Emergency Department Management Of Patients Research Articles

Impact of a Point-of Care Ultrasound Examination on the Management of Acute Respiratory or Circulatory Failure Patients in the Emergency Department: The Impulse Before-and-After Implementation Study

Background: Despite its diagnostic accuracy, the clinical impact of the use of Point-of-care Ultrasound (POCUS) in the emergency department (ED) is not well described, especially when performed by junior in-training residents. Aim of the study: To assess the effect of a short, structured POCUS training program on the management of ED patients by in-training residents. Method: IMPULSE is a before-and-after implementation study, evaluating the impact of a structured POCUS training program for ED in-training residents on the management of patients admitted for acute respiratory and/or circulatory failure in a Swiss regional hospital. The training curriculum was organized in three stages and combined an on-line training course, an 8-hour practical hands-on session, and 10 supervised POCUS exams. The ED residents who successfully completed the curriculum participated in the study. Observed outcomes were time to ED diagnosis, rate of correct diagnosis made during the ED stay and time needed to reach it, time to prescribe an appropriate treatment, and hospital mortality. Standard statistical analyses were performed with the use of Chi-square and Mann-Whitney U tests as appropriate, completed by a Bayesian analysis, with a Bayes Factor (BF) >3 considered as significant. Results: Sixty-nine patients were included before the training program implementation and 54 after. After implementation, the median time to ED diagnosis was 25 minutes (IQR 44) vs 30 minutes (IQR 56) before implementation, a difference that was significant (BF 9.6). The rate of correct diagnosis was higher (95 vs 52%) (p<0.001) and the time to make this correct diagnosis was significantly shorter after implementation (25 minutes, IQR 45, vs 43, IQR 60) (BF 5.0). This had an impact on the median time to prescribe the appropriate therapy, with a trend toward a shorter delay (47 minutes, IQR 76, vs 70, IQR 100) (BF 2.0). Eventually, there was a significant difference in hospital mortality (13% vs 5.5%, BF 15.7). Conclusion: The IMPULSE study shows that the implementation of a short, structured POCUS training program for ED residents to use ultrasound for the initial evaluation of acute respiratory and circulatory failure patients has an impact on diagnostic accuracy, on time to make a correct diagnosis and to prescribe an appropriate therapy, and eventually possibly on hospital mortality. If these results are reproduced in other settings, POCUS use by ED residents after short, structured training curriculum could become the standard of care for these patients.

Physicians’ Perceptions of Clinical Decision Support to Treat Patients With Heart Failure in the ED

Clinical decision support (CDS) could help emergency department (ED) physicians treat patients with heart failure (HF) by estimating risk, collating relevant history, and assisting with medication prescribing if physicians' perspectives inform its design and implementation. To evaluate CDS usability and workflow integration in the hands of ED physician end users who use it in clinical practice. This mixed-methods qualitative study administered semistructured interviews to ED physicians from 2 community EDs of Kaiser Permanente Northern California in 2023. The interview guide, based on the Usability Heuristics for User Interface Design and the Sociotechnical Environment models, yielded themes used to construct an electronic survey instrument sent to all ED physicians. Main outcomes were physicians' perceptions of using CDS to complement clinical decision-making, usability, and integration into ED clinical workflow. Seven key informant physicians (5 [71.4%] female, median [IQR] 15.0 [9.5-15.0] years in practice) were interviewed and survey responses from 51 physicians (23 [45.1%] female, median [IQR] 14.0 [9.5-17.0] years in practice) were received from EDs piloting the CDS intervention. Response rate was 67.1% (51 of 76). Physicians suggested changes to CDS accessibility, functionality, and workflow integration. Most agreed that CDS would improve patient care and fewer than half of physicians expressed hesitation about their capacity to consistently comply with its recommendations, citing workload concerns. Physicians preferred a passive prompt that encouraged, but did not mandate, interaction with the CDS. In this qualitative study of physicians who were using a novel CDS intervention to assist with ED management of patients with acute HF, several opportunities were identified to improve usability as well as several key barriers and facilitators to CDS implementation.

Clinical Policy: Critical Issues in the Evaluation and Management of Emergency Department Patients With Suspected Appendicitis: Approved by ACEP Board of Directors February 1, 2023.

This clinical policy from the American College of Emergency Physicians is a revision of the 2010 “Clinical Policy: Critical Issues in the Evaluation and Management of Emergency Department Patients With Suspected Appendicitis.” A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions: 1) in ED patients with possible acute appendicitis, can a clinical prediction rule be used to identify patients for whom no advanced imaging is required? 2) in ED patients with suspected acute appendicitis, is the diagnostic accuracy of ultrasound comparable with computed tomography or magnetic resonance imaging for the diagnosis of acute appendicitis? 3) in ED patients who are undergoing computed tomography of the abdomen and pelvis for suspected acute appendicitis, does the addition of contrast improve diagnostic accuracy? Evidence was graded, and recommendations were made based on the strength of the available data.

