Emergency Department Registration Research Articles

The implementation of the acute care surgery model in the management of patients with acute appendicitis - A 5-year single-center, retrospective experience: An observational study.

We conducted this study to assess the effects of the acute care surgery (ACS) model in the management of patients with acute appendicitis (AA) based on our 5-year single-center, retrospective experience. The current single-center, retrospective, observational study was conducted in a consecutive series of the patients with AA who had been surgically treated at a tertiary referral hospital in Seoul, Korea, between January 2016 and December 2020. At our institution, the ACS model was first introduced in March 2018. Therefore, our clinical series of the patients were divided into 2 groups: the pre-ACS group (March 2014 to February 2018) and the post-ACS group (March 2018 to December 2022). Key time intervals include emergency department registration to request for surgical consultation, request for surgical consultation to decision on surgery, decision-to-operating room, time to decision on surgery and length of emergency department stay. Moreover, outcomes include rates of perforation and complications and discharge within 24 or 48 hours. We compared key time intervals, outcomes, and length of hospital stay between the 2 groups. A total of 900 patients with AA were finally included in the current study, 447 and 453 of whom were divided into the pre-ACS group (n = 447) and the post-ACS group (n = 453), respectively. There were significant differences in key time intervals, outcomes, and length of hospital stay between the 2 groups (P < .05). In conclusion, our results showed that the implementation of the ACS model was effective in improving key time intervals, rates of perforation, and discharge within 24 or 48 hours in the patients with AA.

Disposition of emergency department patients with acute pulmonary embolism after ambulance arrival.

Most outpatients with pulmonary embolism (PE) are diagnosed in the emergency department (ED). The relationship between means of arrival, site of diagnosis, and disposition in ED patients with PE is unknown. We compared discharge home between patients arriving by emergency medical services (EMS) and those arriving by other means. Within the EMS cohort, we compared those with a recent PE diagnosis in the outpatient clinic setting to those who were diagnosed with PE in the ED. This study was a secondary analysis of a retrospective cohort that included all adult, non-pregnant ED patients treated for acute PE across 21 community EDs from January 2013 to April 2015. The primary outcome was discharge home within 24h of ED registration; we also examined mortality. We described associations with patient arrival method and other patient characteristics. Among 2996 ED patient encounters with acute PE, 644 (21.5%) arrived by EMS. This group had a lower frequency of discharge (9.2% vs 26.4%) and higher 30-day all-cause mortality (8.7% vs 3.1%) than their counterparts (p<0.001 for both). These associations remained after adjusting for confounding variables. Among the EMS cohort, 14 patients (2.2%) arrived with a PE diagnosis recently made in the outpatient setting. Patients with PE who arrived at the ED by EMS were less likely to be discharged home within 24h and more likely to die within 30 days than those who arrived by other means. Less than 3% of the EMS group had been diagnosed with PE before ED arrival.

The Association Between Frailty and a Nurse-Identified Need for Comprehensive Geriatric Assessment Referral from the Emergency Department.

Emergency nurses commonly conduct geriatric assessments in the emergency department (ED). However, little is known about what geriatric syndromes or clinical presentations prompt a nurse to document an identified need for comprehensive geriatric assessment (CGA). To examine the association between geriatric syndromes, like frailty, and a nurse-identified need for a CGA following emergency care. We conducted a secondary analysis of a multi-province Canadian cohort from the InterRAI Multinational Cohort Study. We collected data at ED registration from patients 75 years of age and older (n = 2,274) from eight ED sites across Canada between November 2009 and April 2012. Geriatric syndromes were assessed by trained emergency nurses using the interRAI ED Contact Assessment; and we retrospectively calculated the ED frailty index. We employed binary logistic regression to determine the adjusted associations between geriatric syndromes and a nurse-identified need for a CGA. Approximately one-quarter (28%) of older adults were identified to need a CGA following emergency care. A 0.1 unit increase in the ED frailty index increased the likelihood of a nurse identify a need for CGA (RD: 6.6; 95% CI = 5.5-7.9). Most geriatric syndromes increased the probability of a nurse documenting the need for a CGA. When assessed by emergency nurses, the identified need for CGA is strongly linked to the presence of geriatric syndromes, including frailty. We provide face validity for the continued use of emergency nurses for screening and assessing older ED patients.

