Hours Of Emergency Department Arrival Research Articles

Does time to operating room affect outcomes after pediatric blunt hollow viscus injury? A Trauma Quality Improvement Program analysis.

Blunt hollow viscus injuries (HVIs) are relatively rare and difficult to diagnose. Whether a delay in operative intervention impacts outcomes for pediatric patients with blunt HVI has not been investigated via analysis of multicenter databases. We queried the Trauma Quality Improvement Program database from 2016 to 2020 for patients younger than 18 years who underwent an operation of the stomach, small intestine, large intestine, or rectum within 72 hours of emergency department arrival after blunt injury. We excluded patients with solid organ injury and additional extra-intestinal abdominal or thoracic operations. Patients were categorized by the time from emergency department presentation to operating room arrival: 1 to 5, 5 to 12, 12 to 24, and 24 to 72 hours. We analyzed baseline characteristics and outcomes between groups. We identified 1,700 patients, including 147 (9%) who were operated on >24 hours after arrival. Patients with delayed operations demonstrated higher Injury Severity Scores and higher Abbreviated Injury Scale scores for the head, face, and upper extremities and were more likely to require an orthopedic operation. Patients who received a delayed operation were less likely to have full-thickness injury noted in the operating room and demonstrated longer hospital and intensive care unit stays. However, there was no difference in superficial surgical site infection (SSI), deep SSI, organ space SSI, severe sepsis, or mortality between groups. Diagnosis and operative intervention for blunt HVI may be delayed in the presence of distracting injuries and in the absence of full-thickness perforation. While these patients typically have a more severe injury profile and require longer hospital stays, they do not appear to have increased rates of SSI, sepsis, or mortality. Therapeutic/Care Management; Level IV.

Prehospital Delta Shock Index Predicts Mortality and Need for Life Saving Interventions in Trauma Patients

Objectives The delta shock index (ΔSI), defined as the change in shock index (SI) over time, is associated with hospital morbidity and mortality, but prehospital studies about ΔSI are limited. We investigate the association of prehospital ΔSI with mortality and resource utilization, hypothesizing that increases in SI among field trauma patients are associated with increased mortality and blood product transfusion. Methods We performed a multicenter, retrospective, observational study from the Linking Investigators in Trauma and Emergency Services (LITES) network. We obtained data from January 2017 to June 2021. We fit logistic regression models to evaluate the association between an increase ΔSI > 0.1 and 28-day mortality and blood product transfusion within 4 h of emergency department (ED) arrival. We used negative binomial models to evaluate the association between ΔSI > 0.1 and days in hospital, intensive care unit (ICU), and on ventilator (up to 28 days). Results We identified 33,219 prehospital patients. We excluded burn patients and those without documented prehospital or ED heart rate or blood pressure, resulting in 30,511 cases for analysis. In adjusted analysis for the primary outcome of 28-day mortality, patients who had a ΔSI > 0.1 based on initial vital signs were 31% more likely to die (adjusted odds ratio (AOR) of 1.31, 95% CI 1.21-1.41) compared to those patients who had a ΔSI ≤0.1. These patients also spent 16% more days in hospital (adjusted incident rate ratio (AIRR) 1.16, 95% CI 1.14-1.19), 34% more days in ICU (AIRR 1.34, 95% CI 1.28-1.41), and 61% more days on ventilator (ARR 1.61, 95% CI 1.47-1.75). Additionally, patients with a ΔSI > 0.1 had higher odds of receiving blood products (AOR 2.00, 95% CI 1.88-2.12) within 4 h of ED arrival. Models fit excluding hypotensive patients performed similarly. Conclusions An increase of greater than 0.1 in the ΔSI was associated with increased 28-day mortality; increased days in hospital, in ICU, and on ventilator; and increased need for blood product transfusion within 4 h of ED arrival. This association held true for initially normotensive patients. Validation and implementation are needed to incorporate ΔSI into prehospital and ED triage.

