Emergency Department Of University Hospital Research Articles

AEGIS-AcutE Geriatric Intervention Study: pilot study of frontline acute geriatric assessment to improve quality of care in emergency department.

Due to the increasing number of older patients in emergency departments (EDs) with frailty, cognitive impairment and multimorbidity, there is a need for geriatric expertise in EDs. This retrospective study is of older patients visiting Turku University Hospital ED between 2 January and 31 December 2022. Patients aged 75years of older were screened for frailty using Triage Risk Screening Tool (TRST) and Clinical Frailty Scale (CFS). Nonacute, frail patients (CFS ≥4) suitable for Targeted Geriatric Assessment (TGA) (n = 1096) were scanned for the risk of delirium, cognitive impairment, change in functional status, falls, malnutrition and depression. A comprehensive patient record was made with recommendations for future care. TRST was completed in 70% of the ED visits, and two-thirds of those were considered high-risk. Among the patients assessed by the geriatric team (TGA), nonspecific complaint (38%) and falls (35%) were the main reasons for ED admission. Cognitive impairment was present in over 60% and orthostatic hypotension in 40% of the patients. The 72-hour revisit rate for TGA-patients was 2.3%. For the real-life control group, the 72-hour revisit rate was 4.6% (P = .001). Thirty-day revisit rates were 10% and 16%, respectively (P < .001). The need for rehabilitation, cognitive evaluation and intensifying home care were the main recommendations for future care. TGA approach provides structured and accurate information on older patients' background. This may lead to more precise diagnostics, a thorough consideration of hospital intake and a secure discharge from the ED. Ensuring continuity of care may help to reduce readmissions to EDs.

Factors associated with hospital revisitation within 7 days among patients discharged at triage: a case-control study.

Existing data are limited for determining the medical conditions best suited for an emergency department (ED) redirection strategy in a heterogeneous, nonurgent patient population. The aim was to establish factors associated with hospital revisits within 7 days among patients discharged or redirected by a triage team. An observational single-center case-control study was conducted at the Tampere University Hospital ED for the full calendar year of 2019. The cases comprised unplanned hospital revisits within 7 days of being discharged or redirected by triage, while the controls were discharged or redirected but did not revisit. The primary outcome was an unplanned hospital revisit within 7 days. A subgroup analysis was conducted for revisits leading to hospitalization. Basic demographics, comorbidities before triage, and triage visit characteristics were considered as predictive factors for the revisit. A backward stepwise conditional logistic regression analysis was performed. During the calendar year of 2019, there were a total of 92 406 ED visits. Of these, 7216 (7.8%) visits were discharged or redirected by triage, and 6.5% (n = 467) of all these patients revisited. Of the revisiting patients, 25% (n = 117) were hospitalized. In multivariable analysis, higher age was associated with both revisitation [odds ratio (OR): 1.01, 95% confidence interval (CI): 1.00-1.02] and hospitalization (OR: 1.02, 95% CI: 1.00-1.04). Furthermore, using other visits as a reference, abdominal pain was associated with revisitation and hospitalization (OR: 3.70, 95% CI: 2.24-6.11 and OR: 5.28, 95% CI: 2.08-13.4, respectively). Higher age and abdominal pain were associated with hospital revisitation and hospitalization within 7 days among patients directly discharged or redirected by the triage team. Regardless of the triage system in use, there might be patient groups that should be evaluated more cautiously if a triage-based discharge or redirection strategy is to be considered.

Investigation of the relationship between the measured alpha angle in capnography and readmission within thirty days in COPD who presented to the emergency department.

Background/AimIndividuals with chronic obstructive pulmonary disease (COPD) constitute a significant portion of patients who present to the emergency department with dyspnea. However, there is no ideal method for predicting mortality or making hospitalization decisions in the emergency department (ED). In this regard, objective findings are needed for these patients. Since there are no objective findings regarding the hospitalization decision, there may be an increase in the re-admission rate of patients who needed hospitalization but were decided to be discharged. Side-stream end-tidal carbon dioxide (EtCO2) measurements offer a non-invasive, easy-to-interpret, quickly accessible, and reproducible method that can be applied at the bedside. ObjectivesThe aim of this study was to evaluate the relationship between the alpha angle values obtained by capnography and readmission rates within 30 days for patients experiencing COPD exacerbations who presented to the ED with dyspnea and were discharged after treatment. MethodsIn this study, we studied with 130 participants presented to the emergency department of a tertiary care university hospital with dyspnea, who are >18y. Forty patients were excluded after evaluation for eligibility for the study. Thus, the data of 90 patients included were analyzed. We obtained alpha angle and EtCO2 values for all patients at the time of admission and also after treatment. The primary outcome measure of the study was the relationship between the patients’ readmission situations within 30 days of the alpha angle measurements. The secondary outcome measure was the association between patients’ EtCO2 values ​​and readmission within 30 days. ResultsIt was observed that both the pretreatment alpha angle values and the posttreatment alpha angle variables were statistically significant in predicting the readmission of the patients within 30 days (p=0.001, p=0.003) ConclusionThe results of this study show that alpha angle values measured for patients with COPD who present to the ED with the complaint of dyspnea may be used to predict readmission.