Assessment of Emergency Department Care for Patients with Acute Pain Crisis after the Formation of a Multidisciplinary Team

Introduction:American Society of Hematology (ASH) guidelines recommend the rapid evaluation and treatment of patients presenting to the Emergency Department (ED) with pain from an acute vaso-occlusive episode (VOE) related to sickle cell disease (SCD). The treatment of severe pain from VOE in SCD is time dependent and time sensitive. Guidelines recommend that treatment for acute VOE with parental opioid analgesia occurs within 60 minutes of ED registration. With respect to the five-level Emergency Severity Index (ESI) triage tool, in which lower numbers indicate higher acuity, patients with SCD are to be assigned an Emergency Severity Index (ESI) of 2 indicating (a) greater disease burden, and (b) the need for high priority bed assignment. Objectives: We aimed to create a multidisciplinary team of providers to assess and address the existing barriers and facilitators to improving guideline adherence for the management of acute crises in our large academic health system. The primary outcome of this initiative was to improve guideline adherence by ensuring 90% or greater adherence to ESI 2 assignment to acknowledge illness severity as well as timely, within 60-minute opioid analgesia. Methods: In March 2020, we convened a multidisciplinary team of stakeholders to discuss the ED care of patients with SCD presenting with an acute VOE. The group comprises ED and infusion center nurse champions, nurse educators, nurse leaders, hematologists, palliative care specialists, primary care physicians, psychologists, advanced practice providers and other allied health professionals including social work and spiritual care. Initial monthly meetings established recommendations based on national guidelines and discussed interventions to improve guideline adherence including 1. a nursing driven pain management orderset with subcutaneous and intranasal opioids, 2. a best practice alert with the recommended guidelines. We conducted a retrospective review of ED visit data including all patients with a known diagnosis of sickle cell disease presenting to the ED with a chief complaint of acute pain related to VOE from January 2018-February 2020 and March 2020 to March 2022. We compared the before and after intervention using descriptive statistics. Results: Of the 760 unique encounters for acute pain related to sickle cell disease from 2018-2022, 406 visits occurred before the group formation and 354 visits occurred after the group formed. Mean age was 30.5 years (+/- 19.5) in the pre-intervention period compared to the 29.5 years (+/- 18.9) in the post intervention period. The time to the first opioid order placed pre-intervention averaged 53.3 mins (+/- 64.9) was not significantly different compared to the post period 75.2 mins (+/- 125.8; p =0.17). The proportion of patients assigned an ESI 2 changed from 49.3% to 50.5%. Conclusion: While there was a marginal increase in the ESI 2 assignment among SCD patients presenting in acute VOE, there was no significant change in the ED time to first opioid after the formation of a multidisciplinary team.

Comparison of Chest Radiograph Impressions for Diagnosing Pneumonia: Accounting for Categories of Language Certainty.

Uncertain language in chest radiograph (CXR) reports for the diagnosis of pneumonia is prevalent. The purpose of this study is to validate an a priori stratification of CXR results for diagnosing pneumonia based on language of certainty. Retrospective chart review. CXR reports of 2,411 patient visits ≥ 18 years, admitted to medicine, who received a CXR and noncontrast chest CT within 48 hours of emergency department registration at two large academic hospitals (tertiary and quaternary care) were reviewed. The CXR and CT report impressions were categorized as negative, uncertain, or positive. Uncertain CXRs were further stratified into four categories based on language modifiers for the degree of pneumonia certainty. Comparison of CXR and CT results were determined using χ2 test; a P value of less than .0033 was considered significant to account for multiple comparisons. CXR reports for the diagnosis of pneumonia revealed the following distribution: 61% negative, 32% uncertain, and 7% positive; CT reports were 55% negative, 22% uncertain, and 23% positive for the diagnosis of pneumonia. There were significant differences between CXR categories compared with CT categories for diagnosis of pneumonia (P < .001). Negative CXR results were not significantly different than the uncertain category with the most uncertain language (P= .030) but were significantly different from all other uncertain categories and positive CXR results (each P < .001). Positive CXR results were not significantly different than the least uncertain category (most certain language) (P= .130) but were significantly different from all other categories (each P < .001). Language used in CXR reports to diagnose pneumonia exists in categories of varying certainty and should be considered when evaluating patients for pneumonia.