Enhancing Performance of the National Field Triage Guidelines Using Machine Learning: Development of a Prehospital Triage Model to Predict Severe Trauma.

Prehospital trauma triage is essential to get the right patient to the right hospital. However, the national field triage guidelines proposed by the American College of Surgeons have proven to be relatively insensitive when identifying severe traumas. This study aimed to build a prehospital triage model to predict severe trauma and enhance the performance of the national field triage guidelines. This was a multisite prediction study, and the data were extracted from the National Trauma Data Bank between 2017 and 2019. All patients with injury, aged 16 years of age or older, and transported by ambulance from the injury scene to any trauma center were potentially eligible. The data were divided into training, internal, and external validation sets of 672,309; 288,134; and 508,703 patients, respectively. As the national field triage guidelines recommended, age, 7 vital signs, and 8 injury patterns at the prehospital stage were included as candidate variables for model development. Outcomes were severe trauma with an Injured Severity Score ≥16 (primary) and critical resource use within 24 hours of emergency department arrival (secondary). The triage model was developed using an extreme gradient boosting model and Shapley additive explanation analysis. The model's accuracy regarding discrimination, calibration, and clinical benefit was assessed. At a fixed specificity of 0.5, the model showed a sensitivity of 0.799 (95% CI 0.797-0.801), an undertriage rate of 0.080 (95% CI 0.079-0.081), and an overtriage rate of 0.743 (95% CI 0.742-0.743) for predicting severe trauma. The model showed a sensitivity of 0.774 (95% CI 0.772-0.776), an undertriage rate of 0.158 (95% CI 0.157-0.159), and an overtriage rate of 0.609 (95% CI 0.608-0.609) when predicting critical resource use, fixed at 0.5 specificity. The triage model's areas under the curve were 0.755 (95% CI 0.753-0.757) for severe trauma prediction and 0.736 (95% CI 0.734-0.737) for critical resource use prediction. The triage model's performance was better than those of the Glasgow Coma Score, Prehospital Index, revised trauma score, and the 2011 national field triage guidelines RED criteria. The model's performance was consistent in the 2 validation sets. The prehospital triage model is promising for predicting severe trauma and achieving an undertriage rate of <10%. Moreover, machine learning enhances the performance of field triage guidelines.

Trends in Patient-Reported Physical Function After Hip Fracture Surgery.

Background Hip fractures carry significant morbidity and mortality, yet studies assessing post-surgical functional recovery from the patient's perspective are scarce, lacking benchmarks against age-matched populations. This study aimed to identify factors influencing postoperative functional outcomes, compared to the lower 25th percentile of normal age-matched populations, and to compare postoperative physical function with one-year mortality following hip fracture surgery. Methodology A retrospective review of 214 hip fracture patients reporting to the emergency department (ED) from July 2020 to June 2023 was conducted, with all completing a three-month postoperative Patient-Reported Outcomes Measurement Information System-Physical Function (PROMIS-PF) survey. Primary outcomes included three-month PROMIS-PF scores, with secondary outcomes focusing on one-year mortality. Factors such as demographics, comorbidities, procedures, time to surgery, length of stay, and postoperative outcomes were analyzed for correlation. Multivariate logistic regression assessed predictors of achieving a PROMIS-PF T-score of at least 32.5, representing the bottom 25th percentile for age-matched populations, and the relationship between three-month PROMIS PF T-scores and one-year mortality. Results Surgery was performed within 24 hours of ED arrival in 118 (55.1%) patients, the average length of stay was 5.2 days, and 64 (29.9%) were discharged home. Total hip arthroplasty and home discharge correlated with higher physical function scores. In contrast, older age, higher American Society of Anesthesiologists scores, certain comorbidities, specific surgical procedures, and longer hospital stays were associated with lower scores. Fewer than half (102 [47.7%]) achieved functional levels comparable to the 25th percentile of age-matched populations. Multivariate analysis indicated chronic obstructive pulmonary disease and home discharge as predictors of achieving this threshold, while higher PROMIS-PF T-scores were associated with reduced one-year mortality. Conclusions Patients undergoing hip fracture surgery are unlikely to achieve high levels of physical function within the three-month postoperative period. Fewer than half of these patients will reach functional levels, and decreased early function is associated with an increased risk of one-year mortality.

