Emergency Department Patients Research Articles

Survey of Emergency Department Clinicians on the Utility of the Guaiac Fecal Occult Blood Test.

Emergency department (ED) clinicians utilize the guaiac fecal occult blood test (gFOBT) in their assessment of suspected gastrointestinal bleeding or unexplained anemia despite supporting evidence. ED clinicians' ability to predict the gFOBT results and how the gFOBT results could affect ED patient disposition has not been previously studied. Methods: From October 16, 2019, through September 15, 2020, we conducted a single-site survey of ED clinicians before and after performing gFOBTs during routine clinical care. Survey data were collected and retrospectively evaluated with unadjusted and multivariable regression analyses. We examined a total of 133 combined pre-gFOBT and post-gFOBT surveys. ED clinicians accurately predicted gFOBT results with an area under the receiver operating characteristic curve of 0.75 (95%CI, 0.66-0.85). Of clinician-predicted certain or very probable positive gFOBT results, only 79% were actually positive. In multivariable analyses, decreased hematocrit level (odds ratio (OR), 0.31/10% increase; 95%CI, 0.14-0.61), decreased red blood cell count (OR, 0.41/1x1012/L increase; 95%CI, 0.21-0.75), and absence of firm stool consistency (OR, 0.09; 95%CI, 0.01-0.42) were associated with positive gFOBT results (allP<.006). The most common reason for performing gFOBTs was black stool or suspected melena, followed by decreased hemoglobin level, red blood in stool, and suspected upper gastrointestinal tract bleeding. Before performing gFOBT, 50.8% of clinicians responded that the test results would change patient disposition, which decreased to 30.5% after the gFOBT result. We found that ED clinicians cannot predict the gFOBT results with high accuracy. A suspected GI bleed is the main reason for performing the test in the ED.

Diverticulitis evaluation and management among United States emergency departments over an eight-year period

IntroductionDiverticulitis is a common reason for presentation to the Emergency Department (ED). However, as imaging options, risk stratification tools, and antibiotic options have expanded, there is a need for current data on the changes in incidence, computed tomography (CT) performance, antibiotic usage, and disposition over time. MethodsThis was a cross-sectional study of ED patients with a diagnosis of diverticulitis from 1/1/2016 to 12/31/2023. Using the Epic Cosmos database, all ED visits for acute diverticulitis were identified using ICD-10 codes. Outcomes included total ED presentations for diverticulitis, admission rates, CTs performed, outpatient antibiotic prescriptions, and antibiotics administered in the ED for admitted patients. ResultsThere were 186,138,130 total ED encounters, with diverticulitis representing 927,326 (0.50 %). The rate of diverticulitis diagnosis increased from 0.40 % to 0.56 % over time. The admission rate declined over time from 33.6 % to 27.7 %, while the CT rate rose from 83.0 % to 92.6 %. Among those discharged, 90.4 % received an antibiotic, which remained consistent over time. Metronidazole (55.1 %) and ciprofloxacin (40.8 %) were the most commonly prescribed antibiotics, followed by amoxicillin-clavulanate (36.1 %). Among those admitted, most received either metronidazole (62.0 %), a fluoroquinolone (40.4 %), a third-generation cephalosporin (18.9 %), or a penicillin-based agent (38.1 %). Among both discharged and admitted patients, there was a marked shift to penicillin-based agents as the primary antibiotic regimen. ConclusionDiverticulitis remains a common ED presentation, with a gradually rising incidence over time. Admission rates have decreased, while CT imaging has become more common. Most patients receive antibiotics, though the specific antibiotic has shifted in favor of penicillin-based agents. These findings can provide key benchmarking data and inform future initiatives to guide imaging and antibiotic use.