251 Emergency Department Arrival by Ambulance for Patients Receiving a Pulmonary Embolism Diagnosis Is Associated With Hospitalization: Is Coming from Off-site Radiology an Exception?

251 Emergency Department Arrival by Ambulance for Patients Receiving a Pulmonary Embolism Diagnosis Is Associated With Hospitalization: Is Coming from Off-site Radiology an Exception?

Assessing the Variability of Antibiotic Management in Patients With Open Hand Fractures Presenting to the Pediatric Emergency Department.

Open hand fractures may be difficult to recognize and treat. There is variability in management and administration of antibiotics for these types of injuries. Unlike open long bone fractures, there is no standardized protocol for antibiotic administration for open hand fractures in children. The objective of this study is to assess the variability of antibiotic management of open hand fractures in children. We performed a retrospective chart review at a tertiary hospital in New York of patients with hand injuries between ages 0 and 18 years presenting to the emergency department during January 2019 and December 2020. Patient encounters were reviewed for open fractures of the hand. Descriptive statistics were included for demographic and physical characteristics. There were 80 encounters with open hand fractures, of which the most common being tuft fractures (77.5%). The mean age was 7.6 years (SD, 4.7 years) with male predominance (58.8%). Crush injuries were the most common mechanism of injury (78.8%). Bedside repair was performed on 62 encounters (77.5%), of which 45 (72.5%) required nail bed repair, 56 (90.3%) required suturing, and 24 (38.7%) required reduction. Antibiotics were given to 62 (77.5%) encounters, most commonly oral cefalexin (45.2%), oral amoxicillin-clavulanic acid (27.4%), and intravenous cefazolin (14.5%). Median time to antibiotics from emergency department registration to administration was 150 minutes (interquartile range, 92-216 minutes). Antibiotic prescriptions were sent for 71 encounters (88.8%). Seventy seven (96.3%) of the encounters were discharged home. Pediatric open hand fractures have a variability of type and timing to antibiotics. Future initiatives should attempt to create standardized guidelines for management of open hand fractures.

Improving Data Collection and Abstraction to Assess Health Equity in Trauma Care.

Current trauma registries suffer from inconsistent collection of data needed to assess health equity. To identify barriers/facilitators to collecting accurate equity-related data elements, we assessed perspectives of national stakeholders, Emergency Department (ED) registration, and Trauma Registry staff. We conducted a Delphi process with experts in trauma care systems and key informant interviews and focus groups with ED patient registration and trauma registry staff at a regional Level I trauma center. Topics included data collection process, barriers/facilitators for equity-related data collection, electronic health record (EHR) entry, trauma registry abstraction, and strategies to overcome technology limitations. Responses were qualitatively analyzed and triangulated with observations of ED and trauma registry staff workflow. Expert-identified barriers to consistent data collection included lack of staff investment in changes and lack of national standardization of data elements; facilitators were simplicity, quality improvement checks, and stakeholder investment in modifying existing technology to collect equity elements. ED staff reported experiences with patients reacting suspiciously to queries regarding race and ethnicity. Cultural resonance training, a script to explain equity data collection, and allowing patients to self-report sensitive items using technology were identified as potential facilitators. Trauma registry staff reported lack of discrete fields, and a preference for auto-populated and designated EHR fields. Identified barriers and facilitators of collection and abstraction of equity-related data elements from multiple stakeholders provides a framework for improving data collection. Successful implementation will require standardized definitions, staff training, use of existing technology for patient self-report, and discrete fields for added elements.