Emergency Department Management of Patients With Alcohol Intoxication, Alcohol Withdrawal, and Alcohol Use Disorder: A White Paper Prepared for the American Academy of Emergency Medicine

Emergency Department Management of Patients With Alcohol Intoxication, Alcohol Withdrawal, and Alcohol Use Disorder: A White Paper Prepared for the American Academy of Emergency Medicine

Evaluating Safety, Effectiveness, and Resource Efficiency in Management Strategies for Intermediate Risk Choledocholithiasis: Defining the Optimal Approach

INTRODUCTION: Optimal management of emergency department patients with intermediate-risk choledocholithiasis (IR-CDL) remains undefined. At a safety-net hospital where timely patient throughput is essential, we hypothesized that forgoing additional preoperative diagnostics and proceeding directly to laparoscopic cholecystectomy (LC) ± intraoperative cholangiogram (IOC) is a safe, effective, and resource-efficient strategy. METHODS: Adults with IR-CDL who underwent cholecystectomy during index hospitalization from 2016 to 2020 were included. IR-CDL was defined as total bilirubin 1.8 to 4.0 mg/dL, common bile duct (CBD) >6 mm, or gallstone pancreatitis on admission. Safety was assessed using the rate of CBD injury, reoperation, readmission, and retained CBD stones within 30 days of discharge. Effectiveness was assessed using the rate of successful endoscopic CBD clearance. Efficiency was measured using hospital length of stay (LOS) and direct and total cost. Patients taken direct-to-operating room (OR) for LC ± IOC were compared with those who received preoperative magnetic resonance cholangiopancreatography (MRCP) and/or endoscopic retrograde cholangiopancreatography (ERCP) (“additional-workup”). RESULTS: Of 655 patients, 611 (93%) were direct-to-OR and 44 (7%) were additional workup. Demographics were similar between groups. There was no difference in CBD injury, reoperation, readmission, or retained stones after discharge (all p > 0.05; Table). Of direct-to-OR patients who underwent LC+IOC, 34% had choledocholithiasis. Rates of successful endoscopic CBD clearance were similar between preoperative and postoperative ERCP (97% vs 100%, p = 0.96). Direct-to-OR patients had a shorter median hospital LOS by 38.5 hours and lower median direct and total cost by $5,121/patient and $8,535/patient, respectively.TableCONCLUSION: Proceeding directly to the OR for LC ± IOC expedites treatment of IR-CDL at lower cost without compromising safety or efficacy. These findings help clarify optimal management of IR-CDL.

Using a 29-mRNA Host Response Classifier To Detect Bacterial Coinfections and Predict Outcomes in COVID-19 Patients Presenting to the Emergency Department.

Clinicians in the emergency department (ED) face challenges in concurrently assessing patients with suspected COVID-19 infection, detecting bacterial coinfection, and determining illness severity since current practices require separate workflows. Here, we explore the accuracy of the IMX-BVN-3/IMX-SEV-3 29 mRNA host response classifiers in simultaneously detecting severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and bacterial coinfections and predicting clinical severity of COVID-19. A total of 161 patients with PCR-confirmed COVID-19 (52.2% female; median age, 50.0 years; 51% hospitalized; 5.6% deaths) were enrolled at the Stanford Hospital ED. RNA was extracted (2.5 mL whole blood in PAXgene blood RNA), and 29 host mRNAs in response to the infection were quantified using Nanostring nCounter. The IMX-BVN-3 classifier identified SARS-CoV-2 infection in 151 patients with a sensitivity of 93.8%. Six of 10 patients undetected by the classifier had positive COVID tests more than 9 days prior to enrollment, and the remaining patients oscillated between positive and negative results in subsequent tests. The classifier also predicted that 6 (3.7%) patients had a bacterial coinfection. Clinical adjudication confirmed that 5/6 (83.3%) of the patients had bacterial infections, i.e., Clostridioides difficile colitis (n = 1), urinary tract infection (n = 1), and clinically diagnosed bacterial infections (n = 3), for a specificity of 99.4%. Two of 101 (2.8%) patients in the IMX-SEV-3 "Low" severity classification and 7/60 (11.7%) in the "Moderate" severity classification died within 30 days of enrollment. IMX-BVN-3/IMX-SEV-3 classifiers accurately identified patients with COVID-19 and bacterial coinfections and predicted patients' risk of death. A point-of-care version of these classifiers, under development, could improve ED patient management, including more accurate treatment decisions and optimized resource utilization. IMPORTANCE We assay the utility of the single-test IMX-BVN-3/IMX-SEV-3 classifiers that require just 2.5 mL of patient blood in concurrently detecting viral and bacterial infections as well as predicting the severity and 30-day outcome from the infection. A point-of-care device, in development, will circumvent the need for blood culturing and drastically reduce the time needed to detect an infection. This will negate the need for empirical use of broad-spectrum antibiotics and allow for antibiotic use stewardship. Additionally, accurate classification of the severity of infection and the prediction of 30-day severe outcomes will allow for appropriate allocation of hospital resources.

