Emergency Department Score Research Articles

Workplace violence against healthcare workers in the emergency department — a 10-year retrospective single-center cohort study

BackgroundMedical staff are regularly confronted with workplace violence (WPV), which poses a threat to the safety of both staff and patients. Structured de-escalation training (DET) for Emergency Department (ED) staff has been shown to positively affect the reporting of WPV incidents and possibly reduce its impact. This study aimed to describe the development of incidence rates, causes, means, targets, locations, responses, and the time of WPV events. Additionally, it explored the effect of the staff trained in DET on the objective and subjective severity of the respective WPV events.MethodsIn a retrospective, single-center cohort study, we analyzed ten years of WPV events using the data of Staff Observation Aggression Scale-Revised (SOAS-R) score (ranging from 0 to 22) in a tertiary ED from 2014 to 2023. The events were documented by ED staff and stored in the electronic health record (EHR).ResultsBetween 2014 and 2023, 160 staff members recorded 859 incidents, noting an average perceived severity of 5.78 (SD = 2.65) and SOAS-R score of 11.18 (SD = 4.21). Trends showed a non-significant rise in incident rates per 10,000 patients over time. The WPV events were most frequently reported by nursing staff, and the cause of the aggression was most often not discernible (n = 353, 54.56%). In total, n = 273 (31.78%) of the WPV events were categorized as severe, and the most frequent target of the aggressive behavior was the staff. WPV events occurred most frequently in the traumatology section and the detoxification rooms. While the majority of events could be addressed with verbal interventions, more forceful interventions were performed significantly more often for higher severity WPV events. More WPV events occurred during off-hours and were of a significantly higher objective and subjective severity. Overall, the presence of staff with completed DET led to significantly higher SOAS-R scores and higher perceived severity.ConclusionThe findings underline the relevance of WPV events in the high-risk environment of an ED. The analyzed data suggest that DET significantly fostered the awareness of WPV. While most events can be addressed with verbal interventions, WPV remains a concern that needs to be addressed through organizational measures and further research.

Retrospective Analysis of Risk Factors in Geriatric Hip Fracture Patients Predictive of Surgical Intensive Care Unit Admission.

Although numerous risk factors and prediction models affecting morbidity and mortality in geriatric hip fracture patients have been previously identified, there are scant published data on predictors for perioperative Surgical Intensive Care Unit (SICU) admission in this patient population. Determining if a patient will need an SICU admission would not only allow for the appropriate allocation of resources and personnel but also permit targeted clinical management of these patients with the goal of improving morbidity and mortality outcomes. The purpose of this study was to identify specific risk factors predictive of SICU admission in a population of geriatric hip fracture patients. Unlike previous studies which have investigated predominantly demographic, comorbidity, and laboratory data, the present study also considered a frailty index and length of time from injury to presentation in the Emergency Department (ED). A total of 501 geriatric hip fracture patients admitted to a Level 1 trauma center were included in this retrospective, single-center, quantitative study from January 1, 2019, to December 31, 2022. Using a logistical regression analysis, more than 25 different variables were included in the regression model to identify values predictive of SICU admission. Predictive models of planned versus unplanned SICU admissions were also estimated. The discriminative ability of variables in the final models to predict SICU admission was assessed with receiver operating characteristic curves' area under the curve estimates. Frailty,serum lactate > 2, andpresentation to the ED > 12 hours after injurywere significant predictors of SICU admission overall (P = 0.03, 0.038, and 0.05 respectively). Additionally, the predictive model for planned SICU admission had no common significant predictors with unplanned SICU admission. Planned SICU admission significant predictors included an Injury Severity Score (ISS) of 15 and greater, a higher total serum protein, serum sodium <135, systolic blood pressure (BP) under 100, increased heart rate on admission to ED, thrombocytopenia (<120), and higher Anesthesia Society Association physical status classification (ASA) score (P = 0.007, 0.04, 0.05, 0.002, 0.041, 0.05, and 0.005 respectively). Each SICU prediction model (overall, planned, and unplanned) demonstrated sufficient discriminative ability with the area under the curve (AUC) values of 0.869, 0.601, and 0.866 respectively.Finally, mean hospital Length of Stay (LOS) and mortality were increased in SICU admissions when compared to non-SICU admissions. Of the three risk factors predictive of SICU admission identified in this study, two have not been extensively studied previously in this patient population. Frailty has been associated with increased mortality and postoperative complications in hip fracture patients, but this is the first study to date to use a novel frailty index specifically designed and validated for use in hip fracture patients. The other risk factor, time from injury to presentation to the ED serves as an indicator for time a hip fracture patient spent without receiving medical attention. This risk factor has not been investigated heavily in the past as a predictor of SICU admissions in this patient population.