Craniofacial Trauma of Equestrian Origin.

Horse riding is a popular yet dangerous sport, often resulting in facial traumas due to unpredictable horse reactions or falls. This retrospective study examines 20 patients. The aim of the study is to analyze maxillofacial traumas of equine origin and discuss prevention strategies. Conducted from 2004 to 2021 at our university hospital's emergency department in France, inclusion criteria encompassed patients with maxillofacial trauma admitted to the emergency department and referred to ENT and/or dentistry post-horse-related accidents. Patients were identified from the Health Data warehouse. While 35 medical files were accessed, 15 did not meet inclusion criteria. Analysis of patient parameters, including age, sex, injury date, circumstances, injury type, management, helmet usage, operative interventions, and potential sequelae, revealed a predominantly female population (16 versus 4) under 48 years old. Traumas were most prevalent in summer (80%) and frequently involved riders on foot (60%). Seventy percent of patients sustained at least 1 facial fracture, with helmet use documented in only 1 case. In conclusion, horse riding can lead to various traumas, often necessitating surgical intervention. Preventive measures such as protective helmets, even for nonmounted riders, are crucial as the literature highlights many injuries occurring due to helmet omission.

CLASS 1C AGENTS ARE EFFECTIVE AND SAFE IN TERMINATING RECENT–ONSET ATRIAL FIBRILLATION IN ELDER PATIENTS TOO

Abstract Background Amiodarone is still widely used in recent–onset atrial fibrillation (AF), mainly in elder people, for its presumed safety. Nevertheless the growing experience with class 1c agents could encourage their use in order to improve the management of AF in elderly too. Aim: To assess whether class 1c agents could be considered effective and safe in elder people, as well in younger, in terminating recent–onset AF. Methods We retrospectively evaluated a three–years experience in over 75 patients treated in the Emergency Department of University Hospital of Verona for recent–onset AF (&amp;lt; 48 h). We excluded patients submitted to electrical cardioversion and those in whom the choice of treatment was forced by clinical conditions or coronary and structural heart disease. Then we compared the results in terms of effectiveness and safety between the two groups of treatment, class 1c agents vs amiodarone. Statistical analysis was performed using Chi–square test, with significance level set at p&amp;lt;0.05. Results We attempted at restoration of sinus rhythm in 264 patients older than 75 years observed for recent–onset AF from January 2018 to December 2020. According to exclusion criteria, the study population was restricted to 147 patients (53 males, 94 females; mean age 80 years, range 75–95) where the treatment depended on the physician‘s choice only. Most of these patients (61.2%) was treated with amiodarone, while in 38.8% class 1c agents were administered. Mean age was not significantly different between the groups (81 vs 78.5). After treatment, stable restoration of sinus rhythm was reported in 43 patients (47.7%) in amiodarone and in 47 (82.4%) in class 1c group (p&amp;lt;0.01). Median time of conversion was 240 minutes (range 30–680) in amiodarone while 60 (range 15–530) in class 1c group (p&amp;lt;0.01), as shown in fig. 1. Surprisingly, even the narrow sample did not allow any significance, the incidence of adverse events was notably superior in amiodarone patients, both in number (5 cases) and seriousness (2 cases). Whereas in class 1c group we reported only one mild adverse event. At the end of observation, 43 patients (75.4%) in class 1c but only 38 (42.2%) in amiodarone group were discharged with stable sinus rhythm (p&amp;lt;0.02). Conclusions Class 1c agents appear to be more effective and as safe as amiodarone in terminating recent–onset AF even in selected elder people. However these preliminary results need to be confirmed in a larger and prospective study.

