and 44.7% (n=42) male. The median wait time in ED for patients with a 4AT ≥4 was 25.26 hours (range 6.75-83.73) vs 21.65 hours (range 5.98-50.53) in patients with a 4AT=0. Only 19% (n=18) of patients with a 4AT ≥4 were admitted to a Specialist Geriatric Ward. The mean length of stay in patients with a 4AT ≥4 was 28.457 days vs 14.132 days in those with a 4AT=0 (p value=0.002, Mann-Whitney U test). Conclusion Older adults with a delirium spend prolonged periods of time in the ED. We are not meeting our local target of 6 hours from ED presentation to ward bed. Length of hospital stay is prolonged in patients with delirium. Our aim is to create a dedicated delirium bed on our Geriatric Specialty Ward so that we can provide delirium specific care and reduce overall length of hospital stay.

SP9.11 - Characteristics and predictive factors associated with on table mortality in emergency laparotomy: insights from the National Emergency Laparotomy Audit

Abstract Aims Mortality during emergency laparotomy is a rare but significant event that can have a profound impact on patient’s families and the healthcare team. The aims of this study were to define the frequency of this occurrence within the National Emergency Laparotomy Audit (NELA) database and to investigate predictive factors. Methods All patients entered into the database between 2013-2020 were included. Multilevel logistic regression was used, with clinically important factors identified a a priori, to identify variables associated with intra-operative mortality. Results The overall incidence of intra-operative mortality was 1 in 400 cases (450/180,985). There was no difference in mortality rate between day-time and night-time operations. These patients presented critically unwell with signs of shock (50%, 225/450) and an ASA grade of ≥4 (76%, 343/450). Their baseline function status was good with a high proportion residing in their own home (97%, 437/450) and minimal signs of frailty. Acute mesenteric ischaemia was the indication for laparotomy for 46% of patients (207/450) and was associated with a threefold increase in the risk of intra-operative death (OR 2.97 (95% CI 2.35-3.75)). Other important predictive factors were hypotension at presentation (OR 1.56 (95% CI 1.22-1.99)) and a blood lactate of 4-6 (OR 3.89 (95% CI 2.62-5.76)). Conclusions Intra-operative mortality during emergency laparotomy is rare but remains a significantly higher occurrence than in other emergency surgical specialities. The strong association with acute mesenteric ischaemia necessitates optimisation of UK emergency department assessment pathways and more nuanced discussions about the risks of surgery in such high-risk patients.

Pulmonary embolism (PE) diagnosed in a 19-year-old lady found to have underlying Antiphospholipid syndrome (APS)

ABSTRACT Background A 19-year-old woman visited a family medicine clinic to obtain her laboratory test results. This case highlights a close call involving a young woman with a potentially serious condition. Pulmonary embolism (PE) is often overlooked during initial assessments in emergency departments or primary care clinics. Case presentation The patient casually mentioned having a cough toward the end of the consultation, revealing she has been using a salbutamol inhaler due to a family history of asthma. Despite appearing well, she had an audible wheezy cough during the examination. Following a chest X-ray (CXR) that indicated a right lung opacity and possible cardiomegaly, an electrocardiogram (ECG) was arranged. The ECG showed an incomplete right bundle branch block (RBBB) and STT changes in leads V3-V6 and lead 3, prompting her transfer to the emergency department for suspected Pulmonary embolism (PE). Further evaluation confirmed acute on chronic PE, with a positive lupus screen leading to the diagnosis of antiphospholipid syndrome (APS) upon detection of anti-phospholipid antibodies in her serology. Discussion The patient’s case was unique, but a basic CXR was performed to investigate their exertional shortness of breath. This led to appropriate action being taken to ensure the patient’s safety. It is important to note that pulmonary embolism can occur in young individuals, highlighting the need for attentive and skilled healthcare professionals. Basic tests such as CXR and ECG can be crucial in cases of ongoing symptoms where uncertainty exists.

