Emergency Department Observation Unit Research Articles

Antimicrobial Stewardship in the Emergency Department Observation Unit: Definition of a New Indicator and Evaluation of Antimicrobial Use and Clinical Outcomes.

We aimed to define a novel indicator for monitoring antimicrobial use specifically in the Emergency Department Observation Unit (EDOU) and to assess the long-term impact of an institutional education-based antimicrobial stewardship program (ASP) on the antimicrobial prescribing pattern and clinical outcomes in this setting. A quasi-experimental interrupted time-series study was performed from 2011 to 2022. An educational ASP was implemented at the EDOU in 2015. To estimate changes in antimicrobial use, we designed an indicator adjusted for patients at risk of antimicrobial prescribing: defined daily doses (DDDs) per 100 patients transferred from the Emergency Department to the Observation Unit (TOs) per quarter. The number of bloodstream infections (BSIs) and the crude all-cause 14-day mortality were assessed as clinical outcomes. Antimicrobial use showed a sustained reduction with a trend change of -1.17 DDD per 100 TO and a relative effect of -45.6% (CI95% -64.5 to -26.7), particularly relevant for meropenem and piperacillin-tazobactam, with relative effects of -80.4% (-115.0 to -45.7) and -67.9% (-93.9 to -41.9), respectively. The incidence density of all BSIs increased significantly during the ASP period, with a relative effect of 123.2% (41.3 to 284.7). The mortality rate remained low and stable throughout the study period, with an absolute effect of -0.7% (-16.0 to 14.7). The regular monitoring of antimicrobial use in the EDOU by using this new quantitative indicator was useful to demonstrate that an institutional education-based ASP successfully achieved a long-term reduction in overall antimicrobial use, with a low and steady BSI mortality rate.

The feasibility of emergency department observation units in the management of mild to moderate hyponatremia

ObjectiveTo describe the feasibility of managing hyponatremia patients under outpatient observation status in an academic medical center, and compare outcomes based on the use of an emergency department observation unit (EDOU). MethodsThis is a retrospective cohort study of emergency department hyponatremic patients managed in four hospitals within a large urban academic medical center over 27 months. All patients had an admit-to-observation order, ICD-10 codes for hyponatremia, and mild (130–135 mmol/L) to moderate (121–129 mmol/L) hyponatremia. Observation settings were divided into two groups: EDOU and Non-Observation Unit (NOU) inpatient beds. Severe hyponatremia (≤120 mmol/L) was excluded. Primary clinical outcomes were inpatient admit rate, length of stay (LOS), total direct cost, the rate of adverse events and 30-day recidivism. Results188 patients were managed as an observation patient, with 64 managed in an EDOU setting (age 74.0 yr, 70.3% female) and 124 managed in a NOU setting (age 71.5 yr, 64.5% female). Patient subgroups were similar in terms of presenting complaints, comorbidities, and medication histories. Initial and final sodium levels were similar between settings: EDOU (125.1 to 132.6 mmol/L) vs NOU (123.5 to 132.0 mmol/L). However, outcomes differed by setting for observation to inpatient admit rate (EDOU 28.1% vs NOU 37.9%, adjusted effect 0.70), overall length of stay (EDOU 19.2 h vs NOU 31.9 h; adjusted effect −10.5 h and total direct cost ($1230 vs $1531; adjusted effect -$167). EDOU sodium correction rates were faster (EDOU 0.44 mmol/L/h vs 0.24 mmol/L/h; adjusted effect 0.15 mmol/L/h) and 30-day recidivism rate was similar (EDOU 13% vs NOU 15%). There were no index visit deaths or intensive care unit admissions. ConclusionManagement of selected hyponatremia patients under observation status is feasible, with the EDOU setting demonstrating lower admit rates, shorter length of stay, and lower total direct costs with similar clinical outcomes.