Effectiveness of early and intensive intervention on suicide prevention: CARS programme

The aim of this study was to evaluate the outcomes of the Programme for Management of Suicidal Behaviour and Suicide Prevention (CARS). Individuals treated in the emergency department of University Hospital Marqués de Valdecilla for suicidal thoughts or attempts (N = 401) between 1-March-2016 and 31-December-2018 were considered. No randomization by patients or groups was performed. Student's t-test, chi-square and repeated measure analysis of variance were used. Kaplan-Meier survival function and Cox proportional hazard regression models were employed to estimate the risks of relapse. Outcome of those who voluntary enrol CARS were compared with treatment as usual (TAU) at 6- and 12-months follow-up. The results indicate a significant reduction and delayed occurrence of suicidal behaviour over a 12-month follow-up period with the CARS programme compared to TAU, along with a decreased frequency of hospital admissions. CARS programme demonstrates a substantial impact, significantly reducing the risk of recurrent suicidal behaviour by 35.5 % and the risk of repeated suicidal attempts by 47.2 % at the 12-month follow-up. The programme exhibits a dual protective effect, diminishing suicidal behaviour and fostering improved long-term outcomes. In conclusion, CARS effectively reduced suicidal behaviour recurrence, achieving significant decreases in suicidal thoughts, plans and attempts.

An observational study on the impact of overcrowding towards door-to-antibiotic time among sepsis patients presented to emergency department of a tertiary academic hospital

BackgroundThe latest Surviving Sepsis Campaign 2021 recommends early antibiotics administration. However, Emergency Department (ED) overcrowding can delay sepsis management. This study aimed to determine the effect of ED overcrowding towards the management and outcome of sepsis patients presented to ED.MethodsThis was an observational study conducted among sepsis patients presented to ED of a tertiary university hospital from 18th January 2021 until 28th February 2021. ED overcrowding status was determined using the National Emergency Department Overcrowding Score (NEDOCS) scoring system. Sepsis patients were identified using Sequential Organ Failure Assessment (SOFA) scores and their door-to-antibiotic time (DTA) were recorded. Patient outcomes were hospital length of stay (LOS) and in-hospital mortality. Statistical analysis was done using Statistical Package for Social Sciences (SPSS) version 26. P-value of less than 0.05 for a two-sided test was considered statistically significant.ResultsTotal of 170 patients were recruited. Among them, 33 patients presented with septic shock and only 15% (n = 5) received antibiotics within one hour. Of 137 sepsis patients without shock, 58.4% (n = 80) received antibiotics within three hours. We found no significant association between ED overcrowding with DTA time (p = 0.989) and LOS (p = 0.403). However, in-hospital mortality increased two times during overcrowded ED (95% CI 1–4; p = 0.041).ConclusionED overcrowding has no significant impact on DTA and LOS which are crucial indicators of sepsis care quality but it increases overall mortality outcome. Further research is needed to explore other factors such as lack of resources, delay in initiating fluid resuscitation or vasopressor so as to improve sepsis patient care during ED overcrowding.

Laparoscopic drainage versus interventional radiology for management of appendicular abscess: a randomized controlled trial

Background Laparoscopic drainage of appendicular abscess has become a novel technique due to its advantages over interventional radiology like a complete exploration of the abdomen, exclusion of other pathologies, excision of the appendix at the same session, better cosmesis, decreased incidence of wound infection, better visualization of surgical field, fine handling of edematous tissue and drainage of multiple collections. Patients and methods This randomized controlled clinical trial included all patients who developed the manifestations of appendicular abscess and were referred to the Zagazig University Hospital Emergency Department between January 2020 and February 2022. The study was prospectively approved by the Zagazig University Faculty of Medicine Institutional Review Board (Approval Number: 9871/26-9-2022), and was retrospectively submitted to clinicaltrials.gov in June 2022 (ClinicalTrials.gov ID: NCT05419440). The sample size was 172 patients divided into two equal groups, a laparoscopic group involved 86 patients (group 1) and an interventional radiology group involved 86 patients (group 2). Results Group 1 (laparoscopic drainage group) included 86 patients: 55.8% were males, with a mean age of 41.2 SD 12.2 years-old, while group 2 (interventional radiology group) included 86 patients: 51.2% were males, with a mean age of 36.8 SD 10.9 years-old. The incidence of reported complications in group (1) was 1 (1.2%) for bowel injury, 3 (3.5%) for fecal fistula, 0 (0%) for recurrence, 0 (0%) for pelvic collection and 0 (0%) for mortality while in group (2) were 5 (5.8%) for bowel injury, 0 (0%) for fecal fistula, 3 (3.5%) for recurrence, 8 (9.3%) for pelvic collection and 1 (1.2%). The incidence rates of quality of life in group (1) were 48 (55.8%) for excellent quality of life, 38 (44.2%) for good quality of life and 0 (0%) for poor quality of life, unlike group (2), the incidence rates of quality of life were 12 (14%) for excellent quality of life, 59 (68.6%) for good quality of life and 15 (17.4%) for poor quality of life. Conclusion Laparoscopic management of appendicular abscess was safely applied in a good experienced hand without the need for interval appendectomy.