Clinical impact of the rapid molecular detection of RSV and influenza A and B viruses in the emergency department.

IntroductionUsing respiratory virus rapid diagnostic tests in the emergency department could allow better and faster clinical management. Point-of-care PCR instruments now provide results in less than 30 minutes. The objective of this study was to assess the impact of the use of a rapid molecular diagnostic test, the cobas® Influenza A/B & RSV Assay, during the clinical management of emergency department patients.MethodsPatients (adults and children) requiring admission or suffering from an underlying condition at risk of respiratory complications were prospectively recruited in the emergency department of four hospitals in the Brussels region. Physicians’ intentions regarding admission, isolation, antibiotic, and antiviral use were collected before and after performing the rapid molecular test. Additionally, a comparison of the analytical performance of this test against antigen rapid tests and viral culture was performed as well as a time-to-result evaluation.ResultsAmong the 293 patients recruited, 90 had a positive PCR, whereas 44 had a positive antigen test. PCR yielded a sensitivity of 100% for all targets. Antigen tests yielded sensitivities ranging from 66.7% for influenza B to 83.3% for respiratory syncytial virus (RSV). The use of PCR allowed a decrease in the overall need for isolation and treatment by limiting the isolation of negative patients and antibiotic use for positive patients. Meanwhile, antiviral treatments better targeted patients with a positive influenza PCR.ConclusionThe use of a rapid influenza and RSV molecular test improves the clinical management of patients admitted to the emergency department by providing a fast and reliable result. Their additional cost compared to antigen tests should be balanced with the benefit of their analytical performance, leading to efficient reductions in the need for isolation and antibiotic use.

The clinical effectiveness of the STUMBL score for the management of ED patients with blunt chest trauma compared to clinical evaluation alone

The STUMBL (STUdy of the Management of BLunt chest wall trauma) score is a new prognostic score to assist ED (Emergency Department) decision making in the management of blunt chest trauma. This is a retrospective cohort chart review study conducted in a UK University Hospital ED seeing 120,000 patients a year, comparing its performance characteristics to ED clinician judgement. All blunt chest trauma patients that presented to our ED over a 6-month period were included. Patients were excluded if age < 18, if they had immediate life-threatening injury, required critical care admission for other injuries or in case of missing identification data. Primary endpoint was complication defined as any of lower respiratory tract infection, pulmonary consolidation, empyema, pneumothorax, haemothorax, splenic or hepatic injury and 30-day mortality. Clinician judgement (clinician decision to admit) and STUMBL score were compared using the receiver-operating curve (ROC) and sensitivity analysis. Three hundred and sixty-nine patients were included. ED clinicians admitted 95 of 369 patients. ED clinician decision to admit had a sensitivity of 83.9% and specificity of 86.0% for predicting complications. STUMBL score ≥ 11 had a sensitivity of 79.0% and specificity of 77.9% for the same and would have led to 117 of 369 patients being admitted. Area under the curve (AUC) of STUMBL score and ED clinician decision to admit was 0.84 (95% CI 0.78–0.90) and 0.85 (95% CI 0.79–0.91), respectively. Our findings show that a STUMBL score ≥ 11 performs no better than ED clinician judgement and leads to more patients being admitted to hospital.

Improving the accuracy of Nurse Initiated X-ray Orders (NIXO) in the Emergency Department