HEART vs EDACS Scores on Predicting Major Events Among Patients With Suspected Acute Coronary Syndrome at the Cardiac Emergency Department.

To compare the accuracy of HEART and EDACS scores in predicting major events among patients suspected of ACS in the cardiac emergency department (ED). A prospective correlational observational study design was performed on cardiac ED patients who presented with suspected ACS. Three tools were utilized to collect data pertinent to the study: Tool I comprises patients' assessment (personal characteristics, risk factors for ACS, and chest pain assessment sheet); Tool II is the risk assessment tool that includes HEART and EDACS scores; and Tool III is MACE incidence among studied patients within 30days. HEART score was significantly (P <.01) higher among patients for whom MACE was present than absent. However, EDACS score showed no significant difference (P >.05) among patients whose MACE was present or absent. HEART risk score >6 correctly predicted MACE cases with sensitivity and specificity of 77.46% and 48.28%, respectively. However, EDACS score >18 correctly predicted MACE cases with sensitivity and specificity of 42.25% and 75.86%, respectively. This study concludes that HEART score has better sensitivity than EDACS in predicting MACE among suspected ACS patients at the cardiac ED. The HEART score provides the nurses with a quicker and more reliable predictor of MACE shortly after the arrival of the suspected ACS patients at the cardiac ED than the EDACS score. The study recommended the implementation of a HEART score in the cardiac ED for predicting MACE in suspected ACS patients. Follow up closely for high-risk patients to MACE. An educational program should be made for nurses about the implementation of the heart score in the cardiac ED.

Impact of Arginine Therapy on Clinical Outcomes, Mitochondrial Function and Oxidative Stress in Children with Sickle Cell Disease Hospitalized with Vasoocclusive Pain Episodes: A Randomized Controlled Trial

Introduction: Vaso-occlusive pain episodes (VOE) are the leading cause of emergency department (ED) visits & hospitalization in patients with sickle cell disease (SCD). During SCD-VOE, patients develop an acute arginine (Arg) deficiency. Supplementation with Arg has shown opioid-sparing effects, improves blood pressure & cardiopulmonary function & decreases length of hospital stay. Though we have previously demonstrated that intravenous (IV) Arg improves mitochondrial (mito) function, the precise mechanisms by which Arg mediates these positive effects remain unclear. Objectives: To determine the role of IV Arg as adjuvant in the management of SCD-VOE Methods: Prospective single-center double-blind randomized controlled trial (RCT) of IV Arg (TID, up to 7 days) in children with SCD age 3-21 years hospitalized for VOE requiring IV opioids. Patients with significant liver/renal dysfunction or those previously enrolled were excluded. Subjects were randomized into 1 of 3 arms: 1) 100 mg/kg/dose Arg, standard dose (SD), 2) loading dose: 200 mg/kg followed by SD or 3) placebo. Demographics, total parenteral opioid (TPO) use (morphine equivalents, mg/kg) time to crisis resolution (time of study drug delivery to last IV opioid in hours), pain scores, patient reported outcomes (PROMIS) & mito function were obtained before treatment & at discharge. The primary outcome measure was TPO use between study arms. Hypothesis tests & unadjusted & covariate-adjusted fixed & mixed effects generalized linear regression models were used, as appropriate, to compare cross-sectional & longitudinal outcomes within & between randomization arms. This protocol utilized IND#66943 (Sponsor-Morris), registered with ClinicalTrials.gov (NCT02536170). Results: 1,548 patients were screened, 266 were eligible, 114 consented, & 108 were randomized. Safety results of this RCT have been previously reported (Reyes et al, Am J Hematol 2022). Demographics & clinical outcomes of subjects randomized by treatment arm are provided in Table 1. While statistically insignificant, there was a clinically relevant decrease in TPO & time to crisis resolution in both Arg arms compared to placebo. The placebo group required 45% higher TPO & experienced >15 hours longer mean time to crisis resolution compared to combined Arg-treated groups when adjusted for HU use, continuous age and sex. Among children <17 years, the placebo group (n=33) required 80% more TPO compared to combined Arg groups (n=57; p=0.075). No differences in ED vs discharge pain scores or patient/parent PROMIS reports across arms were found. Mito Complex V activity was higher (p=0.02) & protein carbonyl levels were lower (p=0.003) at ED visit in patients on Hydroxyurea (HU). Notably mito Complex IV & V activity increased significantly in both Arg arms while there was no change in the placebo group (Fig 1, p<0.001); protein carbonyl levels in platelet rich plasma decreased in both Arg groups (Fig 1, p<0.001), suggesting a decrease in oxidative stress that increased in the placebo arm (p=0.02). Greatest mito improvement occurred with Arg loading dose. Conclusion: Arg supplementation increases mito activity & decreases oxidative stress in children with SCD-VOE. This is the first report to suggest a HU-related impact on mito activity in SCD. Prior reports show that Complex V inhibition leads to increased mito oxidant production in platelets from SCD patients. Acute improvements in Complex IV & V function & decreased oxidative markers with Arg therapy are consistent with Arg-induced reductions in mito oxidant generation. Arg therapy improves symptoms associated with MELAS syndrome (mitochondrial encephalomyopathy, lactic acidosis and stroke-like episodes) suggesting an impact of Arg on mito activity that may be beneficial in SCD. Given emerging data supporting a link between mito function and pain, improved mito activity may mechanistically contribute to decreased pain & ultimately less opioid requirement with IV Arg treatment, as well as have further implications for improved metabolism and oxidative signaling in SCD. In this RCT, Arg therapy also demonstrated clinically relevant opioid-sparing & a decreased time to crisis resolution that was statistically insignificant. A larger sample size may elucidate potential differences; we are currently enrolling 360 children in an ongoing PECARN-endorsed multicenter Phase 3 RCT (SCD Treatment with Arg Therapy - STArT). Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Temporary or Permanent? A Clinical Challenge in the Evaluation of Traumatic Brain Injury Patients with Unconsciousness and Normal Initial Head CT.