Comparison of the preclinical quality of analgesia of emergency physicians and paramedics based on trauma patients

Adequate prehospital pain management is acritical component of emergency medical services. With the introduction of the paramedic profession and the Paramedics Act in Germany, the basis for more extensive competencies of paramedics was established. In many emergency medical service areas it is thus possible for paramedics to perform analgesia and sedation with esketamine/midazolam according to pre-established instructions and/or standard operating procedures. This study assessed the quality of analgesia administered to trauma patients by paramedics compared to emergency medical service physicians. The study included trauma patients who received prehospital administration of analgesia by either emergency medical service physicians or paramedics and were subsequently admitted to the central emergency department of the Saarland University Hospital. Astandardized data collection form was used to collect information from the emergency service protocol and initial emergency department assessment. The evaluation employed descriptive statistical methods and a total of 207 completed records were analyzed. Both professional groups achieved significant pain reduction and fulfilled the criteria for effective pain management (pain reduction: emergency medical service physicians 5.5 ± 2.0/paramedic 4.4 ± 2.1, p < 0.001). Emergency medical service physicians, however, more frequently attained ahigher reduction in numerical rating scale scores and administered oxygen. Notable differences were observed in the range of medications used and the dosages. This study could show that prehospital analgesia is comparable between emergency medical service physicians and paramedics in terms of effectiveness for trauma patients if the indications are correctly set, while observing pre-existing instructions. With their competencies paramedics are able to perform an effective and safe analgesic treatment within the framework of preformulated procedural instructions, which can be equal to that of an emergency medical service physician.

Pain management experience among emergency working nurses

Pain is one of the main reasons why a patient is required to appear at the emergency department. According to the literature, one of the main factors leading to inadequate nursing care of pain has been inadequate assessment of the pain threshold, delay in interventions, and poor knowledge of the nursing staff. This study aimed to explore and describe emergency nurses’ experiences during pain management and identify the barriers they encounter when providing this care. A qualitative study, with a focus group composed of 10 nurses, through open questions, was conducted in April 2023 at the emergency nurses of the Regional Hospital "Xhaferr Kongoli" Elbasan. The questions were designed based on the literature and included the evaluation of the method of pain management in the emergency room, the interventions of nurses, the obstacles that nursing staff face during patient care, and the way to address these obstacles. The duration of the interviews ranged from 25 to 35 minutes. Demographic data were analyzed using descriptive statistics, and interview data were analyzed by qualitative thematic analysis. Ten nurses were interviewed, with a mean age of 40.1 years and 7.3 years of work experience in the emergency department. The thematic analysis of the data identified three main themes and subthemes, including Management of situations, Planning, and Challenges. Our study identified nurses' experiences in planning interventions for patients with pain. Early protocol-based pain management can improve patient outcomes and reduce inappropriate interventions. More research is needed to identify these interventions and examine how they interact with ineffective pain management. More studies are needed to highlight the role of nurses in pain assessment and pain management in emergency departments.

Risk scores and coronary artery disease in patients with suspected acute coronary syndrome and intermediate cardiac troponin concentrations

BackgroundGuidelines recommend the use of risk scores to select patients for further investigation after myocardial infarction has been ruled out but their utility to identify those with coronary artery disease...

Consensus paper on the assessment of adult patients with traumatic brain injury with Glasgow Coma Scale 13-15 at the emergency department: A multidisciplinary overview.

Traumatic brain injury (TBI) is a common reason for presenting to emergency departments (EDs). The assessment of these patients is frequently hampered by various confounders, and diagnostics is still often based on nonspecific clinical signs. Throughout Europe, there is wide variation in clinical practices, including the follow-up of those discharged from the ED. The objective is to present a practical recommendation for the assessment of adult patients with an acute TBI, focusing on milder cases not requiring in-hospital care. The aim is to advise on and harmonize practices for European settings. A multiprofessional expert panel, giving consensus recommendations based on recent scientific literature and clinical practices, is employed. The focus is on patients with a preserved consciousness (Glasgow Coma Scale 13-15) not requiring in-hospital care after ED assessment. The main results of this paper contain practical, clinically usable recommendations for acute clinical assessment, decision-making on acute head computerized tomography (CT), use of biomarkers, discharge options, and needs for follow-up, as well as a discussion of the main features and risk factors for prolonged recovery. In conclusion, this consensus paper provides a practical stepwise approach for the clinical assessment of patients with an acute TBI at the ED. Recommendations are given for the performance of acute head CT, use of brain biomarkers and disposition after ED care including careful patient information and organization of follow-up for those discharged.