Predictive value of IL-8 for mortality risk in elderly sepsis patients of emergency department

BackgroundSepsis significantly impacts morbidity and mortality, particularly among older adults. Despite extensive research, early recognition and prognosis prediction of sepsis remain challenging. IL-8, a chemokine produced by inflammatory cells like monocytes and endothelial cells, has shown potential in predicting mortality in sepsis patients, though its role in elderly sepsis remains unexplored. ObjectivesThe present study aimed to explore the predictive ability of interleukin-8 (IL-8) for mortality risk in elderly septic patients. Methods220 elderly sepsis patients were included in the present study. Serum samples were obtained within 1 h of admission to assess serum IL-8, white blood cell (WBC), procalcitonin (PCT), C-reactive protein (CRP), and lactic acid (LAC) levels. The Sequential Organ Failure Score (SOFA) and Acute Physiological and Chronic Health Assessment II (APACHE II) were recorded. Logistic regression analysis was employed to identify independent predictors of mortality within 28 days for elderly patients diagnosed with sepsis. Further, the capacity of these factors to predict 28-day mortality within this patient cohort was evaluated. ResultsSOFA score, APACHE II score, LAC, and IL-8 were all significant independent predictors for 28-day mortality in elderly sepsis patients (P < 0.05). The AUC of the ROC curve for IL-8 was calculated to be 0.701, indicating a moderately predictive performance. In comparison, the AUC for LAC was marginally higher at 0.708. Nevertheless, the results of the statistical analysis revealed no significant difference in the predictive value between IL-8 and LAC. Moreover, the present findings indicate that the combined assessment of IL-8 and SOFA score demonstrated superior predictive value for mortality compared to using IL-8 alone. ConclusionsIL-8 LAC, APACHE II, and SOFA can be considered independent predictors factors for mortality of elderly sepsis patients. Utilizing the combination of IL-8 and SOFA demonstrates a heightened predictive capability compared to using any single index alone.

A-165 Value Of Monocyte Distribution Width In Bacteremia Assessment In Emergency Department Patients

Abstract Background Monocyte distribution width (MDW) is an immune response biomarker and part of a CBC differential. MDW is derived from the distribution of monocyte volumes and elevated MDW values correlate with severe infections and sepsis in Emergency Department (ED) adult patients. Neutrophil to lymphocyte ratio (NLR) is predictive of infections and inflammatory stress. Evaluating these biomarkers could be valuable in bacteremia risk assessment. Bacteremia is the presence of viable bacteria in the bloodstream and is present in up to 20% of septic patients. Blood cultures establish pathogen identity but require culture time, potentially delaying appropriate treatment. Our goal was to characterize MDW and NLR clinical performance in ED patients with suspected bacteremia. Methods This was an observational cohort study of ED patients 18 years and older with CBC differential and blood cultures obtained. MDW values ≥20 is the published cut-off for increased infection risk. Clinical literature suggests that NLR ≥3 is abnormal. We assessed the diagnostic performance of MDW and NLR for positive blood cultures using SPSS Version 25. Results From 07/2021-09/2023, 9,400 blood cultures were ordered and 5174 patients had differential CBCs. The overall blood culture positivity rate was 14.4%. MDW and NLR performance for positive blood cultures is shown in Table 1. Conclusions Our analysis provides evidence that MDW and NLR may be useful for early recognition of bacteremia in ED patients. CBC differential results are reported sooner than culture results. MDW is directly reported, NLR can be readily calculated from the differential. Therefore both could contribute to earlier risk stratification and our findings suggest potentially distinct information from MDW and NLR. Combining MDW with other CBC parameters may provide additional diagnostic advantage. Further analysis will incorporate added clinical data for enhanced decision support in interpreting MDW values in the context of pending blood culture results.

A-246 Can CRP be used to rule in or rule out elevated procalcitonin concentrations in the emergency department?

