Emergency Department Observation Research Articles

Small bowel obstruction managed without hospital admission: A safe way to reduce both cost and time in the hospital?

BackgroundSmall bowel obstruction management has evolved to incorporate the Gastrografin challenge. We expanded its use to the emergency department observation unit, potentially avoiding hospital admission for highly select small bowel obstruction patients. We hypothesized that the emergency department observation unit small bowel obstruction protocol would reduce admissions, costs, and the total time spent in the hospital without compromising outcomes. MethodsWe reviewed patients who presented with small bowel obstruction from January 2015 to December 2018. Patients deemed to require urgent surgical intervention were admitted directly and excluded. The emergency department observation unit small bowel obstruction guidelines were introduced in November 2016. Patients were divided into pre and postintervention groups based on this date. The postintervention group was further subclassified to examine the emergency department observation unit patients. Cost analysis for each patient was performed looking at number of charges, direct costs, indirect cost, and total costs during their admission. ResultsIn total, 125 patients were included (mean age 69 ± 14.3 years). The preintervention group (n = 62) and postintervention group (n = 63) had no significant difference in demographics. The postintervention group had a 51% (36.7 hours, P < .001) reduction in median duration of stay and a total cost reduction of 49% (P < .001). The emergency department observation unit subgroup (n = 46) median length of stay was 23.6 hours. The readmission rate was 16% preintervention compared to 8% in the postintervention group (P = .18). ConclusionManagement of highly selected small bowel obstruction patients with the emergency department observation unit small bowel obstruction protocol was associated with decreased length of stay and total cost, without an increase in complications, surgical intervention, or readmissions.

Reliability of claims-based measures used to assess cancer care quality.

42 Background: As value-based payment models for cancer care expand, the need for measures which reliably assess the quality of care provided increases. This is especially true for models like the Oncology Care Model (OCM) that rely on quality rankings to determine potential shared savings. Under models like these, unreliable measures may result in arbitrary application of value-based payments. The goal of this project is to evaluate the extent to which measures used within the OCM are reliable indicators of provider performance. Methods: Data for this project came from North Carolina Medicare claims from 2015-2017. Episodes were attributed to physician practices at the tax identification number (TIN) level, lasted 6 months, and were divided into two performance years beginning 1/1/2016 and 7/1/2016. TINs with fewer than 20 attributed patients were excluded. Three claims-based OCM measures were used in this evaluation: 1) proportion of episodes with all-cause hospital admissions; 2) proportion of episodes with all-cause emergency department (ED) visits or observation stays; and 3) proportion of patients that died who were admitted to hospice for 3 days or more. Risk adjustment followed the method described by measure specifications from the OCM. Reliability was calculated as the ratio of between practice variation (e.g. signal) to the sum of between practice variation and within practice variation (e.g. noise). Variance estimates were derived from hierarchical logistic regression models used for risk adjustment. Results: For the hospitalization and ED visit measures, episode counts for years 1 and 2 were 30,746 and 28,430 and TIN counts were 86 and 84, respectively. Hospice use measures had fewer episodes (2,677 and 2,428) and TINs (36 and 33). Across all measures, median reliability scores failed to achieve the recommended 0.7 threshold and only hospice had a median reliability score above 0.5 (Table). Conclusions: These findings suggest claims-based measures included in the OCM may produce imprecise estimates of provider performance and are vulnerable to random variation. Consideration should be given to developing alternative measures which may be more reliable estimates of provider performance and to increasing minimum denominator requirements for existing measures.[Table: see text]

169 Increased Physical and Occupational Therapy Evaluations in Emergency Department Observation Unit Geriatric Patients After Implementation of a Quality Improvement Tool Does Not Impact Length-of-Stay

The Geriatric Emergency Department Accreditation (GEDA) process recommends multidisciplinary innovations and quality improvement (QI) in geriatric emergency care. Screening for functional impairment with tools such as the Identification of Seniors at Risk (ISAR) screening tool to identify patients necessitating physical therapy (PT) and occupational therapy (OT) evaluation and subsequent need for home PT, OT or subacute rehabilitation is one way to improve overall geriatric care. However, these assessments require time and resources for coordination of care.