Integrating social determinants of health screening and referral during routine emergency department care: evaluation of reach and implementation challenges

BackgroundDespite the importance of social determinants in health outcomes, little is known about the best practices for screening and referral during clinical encounters. This study aimed to implement universal social needs screening and community service referrals in an academic emergency department (ED), evaluating for feasibility, reach, and stakeholder perspectives.MethodsBetween January 2019 and February 2020, ED registration staff screened patients for social needs using a 10-item, low-literacy, English-Spanish screener on touchscreens that generated automatic referrals to community service outreach specialists and data linkages. The RE-AIM framework, specifically the constructs of reach and adoption, guided the evaluation. Reach was estimated through a number of approaches, completed screenings, and receipt of community service referrals. Adoption was addressed qualitatively via content analysis and qualitative coding techniques from (1) meetings, clinical interactions, and semi-structured interviews with ED staff and (2) an iterative “engagement studio” with an advisory group composed of ED patients representing diverse communities.ResultsOverall, 4608 participants were approached, and 61% completed the screener. The most common reason for non-completion was patient refusal (43%). Forty-seven percent of patients with completed screeners communicated one or more needs, 34% of whom agreed to follow-up by resource specialists. Of the 482 participants referred, 20% were reached by outreach specialists and referred to community agencies. Only 7% of patients completed the full process from screening to community service referral; older, male, non-White, and Hispanic patients were more likely to complete the referral process. Iterative staff (n = 8) observations and interviews demonstrated that, despite instruction for universal screening, patient presentation (e.g., appearance, insurance status) drove screening decisions. The staff communicated discomfort with, and questioned the usefulness of, screening. Patients (n = 10) communicated a desire for improved understanding of their unmet needs, but had concerns about stigmatization and privacy, and communicated how receptivity of screenings and outreach are influenced by the perceived sincerity of screening staff.ConclusionsDespite the limited time and technical barriers, few patients with social needs ultimately received service referrals. Perspectives of staff and patients suggest that social needs screening during clinical encounters should incorporate structure for facilitating patient-staff relatedness and competence, and address patient vulnerability by ensuring universal, private screenings with clear intent.Trial registrationClinicalTrials.gov, NCT04630041.

Machine learning for developing a prediction model of hospital admission of emergency department patients: Hype or hope?

ObjectiveEarly identification of emergency department (ED) patients who need hospitalization is essential for quality of care and patient safety. We aimed to compare machine learning (ML) models predicting the hospitalization of ED patients and conventional regression techniques at three points in time after ED registration. MethodsWe analyzed consecutive ED patients of three hospitals using the Netherlands Emergency Department Evaluation Database (NEED). We developed prediction models for hospitalization using an increasing number of data available at triage, ∼30 min (including vital signs) and ∼2 h (including laboratory tests) after ED registration, using ML (random forest, gradient boosted decision trees, deep neural networks) and multivariable logistic regression analysis (including spline transformations for continuous predictors). Demographics, urgency, presenting complaints, disease severity and proxies for comorbidity, and complexity were used as covariates. We compared the performance using the area under the ROC curve in independent validation sets from each hospital. ResultsWe included 172,104 ED patients of whom 66,782 (39 %) were hospitalized. The AUC of the multivariable logistic regression model was 0.82 (0.78−0.86) at triage, 0.84 (0.81−0.86) at ∼30 min and 0.83 (0.75−0.92) after ∼2 h. The best performing ML model over time was the gradient boosted decision trees model with an AUC of 0.84 (0.77−0.88) at triage, 0.86 (0.82−0.89) at ∼30 min and 0.86 (0.74−0.93) after ∼2 h. ConclusionsOur study showed that machine learning models had an excellent but similar predictive performance as the logistic regression model for predicting hospital admission. In comparison to the 30-min model, the 2-h model did not show a performance improvement. After further validation, these prediction models could support management decisions by real-time feedback to medical personal.

Transfer boarding delays care more in low-volume rural emergency departments: A cohort study.

Emergency department (ED) crowding is increasing and is associated with adverse patient outcomes. The objective of this study was to measure the relative impact of ED boarding on timeliness of early ED care for new patient arrivals, with a focus on the differential impact in low-volume rural hospitals. A retrospective cohort of all patients presenting to a Veterans Health Administration (VHA) ED between 2011 and 2014. The primary exposure was the number of patients in the ED at the time of ED registration, stratified by disposition (admit, discharge, or transfer) and mental health diagnosis. The primary outcome was time-to-provider evaluation, and secondary outcomes included time-to-EKG, time-to-laboratory testing, time-to-radiography, and total ED length-of-stay. Rurality was measured using the Rural-Urban Commuting Areas. A total of 5,912,368 patients were included from all 123 VHA EDs. Adjusting for acuity, new patients had longer time-to-provider when more patients were in the ED, and patients awaiting transfer for nonmental health conditions impacted time-to-provider for new patients (16.6 min delays, 95% CI: 12.3-20.7 min) more than other patient types. Rural patients saw a greater impact of crowding on care timeliness than nonrural patients (additional 5.3 min in time-to-provider per additional patient in ED, 95% CI: 4.3-6.4), and the impact of additional patients in all categories was most pronounced in the lowest-volume EDs. Patients seen in EDs with more crowding have small, but additive, delays in early elements of ED care, and transferring patients with nonmental health diagnoses from rural facilities were associated with the greatest impact.