The Value of an Emergency Medicine Virtual Observation Unit

We implemented a virtual observation unit in which emergency department (ED) patients receive observation-level care at home. Our primary aim was to compare this new care model to in-person observation care in terms of brick-and-mortar ED length of stay (inclusive of ED observation unit time) as well as secondarily on inpatient admission and 72-hour return visits (overall and with admission). In a retrospective analysis of electronic health record data on ED observation patients from January 1, 2022 to December 29, 2022 from an academic urban ED, we used propensity matching to compare virtual to in-person observation patients on outcomes of interest. Patients were matched 1:1 based on age, sex, Charlson Comorbidity Index, and reason for observation. We also conducted real-time review of all virtual observation cases for potential safety concerns. Of 8,218 observation stays, 361 virtual observation patients were matched with 361 in-person observation patients. Virtual observation patients experienced lower median brick-and-mortar ED + EDOU LOS [14.6 (IQR 10.2, 18.9) versus 33.3 (IQR 28.1, 38.1) hours] and lower inpatient admission rates (10.2% [SD 5.0] versus 24.7% [SD 11.3]). The 72-hour return rate was higher for virtual observation patients (3.6% [SD 3.0] versus 2.5% [SD 3.0]). Among those with return visits, the rate of inpatient admission was higher among virtual observation patients (53.8% [SD 3.2] versus 11.1% [13.0]). There were no significant patient safety events recorded. Virtual observation unit patients used fewer hours in ED and ED observation relative to on-site observation patients. This new care delivery model warrants further study because it has the potential to positively impact ED capacity.

Diagnosis and Management of Amanita Phalloides Toxicity in the Emergency Department Observation Unit: A Case Report.

Mushroom toxicity is an important etiology of acute liver injury in a patient with gastrointestinal symptoms. We present the case of a male patient presenting to the emergency department (ED) with gastrointestinal distress who was placed under ED observation for elevated liver function tests. During his hospital course, it was revealed he had consumed wild mushrooms believed to be Amanita phalloides. While mushroom ingestion and subsequent toxicity are rare, a high index of suspicion in foraging hobbyists is essential to arriving at the correct diagnosis and directing the patient to the appropriate management.

Impact of Geriatric Consult Evaluations on Hospital Admission Rates for Older Adults.

We examined the impact of a geriatric consult program in the emergency department (ED) and an ED observation geriatric care unit (GCU) setting on hospital admission rates for older ED patients. We performed a retrospective case control study from June 1-August 31, 2019 (pre-program) to September 24, 2019-January 31, 2020 (post-program). Post-program geriatric consults were readily available in the ED and required in the GCU setting. Hospital admission rates (outcome) are reported for patients who received a geriatric consult evaluation (intervention). We analyzed probability of admission using a mixed-effects logistic regression model that included age, gender, recent ED visit, Charlson Comorbidity Index, referral to ED observation, and geriatric consult evaluation as predictor variables. A total of 9,663 geriatric ED encounters occurred, 4,042 pre-program and 5,621 post-program. Overall, ED admission rates for geriatric patients were similar pre- and post-program (44.8% vs 43.9%, P = 0.39). Of 243 geriatric consults, 149 (61.3%) occurred in the GCU. Overall admission rates post-program for patients receiving geriatric intervention were significantly lower compared to pre-program (23.4% vs 44.9%, P < 0.001). Post-program GCU hospital admission rates were significantly lower than pre-program ED observation unit admission rates (14/149, 9.4%, vs 111/477, 23.3%, P < 0.001). In the logistic regression model, admissions post-program were lower when a geriatric consult evaluation occurred (odds ratio [OR] 0.58, 95% confidence interval [CI] 0.41-0.83). Hospital admissions for older ED observation patients were also significantly decreased when a geriatric consult was obtained (GCU vs pre-program ED observation unit; OR 0.27, 95% CI 0.14-0.50). Geriatric consult evaluations were associated with significantly lower rates of hospital admission and persisted when controlled for age, gender, comorbidities, and ED observation unit placement. This model may allow healthcare systems to decrease potentially avoidable hospital admission rates in older ED patients.

Utilization of oncologic emergency department observation units by cancer patients presenting with pain

Utilization of oncologic emergency department observation units by cancer patients presenting with pain

Current ED syncope management in Italian hospitals and prospects for optimization: a national survey.