Symptoms and coronary risk factors predictive of adverse cardiac events in chest pain patients in an Asian emergency department: the need for a local prediction score.

Clinical assessment is pivotal in diagnosing acute coronary syndrome. Our study aimed to identify clinical characteristics predictive of major adverse cardiac events (MACE) in an Asian population and to derive a risk score for MACE. Patients presenting to the emergency department (ED) with chest pain and non-diagnostic 12-lead electrocardiograms were recruited. Clinical history was recorded in a predesigned template. Random glucose and direct low-density lipoprotein measurements were taken, in addition to serial troponin. We derived the age, coronary risk factors (CRF), sex and symptoms (ACSS) risk score based on multivariate analysis results, considering age, CRF, sex and symptoms and classifying patients into very low, low, moderate and high risk for MACE. Comparison was made with the ED Assessment of Chest Pain Score (EDACS) and the history, electrocardiogram, age, risk factors, troponin (HEART) score. We also modified the HEART score with the CRF that we had identified. The outcomes were 30-day and 1-year MACE. There were a total of 1689 patients, with 172 (10.2%) and 200 (11.8%) having 30-day and 1-year MACE, respectively. Symptoms predictive of MACE included central chest pain, radiation to the jaw/neck, associated diaphoresis, and symptoms aggravated by exertion and relieved by glyceryl trinitrate. The ACSS score had an area under the curve of 0.769 (95% confidence interval [CI]: 0.735-0.803) and 0.760 (95% CI: 0.727-0.793) for 30-day and 1-year MACE, respectively, outperforming EDACS. Those in the very-low-risk and low-risk groups had <1% risk of 30-day MACE. The ACSS risk score shows potential for use in the local ED or primary care setting, potentially reducing unnecessary cardiac investigations and admission.

Protocol for Improving Care by FAster risk-STratification through use of high sensitivity point-of-care troponin in patients presenting with possible acute coronary syndrome in the EmeRgency department (ICare-FASTER): a stepped-wedge cluster randomised quality improvement initiative

IntroductionClinical assessment in emergency departments (EDs) for possible acute myocardial infarction (AMI) requires at least one cardiac troponin (cTn) blood test. The turn-around time from blood draw to posting results...

Impact of first-line dalbavancin for cellulitis on hospital admissions and costs: A case series

BackgroundMany patients with cellulitis are treated with oral antibiotics as outpatients, but some require hospital admission for intravenous antibiotics. During the coronavirus disease 2019 pandemic, Betsi Cadwaladr University Health Board in Wales approved use of dalbavancin as first-line intravenous antibiotic from April to December 2020 to facilitate early discharge and prevent hospital admission. ObjectivesTo report cost savings and admission avoidance through first-line intravenous use of dalbavancin for cellulitis in one health board in Wales. Patients and methodsPatients with cellulitis who presented to the emergency department or medical assessment unit at Betsi Cadwaladr University Health Board's two hospitals between April and December 2020 were identified for treatment with dalbavancin, because they had not responded to oral antibiotics or their initial presentation warranted intravenous antibiotics. Patients received 1500 mg dalbavancin by intravenous infusion according to prescribing information and were sent home without being admitted. Outcomes were admission within 30 d of dalbavancin and cost savings from avoiding admission. Results31 patients were treated with dalbavancin for cellulitis in the emergency department or medical assessment unit. No patient was admitted within 30 d of receiving dalbavancin. Use of dalbavancin is estimated to have saved 248 bed-days over the study period, with an estimated saving of $120,444.23 based on avoidance of admission. The cost of dalbavancin for these 31 patients was $69,959.08, giving an overall cost saving of $50,485.15 ($1529.95 per patient). ConclusionsPrescribing dalbavancin as first-line intravenous antibiotic for cellulitis prevents admission, saving bed-days and admission-related costs.