Performance of ECG-Derived Digital Biomarker for Screening Coronary Occlusion in Resuscitated Out-of-Hospital Cardiac Arrest Patients: A Comparative Study between Artificial Intelligence and a Group of Experts.

Acute coronary syndrome is a significant part of cardiac etiology contributing to out-of-hospital cardiac arrest (OHCA), and immediate coronary angiography has been proposed to improve survival. This study evaluated the effectiveness of an AI algorithm in diagnosing near-total or total occlusion of coronary arteries in OHCA patients who regained spontaneous circulation. Conducted from 1 July 2019 to 30 June 2022 at a tertiary university hospital emergency department, it involved 82 OHCA patients, with 58 qualifying after exclusions. The AI used was the Quantitative ECG (QCG™) system, which provides a STEMI diagnostic score ranging from 0 to 100. The QCG score's diagnostic performance was compared to assessments by two emergency physicians and three cardiologists. Among the patients, coronary occlusion was identified in 24. The QCG score showed a significant difference between occlusion and non-occlusion groups, with the former scoring higher. The QCG biomarker had an area under the curve (AUC) of 0.770, outperforming the expert group's AUC of 0.676. It demonstrated 70.8% sensitivity and 79.4% specificity. These findings suggest that the AI-based ECG biomarker could predict coronary occlusion in resuscitated OHCA patients, and it was non-inferior to the consensus of the expert group.

Severe pain management in the emergency department: patient pathway as a new factor associated with IV morphine prescription.

Across the world, 25-29% of the population suffer from pain. Pain is the most frequent reason for an emergency department (ED) visit. This symptom is involved in approximately 70% of all ED visits. The effective management of acute pain with adequate analgesia remains a challenge, especially for severe pain. Intravenous (IV) morphine protocols are currently indicated. These protocols are based on patient-reported scores, most often after an immediate evaluation of pain intensity at triage. However, they are not systematically prescribed. This aspect could be explained by the fact that physicians individualize opioid pain management for each patient and each care pathway to determine the best benefit-risk balance. Few data are available regarding bedside organizational factors involved in this phenomenon. This study aimed to analyze the organizational factors associated with no IV morphine prescription in a standardized context of opioid management in a tertiary-care ED. A 3-month prospective study with a case-control design was conducted in a French university hospital ED. This study focused on factors associated with protocol avoidance despite a visual analog scale (VAS) ≥60 or a numeric rating scale (NRS) ≥6 at triage. Pain components, physician characteristics, patient epidemiologic characteristics, and care pathways were considered. Qualitative variables (percentages) were compared using Fisher's exact test or the chi-squared tests. Student's t-test was used to compare continuous variables. The results were expressed as means with their standard deviation (SD). Factors associated with morphine avoidance were identified by logistic regression. A total of 204 patients were included in this study. A total of 46 cases (IV morphine) and 158 controls (IV morphine avoidance) were compared (3:1 ratio). Pain patterns and patient's epidemiologic characteristics were not associated with an IV morphine prescription. Regarding NRS intervals, the results suggest a practice disconnected from the patient's initial self-report. IV morphine avoidance was significantly associated with care pathways. A significant difference between the IV morphine group and the IV morphine avoidance group was observed for "self-referral" [adjusted odds ratio (aOR): 5.11, 95% CIs: 2.32-12.18, p < 0.0001] and patients' trajectories (Fisher's exact test; p < 0.0001), suggesting IV morphine avoidance in ambulatory pathways. In addition, "junior physician grade" was associated with IV morphine avoidance (aOR: 2.35, 95% CIs: 1.09-5.25, p = 0.03), but physician gender was not. This bedside case-control study highlights that IV morphine avoidance in the ED could be associated with ambulatory pathways. It confirms the decreased choice of "NRS-only" IV morphine protocols for all patients, including non-trauma patterns. Modern pain education should propose new tools for pain evaluation that integrate the heterogeneity of ED pathways.