Purpose: In Sengkang General Hospital (SKH), Emergency Department (ED) triage nurses are privileged to order x-rays for patients prior to consultation with the ED doctors based on the initial presenting complaints. This workflow was implemented to improve the efficiency of patient management in ED. However, SKH ED radiographers encountered several orders from triage nurses that were deemed inappropriate or inaccurate. Such orders have led to several near-miss cases that could compromise patient safety and potential medico-legal issues. It also subjects patients to unnecessary radiation. This study aims to evaluate if using an educational tool can improve the accuracy of x-ray orders by ED triage nurses.Methods: Inappropriate or inaccurate x-ray orders are defined as x-ray orders that are ordered for incorrect region, incorrect side or inaccurate clinical history. An educational package in the form of presentation slides was created for the nurses by a team of radiographers. This package is called NIXO, an abbreviation of Nurse Initiated X-ray Orders. NIXO was then presented to the ED triage nurses during their monthly Continuing Professional Development (CPD) session in June 2021. With the assistance of the ED nursing education team, data for nurse's x-ray orders were obtained three months before and after the CPD session. The results of this data will determine the effectiveness of the NIXO presentation to the triage nurses.Results: Data was collected between April 2021 to June 2021 (pre-CPD) and August 2021 to October 2021 (post-CPD). It was found in the initial results that there is a drop in the x-ray orders error rates. This showed that there has been an improvement in the accuracy of ED triage nurse's x-ray ordering. In addition, in a post-CPD presentation survey conducted, 99% of the triage nurses found this initiative to be helpful in their clinical work. Collection of data is still ongoing up till February 2022. The results of this study will be evaluated once again in February 2022.Conclusion: Based on the preliminary findings of this study, it suggests that NIXO has helped reduce the number of inappropriate orders made by ED triage nurses. This inter-professional education initiative has provided ED triage nurses with the knowledge required to order X-rays competently whilst ensuring patient safety and providing care. As such, NIXO education package will be integrated into the ED triage course in future. Purpose: In Sengkang General Hospital (SKH), Emergency Department (ED) triage nurses are privileged to order x-rays for patients prior to consultation with the ED doctors based on the initial presenting complaints. This workflow was implemented to improve the efficiency of patient management in ED. However, SKH ED radiographers encountered several orders from triage nurses that were deemed inappropriate or inaccurate. Such orders have led to several near-miss cases that could compromise patient safety and potential medico-legal issues. It also subjects patients to unnecessary radiation. This study aims to evaluate if using an educational tool can improve the accuracy of x-ray orders by ED triage nurses. Methods: Inappropriate or inaccurate x-ray orders are defined as x-ray orders that are ordered for incorrect region, incorrect side or inaccurate clinical history. An educational package in the form of presentation slides was created for the nurses by a team of radiographers. This package is called NIXO, an abbreviation of Nurse Initiated X-ray Orders. NIXO was then presented to the ED triage nurses during their monthly Continuing Professional Development (CPD) session in June 2021. With the assistance of the ED nursing education team, data for nurse's x-ray orders were obtained three months before and after the CPD session. The results of this data will determine the effectiveness of the NIXO presentation to the triage nurses. Results: Data was collected between April 2021 to June 2021 (pre-CPD) and August 2021 to October 2021 (post-CPD). It was found in the initial results that there is a drop in the x-ray orders error rates. This showed that there has been an improvement in the accuracy of ED triage nurse's x-ray ordering. In addition, in a post-CPD presentation survey conducted, 99% of the triage nurses found this initiative to be helpful in their clinical work. Collection of data is still ongoing up till February 2022. The results of this study will be evaluated once again in February 2022. Conclusion: Based on the preliminary findings of this study, it suggests that NIXO has helped reduce the number of inappropriate orders made by ED triage nurses. This inter-professional education initiative has provided ED triage nurses with the knowledge required to order X-rays competently whilst ensuring patient safety and providing care. As such, NIXO education package will be integrated into the ED triage course in future.

Racial disparities in the management of emergency department patients presenting with psychiatric disorders

PurposeEmergency departments (ED) provide critical resources including stabilization, diagnosis of underlying medical precipitants and transfer to psychiatric hospitals for mental health emergencies. Our objective was to examine the association of race and/or ethnicity and the administration of chemcial sedation using a nationally representative sample of ED visits for psychiatric disorders. MethodsWe analyzed data from 2008 to 2018 through the National Hospital Ambulatory Medical Survey database, a national probability survey based on ED chart abstraction. All ED visits for psychiatric disorders were included. Our primary outcome variable was receipt of chemical sedation among patients presenting with a complaint related to a psychiatric condition. We defined receipt of chemical sedation by the receipt of a first or second-generation antipsychotic or ketamine that was given in the ED. Our secondary outcome was receipt of psychiatric treatment defined as admission to a mental health and/or detox unit at the same hospital or transfer to a psychiatric facility. We used logistic regression models and used marginal effects to report the average adjusted probability in outcomes for different patient characteristics. ResultsNationally after weighting, 76,200,000 of 1,480,102,130 total ED visits (5.1%, 95% CI 4.9%–5.4%) were designated to be for treatment of a psychiatric disorder. When controlling for patient age, sex, initial pulse, presence of chronic medical conditions, geographic region, EMS arrival and nightshift arrival, among patients presenting with psychiatric disorders, Black race was associated with a 2.2% point (95% CI 0.8–3.7, P < .01) greater probability of receiving chemical sedation than non-Hispanic (NH) white race and/or ethnicity (3.0%) and this difference remained significant when accounting for admission or transfer to psychiatric facilities. However, when accounting for the percent of hospital population that was Black (P < .01), individual patient race was no longer associated with a significant increase in receipt of chemical sedation. There was no significant association between race and/or ethnicity and admission or transfer to psychiatric facilities. ConclusionNationally, Black patients presenting to the ED are more likely to receive chemical sedation than NH-white patients for psychiatric complaints, and this appears to be because hospitals serving a high proportion of Black patients use more chemical sedation, suggesting structural racism is a potential root cause.