Abstract Background C-reactive Protein (CRP) and procalcitonin (PCT) are commonly used sepsis biomarkers but have very different properties. PCT rises earlier, has a shorter half-life and is more specific for sepsis than CRP. It is however significantly more expensive. This study examined whether CRP measurement can be used to screen for the need for PCT measurement in emergency department patients. Methods This was a retrospective study of anonymized records of paired CRP and PCT requests from the emergency department during 2023. All testing was performed using Beckman Coulter AU 5800 (CRP) and Roche e601 (PCT). PCT results were interpreted using the 2023 AACC guidelines on PCT use (PCT&amp;lt;0.1 ug/L: strongly discourage antibiotic use; PCT 0.1-0.25: discourage antibiotic use; PCT 0.26-0.5: encourage antibiotic use; PCT&amp;gt;0.5: strongly encourage antibiotic use) and the ability of CRP to predict PCT exceeding the various cutoffs was calculated using Microsoft Excel and Analyse-It statistical add-on. Results There were 1645 paired results available. The CRP concentrations at 95% and 99% sensitivity and specificity levels for the various PCT cutoffs are shown in the table, together with the projected reductions in PCT testing volumes if PCT testing is restricted to samples with CRP within the ranges defined by the 95% or 99% sensitivity/specificity values. For example, from the table, for PCT&amp;gt;0.1 ug/L cutoff at 95% confidence, subsequent PCT measurement on the sample is only performed if CRP is between 3.4 and 90.5 mg/L. Conclusions Limiting PCT measurements to samples with CRP concentrations inside ranges based on the PCT cutoff of interest and the appropriate confidence level (95% or 99%) can potentially reduce PCT testing by 20-40% in emergency department patients. For laboratories which perform CRP and PCT analysis sequentially on different platforms, this approach allows significant reductions in PCT test volumes while ensuring testing is performed in equivocal cases.

A-102 Clinical Evaluation of Novel Markers in Brain Injury

Abstract Background Traumatic brain injury (TBI) is a significant health concern affecting individuals of all ages, demanding precise diagnostic methodologies to guide effective clinical management. According to the 2010 definition, a TBI results from an external force causing an alteration in brain function or other evidence of brain pathology. Current diagnostic tools, i.e. CT scans and the Glasgow Coma Scale (GCS), are inefficient because they are time and labor intensive. The need for rapid diagnostic tools is underscored by the drawbacks of existing methods, such as CT scans, which are expensive, expose patients to large amounts of radiation, and lead to delayed treatment. Recent advances in TBI diagnosis involve novel biomarkers, such as Glial Fibrillary Acidic Protein (GFAP) and Ubiquitin C-Terminal Hydrolase L1 (UCH-L1), which have shown promise in revolutionizing the assessment of head traumas. GFAP, a glial-specific protein, is elevated in circulation after a TBI, distinguishing it from multi-trauma patients without brain injuries. UCH-L1, found in neurons, is significantly elevated in TBI patients compared to uninjured controls. A 2021 study further supports the clinical effectiveness of these biomarkers, demonstrating their capacity to exclude CT-positive injury in acute TBI cases. The primary aim of this study is to explore the clinical utility of the Abbott Alinity TBI assay, specifically biomarkers GFAP and UCH-L1, in emergency department patients with a history of head trauma. Methods A retrospective study involving 238 emergency department patients with a history of head trauma and noncontrast CT scans was conducted using the Abbott Alinity TBI assay. Serum samples were collected, and biomarker values were established and compared to CT scan results. The study was comprised of 94 females and 144 males spanning various age groups. The GFAP and UCH-L1 cutoffs used were FDA approved, at 35.0 ng/L and 400.0 ng/L, respectively. If either marker was above the cutoff the patient ruled at risk for TBI. Results Results demonstrated the assay correctly identified all CT-positive cases (100% sensitivity), placing them in the rule-in group, while identifying 44 patients with a 0 chance of TBI. The negative predictive value for the TBI overall was 100% (95% CI: 91.96%-100%). The GFAP assay alone identified 30/31 positive CT scans, reporting a 98.77% (95% CI: 92.03%-99.82%) negative predictive value. The UCH-L1 assay reported 26/31 positive CT scans with a negative predictive value of 94.68% (95% CI: 88.71-97.58%). Analyzing the data revealed the TBI assay would have reduced CT scans by 18.5%. Conclusions The results of this study did show a potential reduction in the number of patients sent to CT making it a valuable tool for triaging patients presenting with head trauma; however, the complexity of neurological problems may lead to increased false positives, reducing assay specificity. Despite this limitation, this study concludes that the GFAP and UCH-L1 markers could be used to triage patients into CT rule-out and rule-in groups, thereby streamlining clinical management. In conclusion, this assay, incorporating GFAP and UCH-L1 biomarkers, presents as a promising diagnostic tool for emergency departments.