Analysis of Plastic Surgery Consultations in a High-Volume Paediatric Emergency Department: A Quality Improvement Initiative.

Consult services influence emergency department (ED) workflow. Prolonged ED length of stay (LOS) correlates with ED overcrowding and as a consequence decreased quality of care and satisfaction of health team professionals. To improve management of paediatric ED patients requiring plastic and reconstructive surgery (PRS) expertise, current processes were analyzed. Patient characteristics and metrics of PRS consultations in our paediatric ED were collected over a 3-month period. Data analysis was followed by feedback education intervention to ED and PRS staff. Data collection was then resumed and results were compared to the pre-intervention period. One hundred ninety-eight PRS consultations were reviewed, mean patient age was 6.3 years. Most common (52%) diagnoses were burns and hand trauma; 81% of PRS referrals were deemed appropriate; 25% of PRS consults were requested after hour with no differences in patient characteristics compared to regular hours; 60% of consultations involved interventions in the ED. Time between ED registration and PRS consultation request (116.5 minutes), quality of procedural sedation (52% rated inadequate), and overall ED LOS (289.2 minutes) were identified as main areas of concern and addressed during feedback education intervention. Emergency department LOS and quality of sedation did not improve in the post-intervention period. The study provides detailed insights in the characteristics of PRS consultation in the paediatric ED population. Despite high referral appropriateness and education feedback intervention, significant inefficiencies were identified that call for further collaborative efforts to optimize quality of care for paediatric ED patients and improve satisfaction of involved healthcare professionals.

Evaluasi Rekam Medis Elektronik di Tempat Pendaftaran Pasien Gawat Darurat dan Rawat Inap RSUD K.R.M.T Wongsonegoro Kota Semarang

Each hospital is required to hold records or records of all services provided to patients called medical records. Increasing the effectiveness of recording medical data that is accurate, fast, can take advantage of current technological advances through the implementation of the Electronic Medical Record (EMR) system in hospitals. RSUD K.R.M.T Wongsonegoro is one of the hospitals that has implemented an electronic medical record (EMR) especially in the inpatient and emergency department registration units. The application of this electronic medical record still has some flaws that must be evaluated. This study aims to evaluate the implementation of electronic medical records at the emergency and inpatient registrations of Wongsonegoro Hospital. Data collection in this study consisted of observations and interviews. Identification of problems using the TAM (Technology Acceptance Model) method by reviewing from 3 aspects namely perceived usefulness, perceived ease of use, and behavioral intention to use. This type of research is descriptive qualitative by narrating the results of research based on the data obtained. The results obtained from this study are based on the aspect of usefulness (perceived usefulness), namely the use of electronic medical records in TPPGD and TPPRI, making the registration officer work faster and more effective.The aspect of ease (perceived ease of use) obtained from the interview results is that it is able to make it easier to accelerate the registration process in the TPPGD and TPPRI. The behavioral intention to use obtained is that the users of this system really need this electronic medical record and the registration officer at TPPGD and TPPRI plans to use the EMR in the future.