Traumatic brain injury (TBI) patients with unconsciousness and normal initial head computed tomography (CT) present a clinical dilemma for physicians and neurosurgeons in the emergency department (ED). We recorded how long it took for patients to regain consciousness and evaluated the patients' characteristics. From 2018 to 2020, TBI patients with unconsciousness and normal initial head CT [Glasgow coma scale (GCS) score < 13, negative CT scan and normal laboratory test results] were evaluated. Patients who regained consciousness were analyzed. Multivariate logistic regression (MLR) analyses were used to evaluate independent factors for regaining consciousness. A total of 77 patients were included in this study. Fifty-eight (75.3%) patients regained consciousness, most within one day (43.1%). Nineteen (24.7%) patients never regained consciousness. MLR analysis showed that initial GCS score (odds 1.85, p = 0.017), early airway protection in ED (odds 25.02, p = 0.018) and 72-h GCS score improvement by two points (odds 0.02, p = 0.001) were independent factors for regaining consciousness. Overall, 94.1% of patients who received early airway protection and improved 2 points in 72-h GCS score regained consciousness. The association between days to M5 status and days to M6 status (consciousness) was highly significant. Fewer days to M5 status were highly associated with needing fewer days to regain consciousness. For TBI patients with unconsciousness and normal initial head CT, a higher probability of regaining consciousness was observed in those who underwent early airway protection and who improved 2 points in 72-h GCS score. Regaining consciousness within a short period could be expected in patients with M5 status.

A retrospective validation study of the STUMBL score for emergency department patients with blunt thoracic trauma

IntroductionBlunt thoracic trauma (BTT) is a leading cause of emergency department (ED) trauma-related attendance. Risk prediction tools are commonly to predict patients' outcomes and assign them to the most appropriate care setting. The STUMBL score is a prognostic model for BTT, derived and validated in the United Kingdom; items comprising the score are age, number of rib fractures, use of pre-injury anticoagulants, chronic lung disease and oxygen saturation levels. This study's aim was to validate the STUMBL score in an Italian ED. MethodsThis single-centre retrospective validation study was conducted in the ED of Santa Croce and Carle hub hospital in Cuneo, north-western Italy. All patients with an ED attendance for isolated BTT from 2018 to 2021 were included. Exclusion criteria were an age of under eighteen and the presence of any immediately life-threatening lesion. The primary outcome was the development of trauma-related complications, defined by the occurrence of one or more of the following: in-hospital mortality, pulmonary complications (infection, pleural effusion, haemothorax, pneumothorax, pleural empyema), need for intensive care unit admission, hospital length of stay equal to or greater than seven days. The performance of the STUMBL score was analysed in terms of discrimination with the evaluation of the receiver operating characteristic curve and calibration with the Hosmer-Lemeshow test and with the calibration belt. Results745 patients were enroled (median age 64 [25th;75th percentile: 50;78], male/female ratio 1:4, median Charlson comorbidity index 2 [1;4], median STUMBL score 11 [6;17]). 65.2% of patients were discharged home after ED evaluation. 203 patients (27.2%) developed the primary outcome. The STUMBL score was significantly different in patients with complications compared to those without complications (9 [5;13] vs 21 [17;25], p < 0.001). The C index of the score for the primary outcome was 0.90 (95% CI 0.88–0.93), and the result of the Hosmer-Lemeshow test was 9.01 (p = 0.34). STUMBL score = 16 has a sensitivity of 0.80 (95% CI 0.75–0.85), specificity of 0.87 (95% CI 0.84–0.90), a positive predictive value of 0.70 (95% CI 0.64–0.76), and a negative predictive value of 0.92 (95% CI 0.90–0.94). ConclusionIn this validation study, the STUMBL score demonstrated excellent discrimination and calibration in predicting the outcome of patients attending the ED with a BTT.