A Hospice Transitions Program for Patients in the Emergency Department

Patients often visit the emergency department (ED) near the end of life. Their common disposition is inpatient hospital admission, which can result in a delayed transition to hospice care and, ultimately, an inpatient hospital death that may be misaligned with their goals of care. To assess the association of hospice use with a novel multidisciplinary hospice program to rapidly identify and enroll eligible patients presenting to the ED near end of life. This pre-post quality improvement study of a novel, multifaceted care transitions program involving a formalized pathway with email alerts, clinician training, hospice vendor expansion, metric creation, and data tracking was conducted at a large, urban tertiary care academic medical center affiliated with a comprehensive cancer center among adult patients presenting to the ED near the end of life. The control period before program launch was from September 1, 2018, to January 31, 2020, and the intervention period after program launch was from August 1, 2021, to December 31, 2022. The primary outcome was a transition to hospice without hospital admission and/or hospice admission within 96 hours of the ED visit. Secondary outcomes included length of stay and in-hospital mortality. This study included 270 patients (median age, 74.0 years [IQR, 62.0-85.0 years]; 133 of 270 women [49.3%]) in the control period, and 388 patients (median age, 73.0 years [IQR, 60.0-84.0 years]; 208 of 388 women [53.6%]) in the intervention period, identified as eligible for hospice transition within 96 hours of ED arrival. In the control period, 61 patients (22.6%) achieved the primary outcome compared with 210 patients (54.1%) in the intervention period (P < .001). The intervention was associated with the primary outcome after adjustment for age, race and ethnicity, primary payer, Charlson Comorbidity Index, and presence of a Medical Order for Life-Sustaining Treatment (MOLST) (adjusted odds ratio, 5.02; 95% CI, 3.17-7.94). In addition, the presence of a MOLST was independently associated with hospice transition across all groups (adjusted odds ratio, 1.88; 95% CI, 1.18-2.99). There was no significant difference between the control and intervention periods in inpatient length of stay (median, 2.0 days [IQR, 1.1-3.0 days] vs 1.9 days [IQR, 1.1-3.0 days]; P = .84), but in-hospital mortality was lower in the intervention period (48.5% [188 of 388] vs 64.4% [174 of 270]; P < .001). In this quality improvement study, a multidisciplinary program to facilitate ED patient transitions was associated with hospice use. Further investigation is needed to examine the generalizability and sustainability of the program.

Identification of severely injured children at very low risk of emergent surgery: A national trauma registry study

ObjectiveThe number of pediatric trauma patients requiring surgical interventions has been steadily decreasing allowing for a judicious approach to immediately available resources. This study aimed to derive and validate a prediction rule that reliably identifies injured children who are at very low risk for requiring emergency surgery upon emergency department (ED) arrival. MethodsA retrospective cohort study of data included in the Israeli National Trauma Registry from January 1, 2011, through December 31, 2020, was conducted. We included children aged 0–14 years who presented to EDs from the scene of injury and were hospitalized. We excluded patients transferred between facilities or with isolated burns. The primary outcome was emergency operative intervention (EOI) performed within one hour of ED arrival. We tested mechanism, GCS, heart rate, and blood pressure as candidate predictors. We then randomized patients to two cohorts, derived and internally validated a prediction rule. ResultsDuring the study period, 83,859 children met enrollment criteria. The median age was 6 years (IQR 2–10) and 56,867 (67.8 %) were male; 75,450 (90.0 %) sustained blunt trauma. One hundred sixty-nine (0.20 %) children underwent EOI. In the derivation and validation cohorts, 34,138 (81.4 %) and 34,271 (81.7 %) patients, were classified as low risk based on blunt trauma mechanism, normal GCS (15), and low-risk heart rate (according to age). Of those, 8 (0.02 %) and 13 (0.04 %) required an EOI, respectively. In the validation cohort, the prediction rule for EOI had a sensitivity of 84 % (95 % CI 75–91), a specificity of 82 % (95 % CI 81–82), and a negative predictive value of 99.96 % (95 % CI 99.94–99.98). Among children with an Injury Severity Score>15, the sensitivity was 87 % (95 % CI 77–94), the specificity of 57 % (95 % CI 54–59), and the negative predictive value was 98.97 % (95 % CI 98.13–99.44). ConclusionsA limited set of physiologic parameters, readily available at hospital admission can effectively identify injured children at very low risk for emergent surgery. For these children, immediate deployment of surgical resources may not be necessary.