182 A Multi-Center Randomized Trial of Capsule Endoscopy to Reduce Admissions in Emergency Department Patients With Low Risk Upper Gastrointestinal Bleed

In US emergency departments (EDs), the provider has limited ability to evaluate for common and serious conditions of the gastrointestinal (GI) mucosa such as a bleeding peptic ulcer. Despite the fact that many bleeding lesions are self-limited, the majority of these patients require emergency hospitalization for an upper endoscopy (EGD). Our objective is to determine if ED risk stratification with Video Capsule Endoscopy (VCE) reduces need for hospitalization for low-to-moderate risk patients with suspected upper GI bleeding. A prospective multi-center randomized control trial was designed to investigate the safety of ED risk stratification with VCE. Stable ED patients with suspected upper GI bleeding were randomized to one of two treatment arms: (1) an experimental arm which included VCE risk stratification and brief ED observation versus (2) a standard of care arm which included an admission for inpatient EGD. Patients were followed for 30 days for safety outcomes. A total of 24 patients were enrolled in the study. In the experimental group, 2/11 (18.2%) patients were admitted to the hospital; and, in the standard of care group, 10/13 (76.9%) patients were admitted to the hospital (p=0.012). There was no difference in safety at day 7 and day 30 after index ED visit. ED risk stratification with VCE leads to fewer hospitalizations without an increase in adverse events.

Risk stratification with video capsule endoscopy leads to fewer hospital admissions in emergency department patients with low-risk to moderate-risk upper gastrointestinal bleed: A multicenter clinical trial.

ObjectiveIn US emergency departments (EDs), the physician has limited ability to evaluate for common and serious conditions of the gastrointestinal (GI) mucosa such as a bleeding peptic ulcer. Although many bleeding lesions are self‐limited, the majority of these patients require emergency hospitalization for upper endoscopy (EGD). We conducted a clinical trial to determine if ED risk stratification with video capsule endoscopy (VCE) reduces hospitalization rates for low‐risk to moderate‐risk patients with suspected upper GI bleeding.MethodsWe conducted a randomized controlled trial at 3 urban academic EDs. Inclusion criteria included signs of upper GI bleeding and a Glasgow Blatchford score <6. Patients were randomly assigned to 1 of the following 2 treatment arms: (1) an experimental arm that included VCE risk stratification and brief ED observation versus (2) a standard care arm that included admission for inpatient EGD. The primary outcome was hospital admission. Patients were followed for 7 and 30 days to assess for rebleeding events and revisits to the hospital.ResultsThe trial was terminated early as a result of low accrual. The trial was also terminated early because of a need to repurpose all staff to respond to the coronavirus disease 2019 pandemic. A total of 24 patients were enrolled in the study. In the experimental group, 2/11 (18.2%) patients were admitted to the hospital, and in the standard of care group, 10/13 (76.9%) patients were admitted to the hospital (P = 0.012). There was no difference in safety on day 7 and day 30 after the index ED visit.ConclusionsVCE is a potential strategy to decrease admissions for upper GI bleeding, though further study with a larger cohort is required before this approach can be recommended.

Validity of the computerized version of the pediatric triage system CLARIPED for emergency care

ObjectiveTo evaluate the validity of the computerized version of the pediatric triage system CLARIPED. MethodsProspective, observational study in a tertiary emergency department (ED) from Jan-2018 to Jan-2019. A convenience sample of patients aged 0-18 years who had computerized triage and outcome variables registered. Construct validity was assessed through the association between urgency levels and patient outcomes. Sensitivity, specificity, positive and negative predictive values (PPV and NPV), undertriage, and overtriage rates were assessed. Results19,122 of 38,321 visits were analyzed. The urgency levels were: RED (emergency) 0.02%, ORANGE (high urgency) 3.21%, YELLOW (urgency) 35.69%, GREEN (low urgency) 58.46%, and BLUE (no urgency) 2.62%. The following outcomes increased according to the increase in the level of urgency: hospital admission (0.4%, 0.6%, 3.1%, 11.9% and 25%), stay in the ED observation room (2.8%, 4.7%, 15.9%, 40.4%, 50%), ≥ 2 diagnostic or therapeutic resources (7.8%, 16.5%, 33.7%, 60.6%, 75%), and ED length of stay in minutes (18, 24, 67, 120, 260). The odds of using ≥ 2 resources or being hospitalized were significantly greater in the most urgent patients (Red, Orange, and Yellow) compared to the least urgent (Green and Blue): OR 7.88 (95%CI: 5.35-11.6) and OR 2.85 (95%CI: 2.63-3.09), respectively. The sensitivity to identify urgency was 0.82 (95%CI: 0.77-0.85); specificity, 0.62 (95%CI: 0.61-0.6; NPV, 0.99 (95%CI: 0.99-1.00); overtriage rate, 4.28% and undertriage, 18.41%. ConclusionThe computerized version of CLARIPED is a valid and safe pediatric triage system, with a significant correlation with clinical outcomes, good sensitivity, and low undertriage rate.