Patients' Expectations in Emergency Department at King Abdulaziz University Hospital: A Cross-Sectional Survey-Based Study.

Emergency departments (EDs) are vital to the timely and necessary care that a significant percentage of patients get. Emergency medicine places a high priority on quality, and to deliver patient-centered care, it is crucial to first investigate patient expectations from ER visits. This is a cross-sectional study of all visits to the King Abdulaziz University Hospital Emergency Department in Jeddah. The study included adult patients who visited the emergency department and were willing to complete a survey and participate in an interview. Data was collected through face-to-face questionnaires.Patient's expectations during their visit to the emergency department were correlated to different parameters using univariate and bivariate analysis. The study included 291 patients. The majority of patients believed that their medical condition required admission to the hospital and agreed that it would be easier to receive treatment if admitted to the hospital. Results showed that 65.6% (n=191) of patients reported that the most serious patients should be seen first, and 65.3%(n=190) reported that a doctor should determine the seriousness of their health problem upon arrival. There was no significant difference found between age groups in relation to other items of expectations. It is clear that a sizable percentage of patients place a high value on seeing the most urgent cases first and having a doctor assess each patient's condition when they arrive. Our results show that, in order to guarantee the best patient happiness and care, healthcare practitioners must meet patients' expectations and modify their strategies accordingly.

Comparison of vitamin K and non-vitamin K oral anticoagulants and the bleeding frequency in the emergency department.

Safety studies of anticoagulant therapy have so far been conducted on many subjects in controlled conditions (i.e., clinically monitored) and demonstrated the noninferiority of new ones over old anticoagulant drugs. Data on the propositions for the presence of symptoms and signs of bleeding among various anticoagulants in the emergency department indicate that these data do not match the data published so far. The aim of the study was to investigate the differences in the frequency of bleeding and bleeding-related symptoms as a reason for emergency department attendance in patients on anticoagulant therapy. The study included patients from the emergency department of University Hospital for one year, who were on anticoagulant therapy and who met the inclusion criteria. Out of a total of 595 patients, 409 were on warfarin (68.74%), and the rest were taking direct oral anticoagulants (DOAC): dabigatran 71 (11.93%), rivaroxaban 66 (11.09%) and apixaban 49 (8.23%). Out of 409 patients taking warfarin, 34.4% were adequately anticoagulated with the frequency of bleeding 13.7%, while in 57.2% of patients, PT INR was higher than the reference values with the frequency of bleeding 15.0%. A comparison between all DOAC groups and adequately anticoagulated warfarin patients in the frequency of bleeding and bleeding-related symptoms as a reason for emergency attendance yielded a difference that was marginally statistically significant (Pearson Chi-Square = 7.554, p = 0.052). Monitoring the frequency of bleeding and bleeding-related symptoms in patients on oral anticoagulant therapy as a reason for emergency department attendance may be a new safety and efficacy factor in real-life patient scenarios.

The influence of supportive work environment on work-related stress and conflict management style among emergency care nurses: A descriptive correlational study.

Stress and conflict in emergency departments are inevitable but can be managed. A supportive work environment is key to helping emergency care providers, especially nurses, constructively manage work-related stress and conflict. The aim of this study was to assess the influence of supportive work environments on work-related stress and conflict management style among emergency care nurses. A descriptive correlational research design was utilized. Data were collected from 221 staff nurses recruited from two university hospital emergency departments in Alexandria, Egypt. Three instruments were used: (1) perceived organizational support scale, (2) nurses' occupational stressors scale, and (3) conflict management style inventory. There was a highly significant correlation between supportive work environments and work-related stress (p = .000) and a significant correlation between supportive work environments and conflict management style (p = .026). Supportive work environments had a significant inverse negative relationship with work-related stress experienced by nurses (p = .001) and accounted for 51% of variance in work-related stress. Meanwhile, supportive work environments had a significant positive relationship with conflict management styles of nurses (p = .026). Work-related stress had a significant relationship with nurses' conflict management style (p = .000) and accounted for 45% of the variance in conflict management style. The style of conflict management modeled by staff within emergency departments can positively or negatively influence the work environment and level of work-related stress. There is a necessity to cultivate a supportive culture for nurses in emergency departments to develop skills for constructive conflict management styles to reduce work-related stress.