CHEST PAIN IN WOMEN. IS IT ALWAYS ATHEROSCLEROTIC?

Patients both male and female with diagnosis of Acute Coronary Syndrome (ACS) present with chest pain as presenting complaint. Lichtman JH et al. in his study with ACS showed that 93% of women presented with chest pain or discomfort.1 As compared to men women experience more associated symptoms as primary complaint. The associated symptoms are fatigue, dyspnea, backache, flue like symptoms, indigestion, palpitations and most common is anxiety &amp; feeling scarry.2 Keeping these scenarios in mind one should inquire this associated presentation along with chest pain or discomfort in evaluating ACS in women. In continuation with symptoms there is quite a debate on pathophysiology of Acute Myocardial infraction in men and women regarding coronary pathologic features.3 Type 1 plaque rupture most common in both genders with plaque erosion most common in women in non-obstructive coronary artery disease.4 Spontaneous coronary artery dissection (SCAD) having high mortality exists in the absence of risk factor of ACS.5 It was found in women up to 35% of patients with mean age of 42 to 53 years with a MACE (Major acute coronary event) of 47.4% and 10 years mortality rate of 7.7%2 SCAD seen in peripartum cases, oral contraception use, lack of exercise, connective tissue disorders and vasculidites. It is important for the physician to have in mind these disorders to avoid complications of coronary interventions. In a scientific statement from AHA, Mehte LS et al. showed a lower prevalence of atheroscrotic CAD in women.3 These are certain scoring system,6 that under present women because of vague symptoms and presentation. These scoring systems lead to decrease hospital admission and less noninvasive cardiac testing. For risk satisfaction of chest pain female gender should not be taken as sole criteria for presence or absence of coronary events in presence of other multiple factors. The last but not the least is the psychosocial stress more in women than in men. It has been found that young women who present with early onset myocardial infarction have more psychosocial risk factors in comparison to men of similar age,3 probably having high rates of poverty and trauma exposure during childhood because of various reasons.7 Different studies are endorsing relationship between depression and ischemic heart disease as prognostic factor after ACS.7 In our population where there is lack of education, poverty, awareness of disease especially in women the physician should ponder on different factors mentioned above i.e. presentation perceptions, prevalence, pathophysiology and psychosocial stress for evaluation and management of chest pain.

Comparing Treatment Outcomes Between In-Hospital and Emergency Department Management of Patients With Transient Ischemic Attacks.

IntroductionA transient ischemic attack (TIA) is a medical emergency, as it is a sudden neurological episode caused by ischemia in a vascular territory in the brain, which lasts less than one hour. TIA definition has shifted from time-based to tissue-based according to modern literature. It is considered a warning sign for an impending stroke. Symptoms could range from weakness on one side of the body, diaphoresis, to slurred speech. In this study, we examined the differences in health outcomes, when patients diagnosed with TIA are treated and discharged home from the ED, versus when admitted to the hospital for additional care.MethodsThis is a descriptive and retrospective study. We examined all patients’ encounters from January 1, 2018 to December 31, 2019 at four emergency department locations. The cohort compared patients diagnosed with a TIA who takes medications (anti-lipid, antiplatelet drugs) versus patients diagnosed with a TIA who are not on any preventive medication. We compared the hospital readmission rate between these two group of patients and the need for additional medical treatments. Our study also considered hospital length of stay (LOS), admission rate, and its impact on patients with comorbidities.ResultsThere were 983 patients included in the study. The patients on TIA prophylactic medications prior to coming to the ED made up (60.7%), and (51.2%) in this group required additional medications during hospital admission. The remaining 162 (39.3%), p=0.001 patients, were not on TIA prophylactic medications prior to presenting in the ED. The patients who required additional medications while in the ED were significantly older (mean +/-SD, 68.6 +/-14.0 years versus 62.18 +/- 17.4 years, p=0.001). Following a multivariate analysis, age greater than 60 (CI: 3.52-3.91, p=0.001) and results of the head CT/MRI investigations for any signs of neurological damage, were all found to be independent predictors of longer hospital stay and treatment outcomes. There were no significant differences in the treatment outcome for patients with TIA based on longer hospital stay and extra medication administration in the ED.ConclusionIn our study, we observed that approximately, 75% of the patients who were on TIA prophylactic medications prior to presenting in the ED with symptoms of TIA were admitted to the hospital for further monitoring, compared to other group of patients who were not on TIA medications. We did also noted that there were no differences in mortality outcome between patients treated and discharged from the ED, versus patients admitted to the hospital for additional treatment. Lastly, patients who are 68 years and older, made up two-thirds of patient population admitted in the hospital and required additional medications, compared to younger patients.