Delays to Antibiotics in the Emergency Department and Risk of Mortality in Children With Sepsis

Pediatric consensus guidelines recommend antibiotic administration within 1 hour for septic shock and within 3 hours for sepsis without shock. Limited studies exist identifying a specific time past which delays in antibiotic administration are associated with worse outcomes. To determine a time point for antibiotic administration that is associated with increased risk of mortality among pediatric patients with sepsis. This retrospective cohort study used data from 51 US children's hospitals in the Improving Pediatric Sepsis Outcomes collaborative. Participants included patients aged 29 days to less than 18 years with sepsis recognized within 1 hour of emergency department arrival, from January 1, 2017, through December 31, 2021. Piecewise regression was used to identify the inflection point for sepsis-attributable 3-day mortality, and logistic regression was used to evaluate odds of sepsis-attributable mortality after adjustment for potential confounders. Data analysis was performed from March 2022 to February 2024. The number of minutes from emergency department arrival to antibiotic administration. The primary outcome was sepsis-attributable 3-day mortality. Sepsis-attributable 30-day mortality was a secondary outcome. A total of 19 515 cases (median [IQR] age, 6 [2-12] years) were included. The median (IQR) time to antibiotic administration was 69 (47-116) minutes. The estimated time to antibiotic administration at which 3-day sepsis-attributable mortality increased was 330 minutes. Patients who received an antibiotic in less than 330 minutes (19 164 patients) had sepsis-attributable 3-day mortality of 0.5% (93 patients) and 30-day mortality of 0.9% (163 patients). Patients who received antibiotics at 330 minutes or later (351 patients) had 3-day sepsis-attributable mortality of 1.2% (4 patients), 30-day mortality of 2.0% (7 patients), and increased adjusted odds of mortality at both 3 days (odds ratio, 3.44; 95% CI, 1.20-9.93; P = .02) and 30 days (odds ratio, 3.63; 95% CI, 1.59-8.30; P = .002) compared with those who received antibiotics within 330 minutes. In this cohort of pediatric patients with sepsis, 3-day and 30-day sepsis-attributable mortality increased with delays in antibiotic administration 330 minutes or longer from emergency department arrival. These findings are consistent with the literature demonstrating increased pediatric sepsis mortality associated with antibiotic administration delay. To guide the balance of appropriate resource allocation with time for adequate diagnostic evaluation, further research is needed into whether there are subpopulations, such as those with shock or bacteremia, that may benefit from earlier antibiotics.

The predictive value of heart rate in determining clinical course after a bupropion overdose