A-011 Single High-Sensitivity Cardiac Troponin I Compared to High-Sensitivity Cardiac Troponin T Measurement to Rule Out Acute Myocardial Infarction at Low Risk for 30-Day Adverse Events: CONTRAST Study

Abstract Background Cardiac troponin (cTn) is the preferred biomarker for diagnosing myocardial injury and acute myocardial infarction (MI). There are few comparative studies addressing the clinical performance of high-sensitivity (hs)-cTnI and hs-cTnT assays using fresh plasma for early rule out of myocardial infarction (MI) on presentation in patients presenting to emergency departments (ED). This study examined the performance strategies of a derived optimal concentration for a single high-sensitivity cardiac troponin I (hs-cTnI) measurement compared to a derived optimal concentration for a single high-sensitivity cardiac troponin T (hs-cTnT) measurement to rule out acute MI. Methods The COmparisoN of high-sensitivity cardiac TRoponin I and T ASsays Trial (CONTRAST) (NCT03214029) is a prospective, observational cohort study of consecutive adult ED patients (n = 2208) undergoing serial cTn measurements as clinically indicated. hs-cTnI (Abbott ARCHITECT) and hs-cTnT (Gen 5, Roche e601) measurements using fresh EDTA plasma were obtained. We determine optimal hs-cTn cutoffs for negative predictive value (NPV) and sensitivity for the diagnosis of acute MI (type 1 and type 2) to allow for a maximum number for early discharges with minimal risk of adverse events (acute MI or cardiac death) at 30 days. Results Acute MI occurred in 161 patients (7.3%), including 68 (42.2%) type 1 MI and 93 (57.7%) type 2 MI. For hs-cTnI (&amp;lt;2 ng/L) optimal NPV and sensitivity for adverse events were 99.1% (95% confidence interval 97.7%-99.8%) and 98.2% (CI. 95.4-99.5%). 450 Patients (21%) qualified for early rule out, at a 1.8% miss rate at 30 days. For hs-cTnT (&amp;lt;6 ng/L) optimal NPV and sensitivity for adverse events were 99.2% (CI 98.0%-99.8%) and 98.1% (CI. 95.3-99.5%). 513 Patients (24%) qualified for early rule out, at a 1.9% miss rate at 30 days. Conclusions In CONTRAST, a strategy using a single sample hs-cTnI or hs-cTnT alone allows for the early identification of patients unlikely to have acute MI and who are at very low risk for adverse events at 30 days. Minor differences existed between the Abbott ARCHITECT hs-cTnI assay and the Roche e601 hs-cTnT (Gen 5) assay in fresh plasma were found.

Optimal triage of patients with acute chest pain.

Acute chest pain (ACP) is one of the most common symptoms in patients admitted to emergency departments (ED). It can be related to several life-threatening cardiovascular conditions such as acute coronary syndrome (ACS), aortic dissection, and pulmonary embolism. The optimal triage of patients with ACP is a clinical and healthcare necessity given the large number of patients daily admitted to ED with this symptom. The first contact with the patient in ED includes the clinical appraisal of the characteristics of ACP and coexisting symptoms, and the assessment of the patient's medical history. Risk scores may help stratify a patient's likelihood of having cardiac chest pain. The ECG examination allows the identification of patients with ST-segment elevation, depression, or T-wave changes, but may be normal in patients with non-ST-segment elevation ACS. Rapid protocols based on serial high-sensitivity cardiac troponin assays within one or two hours are recommended for identifying candidates for early discharge. Due to the bedside feasibility, non-invasiveness, and wide availability, transthoracic echocardiography represents the first-line imaging modality for evaluating patients with ACP. In selected cases, computed tomography angiography may also be performed. A practical approach to ACP in ED should improve patient outcomes and reduce healthcare system costs. This review aimed to provide an overview of the characteristics of patients with ACP of cardiac origin and to describe the state of the art about their management in the ED.