The Angiotensin Converting Enzyme Deletion/Deletion Genotype Is a Risk Factor for Severe COVID-19: Implication and Utility for Patients Admitted to Emergency Department.

Background and objective: Insertion/deletion polymorphisms of angiotensin-converting enzyme (ACE) have been previously described in association with adult respiratory distress syndrome (ARDS) and correlated to outcome. The ACE deletion/deletion(D/D)genotype represents a marker of thrombosis in subjects apparently without predisposing factors and/or traditional thrombophilic alterations and increases the risk of venous thromboembolism in subjects in whom a thrombogenic condition occurs. Thrombosis seems to play a role very early in the disease caused by SARS-CoV-2, in particular in those with severe COVID-19 pneumonia. The counterbalance between angiotensin-converting enzyme (ACE) and ACE2 activities in COVID-19 disease may play a crucial role in the thrombo-inflammatory process. We hypothesised that a genetic predisposition could condition the severity and complications of SARS-CoV-2 infection. Materials and methods: We conducted a spontaneous, single centre observational study in the Sub-Intensive Care Unit of A.O.R.N. Ospedali dei Colli, Cotugno Hospital, Naples (Italy). In this study, we performed genetic screening for ACE D/D genotype and other thrombophilic mutations in 20 patients affected by ARDS related to COVID-19 pneumonia, compared to 19 age- and sex-matched healthy controls. Results: All tested patients had multiple polymorphisms and, in particular, a significantly higher prevalence of ACE D/D polymorphism in severe COVID-19 patients Conclusion: We found that the majority of patients who tested positive for ACE D-D genotype and who were not associated with other risk factors for VTE showed an evolution to ARDS. This finding could have a predicting role in the selection of patients more prone to developing severe COVID-19 during clinical observation in emergency department.

Arranging Hospice Care from the Emergency Department: A Single Center Retrospective Study

BackgroundArranging hospice services from the Emergency Department (ED) can be difficult due to physician discomfort, time constraints, and the intensity of care coordination needed. We report patient and visit characteristics associated with successful transition from the ED directly to hospice. MethodsSetting: Academic ED with 82,000 annual visits. Population: ED patients with a referral to hospice order placed during the ED visit from January 2014-December 2018. Charts were abstracted by trained, non-blinded personnel. Primary goal was to evaluate patient and visit factors associated with requiring admission for hospice transition. ResultsElectronic Health Record inquiry yielded 113 patients, 93 of which met inclusion criteria. Patients were aged 65.8 years (range 32-92), 54% were female, and 78% were white, non-hispanic. The majority had cancer (78%, n = d72) and were on public insurance (60%, n = 56). Half (55%, n = 51) were full code upon arrival. Average ED length of stay was 4.6 ± 2.6 hours. Discharge from the ED to hospice was successful for 38% (n = 35), a few (n = 5) were dispositioned to an ED observation unit, and 57% (n = 53) were admitted. Only 10 (11%) required an inpatient length of stay longer than an observation visit (2 days). Case management and social work team arranged for transportation (54.8%, n = 51), hospital beds (16.1%, n = 16), respiratory equipment (18.3%, n = 17), facility placement (33.3%, n = 31), and home health aides (29.0%, n = 27). ConclusionTransitioning patients to hospice care from the ED is possible within a typical ED length of stay with assistance from a case manager/social work team.