Can I Discharge This Adult Patient with Abnormal Vital Signs From the Emergency Department?

BackgroundVital signs are an essential component of the emergency department (ED) assessment. Vital sign abnormalities are associated with adverse events in the ED setting and may indicate a risk of poor outcomes after ED discharge. Clinical questionWhat is the risk of adverse events among adult patients with abnormal vital signs at the time of ED discharge? Evidence reviewStudies retrieved included 6 retrospective studies with adult patients discharged from the ED. These studies evaluated adverse outcomes in adult patients discharged from the ED with abnormal vital signs. Hypotension at discharge was associated with the highest odds of adverse events after discharge. Tachycardia was also a key predictor of adverse events after discharge and may be easily missed by ED clinicians. ConclusionBased on the available evidence, the specific vital sign abnormality and the number of total abnormalities influence the risk of adverse outcomes after discharge. Vital sign abnormalities at the time of discharge also increase the risk of ED revisit. The most common abnormal vital sign at the time of discharge is tachycardia.

610 From Flames to Facts: Unveiling Discrepancies in Burn Patient Documentation

Abstract Introduction Comprehensive and accurate burn documentation is essential for initial and ongoing patient care. However, the challenge of inaccurate and incomplete records poses preventable risks. Our study evaluates burn documentation at a tertiary care burn centre, focusing on discrepancies between initial Emergency Department (ED) assessments and final evaluations by the Plastic Surgery Burn Consultant (PS). We hypothesize that the ED reports inaccurate and incomplete burn injury details, leading to differences in burn size and severity compared to PS assessments. Methods We conducted a retrospective review of our provincial burn registry from January 1, 2016, to December 31, 2021. We included patients admitted for burns warranting a PS consultation, excluding isolated first-degree, ocular, and inhalational burns, and those not requiring burn unit admission. Data covering time, date, etiology, injury details, treatment, and follow-up were collected and compared between ED and PS records. Incomplete entries lacked burn-specific data points. Mann-Whitney and Kruskal-Wallis H tests were used to compare continuous outcomes, while Pearson’s Chi-Square test was employed for categorical outcomes. Wilcoxon’s Signed-Rank test was used to identify significant variations in TBSA estimates, with PS considered the "gold" standard. Statistical significance was set at p&amp;lt; 0.05. Results 358 patients were included, with most burns in male patients (76%) occurring at home and involving the head and neck. Burn etiology, circumstances, place, and anatomic location were well reported and consistent across PS and ED documentation. However, there were significant differences in TBSA estimates. The ED calculated a median TBSA of 20 (IQR: 19.8), while PS estimated a median TBSA of 14 (IQR: 16) (p&amp;lt; 0.0019). Notably, TBSA estimates for burns &amp;lt; 10% and 10-25% showed significant differences (p&amp;lt; 0.0001), tending toward overestimation by the ED. Deeper burns were consistently over-reported during initial ED assessments compared to the final PS determinations. Furthermore, 81% of the initial records were incomplete: 66% lacked initial treatment data, 49% missed TBSA, and 39% omitted burn depth. Conclusions Significant discrepancies were appreciated in the initial ED documentation of burn injuries at our tertiary care burn centre, with overestimations in TBSA and burn depth. Over 80% of initial documentation was incomplete, with TBSA omitted in 49% of charts in both local and peripheral transfer consultations. There is a collective urgent need for enhanced awareness and education on the importance of accurate and comprehensive burn patient documentation. Applicability of Research to Practice This research emphasizes the need for improved documentation strategies for burn patients seen in the acute care setting, raising the potential to venture into modalities such as artificial intelligence and electronic health record systems to enhance burn documentation.

Impact of a Nationwide Medication History Sharing Program on the Care Process and End-User Experience in a Tertiary Teaching Hospital: Cohort Study and Cross-Sectional Study.