Disparities in emergency department use between Italians and migrants residing in Rome, Italy: the Rome Dynamic Longitudinal Study from 2005 to 2015

BackgroundThe Emergency Department (ED) can be considered an indicator of accessibility and quality and can be influenced in period of economic downturns. In the last fifteen years, the number of migrants in Italy has doubled (from 2.4 million in 2005 to 5.2 in 2019, 4.1 and 8.7% of the total population, respectively). However, evidence about migrants’ healthcare use is poor, and no studies focused on the ED utilisation rate during the Great Recession are available. This study aims to analyse trends in all-cause and cause-specific ED utilisation among migrants and Italians residing in Rome, Italy, before and after 2008.MethodsLongitudinal study based on data from the Municipal Register of Rome linked to the Emergency Department Register from 2005 to 2015. We analysed 2,184,467 individuals, aged 25–64 in each year. We applied a Hurdle model to estimate the propensity to use the ED and to model how often individuals accessed the ED.ResultsMigrants were less likely to be ED users than Italians, except for Africans (RR = 1.46, 95%CI 1.40–1.52) and Latin Americans (RR = 1.04, 95%CI 1.00–1.08) who had higher all-cause utilisation rates than non-migrants. Compared to the pre-2008 period, in the post-2008 we found an increase in the likelihood of being an ED user (OR = 1.34, 95%CI 1.34–1.35), and a decrease in ED utilisation rates (RR = 0.96, 95%CI 0.96–0.97) for the whole population, with differences among migrant subgroups, regardless of cause.ConclusionsThis study shows differences in the ED utilisation between migrants and Italians, and within the migrant population, during the Great Recession. The findings may reflect differentials in the health status, and barriers to access primary and secondary care among migrants. In this regard, health policies and cuts in health spending measures may have played a key role, and interventions to tackle health and access disparities should include policy measures addressing the underlying factors, adopting a Health in All Policies perspective. Further researches focusing on specific groups of migrants, and on the causes and diagnoses related to the ED utilisation, may help to explain the differences observed.

The association between timely opioid administration and hospitalization in children with sickle cell disease presenting to the emergency department in acute pain.

The National Heart, Lung, and Blood Institute guidelines for sickle cell disease (SCD) pain crisis management recommend opioids within 60 minutes of emergency department (ED) registration and every 30 minutes thereafter until acute pain is managed. These guidelines are based on expert opinion without published, supporting data. To evaluate the association between timely ED opioid administration and hospitalization rates in children with SCD. Retrospective cohort of children presenting to a children's hospital ED with SCD pain between January 1, 2014, and April 30, 2018. Visits were extracted using ICD codes, chief complaints, and receipt of at least one opioid, and then reviewed to confirm the visit was an uncomplicated pain crisis. The primary outcome was hospitalization, yes or no. Generalized estimating equations were used to determine adjusted odds of hospitalization for the timely administration of initial and second doses of opioids. Of the 902 eligible visits, 368 (40.8%) resulted in hospitalization. The mean (SD) age was 11.9 (± 5.2) years. The first opioid was administered within 60 minutes of arrival in 601 (66.6%) visits. The second opioid was administered within 30 minutes of the first in 84 (12.3%) visits. Receipt of the first opioid within 60 minutes of arrival was not associated with decreased hospitalization (1.30 [0.96-1.76]). However, receipt of the second dose within 30 minutes of the first was associated with decreased hospitalization (0.56 [0.33-0.94]). This study suggests an association between children with SCD receiving a second dose within 30 minutes of the first opioid dose and decreased hospitalizations.

ACT-FAST: a quality improvement project to increase the percentage of acute stroke patients receiving intravenous thrombolysis within 60 minutes of arrival at the emergency department.

Stroke is a leading cause of death and disability, with the administration of recombinant transcriptase-plasminogen activator (rtPA) improving outcomes in a time-dependent manner. Only 52.3% of eligible stroke patients at our institution received rtPA within 60 minutes of arrival. We aimed to improve the percentage of acute stroke patients receiving rtPA within 60 minutes of arrival at the emergency department (ED). This study presents results from the first year of a clinical practice improvement project that implemented quality improvement interventions. The primary outcome measure was percentage of acute ischaemic stroke patients receiving rtPA within 60 minutes of arrival at the ED. Secondary outcome measures included components of total door-to-needle (DTN) time and factors for delay to thrombolysis. Interventions were establishment of standardised acute stroke activation guidelines, screening question at ED registration, prehospital notification of stroke activation, public education, scripting for thrombolysis consent and easy access to equipment. The percentage of patients thrombolysed within 60 minutes increased to 60.6% (p = 0.27), and DTN time decreased from 59 minutes to 54.5 minutes (p = 0.15). This was attributable to reduced door-to-physician time, door-to-imaging time and decision time, although the results were not significant. There was no significant increase in symptomatic intracranial haemorrhage or mortality secondary to stroke. Length of stay was significantly reduced by 1.5 days (p < 0.048). The interventions resulted in an increasing but non-significant trend of acute stroke patients receiving thrombolysis within 60 minutes. Outcomes will be monitored for a longer duration to demonstrate trends and sustainability.