The diagnostic yield for computed tomography pulmonary angiography in patients with anticoagulation.

Patients who present to the emergency department (ED) for suspected pulmonary embolism (PE) are often on active oral anticoagulation (AC). However, the diagnostic yield of computed tomography pulmonary angiography (CTPA) in screening for PE in patients who present on AC has not been well characterized. We aim to investigate the diagnostic yield of CTPA in diagnosing PE depending on AC status. We reviewed and analyzed the electronic medical records of patients who underwent CTPA for PE at a university hospital ED from June 1, 2019, to March 25, 2022. Primary outcome was the incidence of PE on CTPA depending on baseline AC status and indication for AC. Of 2,846 patients, 242 were on AC for a history of venous thromboembolism (VTE), 210 were on AC for other indications, and 2,394 were not on AC. The incidence of PE on CTPA was significantly lower in patients on AC for other indications (5.7%) when compared to patients on AC for prior VTE (24.3%) and patients not on AC at presentation (9.8%) (P<0.001). In multivariable analysis among the whole cohort, AC was associated with a positive CTPA (odds ratio [OR] 0.26, 95% confidence interval [CI]: 0.15-0.45, P<0.001). The incidence of PE among patients undergoing CTPA in the ED is lower in patients previously on AC for indications other than VTE when compared to those not on AC or those on AC for history of VTE. AC status and indication for AC may affect pre-test probability of a positive CTPA, and AC status therefore warrants consideration as part of future diagnostic algorithms among patients with suspected PE.

Preliminary Evaluation of the Scandinavian Guidelines for Initial Management of Minimal, Mild, and Moderate Head Injuries with Glial Fibrillary Acidic Protein.

Glial fibrillary acidic protein (GFAP) has become the most promising biomarker for detecting traumatic abnormalities on head computed tomography (CT) in patients with traumatic brain injury (TBI), but most studies have not addressed the potential added value of combining the biomarker with clinical variables that confer risk for intracranial injuries. The Scandinavian Guidelines for Initial Management of Minimal, Mild, and Moderate Head Injuries in Adults were the first clinical decision rules in the field with an incorporated biomarker, the S100 astroglial calcium-binding protein B (S100B), which is used in the Mild (Low Risk) group defined by the guidelines. Our aim was to evaluate the performance of the guidelines when S100B was substituted with GFAP. The sample (N = 296) was recruited from the Tampere University Hospital's emergency department between November 2015 and November 2016, and there were 49 patients with available GFAP results who were stratified in the Mild (Low Risk) group (thus patients undergoing biomarker triaging). A previously reported cutoff of plasma GFAP ≥140 pg/mL was used. Within the Mild (Low Risk) group (n = 49), GFAP sensitivity (with 95% confidence intervals in parentheses) for detecting traumatic CT abnormalities was 1.0 (0.40-1.00), specificity 0.34 (0.19-0.53), the negative predictive value (NPV) 1.0 (0.68-1.00), and the positive predictive value (PPV) 0.16 (0.05-0.37). The sensitivity and specificity of the modified guidelines with GFAP, when applied to all imaged patients (n = 197) in the whole sample, were 0.94 (0.77-0.99) and 0.20 (0.15-0.28), respectively. NPV was 0.94 (0.80-0.99) and PPV 0.18 (0.13-0.25). In the Mild (Low Risk) group, none of the patients with GFAP results below 140 pg/mL had traumatic abnormalities on their head CT. These findings were derived from a small patient subgroup. Future researchers should replicate these findings in larger samples and assess whether GFAP has added or comparable value to S100B in acute TBI management.

Effect and sustainability of a stepwise implemented multidisciplinary antimicrobial stewardship programme in a university hospital emergency department.