The effect of a mobile integrated health program on health care cost and utilization.

To measure the effect of a mobile integrated health community paramedicine (MIH-CP) transitional care program on hospital utilization, emergency department visits, and charges. Retrospective secondary data from the electronic health record and regional health information exchange were used to analyze patients discharged from a large academic medical center and an affiliated community hospital in Baltimore, Maryland, May 2018-October 2019. We performed an observational study comparing patients enrolled in an MIH-CP program to propensity-matched controls. Propensity scores were calculated using measures of demographics, clinical characteristics, social determinants of health, and prior health care utilization. The primary outcome is inpatient readmission within 30 days of discharge. Secondary outcomes include excess days in acute care 30 days after discharge and emergency department visits, observation hospitalizations, and total health care charges within 30 and 60 days of discharge. Included patients were over 18 years old, discharged to home from internal/family medicine services, and live in eligible ZIP codes. The intervention group was enrolled in the MIH-CP program; controls met inclusion criteria but were not enrolled during the study period. The adjusted model showed no difference in 30-day inpatient readmission between 464 enrolled patients and propensity-matched controls (adjusted incidence rate ratio=1.19, 95% confidence interval [CI] [0.89, 1.60]). There was a higher rate of observation hospitalizations within 30 days of index discharge for MIH-CP patients (adjusted incidence rate ratio=1.78, 95% CI=[1.01, 3.14]). This difference did not persist at 60 days, and there were no differences in other secondary outcomes. We found no significant difference in short-term health care utilization or charges between patients enrolled in an MIH-CP transitional care program and propensity-matched controls. This highlights the importance of well-controlled, robust evaluations of effectiveness in novel care-delivery systems.

National Early Warning Score in Predicting Severe Adverse Outcomes of Emergency Medicine Patients: A Retrospective Cohort Study.

BackgroundFor emergency triage, it is very important to identify patient severity according to their vital signs and chief complaint. Several studies have examined the predictive value of the National Early Warning Score (NEWS) for specific emergency patients and have shown it to be effective. However, few have studied the utility of NEWS in emergency triage for general emergency medicine patients. The aim of this research was to investigate the performance of NEWS in emergency triage with regard to predicting adverse outcomes.MethodsThis was a retrospective cohort study carried out at a tertiary care center hospital in Jinhua, China. A total of 62,403 patients attending the emergency department (ED) from January to December 2018 were included. The NEWS, Modified Early Warning Score (MEWS), and quick Sepsis Related Organ Failure Assessment (qSOFA) score were obtained from emergency triage. Multivariate logistic regression analysis was performed to evaluate the associations between the NEWS, MEWS, and qSOFA, as well as those between other parameters with ED mortality. The predictive performances for emergency observation, death, and intensive care unit (ICU) admission of NEWS, MEWS and qSOFA were compared to the area under the receiver operating characteristic curve (AUROC).ResultsOf the total participants, 6502 were placed under emergency observation, 106 died in the ED, 638 were admitted to the ICU, and 324 died in-hospital. The NEWS, qSOFA, age, and gender were significantly associated with ED mortality. NEWS was significantly better at discriminating all outcomes, and the area under the curve and 95% confidence intervals for ED mortality, observation in ED, composite of ED mortality and ICU admission, and in-hospital mortality were 0.862 (0.859–0.865), 0.691 (0.687–0.695), 0.859 (0.856–0.861), and 0.805 (0.802–0.808), respectively.ConclusionNEWS shows good performance in discriminating critical emergency patients in ED triage for emergency medicine patients.