Does inappropriate initial antibiotic therapy affect in-hospital mortality of patients in the emergency department with Escherichia coli and Klebsiella pneumoniae bloodstream infections?

Extended-spectrum β-lactamase (ESBL)-positive bloodstream infection (BSI) is on the rise worldwide. The purpose of this study is to evaluate the impact of inappropriate initial antibiotic therapy (IIAT) on in-hospital mortality of patients in the emergency department (ED) with Escherichia coli and Klebsiella pneumoniae BSIs. This retrospective single-center cohort study included all adult patients with E. coli and K. pneumoniae BSIs between January 2007 and December 2013, who had undergone a blood culture test and initiation of antibiotics within 6 h of ED registration time. Multiple logistic regression was used to adjust for bacterial species, IIAT, time to antibiotics, age, sex, quick Sepsis Related Organ Failure Assessment (qSOFA) score ⩾ 2, and comorbidities. A total of 3533 patients were enrolled (2967 alive and 566 deceased, in-hospital mortality rate 16%). The patients with K. pneumoniae ESBL-positive BSI had the highest mortality rate. Non-survivors had qSOFA scores ⩾ 2 (33.6% vs 9.5%, P < 0.001), more IIAT (15.0% vs 10.7%, P = 0.004), but shorter mean time to antibiotics (1.70 vs 1.84 h, P < 0.001). A qSOFA score ⩾ 2 is the most significant predictor for in-hospital mortality; however, IIAT and time to antibiotics were not significant predictors in multiple logistic regression analysis. In subgroup analysis divided by qSOFA scores, IIAT was still not a significant predictor. Severity of the disease (qSOFA score ⩾ 2) is the key factor influencing in-hospital mortality of patients with E. coli and K. pneumoniae BSIs. The time to antibiotics and IIAT were not significant predictors because they in turn were affected by disease severity.

CAM-ICU may not be the optimal screening tool for early delirium screening in older emergency department patients: a prospective cohort study.

Delirium is a frequent problem among older patients in the emergency department (ED) and early detection is important to prevent its associated adverse outcomes. Several screening tools for delirium have been proposed for the ED, such as the 6-Item Cognitive Impairment Test (6-CIT) and the Confusion Assessment Method-ICU (CAM-ICU). Previous validation of the CAM-ICU for use in the ED showed varying results, possibly because it was administered at different or unknown time points. The aim was to study the prevalence of delirium in older ( ≥ 70 years) ED patients using the CAM-ICU and 6-CIT. A prospective cohort study was carried out in one tertiary care and one secondary care hospital in the Netherlands. Patients aged 70 years and older attending the ED were included. Delirium screening was performed within 1 h after ED registration using the CAM-ICU. The 6-CIT was determined for comparison using a cut-off point of at least 14 points indicating possible delirium. A total of 997 patients were included in the study, with a median age of 78 years (interquartile range 74-84). Delirium as assessed with CAM-ICU was positive in only 13 (1.3%, 95% confidence interval: 0.8-2.2) patients. Ninety-five (9.5% 95% confidence interval: 7.9-11.5) patients had 6-CIT more than or equal to 14. We found a delirium prevalence of 1.3% using the CAM-ICU, which was much lower than the expected prevalence of around 10% as being frequently reported in the literature and what we found when using the 6-CIT. On the basis of these results, caution is warranted to use the CAM-ICU for early screening in the ED.