Biomarker Rule-in or Rule-out in Patients With Acute Diseases for Validation of Acute Kidney Injury in the Emergency Department (BRAVA): A Multicenter Study Evaluating Urinary TIMP-2/IGFBP7.

BackgroundUrine tissue inhibitor of metalloproteinases-2/insulin-like growth factor-binding protein 7 (TIMP-2/IGFBP7) (NephroCheck, Ortho Clinical Diagnostics, Raritan, NJ, USA) is a US Food and Drug Administration-approved biomarker for risk assessment of acute kidney injury (AKI) in critically ill adult patients in intensive care units; however, its clinical impact in the emergency department (ED) remains unproven. We evaluated the utility of NephroCheck for predicting AKI development and short-term mortality in the ED.MethodsThis was a prospective, observational, five-center international study. We consecutively enrolled ED patients admitted with ≥30% risk of AKI development (assessed by ED physician ED score) or acute diseases. Serum creatinine was tested on ED arrival (T0), day 1, and day 2 (T48); urine for NephroCheck was collected at T0 and T48. We performed ROC curve and reclassification analyses.ResultsAmong the 529 patients enrolled (213 females; median age, 65 years), AKI developed in 59 (11.2%) patients. The T0 NephroCheck value was higher in the AKI group than in the non-AKI group (median 0.77 vs. 0.29 (ng/m)2/1,000, P=0.001), and better predicted AKI development than the ED score (area under the curve [AUC], 0.64 vs. 0.53; P=0.04). In reclassification analyses, adding NephroCheck to the ED score improved the prediction of AKI development (P<0.05). The T0 NephroCheck value predicted 30-day mortality (AUC, 0.68; P<0.001).ConclusionsNephroCheck can predict both AKI development and short-term mortality in at-risk ED patients. NephroCheck would be a useful biomarker for early ruling-in or ruling-out of AKI in the ED.

Elevated pediatric age-adjusted shock-index (SIPA) in blunt solid organ injuries

Background/PurposeShock index-pediatric age-adjusted (SIPA) is a proven tool to predict outcomes in blunt pediatric trauma. We hypothesized that an elevated SIPA in either the pre-hospital or in the emergency department (ED) would identify children with blunt liver or spleen injury (BLSI) needing a blood transfusion and those at risk for failure of non-operative management (NOM). MethodsPediatric patients (1–18 years) in the ACS pediatric-TQIP database (2014–2016) with a BLSI were included. Patients were stratified by the need for a blood transfusion and/or abdominal operation. ResultsA total of 3561 patients had BLSI, of which 4% received a blood transfusion, and 4% underwent an abdominal operation. Patients who received blood had higher ISS scores (27.0 vs. 5.0, p < 0.001) and mortality (22% vs. 0.4%, p < 0.001). Those who failed NOM had higher ISS scores (17.0 vs. 5.0, p < 0.001) and mortality (7.9% vs. 0.9%, p < 0.001). On multivariable regression, an elevated SIPA score in either pre-hospital or ED was significantly associated with blood transfusion (odds ratio (OR) 8.2, 95% confidence intervals (CI) 5.8–11.5, p < 0.001) and failure of NOM (OR 2.3, CI 1.5–3.4, p < 0.001). ConclusionsHemodynamic instability, represented by an elevated pre-hospital or ED SIPA, accurately identifies children with BLSI who may need blood products or an operative intervention. Type of StudyRetrospective Comparative Study. Level of EvidenceLevel III.