To explore effectiveness and sustainability of guideline adherence and antibiotic consumption after establishing treatment guidelines and initiating antimicrobial stewardship (AMS) ward rounds in a university hospital emergency department (ED). Data were gathered retrospectively from 2017 to 2021 in the LMU University Hospital in Munich, Germany. Four time periods were compared: P1 (pre-intervention period); P2 (distribution of guideline pocket cards); P3 (reassessment after 3 years); and P4 (refresher of guideline pocket cards and additional daily AMS ward rounds for different medical disciplines). Primary outcome was adherence to guideline pocket cards for community-acquired pneumonia, cystitis, pyelonephritis and COVID-19-associated bacterial pneumonia. Secondary outcomes were reduction in antibiotic consumption and adherence to AMS specialist recommendations. The study included 1324 patients. Guideline adherence increased in P2 for each of the infectious diseases entities. After 3 years (P3), guideline adherence decreased again, but was mostly on a higher level than in P1. AMS ward rounds resulted in an additional increase in guideline adherence (P1/P2: 47% versus 58.6%, P = 0.005; P2/P3: 58.6% versus 57.3%, P = 0.750; P3/P4: 57.3% versus 72.5%, P < 0.001). Adherence increased significantly, not only during workdays but also on weekends/nightshifts. Adherence to AMS specialist recommendations was excellent (91.3%). We observed an increase in use of narrow-spectrum antibiotics and a decrease in the application of fluoroquinolones and cephalosporins. Establishing treatment guidelines in the ED is effective. However, positive effects can be diminished over time. Daily AMS ward rounds are useful, not only to restore but to further increase guideline adherence significantly.

An augmented reality mobile application for weight estimation in paediatric patients: A prospective single-blinded cross-sectional study.

Determining the exact weight of children is a challenging task during emergency situations. Current guidelines recommend the use of length-based weight-estimating tapes. However, healthcare providers must either always carry the tapes or take time to locate them. Moreover, they may not know how to use them. To address these issues, we developed an augmented reality smartphone application for length-based weight estimation called the Paediatric Augmented Reality Scale (PARS). We evaluated its performance and compared it to that of the Broselow tape (BT) and Paediatric Advanced Weight Prediction in the Emergency Room extra-long and extra-large (PAWPER-XL) tape methods. A prospective, single-blinded cross-sectional study was conducted with children aged 1 month to 12 years who visited the emergency department of the tertiary university hospital in Bucheon, South Korea between July 2021 and February 2022. This study aimed to evaluate the measurement agreement and performance of 3 methods: BT, PAWPER-XL and PARS. In all, 1090 participants were enrolled, and 639 (58.6%) were male. The mean age of the participants was 4.1 ± 2.8 years, with a mean height of 102.7 ± 21.7 cm and mean weight of 18.8 ± 9.5 kg. Compared to BT and PAWPER-XL, PARS exhibited lower mean absolute percentage error (9.60%) and root mean square percentage error (3.02%). PARS achieved a higher proportion of weights estimated within 10% of the actual weight (63.21%), outperform-ing BT (57.25%) and PAWPER-XL (62.47%). The intraclass correlation coefficients for the actual and estimated weights of BT, PAWPER-XL and PARS were 0.952, 0.969 and 0.973, respectively (P<0.001). PARS exhibited a modestly better performance than BT and PAWPER-XL in estimating body weight. PARS-estimated body weights correlated fairly accurately with the actual body weights. PARS holds potential utility in paediatric emergencies.

Diagnostic accuracy of Point Of Care UltraSound (POCUS) in clinical practice: A retrospective, emergency department based study.

Point-of-care ultrasound (POCUS) is the acquisition and interpretation of ultrasound imaging at the bedside to solve specific clinical questions based on signs and symptoms of presentation. While several studies evaluated POCUS diagnostic accuracy for a variety of clinical pictures in the emergency department (ED), only a few data are available on POCUS diagnostic accuracy performed by physicians with different POCUS skills. The objective of this research was to evaluate the diagnostic accuracy of POCUS compared to standard diagnostic imaging in the ED. This was a retrospective study conducted in the ED of a third-level university hospital. Patients who underwent cardiac, thoracic, abdominal, or venous lower limb POCUS and a standard imaging examination between June 2021 and January 2022 were included. 1047 patients were screened, and 844 patients included. A total of 933 POCUS was included (102, 12.09%, cardiac; 466, 55.21%, thoracic; 336, 39.8%, abdominal; 29, 3.44%, lower limb venous POCUS), accounting for 2029 examinations. POCUS demonstrated 96.6% (95% CI 95.72-97.34) accuracy, 47.73 (95% CI 33.64-67.72) +LR, 0.09 (95% CI 0.06-0.12) -LR. +LR was greater than 10 for all investigations but for hydronephrosis (5.8), and -LR never exceeded 0.4. POCUS exhibited high diagnostic accuracy for virtually all conditions when performed by emergency department physicians.