Timely and comprehensive collection of a patient's medication history in the emergency department (ED) is crucial for optimizing health care delivery. The implementation of a medication history sharing program, titled "Patient's In-home Medications at a Glance," in a tertiary teaching hospital aimed to efficiently collect and display nationwide medication histories for patients' initial hospital visits. As an evaluation was necessary to provide a balanced picture of the program, we aimed to evaluate both care process outcomes and humanistic outcomes encompassing end-user experience of physicians and pharmacists. We conducted a cohort study and a cross-sectional study to evaluate both outcomes. To evaluate the care process, we measured the time from the first ED assessment to urgent percutaneous coronary intervention (PCI) initiation from electronic health records. To assess end-user experience, we developed a 22-item questionnaire using a 5-point Likert scale, including 5 domains: information quality, system quality, service quality, user satisfaction, and intention to reuse. This questionnaire was validated and distributed to physicians and pharmacists. The Mann-Whiteny U test was used to analyze the PCI initiation time, and structural equation modeling was used to assess factors affecting end-user experience. The time from the first ED assessment to urgent PCI initiation at the ED was significantly decreased using the patient medication history program (mean rank 42.14 min vs 28.72 min; Mann-Whitney U=346; P=.03). A total of 112 physicians and pharmacists participated in the survey. Among the 5 domains, "intention to reuse" received the highest score (mean 4.77, SD 0.37), followed by "user satisfaction" (mean 4.56, SD 0.49), while "service quality" received the lowest score (mean 3.87, SD 0.79). "User satisfaction" was significantly associated with "information quality" and "intention to reuse." Timely and complete retrieval using a medication history-sharing program led to an improved care process by expediting critical decision-making in the ED, thereby contributing to value-based health care delivery in a real-world setting. The experiences of end users, including physicians and pharmacists, indicated satisfaction with the program regarding information quality and their intention to reuse.

Applying Sydney Triage to Admission Risk Tool (START) to improve patient flow in emergency departments: a multicentre randomised, implementation study

BackgroundTo determine the effectiveness of applying the Sydney Triage to Admission Risk Tool (START) in conjunction with senior early assessment in different Emergency Departments (EDs).MethodsThis multicentre implementation study, conducted in two metropolitan EDs, used a convenience sample of ED patients. Patients who were admitted, after presenting to both EDs, and were assessed using the existing senior ED clinician assessment, were included in the study. Patients in the intervention group were assessed with the assistance of START, while patients in the control group were assessed without the assistance of START. Outcomes measured were ED length of stay and proportion of patients correctly identified as an in-patient admission by START.ResultsA total of 773 patients were evaluated using the START tool at triage across both sites (Intervention group n = 355 and control group n = 418 patients). The proportion of patients meeting the 4-hour length of stay thresholds was similar between the intervention and control groups (30.1% vs. 28.2%; p = 0.62). The intervention group was associated with a reduced ED length of stay when compared to the control group (351 min, interquartile range (IQR) 221.0–565.0 min versus 383 min, IQR 229.25–580.0 min; p = 0.85). When stratified into admitted and discharged patients, similar results were seen.ConclusionIn this extension of the START model of care implementation study in two metropolitan EDs, START, when used in conjunction with senior early assessment was associated with some reduced ED length of stay.

External Validation of the Post-Concussion Symptoms Rule for Predicting Mild Traumatic Brain Injury Outcome.

Persistent symptoms are common after a mild traumatic brain injury (mTBI). The Post-Concussion Symptoms (PoCS) Rule is a newly developed clinical decision rule for the prediction of persistent post-concussion symptoms (PPCS) 3 months after an mTBI. The PoCS Rule includes assessment of demographic and clinical characteristics and headache presence in the emergency department (ED), and follow-up assessment of symptoms at 7 days post-injury using two thresholds (lower/higher) for symptom scoring. We examined the PoCS Rule in an independent sample. We analyzed a clinical trial that recruited participants with mTBI from EDs in Greater Vancouver, Canada. The primary analysis used data from 236 participants, who were randomized to a usual care control group, and completed the Rivermead Postconcussion Symptoms Questionnaire at 3 months. The primary outcome was PPCS, as defined by the PoCS authors. We assessed the overall performance of the PoCS rule (area under the receiver operating characteristic curve [AUC]), sensitivity, and specificity. More than 40% of participants (median age 38 years, 59% female) reported PPCS at 3 months. Most participants (88%) were categorized as being at medium risk based on the ED assessment, and a majority were considered as being at high risk according to the final PoCS Rule (81% using a lower threshold and 72% using a higher threshold). The PoCS Rule showed a sensitivity of 93% (95% confidence interval [CI], 88-98; lower threshold) and 85% (95% CI, 78-92; higher threshold), and a specificity of 28% (95% CI, 21-36) and 37% (95% CI, 29-46), respectively. The overall performance was modest (AUC 0.61, 95% CI 0.59, 0.65). In conclusion, the PoCS Rule was sensitive for PPCS, but had a low specificity in our sample. Follow-up assessment of symptoms can improve risk stratification after mTBI.