Comparative analysis of Glasgow Coma Scale, quick Sepsis-related Organ Failure Assessment, base excess, and lactate for mortality prediction in critically ill emergency department patients.

It is crucial to promptly identify high-mortality patients in emergency departments and initiate their treatment as soon as possible. Although many parameters have been studied to select patients with high mortality, no comprehensive evaluation exists in previous literature on these parameters in critically ill patients, regardless of patient groups. The aim of this study is to evaluate the Glasgow Coma Scale (GCS), quick Sepsis-related Organ Failure Assessment (qSOFA), blood gas base excess (BE), and blood gas lactate in predicting mortality in critically ill patients admitted to the emergency department. This prospective observational cohort study included adult patients with Emergency Severity Index 1-2 (critically ill) admitted to the emergency department. All patients were evaluated by the physician within 10 min, and blood gas samples were taken. The data collection forms recorded the patients' GCS and qSOFA scores at the time of first evaluation by the physician. The qSOFA score assessment was performed in all patients with ESI levels 1 and 2, regardless of whether infective pathology was suspected. Blood gas BE and lactate values were also from laboratory test results. Patients or their relatives were contacted by phone at the end of the 1st month to obtain information about the clinical condition (survival or mortality). A total of 868 patients were included, with 163 deaths observed within 30 days. GCS score, qSOFA score, and lactate value were significant in predicting mortality within 30 days. While the BE value was significant for predicting 30-day mortality for values equal to or below the lower limit of -1.5 (P < 0.001), it was not significant for values equal to or above the upper limit of +3 (P > 0.05). The most successful prediction model for predicting 30-day mortality was found to be qSOFA with a cutoff value of ≥1. In emergency departments, each of the GCS, qSOFA scores, BE, and lactate values can be used independently as a practical mortality prediction model in critically ill patients. Among these four models, qSOFA is the most successful practical mortality prediction model in critically ill patients.

Oral varespladib for the treatment of snakebite envenoming in India and the USA (BRAVO): a phase II randomised clinical trial

IntroductionSnakebite envenoming (SBE) results in over 500 000 deaths or disabling injuries annually. Varespladib methyl, an oral inhibitor of secretory phospholipase A2, is a nearly ubiquitous component of snake venoms....

The comprehensive geriatric assessment in emergency and intensive unit settings

This review discusses the challenges that hospitals face when caring for older patients in emergency departments and intensive care units. Beyond chronic diseases, the older person is often affected by acute events, which require, in addition to the typical knowledge of emergency medicine and anesthesia, the holistic and targeted approach of the comprehensive geriatric assessment in the emergency room and intensive care setting. With Italy’s health centers struggling to manage the increasing pressure of patients, the COVID-19 pandemic has highlighted the need for a geriatric approach to address this challenge. This review outlines the Geriatric 5Ms Model of Care, which addresses five domains, and the Domain Management Model, which provides acute medical management.

Evaluation of an emergency department-based approach to reduce subsequent opioid overdoses.