To investigate current ED management of patients with syncope in Italy and opportunities for optimization, we carried out a questionnaire survey involving 102 directors of ED facilities in our country, of any complexity level, with 55.9% located in the North, 97% equipped with an ED Observation Unit (EDOU), and 21.8% with an outpatient Syncope Unit (SU). 43.6% of EDs management is not standardized. Clinical judgment and monitoring are the main factors leading management while old age and neuropsychic comorbidities the most hindering it. More than one third of ED facilities treats fewer than half of patients in EDOU. Most of respondents (73.7%) reported an admission rate within 20%, primarily in cardiology, in the case of an established or suspected cardiac etiology of syncope. In most centers, the referral to the general practitioner is the priority path at discharge from ED. Nearly 50% of participants rated syncope management in their own center as sub-optimal. To optimize it, 98% of them believe that is appropriate to implement a standardized approach, with and a large majority focusing on increasing diagnostic yield and safety; other priorities include application of guidelines, implementation of care pathways, enhancement of the role of EDOU, and direct path to the SU. This study highlights that the management of syncope patients in our country requires a further improvement, especially through standardization of pathways and adoption of innovative organizational solutions. Admissions appear to be lower than reported in the literature but this finding must be confirmed by a multicentric study based on direct collection of data.

Hyperactive delirium during emergency department stay: analysis of risk factors and association with short-term outcomes

To investigate factors related to the development of hyperactive delirium in patients during emergency department (ED) stay and the association with short-term outcomes. A secondary analysis of the EDEN (Emergency Department and Elderly Needs) multipurpose multicenter cohort was performed. Patients older than 65 years arriving to the ED in a calm state and who developed confusion and/or psychomotor agitation requiring intravenous/intramuscular treatment during their stay in ED were assigned to delirium group. Patients with psychiatric and epileptic disorders and intracranial hemorrhage were excluded. Thirty-four variables were compared in both groups and outcomes were adjusted for age, sex, Charlson Comorbidity Index, Barthel Index and polypharmacy. Hyperactive delirium that needed treatment were developed in 301 out of 18,730 patients (1.6%). Delirium was directly associated with previous episodes of delirium (OR: 2.44, 95% CI 1.24–4.82), transfer to the ED observation unit (1.62, 1.23–2.15), chronic treatment with opiates (1.51, 1.09–2.09) and length of ED stay longer than 12 h (1.41, 1.02–1.97) and was indirectly associated with chronic kidney disease (0.60, 0.37–0.97). The 30-day all-cause mortality was 4.0% in delirium group and 2.9% in non-delirium group (OR: 1.52, 95% CI 0.83–2.78), need for hospitalization 25.6% and 25% (1.09, 0.83–1.43), in-hospital mortality 16.4% and 7.3% (2.32, 1.24–4.35), prolonged hospitalization 54.5% and 48.6% (1.27, 0.80–2.00), respectively, and 90-day post-discharge combined adverse event 36.4% and 35.8%, respectively (1.06, 0.82–2.00). Patients with previous episodes of delirium, treatment with opioids and longer stay in ED more frequently develop delirium during ED stay and preventive measures should be taken to minimize the incidence. Delirium is associated with in-hospital mortality during the index event.

GeriCarED: Feasibility of a pilot program of a geriatric personal care attendant addressing mentation, mobility and matters most in an Emergency Department Observation Unit

GeriCarED: Feasibility of a pilot program of a geriatric personal care attendant addressing mentation, mobility and matters most in an Emergency Department Observation Unit

An Electronic Medical Record Intervention to Increase Pharmacologic Prophylaxis for Venous Thromboembolism in Emergency Department Observation Patients

The role of venous thromboembolism (VTE) prophylaxis among patients receiving emergency department (ED) observation unit care is unclear. We investigated an electronic health record-based clinical decision support tool aimed at increasing pharmacologic VTE prophylaxis use among at-risk patients placed in ED observation units. We conducted an interrupted time-series study of an Epic-based best practice advisory implemented in May 2019 at a health care system comprising 2 academic medical centers and 4 community hospitals with dedicated ED observation units. The best practice advisory alerted staff at 24 hours to conduct a risk assessment and linked to a VTE prophylaxis order set. We used an interrupted time series, Bayesian structured time series, and a multivariable mixed-effect regression model to estimate the intervention effect. Prior to the best practice advisory implementation, there were 8,895 ED observation unit patients with a length of stay more than or equal to 24 hours, and 0.9% received pharmacologic VTE prophylaxis. Afterward, there were 12,664 ED observation unit patients with a length of stay more than or equal to 24 hours, and 4.8% received pharmacologic VTE prophylaxis. The interrupted time series and causal impact analysis showed a statistically significant increase in VTE prophylaxis (eg, absolute percent difference 3.8%, 95% confidence interval 3.5 to 4.1). In a multivariable model, only the intervention was significantly associated with receiving VTE prophylaxis (odds ratio 4.56, 95% confidence interval 2.22 to 9.37). An electronic health record-based alert helped to prompt staff caring for ED observation unit patients at risk for VTE with prolonged visits to order recommended pharmacologic prophylaxis. The best risk assessment model to use and the true incidence of VTE events in this population are unclear.