91. Implementation of a blood culture algorithm in emergency department patients as a diagnostic stewardship intervention

Abstract Background Blood cultures (BCx) are commonly ordered for patients at low risk of bacteremia. Liberal ordering can increase false-positive results due to contamination, along with increasing length of stay, excess antibiotics, and unnecessary diagnostic procedures. We implemented an algorithm for appropriate blood culture obtainment (Figure 1) in an academic tertiary care emergency department (ED) and assessed the intervention’s impact on various operational, clinical, and safety metrics.Figure 1:ED Blood culture algorithm Methods We performed a prospective cohort study in the Duke University Hospital ED from 12/2022 to 3/2023 using historical controls from 12/2020-11/2022. The BCx algorithm was disseminated in-person, electronically, and accessible online. Weekly chart review of all eligible patients for algorithm adherence was completed by 7 ED clinicians with monthly feedback provided to all ED providers. We defined a BCx event as 1 or more BCx sets within 24 hours. We excluded patients &amp;lt; 18 years, absolute neutrophil count &amp;lt; 500 109/L, and heart and lung transplant recipients. We measured BCx order volume, indication, algorithm adherence, BCx positivity rate, antibiotic days of therapy (DOT), and 30-day hospital readmission. Results Average monthly BCx volume was 1387 pre-intervention compared to 1226 post-intervention (p= 0.046). An increase in culture positivity was see post-intervention with a rate of 13.9% compared to 11.23% in the pre-intervention group (Figure 2, p&amp;lt; 0.001). The majority of the 2168 BCx adhered to the algorithm. (Figure 3). The most common reasons for non-adherence were isolated fever or leukocytosis (29%), non-severe community-acquired pneumonia or healthcare-associated pneumonia (6.9%) and non-severe cellulitis (4%). No change in DOT (786 vs. 783 days of therapy per 1000 patient days, p-value 0.85) (Figure 4) or monthly 30-day hospital readmission (21.1% vs 19.6%, p-value 0.30) was observed.Figure 2:Blood cultures drawn per month and % appropriate pre/post-intervention (N=2168)Figure 3:Algorithm Adherent vs. Algorithm Non-Adherent blood cultures per month (N=2168)Figure 4:Emergency Department anti-bacterial days of antibiotic therapy per 1000 patient days Conclusion Introduction of a BCx algorithm in an academic tertiary care ED, resulted in a decrease in BCx volume, increase in BCx positivity rate, and no increase in DOT or readmission was observed. (Table 1)Table 1:Blood culture volume, positivity rate, days of antibiotic therapy, and 30-day readmission Disclosures Jessica Seidelman, MD, MPH, Uptodate: content editor for pelvic osteomyelitis page

Development of an Emergency Department Case Management Case-Finding Tool.

Identifying emergency department (ED) patients who are at high risk for return visits is an important goal for case management to improve patient care. This quality improvement study describes the development and evaluation of the Emergency Department Case Management Priority Score (EDCMPS), an electronic medical record (EMR)-based "case-finding" system, and its ability to identify these high-risk patients. In addition, the authors present data about its acceptability among emergency department case managers (ED CMs). Emergency departments with case management availability and staffing. A retrospective analysis at Duke University Hospital ED compared patient data pre- and postimplementation of the EDCMPS. The tool was developed using the LEAN and Plan-Do-Study-Act (PDSA) quality improvement methodologies, with ED CM participation. ED return and hospitalization rates within 7 and 30 days between both methods were compared, and a survey evaluated CM satisfaction with the EDCMPS. The 2-month preintervention period (July 1, 2022, to August 31, 2022) included 8,677 patients discharged from the ED, with 897 patients (10.3%) identified as at high risk for return based on the previous manual methodology. In the 3-month postintervention period (September 1, 2022, to November 30, 2022), there were 13,566 patients discharged, with 692 patients (5.1%) identified as at high risk for return using the EDCMPS. The EDCMPS outperformed the manual method, yielding a significantly higher odds ratio (OR) for 7- and 30-day ED return or hospitalization (e.g., 30-day any return OR = 4.21 vs. 1.69). The survey showed broad ED CM agreement on the tool's superior performance, especially in organizing outpatient resources and referring to support programs. However, challenges in securing primary care follow-up, housing, and health insurance applications were identified. The tool's collaborative development approach ensured its fit to ED CM needs, contributing to its success. The EDCMPS showcases promise in enhancing ED CM efficiency, with strong frontline staff endorsement. It pinpoints areas needing focus for patient support and has the potential to reduce ED revisits and therefore health care utilization. Its methodology offers insights for similar future implementations in health care institutions.