The purpose of this study was to determine the association of a multi-pronged treatment program in emergency department (ED) patients with an acute presentation of opioid use disorder (OUD) on the rate of subsequent opioid overdose (OD). This approach included ED-initiated take-home naloxone, prescription buprenorphine, and an ED-based peer support and recovery program. This was a retrospective observational analysis of adult patients presenting to the ED at a large urban hospital system from November 1, 2017 to March 17, 2023. Patients with an ED discharge diagnosis of OD or OUD were included. Outcomes determined were subsequent 90-day OD and 180-day OD death. Post hoc analyses were performed to identify intervention utilization throughout the study period including the COVID-19 pandemic as well as ED characteristics associated with subsequent OD and OD death. Statistical comparisons were made using logistic regression and chi-squared test. A total of 2634 patients presented to the ED with an opioid OD or diagnosis of OUD. Subsequent 90-day OD decreased significantly over time (11.5%-2.3%, odds ratio [OR] 0.85, confidence interval [CI] 0.82-0.89). No single intervention was independently associated with 90-day OD or 180-day OD death. Resource utilization was stable during the COVID-19 pandemic and increased afterward. A higher buprenorphine fill-rate among all patients and the Back race subgroup was associated with a decrease in 90-day OD. Subsequent OD and OD death decreased over time after implementation of a multi-pronged treatment program to ED patients with OUD. No single intervention was associated with a decrease of subsequent OD or OD death.

Outcomes for Emergency Presentations of Lung Cancer: A Scoping Review

BackgroundLung cancer is frequently detected during visits to the emergency department (ED). The ED is crucial for identifying likely cases of lung cancer and coordinating the subsequent care for these patients. ObjectivesThis scoping review aims to explore the definitions of emergency presentations (EPs) of lung cancer, along with mortality rates, cancer stage, and treatments for patients diagnosed with lung cancer following an EP. MethodsWe conducted a scoping review of the literature on EPs of lung cancer, identifying 27 relevant articles out of 1,338 initially screened. ResultsMost studies originated from the United Kingdom, collectively reporting over 270,000 EPs of lung cancer. The majority of included studies provided strong evidence. Key findings revealed higher mortality rates among patients diagnosed with lung cancer through emergency presentations, with a significant proportion presenting at advanced stages. Patients with EPs were less likely to undergo surgical removal or receive radiotherapy. Lastly, only 66.7% of the studies defined an EP, with great heterogeneity among EP definitions. Methodological differences precluded meta-analysis. ConclusionDespite methodological heterogeneity, our synthesis indicates that patients presenting acutely with undiagnosed lung cancer often present at advanced stages and experience high mortality rates. These findings underscore the need for further research to develop evidence-based interventions for improving outcomes among ED patients with suspected lung cancer.

379 Sex Differences in Testing for Pulmonary Embolism in Emergency Department Patients by Chief Complaint

379 Sex Differences in Testing for Pulmonary Embolism in Emergency Department Patients by Chief Complaint

494 Demographic and Societal Risk Factors for Pediculus-Associated Severe Anemia in Emergency Department Patients

494 Demographic and Societal Risk Factors for Pediculus-Associated Severe Anemia in Emergency Department Patients

233 Medical Jargon Is Often Misunderstood by Emergency Department Patients

233 Medical Jargon Is Often Misunderstood by Emergency Department Patients

305 Accuracy of a Host Response Test for Diagnosis of Bacterial and Viral Infections and Prediction of Illness Severity in Emergency Department Patients Is Not Impacted by the Patient's Immune Status

305 Accuracy of a Host Response Test for Diagnosis of Bacterial and Viral Infections and Prediction of Illness Severity in Emergency Department Patients Is Not Impacted by the Patient's Immune Status

407 The Effect of Naloxone Administration on the Treat and Release Length of Stays in Emergency Department Patients With Suspected Opioid Overdoses

407 The Effect of Naloxone Administration on the Treat and Release Length of Stays in Emergency Department Patients With Suspected Opioid Overdoses

199 Evaluation of the Diagnostic Accuracy of Exhaled Nitric Oxide as a Marker of Infection and Sepsis in Emergency Department Patients

199 Evaluation of the Diagnostic Accuracy of Exhaled Nitric Oxide as a Marker of Infection and Sepsis in Emergency Department Patients

171 Cardiovascular Risks Associated With Cannabis Use in Emergency Department Patients

171 Cardiovascular Risks Associated With Cannabis Use in Emergency Department Patients