MP54-18 USE OF MACHINE LEARNING IN THE PREDICTION OF EMERGENCY DEPARTMENT MANAGEMENT OF PATIENTS WITH UROLITHIASIS

You have accessJournal of UrologyStone Disease: Epidemiology & Evaluation II (MP54)1 Sep 2021MP54-18 USE OF MACHINE LEARNING IN THE PREDICTION OF EMERGENCY DEPARTMENT MANAGEMENT OF PATIENTS WITH UROLITHIASIS Akhil A. Saji, John L. Phillips, Majid Eshghi, and Nathan C. Wong Akhil A. SajiAkhil A. Saji More articles by this author , John L. PhillipsJohn L. Phillips More articles by this author , Majid EshghiMajid Eshghi More articles by this author , and Nathan C. WongNathan C. Wong More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002084.18AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The initial acute management of patients with urolithiasis is often conducted by non-urologists. We explored whether machine learning (ML) algorithms can be used to aid in the identification of patients who are appropriate for conservative management or prioritized for acute urologic intervention. METHODS: We performed a retrospective review of patients who presented to the emergency department and underwent initial observation with a diagnosis of urolithiasis at our tertiary center between January 2014 and October 2016. We trained six unique machine learning models with 27 different variables including patient demographics, clinical presentation, laboratory/imaging, initial management) in a hypothesis-free manner to build models that could predict need for urologic intervention. To create our ML models, the cohort data was randomly split into 80/20 training and test sub-cohorts with a respective intervention prevalence of 35.4% and 43.9%. RESULTS: A total of 137 patients were included in our study cohort, of which 52 (38%) were admitted to hospital and underwent urologic intervention (our predictive outcome of interest) including stent placement and ureteroscopy or percutaneous nephrolithotripsy. The other 85 patients were discharged and underwent outpatient management. The area under the curve for our models was highest with random forest (RF) (0.957) and gradient boost (GB) (0.918), followed by decision tree (0.792) and K-nearest neighbor (0.746), and then stochastic gradient descent (0.657) and naïve bayes (0.623). We also evaluated the predictive capacity of traditional statistic modeling with logistic regression (LR) as a comparator which had an AUC of 0.667 (Figure 1). CONCLUSIONS: Our machine learning algorithms may accurately predict the need for urologic intervention for patients with urolithiasis, particularly random forest and gradient boost classifiers which both outperformed traditional logistic regression. With further refinement and the addition of more data, these algorithms may be used by non-urologists to aid in the decision making process of these patients. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e956-e957 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Akhil A. Saji More articles by this author John L. Phillips More articles by this author Majid Eshghi More articles by this author Nathan C. Wong More articles by this author Expand All Advertisement Loading ...

A survey of current practice in UK emergency department management of patients with blunt chest wall trauma not requiring admission to hospital

IntroductionThere is no universal agreement or supporting evidence for the content or format of a standardised guidance document for patients with blunt chest wall trauma. The aim of this study is to investigate current UK Emergency Medicine practice of the management of patients with blunt chest wall trauma, who do not require admission to hospital. MethodsThis was a cross-sectional survey study, with mixed quantitative / qualitative analysis methods. A convenience sample of all professions working in the Emergency Departments / Urgent Care Centres in the UK was used. A combination of closed and open-ended questions were included, covering demographics and current practice in the respondent's main place of work. Themes explored included management strategies for safe discharge home, risk prediction and variables considered relevant for inclusion in patient guidance. ResultsA total of 113 clinicians responded from all UK trauma networks, including all devolved nations. A total of 20 different risk prediction tools / pathways were reported to be used when assessing whether a patient is safe for discharge home, with over 35 different variables listed by respondents as being important to highlight to patients. Qualitative analysis revealed that a small number of respondents believe patients can be better managed through the improvement of the following; identification of the high-risk patient, initial assessment and current management strategies used in the ED / UCC. DiscussionThe wide variation in practice highlighted in this study may be due in part to a lack of national consensus guidelines on how to manage this complex patient group. Further research is needed into whether structured national guidelines for the assessment and management of such patients could potentially lead to an overall improvement in outcomes. Such guidelines should be developed by not only expert clinicians and researchers, but also and more importantly by those service-users who have lived experience of blunt chest wall trauma.