Estimation of racial and language disparities in pediatric emergency department triage using statistical modeling and natural language processing.

The study aims to assess racial and language disparities in pediatric emergency department (ED) triage using analytical techniques and provide insights into the extent and nature of the disparities in the ED setting. The study analyzed a cross-sectional dataset encompassing ED visits from January 2019 to April 2021. The study utilized analytical techniques, including K-mean clustering (KNN), multivariate adaptive regression splines (MARS), and natural language processing (NLP) embedding. NLP embedding and KNN were employed to handle the chief complaints and categorize them into clusters, while the MARS was used to identify significant interactions among the clinical features. The study also explored important variables, including age-adjusted vital signs. Multiple logistic regression models with varying specifications were developed to assess the robustness of analysis results. The study consistently found that non-White children, especially African American (AA) and Hispanic, were often under-triaged, with AA children having >2 times higher odds of receiving lower acuity scores compared to White children. While the results are generally consistent, incorporating relevant variables modified the results for specific patient groups (eg, Asians). By employing a comprehensive analysis methodology, the study checked the robustness of the analysis results on racial and language disparities in pediatric ED triage. The study also recognized the significance of analytical techniques in assessing pediatric health conditions and analyzing disparities. The study's findings highlight the significant need for equal and fair assessment and treatment in the pediatric ED, regardless of their patients' race and language.

Maxillofacial haemorrhagic symptoms in emergency department patients: impact of antithrombotics

PurposeTo investigate the effect of antithrombotics on the occurrence of maxillofacial haemorrhagic symptoms, and to determine if these haemorrhagic symptoms are predictors of maxillofacial fractures.MethodA prospective cohort study was conducted of consecutive patients with maxillofacial trauma who had been admitted to the emergency department of four hospitals in the Netherlands. This study compared five haemorrhagic symptoms (peri-orbital haematoma, raccoon eyes, epistaxis, subconjunctival ecchymosis, and intra-oral haematoma) between patients not-using (NUA) and using (UA) of antithrombotics, and whether these maxillofacial haemorrhagic symptoms served as predictors for maxillofacial fractures.ResultsOut of the 1005 patients, 812 (81%) belonged to the NUA group, and 193 (19%) to the UA group. UA patients exhibited higher frequencies of peri-orbital hematoma (54% vs. 39%, p < 0.001), raccoon eyes (10% vs. 5%, p = 0.01), and subconjunctival ecchymoses (16% vs. 7%, p < 0.001). In NUA, peri-orbital hematoma (OR = 2.5, p < 0.001), epistaxis (OR = 4.1, p < 0.001), subconjunctival ecchymosis (OR = 2.3, p = 0.02), and intra-oral hematoma (OR = 7.1, p < 0.001) were significant fracture predictors. Among UA, peri-orbital hematoma (OR = 2.2, p = 0.04), epistaxis (OR = 5.4, p < 0.001), subconjunctival ecchymosis (OR = 3.7, p = 0.008), and intra-oral hematoma (OR = 22.0, p < 0.001) were significant fracture predictors.ConclusionMaxillofacial haemorrhagic symptoms were observed more frequently in the UA group than in the NUA group. However, in both groups, maxillofacial haemorrhagic symptoms appear to be predictors of maxillofacial fractures. Caution is warranted in attributing these symptoms solely to antithrombotic use during emergency department assessments.