Implementation of an Evidence-Based Care Pathway for Emergency Department Management of Sickle Cell Vaso-Occlusive Crisis Leads to Improved Clinical Outcomes

BACKGROUND Painful vaso-occlusive crises (VOC) are the most common reason for acute care utilization in patients with sickle cell disease (SCD), and the emergency department (ED) is often the site of initial management and treatment. Treatment guidelines recommend initiation of analgesia with parenteral opioids within 30 minutes of presentation, timely reassessment of pain, and additional opioids as needed every 15-30 minutes. These targets are infrequently met, resulting in uncontrolled pain, increased likelihood of hospital admission, and deterioration of physician-patient relationships. METHODS We undertook a multidisciplinary effort to improve the management of VOC in the ED, by development and implementation of an evidence-based clinical care pathway. The clinical pathway was implemented at the Hospital of the University of Pennsylvania in December 2018, with direct education of hematology and ED providers around the content of the clinical pathway, and availability of the pathway on the institutional intranet. Specific areas of focus in the pathway included appropriate triaging of patients as emergency severity index 2, timely administration of initial opioid dose, rapid reassessment and administration of additional opioid doses as needed, as well as appropriate laboratory evaluation and evaluation for other common and/or serious complications of SCD. Outcome measures included time from ED registration to administration of first opioid dose, time between administration of first opioid dose and second opioid dose, and proportion of patients discharged from the ED. Balance measures included rate of ED readmission and length of stay. RESULTS There were 602 ED visits from 103 unique patients in the study period, with 256 visits in the six-month period prior to pathway implementation and 346 visits in the six-month period after implementation. Following pathway implementation, time from registration to first opioid dose fell from 114 minutes to 93 minutes (p = 0.003). The proportion of patients receiving their first opioid dose within 60 minutes of registration increased from 19% to 33%. Time from administration of the first opioid dose to the second opioid dose improved from 117 minutes to 94 minutes (p = 0.002). The proportion of patients receiving their second opioid dose within 60 minutes of the first opioid dose increased from 27% to 37%. There was no change in the rate of hospital admission from the ED, or in the proportion of patients who left without being seen (p = 0.710). There was also no change in rate of ED readmissions (p = 0.138) or length of stay (p = 0.483). CONCLUSION Implementation of an evidence-based clinical care pathway in the ED for SCD patients presenting with VOC led to significant improvement in outcomes, with decreased time to first opioid dose and decreased time from first to second opioid dose. Nevertheless, very few patients received guideline-based care, particularly with the goal of time to first opioid dose of less than 30 minutes. While our data demonstrate that provider education and clinical pathways clearly improve the management of VOC in the ED, additional interventions will be required to target other barriers to optimal management, including implicit biases, negative provider attitudes, and social stigma surrounding SCD. Disclosures No relevant conflicts of interest to declare.

A Gradient Boosting Machine Learning Model for Predicting Early Mortality in the Emergency Department Triage: Devising a Nine-Point Triage Score.

Emergency departments (ED) are becoming increasingly overwhelmed, increasing poor outcomes. Triage scores aim to optimize the waiting time and prioritize the resource usage. Artificial intelligence (AI) algorithms offer advantages for creating predictive clinical applications. Evaluate a state-of-the-art machine learning model for predicting mortality at the triage level and, by validating this automatic tool, improve the categorization of patients in the ED. An institutional review board (IRB) approval was granted for this retrospective study. Information of consecutive adult patients (ages 18-100) admitted at the emergency department (ED) of one hospital were retrieved (January 1, 2012-December 31, 2018). Features included the following: demographics, admission date, arrival mode, referral code, chief complaint, previous ED visits, previous hospitalizations, comorbidities, home medications, vital signs, and Emergency Severity Index (ESI). The following outcomes were evaluated: early mortality (up to 2days post ED registration) and short-term mortality (2-30days post ED registration). A gradient boosting model was trained on data from years 2012-2017 and examined on data from the final year (2018). The area under the curve (AUC) for mortality prediction was used as an outcome metric. Single-variable analysis was conducted to develop a nine-point triage score for early mortality. Overall, 799,522 ED visits were available for analysis. The early and short-term mortality rates were 0.6% and 2.5%, respectively. Models trained on the full set of features yielded an AUC of 0.962 for early mortality and 0.923 for short-term mortality. A model that utilized the nine features with the highest single-variable AUC scores (age, arrival mode, chief complaint, five primary vital signs, and ESI) yielded an AUC of 0.962 for early mortality. The gradient boosting model shows high predictive ability for screening patients at risk of early mortality utilizing data available at the time of triage in the ED.