Emergency department management of patients with adult congenital heart disease: a consensus paper from the ESC Working Group on Adult Congenital Heart Disease, the European Society for Emergency Medicine (EUSEM), the European Association for Cardio-Thoracic Surgery (EACTS), and the Association for Acute Cardiovascular Care (ACVC).

Adult congenital heart disease (ACHD) patients represent a growing population with increasing use of acute emergency department (ED) care. Providing comprehensive ED care necessitates an understanding of the most common clinical scenarios to improve morbidity and mortality in this population. The aim of this position document is to provide a consensus regarding the management of the most common clinical scenarios of ACHD patients presenting to the ED.

Clinical Practice Statement: What is the Emergency Department Management of Patients with Angioedema Secondary to an ACE-Inhibitor?

Angioedema is a complication that has been reported in up to 1.0% of individuals taking angiotensin-converting enzyme inhibitors (ACE-Is). Importantly, the onset of angioedema can occur anywhere from hours to several years after initiation of therapy with ACE-Is. Although most cases of ACE-I-induced angioedema (ACE-I-AE) are self-limiting, a major clinical concern is development of airway compromise, which can potentially require emergent airway management. The underlying pathophysiology of ACE-I-AE is incompletely understood, but is considered to be due in large part to excess bradykinin. Numerous medications have been proposed for the treatment of ACE-I-AE. This article is an update to the 2011 Clinical Practice Committee (CPC) statement from the American Academy of Emergency Medicine. A literature search in PubMed was performed with search terms angioedema and ACE inhibitors from August 1, 2012 to May 13, 2019. Following CPC guidelines, articles written in English were identified and then underwent a structured review for evaluation. The search parameters resulted in 323 articles. The abstracts of these articles were assessed independently by the reviewers, who determined there were 63 articles that were specific to ACE-I-AE, of which 46 were deemed appropriate for grading in the final focused review. The primary focus for the treatment of ACE-I-AE is airway management. In the absence of high-quality evidence, no specific medication therapy is recommended for its treatment. If, however, the treating physician feels the patient's presentation is more typical of an acute allergic reaction or anaphylaxis, it may be appropriate to treat for those conditions. Any patient with suspected ACE-I-AE should immediately discontinue that medication.

482 New Zealand Rural Hospital Junior Doctor General Surgery Guidelines for Emergency Department (ED): every little helps

Abstract Introduction Clinical guidelines are associated with improved patient outcomes. This is especially true for junior staff members with little clinical experience. We created Pocket Guidelines for the management of surgical patients in ED, aimed at house officers. Method Seventeen common surgical conditions were selected for guidelines. Information was collated on presentation, exam findings, differential diagnosis, laboratory tests, imaging, indications for referral, and timing. Evidence based guidelines were approved by General Surgical consultants in the department. The utility of our guidelines was assessed by surveying 20 junior doctors. Results 16 out of 20 house officers responded to the survey, ranging from post graduate year (PGY) 1 to 4, majority of them (37.5%) being PGY1. 69% were female and 31% were male. A 5- point Likert scale was utilised for answers. No house officers ‘strongly agreed’ with being confident in managing surgical conditions in ED. Over 80% strongly agreed with the need to have ED clinical guidelines for surgical patients. Over 90% of house officers, having studied the pocket guidelines, found these useful. Conclusions We implemented pocket guidelines for general surgery in a rural hospital ED to streamline surgical admissions. Guidelines were found to be beneficial by the majority of junior doctors.

Evaluating Sex Disparities in the Emergency Department Management of Patients With Suspected Acute Coronary Syndrome

We compare clinical management and outcomes of emergency department (ED) encounters by sex after implementation of a clinical care pathway in 15 community EDs that standardized recommendations based on patient risk, using the History, ECG, Age, Risk Factors, and Troponin (HEART) score. This was a retrospective analysis of adult ED encounters evaluated for suspected acute coronary syndrome with a documented HEART score from May 20, 2016, to December 1, 2017. The primary outcomes were hospitalization or 30-day stress testing. Secondary outcomes included 30-day acute myocardial infarction or all-cause death (major adverse cardiac event). A generalized estimating equation regression model was used to compare the odds of hospitalization or stress testing by sex; we report HEART scores (0 to 10) stratified by sex and describing major adverse cardiac events. A total of 34,715 adult ED encounters met the inclusion criteria (56.0% women). A higher proportion of women were classified as low risk (60.5% versus 52.4%; odds ratio [OR] 1.39; 95% confidence interval [CI] 1.33 to 1.45). Women were hospitalized or received stress testing less frequently than men for low HEART scores (18.8% versus 22.8%; OR 0.79; 95% CI 0.73 to 0.84) and intermediate ones (46.7% versus 49.7%; OR 0.88; 95% CI 0.83 to 0.95), but similarly for high-risk ones (74.1% versus 74.4%; OR 0.99; 95% CI 0.77 to 1.28). Women had 18% lower odds of hospitalization or noninvasive cardiac testing (OR 0.82; 95% CI 0.78 to 0.86), even after adjusting for HEART score and comorbidities. Men had higher risks of major adverse cardiac events than women for all HEART score categories but the risk for men was significantly higher among low-risk HEART scores (0.4% versus 0.1%). Women with low-risk HEART scores are hospitalized or stress tested less than men, which is likely appropriate, and women have better outcomes than men. Use of the HEART score has the potential to reduce sex disparities in acute coronary syndrome care.