Use of Endocrine Consultation for Hemoglobin A1C ≥9.0% as a Standardized Practice in an Emergency Department Observation Unit

ObjectiveSeverely uncontrolled diabetes mellitus (DM) is associated with poor long-term outcomes and may remain unrecognized. A high frequency of uncontrolled DM has been identified in the acute-care setting, including the emergency department observation unit (EDOU). We assess the use of standardized endocrine consultation in the EDOU for hemoglobin A1C (HbA1C) levels ≥9%. MethodsStandard practice in our EDOU includes universal HbA1C screening and endocrine consultation for HbA1C levels ≥9.0%. As part of a quality improvement program, EDOU patients with HbA1C levels ≥9.0% had an endocrinology consult. One-month follow-up phone calls assessed the effects of consultation after discharge. ResultsHbA1C tests were administered to 3688 (95.7%) of 3853 EDOU patients, of which 7.0% (n = 258) were found to have an HbA1C level ≥9% (mean ± SD, 11.7 ± 1.8%; range, 9%-16.6%). Endocrine consults were completed for 73.6% (190/258) patients with severely uncontrolled DM. Among the 190 patients, 92.1% (n = 175) had discharge DM medication adjustments. For known patients with DM (n = 142), injectable diabetes medication prescriptions increased from 47.2% (67/142) on EDOU arrival to 78.2% (111/142) upon discharge. Newly diagnosed DM injectable prescriptions increased from 0% (0/48) on arrival to 72.9% (35/48) upon discharge. A total of 72.6% (n = 138) were contacted at a 1-month follow-up and 94.9% (n = 131) reported taking DM medications, compared with 68.2% (n = 94) before consult. ConclusionHbA1C screening coupled with endocrine consultation for HbA1C levels ≥9.0% was assessed as a performance improvement study and is shown to have valuable results. Further investigation is required to determine the long-term clinical impact and cost analysis for this novel approach.

Management of Minor Traumatic Brain Injury in an ED Observation Unit.

IntroductionTraumatic intracranial hemorrhages (TIH) have traditionally been managed in the intensive care unit (ICU) setting with neurosurgery consultation and repeat head CT (HCT) for each patient. Recent publications indicate patients with small TIH and normal neurological examinations who are not on anticoagulation do not require ICU-level care, repeat HCT, or neurosurgical consultation. It has been suggested that these patients can be safely discharged home after a short period of observation in emergency department observation units (EDOU) provided their symptoms do not progress.MethodsThis study is a retrospective cross-sectional evaluation of an EDOU protocol for minor traumatic brain injury (mTBI). It was conducted at a Level I trauma center. The protocol was developed by emergency medicine, neurosurgery and trauma surgery and modeled after the Brain Injury Guidelines (BIG). All patients were managed by attendings in the ED with discretionary neurosurgery and trauma surgery consultations. Patients were eligible for the mTBI protocol if they met BIG 1 or BIG 2 criteria (no intoxication, no anticoagulation, normal neurological examination, no or non-displaced skull fracture, subdural or intraparenchymal hematoma up to 7 millimeters, trace to localized subarachnoid hemorrhage), and had no other injuries or medical co-morbidities requiring admission. Protocol in the EDOU included routine neurological checks, symptom management, and repeat HCT for progression of symptoms. The EDOU group was compared with historical controls admitted with primary diagnosis of TIH over the 12 months prior to the initiation of the mTBI protocols. Primary outcome was reduction in EDOU length of stay (LOS) as compared to inpatient LOS. Secondary outcomes included rates of neurosurgical consultation, repeat HCT, conversion to inpatient admission, and need for emergent neurosurgical intervention.ResultsThere were 169 patients placed on the mTBI protocol between September 1, 2016 and August 31, 2019. The control group consisted of 53 inpatients. Median LOS (interquartile range [IQR]) for EDOU patients was 24.8 (IQR: 18.8 – 29.9) hours compared with a median LOS for the comparison group of 60.2 (IQR: 45.1 – 85.0) hours (P < .001). In the EDOU group 47 (27.8%) patients got a repeat HCT compared with 40 (75.5%) inpatients, and 106 (62.7%) had a neurosurgical consultation compared with 53 (100%) inpatients. Subdural hematoma was the most common type of hemorrhage. It was found in 60 (35.5%) patients, and subarachnoid hemorrhage was found in 56 cases (33.1%). Eleven patients had multicompartment hemorrhage of various classifications. Twelve (7.1%) patients required hospital admission from the EDOU. None of the EDOU patients required emergent neurosurgical intervention.ConclusionPatients with minor TIH can be managed in an EDOU using an mTBI protocol and discretionary neurosurgical consults and repeat HCT. This is associated with a significant reduction in length of stay.