Ambulatory care, insurance, and avoidable emergency department utilization in North Carolina

To examine whether and how avoidable emergency department (ED) utilization is associated with ambulatory or primary care (APC) utilization, insurance, and interaction effects. A cross-sectional analysis of electronic health records from 70,870 adults residing in Mecklenburg County, North Carolina, who visited an ED within a large integrated healthcare system in 2017. APC utilization was measured as total visits, categorized as: 0, 1, and>1. Insurance was defined as the method of payment for the ED visit as: Medicaid, Medicare, private, or uninsured. Avoidable ED utilization was quantified as a score (aED), calculated as the sum of New York University Algorithm probabilities multiplied by 100. Quantile regression models were used to predict the 25th, 50th, 75th, 95th, and 99th percentiles of avoidable ED scores with APC visits and insurance as predictors (Model 1) and with an interaction term (Model 2). Having >1 APC visit was negatively associated with aED at the lower percentiles and positively associated at higher percentiles. A higher aED was associated with having Medicaid insurance and a lower aED was associated with having private insurance, compared to being uninsured. In stratified models, having >1 APC visit was negatively associated with aED at the 25th percentile for the uninsured and privately insured, but positively associated with aED at higher percentiles among the uninsured, Medicaid-insured, and privately insured. The association between APC utilization and avoidable ED utilization varied based on segments of the distribution of ED score and differed significantly by insurance type.

Quality of Respiratory Infection Disease Prevention in Outpatient and Emergency Departments in Hospitals in Inner Mongolia, China: An Exit Poll Survey.

PurposeMeasures to prevent respiratory infection diseases (RIDs) in hospitals are important to protect both patients and physicians. In 2003, an outbreak of severe acute respiratory syndrome occurred in Inner Mongolia Autonomous Region (IMAR) of China. We aimed to evaluate competency in RID prevention procedures in terms of hospital performance and physician behavior.Patients and MethodsWe conducted a cross-sectional study in 10 tertiary general public hospitals in 3 cities of IMAR. In each hospital, we chose the respiratory and ear–nose–throat outpatient departments (OPDs) and the emergency department (ED) to invite patients with symptoms of cough to join the study before they consulted a physician. After their consultation, we asked the patients to complete a checklist to score the performance of the departments and the behavior of their physicians in terms of RID prevention practices according to international professional guidelines.ResultsFrom 711 respondents, in the domain of hospital performance, display of posters on directive to wash hands after coughing/sneezing had an average score of 0.452 (range 0–1), while other cough etiquette items had scores averaging between 0.33 and 0.39. The average score for air ventilation was 0.66. For physicians’ performance, informing patients the location of handwashing facilities scored the highest (0.62), while low scores were seen for offering a mask to coughing patients (0.14) and encouraging coughing patients to distance themselves from others (0.17). Most RID prevention procedures received low scores in EDs in both hospital performance and physician behavior domains.ConclusionHospitals in IMAR should improve their performance in RID prevention procedures, especially in giving information to RID patients through the display of posters. The practice of physicians in preventing respiratory infection spread was suboptimum. ED staff and hospital administrators should improve their procedures to prevent the spread of respiratory infections, especially given the increasing occurrences of global pandemics such as COVID-19.

Ignorance of pre-ED healthcare setting is a factor leading to inappropriate initial antibiotic treatment of sepsis in ED and poor outcomes in ICU.

Appropriate initial antibiotic therapy is critical for successfully treating sepsis. In the emergency department (ED), clinicians often rely on septic symptoms to guide empirical therapy. The aim of this study was to investigate whether history of contacting pre-ED healthcare setting is easy to be neglected and whether the patients received more inappropriate initial antibiotic therapy and developed poorer outcomes. Septic patients (n=453) admitted from ED to the intensive care unit (ICU) between 2014 and 2017 were retrospectively selected. Appropriate antibiotic treatment or not was determined by checking whether the selected antibiotics can effectively eradicate the bacteria identified. Various indexes were compared between patients with appropriate and inappropriate initial antibiotic treatments, including septic symptoms (qSOFA scores) in ED, septic-severity change in ICU (SOFA-score ratios), and septic outcomes (APACHE II scores, stay length, 30-day survival probability). These indexes were also compared between pre-ED healthcare and pre-ED community patients. In comparison with pre-ED community patients, pre-ED healthcare patients received more inappropriate initial antibiotic treatment in ED, showing poorer outcomes in ICU, including septic severity, stay-lengths in ICU and 30-day survival probabilities. Pre-ED settings is more significant than qSOFA scores to predict the inappropriate initial antibiotic treatment. Pre-ED healthcare settings, which are indexes for infection with antibiotic resistant pathogens, are easy to be neglected in the first hour in ED. We suggested that standard operating procedure for getting enough information of pre-ED settings should be incorporated to the 1h bundle of sepsis guideline.