Emergency Department Observation Unit Patients Want Evaluation and Treatment for Hypercholesterolemia: A Health Belief Model Study.

Hypercholesterolemia (HCL) is common among emergency department (ED) and ED observation unit (EDOU) patients with chest pain but is not typically addressed in these settings. The objective of this study was to assess patient attitudes towards EDOU-based HCL care using the Health Belief Model. We conducted a cross-sectional survey study among 100 EDOU patients ≥18 years-old evaluated for chest pain in the EDOU of a tertiary care center from September 1, 2020, to November 01, 2021. Five-point Likert-scale surveys were used to assess each Health Belief Model domain: Cues to Action, Perceived Susceptibility, Perceived Barriers, Perceived Self-Efficacy, and Perceived Benefits. Responses were categorized as agree or do not agree. The participants were 49.0% (49/100) female, 39.0% (39/100) non-white, and had a mean age of 59.0 ± 12.4 years. Most (83.0% [83/100, 95% confidence interval (CI), 74.2%-89.8%]) agreed the EDOU is an appropriate place for HCL education and 52.0% (52/100, 95% CI, 41.8%-62.1%) were interested in talking with their EDOU care team about HCL. Regarding Perceived Susceptibility, 88.0% (88/100, 95% CI, 80.0%-93.6%) believed HCL to be bad for their health, while 41.0% (41/100, 95% CI, 31.3%-51.3%) believed medication costs could be a barrier. For Perceived Self-Efficacy, 76.0% (76/100, 95% CI, 66.4%-84.0%) were receptive to taking medications. Overall, 95.0% (95/100, 95% CI, 88.7%-98.4%) believed managing HCL would benefit their health. This Health Belief Model-based survey indicates high patient interest in EDOU-initiated HCL care. Patients reported high rates of Perceived Susceptibility, Self-Efficacy, and Benefits and a minority found HCL therapy costs a barrier.

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

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

Emergency department observation implementation guide.

Emergency department (ED) crowding poses significant operational challenges to hospitals. One strategy to address these issues is the implementation of an ED observation (EDO) unit. EDO involves placing patients in observation status after their initial evaluation, allowing for continued assessment, treatment, and the determination of a safe disposition. This paper provides a comprehensive guide for ED leaders on the implementation of ED observation in their departments. It includes a checklist summarizing key implementation points, operational and financial considerations, staffing and location planning, patient selection, clinical care protocols, documentation and communication processes, securing buy-in from stakeholders, and outcome measurement. The guide also highlights the updated billing codes based on the 2023 updated Current Procedural Terminology (CPT) guidelines. Successful implementation of an EDO program has shown benefits such as improved patient flow, enhanced revenue generation, reduced costs, and comparable clinical outcomes. This guide aims to equip ED leaders with the necessary knowledge and tools to implement and manage an effective ED observation program in their departments, ultimately improving the overall efficiency of emergency care delivery.

Rarely tested or treated but highly prevalent: Hypercholesterolemia in ED observation unit patients with chest pain