Interprofessional Chronic Pain and Addiction Training on an Emergency Department Observation Unit.

Interprofessional Chronic Pain and Addiction Training on an Emergency Department Observation Unit.

349-P: Hospital Utilization for Hypoglycemia among Patients with Type 2 Diabetes Using Pooled Data from Six Health Systems

Hypoglycemia is the most common serious adverse effect of diabetes treatment and a major cause of medication-related hospitalization. This study aimed to identify trends and predictors of hospital utilization for hypoglycemia among adults with type 2 diabetes. Using electronic health record data from six academic health systems, we performed a retrospective open cohort study including 532,323 patients aged ≥18 years with type 2 diabetes receiving regular care between 2009 and 2019. The primary outcome was the yearly event rate for hypoglycemia hospital utilization: emergency department visits, observation visits, or inpatient admissions for hypoglycemia identified using a validated ICD-9 algorithm. After the transition to ICD-10 in 2015, we used two ICD-10 code sets for hypoglycemia (limited and expanded) that were used in prior studies. We identified independent predictors of hypoglycemia hospital utilization using multivariable logistic regression analysis with data from 2014. We found that yearly rates of hypoglycemia hospital utilization decreased non-significantly from 3.4 to 2.6 events per 1,000 patients from 2009 to 2014. From 2016 to 2019, yearly event rates ranged from 15.5 to 16.5, or 21.1 to 21.8, using the limited and expanded ICD-10 code sets, respectively. The strongest independent risk factors for hypoglycemia hospital utilization were chronic kidney disease (OR 3.13, 95% CI 2.63-3.70), age 18-39 years (OR 3.00 vs. age 40-64 years, 95% CI 2.42-3.73), and insulin use (OR 2.61 vs. no diabetes medications, 95% CI 2.16-3.15). In this multicenter open cohort study, we found that rates of hypoglycemia hospital utilization were stable from 2009 to 2014 and varied considerably by clinical risk factors such that younger adults, insulin users, and those with chronic kidney disease were at especially high risk. There is a need to validate hypoglycemia ascertainment using ICD-10 codes, which detect a substantially higher number of events compared to ICD-9. Disclosure S. J. Pilla: None. J. L. Kraschnewski: None. E. Lehman: None. L. Kong: None. E. Francis: None. J. M. Poger: None. C. L. Bryce: None. N. M. Maruthur: Other Relationship; Self; Johns Hopkins HealthCare Solutions. H. Yeh: None. Funding National Institutes of Health (KL2TR003099); Patient-Centered Outcomes Research Institute (1306-04912)

Management of acute pyelonephritis in the emergency department observation unit.

This study aimed to assess the effectiveness of the emergency department observation unit (EDOU) for patients with acute pyelonephritis in a Singapore tertiary academic medical centre. We reviewed the clinical records of consecutive patients who presented with pyelonephritis between 1 July 2012 and 31 October 2014 to collect information on demographics, symptoms, signs, laboratory and radiological results, treatment, and clinical outcomes. Of 459 emergency department (ED) patients who were identified as having pyelonephritis, 164 (35.7%) were managed in the EDOU. Successful management in the EDOU was achieved in 100 (61.0%) patients. Escherichia coli was the predominant (64.6%) micro-organism in urine cultures and was positive in 106 patients. Patients diagnosed with acute pyelonephritis who were successfully managed in the EDOU had a lower incidence of nausea (32.0% vs. 60.9%, p < 0.001) and vomiting (15.0% vs. 50.0%, p < 0.001) compared to those who were not successful. EDOU is useful for both observation and treatment of patients with acute pyelonephritis. Urine cultures are sufficient for the identification of the culprit micro-organism. Patients who present with prominent symptoms of vomiting should have routine administration of antiemetics, while consideration for second-line antiemetics is recommended for those with persistent symptoms.