The REDS score: a new scoring system to risk-stratify emergency department suspected sepsis: a derivation and validation study

ObjectiveTo derive and validate a new clinical prediction rule to risk-stratify emergency department (ED) patients admitted with suspected sepsis.DesignRetrospective prognostic study of prospectively collected data.SettingED.ParticipantsPatients aged ≥18 years who met...

Healthcare provider compassion is associated with lower PTSD symptoms among patients with life-threatening medical emergencies: a prospective cohort study.

We tested the hypothesis that, during a life-threatening medical emergency, patient perception of healthcare provider (HCP) compassion is associated with the subsequent development of post-traumatic stress disorder (PTSD) symptoms. Prospective cohort study in the emergency department (ED) of an urban academic medical center. We included adult patients presenting with a life-threatening medical emergency, defined as respiratory or cardiovascular instability requiring a potentially life-sustaining intervention in the ED. We measured patient perception of HCP compassion in the ED using the Consultation and Relational Empathy (CARE) measure, a validated 40-point scale. Blinded to clinical outcomes (including the CARE measure), we assessed PTSD symptoms 1month post-discharge using the PTSD Checklist for the Diagnostic and Statistical Manual of Mental Disorders-5. Of the 99/113 (88%) patients who completed follow-up, 25% (95% CI 17-35%) had PTSD symptoms at 1 month. In a multivariable model adjusting for potential confounders (e.g. severity of illness score in ED, need for intensive care unit admission, ED overcrowding, and family member emotional support in the ED), patient perception of greater HCP compassion in the ED was independently associated with lower PTSD symptoms at 1month [odds ratio 0.93 (95% CI 0.89-0.98)]. A one-point increase in the CARE measure was associated with a 7% decrease in the odds of developing PTSD symptoms. PTSD symptoms are common among ED patients with life-threatening medical emergencies. Patient perception of greater HCP compassion during the emergency is independently associated with lower risk of developing PTSD symptoms.

Documentation of HEART score discordance between emergency physician and cardiologist evaluations of ED patients with chest pain

IntroductionA triage cardiology program, in which cardiologists provide consultation to the Emergency Department (ED), may safely reduce admissions. For patients with chest pain, the HEART Pathway may obviate the need for cardiology involvement, unless there is a difference between ED and cardiology assessments. Therefore, in a cohort concurrently evaluated by both specialties, we analyzed discordance between ED and cardiology HEART scores. MethodsWe performed a single-center, cross-sectional, retrospective study of adults presenting to the ED with chest pain who had a documented bedside evaluation by a triage cardiologist. Separate ED and cardiology HEART scores were computed based on documentation by the respective physicians. Discrepancies in HEART score between ED physicians and cardiologists were quantified using Cohen κ coefficient. ResultsThirty-three patients underwent concurrent ED physician and cardiologist evaluation. Twenty-three patients (70%) had discordant HEART scores (κ = 0.13; 95% confidence interval, −0.02 to 0.32). Discrepancies in the description of patients' chest pain were the most common source of discordance and were present in more than 50% of cases. HEART scores calculated by ED physicians tended to overestimate the scores calculated by cardiologists. When categorized into low-risk or high-risk by the HEART Pathway, more than 25% of patients were classified as high risk by the ED physician, but low risk by the cardiologist. ConclusionThere is substantial discordance in HEART scores between ED physicians and cardiologists. A triage cardiology system may help refine risk stratification of patients presenting to the ED with chest pain, even when the HEART Pathway tool is used.