BackgroundHypercholesterolemia (HCL) is common among Emergency Department (ED) patients with chest pain but is typically not addressed in this setting. This study aims to determine whether a missed opportunity for Emergency Department Observation Unit (EDOU) HCL testing and treatment exists. MethodsWe conducted a retrospective observational cohort study of patients ≥18 years old evaluated for chest pain in an EDOU from 3/1/2019–2/28/2020. The electronic health record was used to determine demographics and if HCL testing or treatment occurred. HCL was defined by self-report or clinician diagnosis. Proportions of patients receiving HCL testing or treatment at 1-year following their ED visit were calculated. HCL testing and treatment rates at 1-year were compared between white vs. non-white and male vs. female patients using multivariable logistic regression models including age, sex, and race. ResultsAmong 649 EDOU patients with chest pain, 55.8% (362/649) had known HCL. Among patients without known HCL, 5.9% (17/287, 95% CI 3.5–9.3%) had a lipid panel during their index ED/EDOU visit and 26.5% (76/287, 95% CI 21.5–32.0%) had a lipid panel within 1-year of their initial ED/EDOU visit. Among patients with known or newly diagnosed HCL, 54.0% (229/424, 95% CI 49.1–58.8%) were on treatment within 1-year. After adjustment, testing rates were similar among white vs. non-white patients (aOR 0.71, 95% CI 0.37–1.38) and men vs. women (aOR 1.32, 95% CI 0.69–2.57). Treatment rates were similar among white vs. non-white (aOR 0.74, 95% CI 0.53–1.03) and male vs. female (aOR 1.08, 95% CI 0.77–1.51) patients. ConclusionsFew patients were evaluated for HCL in the ED/EDOU or outpatient setting after their ED/EDOU encounter and only 54% of patients with HCL were on treatment during the 1-year follow-up period after the index ED/EDOU visit. These findings suggest a missed opportunity to reduce cardiovascular disease risk exists by evaluating and treating HCL in the ED or EDOU.

Utility of an Emergency Department Observation Unit in Providing Care for Patients With Blunt Thoracic Trauma.

Background The use of Emergency Department Observation Units (EDOUs) to treat patients with a variety of complaints has grown over recent years. However, the treatment of patients with traumatic injuries in EDOUs is infrequently described. Our study sought to describe the feasibility of treating patients with blunt thoracic trauma in an EDOU in consultation with our trauma and acute care surgery (TACS) team. Together, our Emergency Department (ED) and TACS teams designed a protocol for the treatment of patients with specific blunt thoracic injuries (fewer than three rib fractures, nondisplaced sternal fractures) that we felt would require less than 24 hours of care in a hospital setting. Methods This study is an IRB-approved retrospective analysis comparing two groups before (pre-EDOU) and after (EDOU) the creation of the EDOU protocol, which was implemented in August 2020. Data was collected at a single, Level 1 trauma center with approximately 95,000 annual visits. Similar inclusion and exclusion criteria were used to select patients in both groups. We conducted two-sample t-tests and Chi-square testing to assess for significance. Primary outcomes include length of stay and bounce-back rate. Results A total of 81 patients were included in our data set across both groups. Forty-three patients were included in our pre-EDOU group while 38 patients were treated in our EDOU once the protocol was implemented. Patients in both groups were of similar age, gender and had similar Injury Severity Scores (ISS) ranging from 9 to 14. Hospital length of stay was shorter for the EDOU group (31.5 hours) compared to the pre-EDOU group (36.4 hours) although not statistically significant. When risk stratified by ISS, hospital length of stay did reach statistical significance and was found to be shorter for patients with ISS scores greater than or equal to 9 that were treated in the EDOU (29.1 hours vs. 43.8 hours, p = .028). Both groups had one patient each bounce back for repeat evaluation and additional care. Conclusion This study demonstrates the potential use of EDOUs to treat patients with mild to moderate blunt thoracic injuries. The availability of trauma surgeons for consultation along with ED provider experience may be rate-limiting steps in utilizing observation units to care for trauma patients. Additional research with more participants is needed to determine the impact of implementing such a practice at other institutions.

Returns After Discharge From the Emergency Department Observation Unit: Who, What, When, and Why?