24-hr observation unit is safe location for rapid glucose control in uncomplicated severe hyperglycaemia

BackgroundUncomplicated hyperglycaemia is a common presentation in the emergency department (ED). Rapid glucose control is associated with the risk of iatrogenic hypoglycaemia. We sought to determine the safety of a rapid glucose control protocol delivered in a 24-h emergency department observation unit (OU).MethodsThis is a retrospective chart review of patients admitted to the OU for hyperglycaemia where the assessing clinician deemed there was no other reason for medical admission apart from hyperglycaemia; and that the patient could be safely discharged provided their hyperglycaemia was adequately treated. The rapid glucose control protocol consists of 4–6 hourly glucose monitoring and insulin injections according to a sliding scale. We report the demographics, reduction in glucose values and the incidence of hypoglycaemia in the OU. We also determine the rate of discharge from OU and the rate of hospital admission at 30 days.ResultsWe included 101 patients. The mean age was 53.5 years (95% CI 50.4–56.6) and 64% of patients were male. The mean HbA1c value was 12.8% (95% CI 12.3–13.3). The mean admission and discharge glucose values were 27.2 (95% CI 26.3–28.1) and 13.9 (95% CI 13.2–14.6) mmols/l respectively. There was no incidence of hypoglycaemia in the OU. We successfully discharged 90.1% of the patients from the OU, of which 3 (3.3%) patients were admitted to the hospital within 30 days of discharge.ConclusionED OU is a safe location to deliver effective management for patients presented with uncomplicated severe hyperglycaemia.

Acute-care hospital reencounters in COVID-19 patients.

Acute-care hospital reencounters (ACHEs)—encompassing emergency department visits, observation stays, and hospital readmissions—following COVID-19 hospitalization may exacerbate health care system strain and impair recovery from illness. We sought to characterize these reencounters and factors associated with reencounters. We identified the first consecutive 509 patients hospitalized for COVID-19 within an IL hospital network, and examined ACHEs, experienced within 30 days and 4 months of index hospitalization. We identified independent predictors of reencounter using binary logistic regression. Of 509 patients, 466 (91.6%) were discharged alive from index COVID-19 hospitalization. Within 30 days and 4 months, 12.4% and 21.5% of patients, respectively, experienced ACHEs. The median time to first ACHE was 24.2 (IQR 6.5, 55) days. COVID-19 symptom exacerbation was the leading reason for early ACHE (44.8%). Reencounters, both within 30 days and 4 months, were associated with a history of a neurological disorder before COVID-19 (OR 2.78 [95% CI 1.53, 5.03] and OR 2.75 [95% CI 1.67, 4.53], respectively). Older patients and those with diabetes mellitus, chronic obstructive pulmonary disease, or organ transplantation tended towards more frequent ACHEs. Steroid treatment during COVID-19 hospitalization demonstrated reduced odds of 30-day reencounter (OR 0.31 [95% CI 0.091, 0.79]). Forty-nine patients had repeat SARS-CoV-2 nasopharyngeal testing during a reencounter; twelve (24.5%) patients had positive reencounter tests and experienced more frequent reencounters than those testing negative. COVID-19 symptom exacerbation is a leading cause of early ACHE after COVID-19 hospitalization, and steroid use during index hospitalization may reduce early reencounters. Neurologic illness before COVID-19 predicts ACHEs.

Clinical alarms and alarm fatigue in a University Hospital Emergency Department-A retrospective data analysis.

Alarm fatigue is hypothesized to be caused by vast amount of patient monitor alarms. Objectives were to study the frequency and types of patient monitor alarms, to evaluate alarm fatigue, and to find unit specific alarm threshold values in a university hospital emergency department. We retrospectively gathered alarm data from 9 September to 6 October 2019, in Jorvi Hospital Emergency department, Finland. The department treats surgical, internal and general medicine patients aged 16 and older. The number of patients is on average 4600 to 5000 per month. Eight out of 46 monitors were used for data gathering and the monitored modalities included electrocardiography, respiratory rate, blood pressure, and pulse oximetry. Total number of alarms in the study monitors was 28176. Number of acknowledged alarms (ie acknowledgement indicator pressed in the monitor) was 695 (2.5%). The most common alarm types were: Respiratory rate high, 9077 (32.2%), pulse oximetry low, 4572 (16.2%) and pulse oximetry probe off, 4036 (14.3%). Number of alarms with duration under 10s was 14936 (53%). Number of individual alarm sounds was 105 000, 469 per monitor per day. Of respiratory rate high alarms, 2846 (31.4%) had initial value below 30 breaths min-1 . Of pulse oximetry low alarms, 2421 (53.0%) had initial value above 88%. Alarm sound load, from individual alarm sounds, was nearly continuous in an emergency department observation room equipped with nine monitors. Intervention by the staff to the alarms was infrequent. More than half of the alarms were momentary.