Same Physician, Different Location, Different Patient Satisfaction Scores

We assess whether patient satisfaction scores differ for individual emergency physicians according to the clinical setting in which patients are treated. We obtained Press Ganey satisfaction survey results from June 2013 to August 2014 for patients treated in either an urban hospital emergency department (ED) or 2 affiliated suburban urgent care centers. The same physicians work in all 3 facilities. Physicians with available survey results from at least 10 patients in both settings were included. Survey scores range from 1 (very poor) to 5 (very good). Survey questions directly assessed physicians' courtesy, ability to keep patients informed about their treatment, concern for patient comfort, listening ability, and the overall care at the facility. We calculated differences in mean urgent care and ED scores for individual physicians, along with the mean of these differences. Our primary outcome was the mean difference between urgent care and ED score with respect to physician courtesy. Seventeen physicians met inclusion criteria. For all 17 physicians, the point estimate for the mean urgent care courtesy score was higher than the point estimate for the mean ED courtesy score. The mean difference in courtesy scores between urgent care and the ED was 0.35 (95% confidence interval 0.22 to 0.49). ED scores were also consistently lower than urgent care scores for keeping patients informed about their treatment, concern for patient comfort, listening ability, and overall care rating. Although these results are limited by small sample size, we found that physicians consistently received lower satisfaction ratings from ED patients than from urgent care patients. This challenges the validity of using satisfaction scores to compare providers in different practice settings.

Are prognostic scores and biomarkers such as procalcitonin the appropriate prognostic precursors for elderly patients with sepsis in the emergency department?

The mortality of patients with severe sepsis and septic shock is still high, and the prognosis of elderly patients tends to be particularly poor. Therefore, this study sought to conduct a comparative analysis of the abbreviated mortality in emergency department sepsis (abbMEDS) score, sequential organ failure assessment (SOFA) score, infection probability score (IPS), initial procalcitonin (PCT), and cytokine levels to investigate the effectiveness of each index in predicting the prognosis of elderly patients with sepsis in the emergency department (ED). This was a single-center prospective study, and classified 55 patients (≥65years of age) with systemic inflammatory response syndrome (SIRS) from January 2013 to December 2013 in the ED. A total of 36 elderly patients were diagnosed with sepsis. The prediction of prognosis using the prognostic scores (abbMEDS, SOFA, IPS) was analyzed. An early blood examination (WBC count, C-reactive protein, PCT, and cytokines) was conducted within the first 2h of the patient's arrival at the ED. The median (IQR) age of subjects was 76.5 (70.5-81.5). After 28days, 27 subjects (75%) had survived, and 9 (25%) had died. Fifteen (41.7%) were sent to intensive care units (ICUs). The SOFA score and abbMEDS showed higher median (IQR) values of 9.5 (7.0-11.0) and 13.5 (12.0-15.0), respectively, in the ICU group than in the general ward group (p<0.001). Analysis of the levels of PCT, IL-10, IL-6, and IL-5 had a significantly better ability to predict ICU admission (p=0.001, p=0.023, p=0.030, p=0.001). The prediction of mortality in the first 28days via SOFA and the abbMEDS resulted in scores of 11.0 (8.0-11.0) and 14.0 (12.5-15.5) (p=0.004, p=0.003), respectively. However, levels of IPS, PCT, and cytokines did not show significant differences. In predicting ICU admission and the death of elderly sepsis patients in ED, SOFA and abbMEDS scores were effective. Of the various biomarkers, PCT, IL-10, IL-6, and IL-5 were effective in predicting ICU admission, but were not effective in predicting the death of elderly sepsis patients.

Intensive care unit scoring systems outperform emergency department scoring systems for mortality prediction in critically ill patients: a prospective cohort study.

BackgroundMultiple scoring systems have been developed for both the intensive care unit (ICU) and the emergency department (ED) to risk stratify patients and predict mortality. However, it remains unclear whether the additional data needed to compute ICU scores improves mortality prediction for critically ill patients compared to the simpler ED scores.MethodsWe studied a prospective observational cohort of 227 critically ill patients admitted to the ICU directly from the ED at an academic, tertiary care medical center. We compared Acute Physiology and Chronic Health Evaluation (APACHE) II, APACHE III, Simplified Acute Physiology Score (SAPS) II, Modified Early Warning Score (MEWS), Rapid Emergency Medicine Score (REMS), Prince of Wales Emergency Department Score (PEDS), and a pre-hospital critical illness prediction score developed by Seymour et al. (JAMA 2010, 304(7):747–754). The primary endpoint was 60-day mortality. We compared the receiver operating characteristic (ROC) curves of the different scores and their calibration using the Hosmer-Lemeshow goodness-of-fit test and visual assessment.ResultsThe ICU scores outperformed the ED scores with higher area under the curve (AUC) values (p = 0.01). There were no differences in discrimination among the ED-based scoring systems (AUC 0.698 to 0.742; p = 0.45) or among the ICU-based scoring systems (AUC 0.779 to 0.799; p = 0.60). With the exception of the Seymour score, the ED-based scoring systems did not discriminate as well as the best-performing ICU-based scoring system, APACHE III (p = 0.005 to 0.01 for comparison of ED scores to APACHE III). The Seymour score had a superior AUC to other ED scores and, despite a lower AUC than all the ICU scores, was not significantly different than APACHE III (p = 0.09). When data from the first 24 h in the ICU was used to calculate the ED scores, the AUC for the ED scores improved numerically, but this improvement was not statistically significant. All scores had acceptable calibration.ConclusionsIn contrast to prior studies of patients based in the emergency department, ICU scores outperformed ED scores in critically ill patients admitted from the emergency department. This difference in performance seemed to be primarily due to the complexity of the scores rather than the time window from which the data was derived.