The number of emergency department observation units (EDOU) and observation stays has continued to increase. Despite this, there is limited data on the characteristics of patients who return unexpectedly to the ED after EDOU discharge. We identified the charts of all patients who were admitted to the EDOU of an academic medical center between January 2018-June 2020 and had a return to the ED within 14 days of discharge from the EDOU. Patients were excluded if they were admitted to the hospital from the EDOU, left against medical advice, or died in the EDOU. We manually extracted selected demographic factors, comorbidities, and healthcare utilization data from the charts. Physician reviewers identified return visits thought to be related to the index visit or potentially avoidable. During the study period, there were 176,471 ED visits, 4,179 admissions to the EDOU, and 333 return visits to the ED within 14 days from discharge from the EDOU, representing 9.4% of all patients discharged from the EDOU. We identified a higher rate of return for patients treated for asthma and lower rates of return for patients treated for chest pain or syncope than the overall return rate. Physician reviewers determined that 64.6% of unplanned returns were related to the index visit, and 4.5% were potentially avoidable. Of potentially avoidable visits, 53.3% occurred within 48 hours of discharge, supporting the use of this period as a potential quality metric. While there was no significant difference in the percentage of related return visits between males and females, there was a higher rate of potentially avoidable visits for male patients. This study adds to the limited body of literature on EDOU returns, finding an overall return rate of under 10%, with about two-thirds of returns determined to be related to the index visit and <5% considered to be potentially avoidable.

Physical therapy consultation in the emergency department for older adults with falls: A qualitative study.

Little is known about current practices in consulting physical therapy (PT) in the emergency department (ED) for older adults with falls, a practice that can reduce fall-related ED revisits. This qualitative study aimed to understand perspectives of ED staff about ED PT consultation for older adults with falls and fall-related complaints, specifically regarding perceived value and associated challenges and strategies. We performed focus groups and key informant interviews with emergency physicians, advanced practice clinicians, nurses, physical therapists, occupational therapists, and technicians who perform ED geriatric screenings. We used rapid qualitative analysis to identify common themes related to decisions to consult PT from the ED, perceived value of PT, and common challenges and strategies in ED PT consultation. Twenty-five participants in 4 focus groups and 3 interviews represented 22 distinct institutions with ED PT consultation available for older adults with falls. About two thirds of EDs represented relied on clinician gestalt to request PT consultation (n=15, 68%), whereas one third used formal consultation pathways (n=7, 32%). Participants valued physical therapists' expertise, time, and facilitation of hospital throughput by developing safe discharge plans and contact with patients to improve outpatient follow-up. Common challenges included limited ED PT staffing and space for PT evaluations; strategies to promote ED PT consultation included advocating for leadership buy-in and using ED observation units to monitor patients and avoid admission until PT consultation was available. ED PT consultation for older adults with falls may benefit patients, ED staff, and hospital throughput. Uncertainty remains over whether geriatric screening-triggered consultation versus emergency clinician gestalt successfully identifies patients likeliest to benefit from ED PT evaluation. Leadership buy-in, designated consultation space, and formalized consultation pathways are strategies to address current challenges in ED PT consultation.

Association of Sonographic Sarcopenia and Falls in Older Adults Presenting to the Emergency Department

To determine the association between point-of-care-ultrasonography (POCUS)-measured sarcopenia and grip strength, as well as the history of prior-year falls among older adults admitted to the emergency department observation unit (EDOU). This cross-sectional observational study was conducted over 8 months at a large urban teaching hospital. A consecutive sample of patients who were 65 years or older and admitted to the EDOU were enrolled in the study. Using standardized techniques, trained research assistants and co-investigators measured patients' biceps brachii and thigh quadriceps muscles via a linear transducer. Grip strength was measured using a Jamar Hydraulic Hand Dynamometer. Participants were surveyed regarding their history of falls in the prior year. Logistic regression analyses assessed the relationship of sarcopenia and grip strength to a history of falls (the primary outcome). Among 199 participants (55% female), 46% reported falling in the prior year. The median biceps thickness was 2.22 cm with an Interquartile range [IQR] of 1.87-2.74, and the median thigh muscle thickness was 2.91 cm with an IQR of 2.40-3.49. A univariate logistic regression analysis demonstrated a correlation between higher thigh muscle thickness, normal grip strength, and history of prior-year falling, with an odds ratio [OR] of 0.67 (95% conference interval [95%CI] 0.47-0.95) and an OR of 0.51 (95%CI 0.29-0.91), respectively. In multivariate logistic regression, only higher thigh muscle thickness was correlated with a history of prior-year falls, with an OR of 0.59 (95% CI 0.38-0.91). POCUS-measured thigh muscle thickness has the potential to identify patients who have fallen and thus are at high risk for future falls.

The Impact of Virtual Care in an Emergency Department Observation Unit.