The impact of emergency department observation units on a health system.

Protocol driven ED observation units (EDOU) have been shown to improve outcomes for patients and payers, however their impact on an entire health system is unknown. Two thirds of US hospitals do not have such units. To determine the impact of a protocol-driven EDOU on health system length of stay, cost, and resource utilization. A retrospective, observational, cross-sectional study of observation patients managed over 25 consecutive months in a four-hospital academic health system. Patients were identified using the "admit to observation" order and limited to adult, emergent / urgent, non-obstetric patients. Data was retrieved from a cost accounting database. The primary study exposure was the setting for observation care which was broken into three discrete groups: EDOUs (n = 3), hospital medicine observation units (HMSOU, n = 2), and a non-observation unit (NOU) bed located anywhere in the hospital. Outcomes included observation-to-inpatient admission rate, length of stay (LoS), total direct cost, and inpatient bed days saved. Unadjusted outcomes were compared, and outcomes were adjusted using multiple study variables. LoS and cost were compared using quantile regressions. Inpatient admit rate was compared using logistic regressions. The sample consisted of 48,145 patients who were 57.4% female, 48% Black, 46% White, median age of 58, with some variation in most common diagnoses and payer groups. The median unadjusted outcomes favored EDOU over NOU settings for admission rate (13.1% vs 37.1%), LoS [17.9 vs 35.6 h), and cost ($1279 vs $2022). The adjusted outcomes favored EDOU over NOU settings for admission rates [12.3% (95% CI 9.7-15.3) vs 26.4% (CI 21.3-32.3)], LoS differences [11.1 h (CI 10.6-11.5 h)] and cost differences [$127.5 (CI $105.4 - $149.5)]. Adjusted differences were similar and favored EDOU over HMSOU settings. For the health system, the total adjusted annualized savings of the EDOUs was 10,399 bed days and $1,329,443 in total direct cost per year. Within an academic medical center, EDOUs were associated with improved resource utilization and reduced cost. This represents a significant opportunity for hospitals to improve efficiency and contain costs.

The Pharmacist Discharge Care (PHARM-DC) study: A multicenter RCT of pharmacist-directed transitional care to reduce post-hospitalization utilization

BackgroundOlder adults commonly face challenges in understanding, obtaining, administering, and monitoring medication regimens after hospitalization. These difficulties can lead to avoidable morbidity, mortality, and hospital readmissions. Pharmacist-led peri-discharge interventions can reduce adverse drug events, but few large randomized trials have examined their effectiveness in reducing readmissions. Demonstrating reductions in 30-day readmissions can make a financial case for implementing pharmacist-led programs across hospitals. Methods/DesignThe PHARMacist Discharge Care, or the PHARM-DC intervention, includes medication reconciliation at admission and discharge, medication review, increased communication with caregivers, providers, and retail pharmacies, and patient education and counseling during and after discharge. The intervention is being implemented in two large hospitals: Cedars-Sinai Medical Center and the Brigham and Women's Hospital. To evaluate the intervention, we are using a pragmatic, randomized clinical trial design with randomization at the patient level.The primary outcome is utilization within 30 days of hospital discharge, including unforeseen emergency department visits, observation stays, and readmissions. Randomizing 9776 patients will achieve 80% power to detect an absolute reduction of 2.5% from an estimated baseline rate of 27.5%. Qualitative analysis will use interviews with key stakeholders to study barriers to and facilitators of implementing PHARM-DC. A cost-effectiveness analysis using a time-and-motion study to estimate time spent on the intervention will highlight the potential cost savings per readmission. DiscussionIf this trial demonstrates a business case for the PHARM-DC intervention, with few barriers to implementation, hospitals may be much more likely to adopt pharmacist-led peri-discharge medication management programs.Trial registration: ClinicalTrials.gov Identifier: NCT04071951