THERM: the Resuscitation Management score. A prognostic tool to identify critically ill patients in the emergency department

IntroductionPrognostic scores are widely used in the emergency department (ED) to stratify risk for critically ill patients. The Prince of Wales ED Score (PEDS) was derived specifically for patients in...

681

Introduction: We compared the prognostic value for mortality of a recently derived pre-hospital critical illness score to established intensive care unit (ICU) and emergency department (ED) scoring systems. Hypothesis: We hypothesized that the ICU and ED scores would outperform a pre-hospital emergency care scoring system. Methods: 227 subjects were enrolled in a prospective observational cohort of critically ill patients admitted to the ICU via the ED. We compared the pre-hospital critical illness prediction score developed by Seymour et al (JAMA 2010) to the ICU scores Acute Physiology and Chronic Health Evaluation (APACHE) II, APACHE III, Simplified Acute Physiology Score (SAPS) II, and the ED scores Modified Early Warning Score (MEWS), Rapid Emergency Medicine Score (REMS), and Prince of Wales Emergency Department Score (PEDS). The primary endpoint was 60-day mortality. We compared the receiver operating characteristic curves of the different scores and assessed calibration using the Hosmer-Lemeshow goodness-of-fit test. Results: The areas under the curve (AUC) for the ICU scores were higher (AUC 0.779-0.799) than the ED scores (AUC 0.698-0.709). Performance of the Seymour score was intermediate between the ED scores and ICU scores, with an AUC of 0.743; this AUC was not significantly different than that of the best performing ICU score, APACHE III (AUC 0.799; p=0.09). In contrast, the ED scores did not discriminate as well as APACHE III (p=0.005 to 0.01 for comparison of ED scores to APACHE III). The differences in discrimination among the Seymour score and the ED scores were not significantly different (AUC 0.698-0.743; p=0.45). There were no significant differences among the ICU-based scoring systems (AUC 0.779-0.799; p=0.60). All scores had acceptable calibration. Conclusions: Although primarily developed to predict need for critical illness prior to arrival to the hospital, the Seymour score shows promise in predicting mortality for critically-ill patients admitted from the ED to the ICU and should be further evaluated in larger cohorts. Support: HL090833, Flight Attendant Medical Research Institute, KL2RR024130 from NCRR (component of NIH)

Emergency Department Sepsis Protocol does not Impact Time to Antibiotics

Background: Early goal directed therapy (EGDT) can reduce mortality in an Intensive Care Unit (ICU) popula- tion with severe sepsis. It is not clear whether EGDT can be effectively implemented in an Emergency Department (ED) with existing resources to achieve the same goals. Objectives: To assess the impact of EGDT in our ED with existing resources on time to antibiotics (ABX) and patient out- comes. Methods: We performed a before and after study of the effects of the EGDT protocol on patients over age 21 with severe sepsis admitted to the ICU. Time to ABX was the primary outcome, mortality and other care processes were secondary. Descriptive statistics, Fisher's exact chi-square, and Wilcoxon rank sum tests compared time periods. Multivariate analy- ses with logistic and Cox proportional hazard regression models were performed. Results: 192 cases: 91 before and 101 after protocol. Groups were similar in demographics, co-morbidities, severity scores, and overall mortality of 17.7%. Patients with higher Mortality in ED scores (MEDS) received ABX sooner than patients with lower MEDS after adjusting for time period. There was no difference in time to ABX between time periods after adjusting for disease severity (Hazard Ratio: 0.88, 95% CI: 0.65-1.18; OR: 0.88, 95% CI: 0.49-1.57). Conclusion: Our EGDT protocol did not change management, time to ABX, or mortality of septic patients admitted to the ICU, when relying on existing resources. Further study is needed to evaluate barriers to EGDT and feasibility of translat- ing resource intensive protocols to the bedside in routine ED care.