We report the impact of telemedicine virtual rounding in emergency department observation units (EDOU) on the effectiveness, safety, and cost relative to traditional observation care. In this retrospective diff-in-diff study, we compared observation visit outcomes from 2 EDOUs before (pre) and after (post) full adoption of telemedicine rounding tele-observation (tele-obs) with usual care in control EDOU and care in a hospital bed in an integrated health system without tele-obs. Tele-obs physicians did not work at the control hospital. Outcomes were the length of stay, total direct costs, admission status, and adverse events (ICU and death). Difference-in-differences modeling evaluated outcomes with covariates including age, sex, payer type, and clinical classification software diagnostic category. Data from a system data warehouse and a cost accounting database were used. Of the 20,861 EDOU visits, 15,630 (74.9%) were seen in the preperiod and 6,657 (31.9%) in control EDOU. Of 23,055 non-EDOU inpatient visits assigned to observation status (nonobservation unit), 76% were seen in the preperiod. Adjusted length of stay was not significantly different for tele-obs and control EDOUs (26.4 hours versus 23.5 hours), which remained lower than in hospital settings (37.9 hours). The pre-post diff-in-diff was not significant (P=.78). Inpatient admission status was similar for tele-obs and control EDOUs (20.9% versus 22.4.%) and lower than in hospital settings (30.3%). Prepost odds ratios for inpatient admission and adverse outcomes did not change significantly for all study groups. Adjusted costs increased over time for all settings; however, the prepost median cost change was not significantly different between tele-obs EDOUs and control EDOUs ($162.5 versus $235) and was lower than the change for control hospital settings ($783). Median tele-obs EDOU cost over both periods ($1,541) remained significantly lower than hospital costs ($2,413). Using tele-obs to manage observation patients in an ED observation unit was not associated with significant differences in length of stay, admission status, measured adverse events, or total direct cost.

Nutritional status and prognostic factors for mortality in patients admitted to emergency department observation units: a national multi-center study in China.

Nutritional risk is common among patients admitted to the emergency department and is associated with adverse clinical outcomes. Despite its large population, few comprehensive studies have been conducted in China concerning the nutritional status of patients admitted to emergency department observation units (EDOUs). Patients admitted to EDOUs of 90 tertiary hospitals in China between June 2020 and December 2020 were enrolled. Demographic information, laboratory parameters, nutritional support therapies, and 28-day mortality were recorded. Risk factors for mortality were examined using multi-variate-adjusted logistic regression analysis. Receiver operating characteristic (ROC) curves for each predictor of mortality were plotted, and the area under the ROC (AUROC) curves was compared. A total of 2,005 eligible patients were finally enrolled. At the 28-day follow-up, 1,911 patients survived, and 94 died. The group with a Nutritional Risk Screening 2002 (NRS 2002) score of 3-4 points was the largest (52.01%). The number of patients receiving oral nutritional supplements, enteral nutrition (EN), parenteral nutrition (PN), and the combination of EN and PN was 425, 314, 853, and 413, respectively. Among the total, 77.55% of patients had nutritional risk (NRS 2002 ≥3). The proportion of patients with high nutritional risk (NRS2002≥5) in the age group >80 years was significantly higher than that in the age group 66-80 years (29.00% vs. 23.93%, P=0.032), but not significantly higher than that in the age group 18-65 years (29.00% vs. 26.54%, P=0.449). Logistic regression analysis revealed that heart failure (odds ratio [OR] 1.856, 95% confidence interval [CI] 1.087-3.167, P=0.023), consciousness (OR 2.967, 95% CI 1.894-4.648, P<0.001), Acute Physiology and Chronic Health Evaluation II (APACHE II) score (OR 1.037, 95% CI 1.017-1.058, P<0.001), NRS 2002 score (OR 1.286, 95% CI 1.115-1.483, P=0.001), and Mini Nutritional Assessment-Short Form score (OR 0.946, 95% CI 0.898-0.997, P=0.039) were all independent risk factors for 28-day mortality. APACHE II and NRS 2002 scores were superior to other predictors according to the comparison of AUROC. Nutritional risk is prevalent among older patients in EDOUs in China. APACHE II and NRS 2002 scores are important risk factors for mortality in patients admitted to the EDOU. Timely and appropriate nutritional screening and support measures are critical to reduce patients' length of hospital stay and mortality.