Quantifying Dynamic Flow of Emergency Department (ED) Patient Managements: A Multistate Model Approach.

Background Emergency department (ED) crowding and prolonged lengths of stay continue to be important medical issues. It is difficult to apply traditional methods to analyze multiple streams of the ED patient management process simultaneously. The aim of this study was to develop a statistical model to delineate the dynamic patient flow within the ED and to analyze the effects of relevant factors on different patient movement rates. Methods This study used a retrospective cohort available with electronic medical data. Important time points and relevant covariates of all patients between January and December 2013 were collected. A new five-state Markov model was constructed by an expert panel, including three intermediate states: triage, physician management, and observation room and two final states: admission and discharge. A day was further divided into four six-hour periods to evaluate dynamics of patient movement over time. Results A total of 149,468 patient records were analyzed with a median total length of stay being 2.12 (interquartile range = 6.51) hours. The patient movement rates between states were estimated, and the effects of the age group and triage level on these movements were also measured. Patients with lower acuity go home more quickly (relative rate (RR): 1.891, 95% CI: 1.881–1.900) but have to wait longer for physicians (RR: 0.962, 95% CI: 0.956–0.967) and admission beds (RR: 0.673, 95% CI: 0.666–0.679). While older patients were seen more quickly by physicians (RR: 1.134, 95% CI: 1.131–1.139), they spent more time waiting for the final state (for admission RR: 0.830, 95% CI: 0.821–0.839; for discharge RR: 0.773, 95% CI: 0.769–0.776). Comparing the differences in patient movement rates over a 24-hour day revealed that patients wait longer before seen by physicians during the evening and that they usually move from the ED to admission afternoon. Predictive dynamic illustrations show that six hours after the patients' entry, the probability of still in the ED system ranges from 28% in the evening to 38% in the morning. Conclusions The five-state model well described the dynamic ED patient flow and analyzed the effects of relevant influential factors at different states. The model can be used in similar medical settings or incorporate different important covariates to develop individually tailored approaches for the improvement of efficiency within the health professions.

Outpatient versus observation/inpatient management of emergency department patients rapidly ruled-out for acute myocardial infarction: Findings from the HIGH-US study

The actual Emergency Department (ED) dispositions of patients enrolled in observational studies and meeting criteria for rapid acute myocardial infarction (AMI) rule-out are unknown. Additionally, their presenting clinical profiles, cardiac testing/treatments received, and outcomes have not been reported. Patients in the HIGH-US study (29 sites) that ruled-out for AMI using a high-sensitivity cardiac troponin I 0/1-hour algorithm were evaluated. Clinical characteristics of patients having ED discharge were compared to patients placed in observation or hospital admitted (OBS/ADM). Reports of any OBS/ADM cardiac stress test (CST), cardiac catheterization (Cath) and coronary revascularization were reviewed. One year AMI/death and major adverse cardiovascular event rates were determined. Of the 1,020 ruled-out AMI patients 584 (57.3%) had ED discharge. The remaining 436 (42.7%) were placed in OBS/ADM. Patients with risk factors for AMI, including personal or family history of coronary artery disease, hypertension, previous stroke or abnormal ECG were more often placed in OBS/ADM. 175 (40.1%) had a CST. Of these 32 (18.3%) were abnormal and 143 (81.7%) normal. Cath was done in 11 (34.3%) of those with abnormal and 13 (9.1%) with normal CST. Of those without an initial CST 85 (32.6%) had Cath. Overall, revascularizations were performed in 26 (6.0%) patients. One-year AMI/death rates were low/similar (P = .553) for the groups studied. Rapidly ruled-out for AMI ED patients having a higher clinician perceived risk for new or worsening coronary artery disease and placed in OBS/ADM underwent many diagnostic tests, were infrequently revascularized and had excellent outcomes. Alternate efficient strategies for these patients are needed.