Introduction Bupropion is a popular antidepressant due to its favorable side effect profile and indications for smoking cessation and weight loss. Due to the possibility of delayed onset seizure and other adverse outcomes after bupropion overdose, patients are often observed for periods of 12-24 hours following suspected ingestion. Tachycardia is a clinical predictor that holds promise in differentiating cases at risk for seizures from low-risk cases that do not require prolonged observation. This study assessed whether heart rate within the first eight hours of presentation can identify cases that do not require extended observation. Methods This is a retrospective cohort study of all supra-therapeutic bupropion cases from two hospital systems between 2010 and 2022. Results Data from 216 charts were included. Seizures, hypotension, and dysrhythmias occurred in 19 percent (n = 41), 1.4 percent (n = 3), 0.9 percent (n = 2) respectively. One patient died. Delayed adverse effects were rare (n = 4); they occurred from 14 hours to 28 hours post-ingestion. Maximum heart rate in eight hours was associated with a risk of adverse outcomes. (odds ratio, 1.07; 95 percent confidence interval: 1.05 to 1.09; P < 0.001). An eight hour maximum heart rate threshold of 104 beats/minute had a negative predictive value of 100 percent (95 percent confidence interval: 96.7 percent to 100 percent) for the occurrence of delayed adverse effects. All patients with delayed effects had tachycardia within five hours of emergency department arrival. Discussion Delayed adverse outcomes of seizures, hypotension, dysrhythmia, and death were uncommon in this cohort. Heart rate during the first eight hours of observation performs reliably as a screening test to identify patients at low risk for delayed adverse outcomes. This study is limited by its retrospective nature, the inability to ascertain time of ingestion for most cases and the lack of confirmatory laboratory testing. Conclusion This study supports the use of an eight hour observation period when there are no other clinical signs of toxicity to warrant admission and if no co-ingestion or administration of substances that mask tachycardia are present.

Timing to First Whole Blood Transfusion and Survival Following Severe Hemorrhage in Trauma Patients

Civilian trauma centers have revived interest in whole-blood (WB) resuscitation for patients with life-threatening bleeding. However, there remains insufficient evidence that the timing of WB transfusion when given as an adjunct to a massive transfusion protocol (MTP) is associated with a difference in patient survival outcome. To evaluate whether earlier timing of first WB transfusion is associated with improved survival at 24 hours and 30 days for adult trauma patients presenting with severe hemorrhage. This retrospective cohort study used the American College of Surgeons Trauma Quality Improvement Program databank from January 1, 2019, to December 31, 2020, for adult patients presenting to US and Canadian adult civilian level 1 and 2 trauma centers with systolic blood pressure less than 90 mm Hg, with shock index greater than 1, and requiring MTP who received a WB transfusion within the first 24 hours of emergency department (ED) arrival. Patients with burns, prehospital cardiac arrest, deaths within 1 hour of ED arrival, and interfacility transfers were excluded. Data were analyzed from January 3 to October 2, 2023. Patients who received WB as an adjunct to MTP (earlier) compared with patients who had yet to receive WB as part of MTP (later) at any given time point within 24 hours of ED arrival. Primary outcomes were survival at 24 hours and 30 days. A total of 1394 patients met the inclusion criteria (1155 male [83%]; median age, 39 years [IQR, 25-51 years]). The study cohort included profoundly injured patients (median Injury Severity Score, 27 [IQR, 17-35]). A survival curve demonstrated a difference in survival within 1 hour of ED presentation and WB transfusion. Whole blood transfusion as an adjunct to MTP given earlier compared with later at each time point was associated with improved survival at 24 hours (adjusted hazard ratio, 0.40; 95% CI, 0.22-0.73; P = .003). Similarly, the survival benefit of earlier WB transfusion remained present at 30 days (adjusted hazard ratio, 0.32; 95% CI, 0.22-0.45; P < .001). In this cohort study, receipt of a WB transfusion earlier at any time point within the first 24 hours of ED arrival was associated with improved survival in patients presenting with severe hemorrhage. The survival benefit was noted shortly after transfusion. The findings of this study are clinically important as the earlier timing of WB administration may offer a survival advantage in actively hemorrhaging patients requiring MTP.

Critical Emergency Department Interventions and Clinical Deterioration in Children With Nonsevere Traumatic Intracranial Hemorrhage.

Substantial practice variation exists in the management of children with nonsevere traumatic intracranial hemorrhage (tICH). A comprehensive understanding of rates and timing of clinically important tICH, including critical interventions and deterioration, along with associated clinical and neuroradiographic characteristics, will inform accurate risk stratification. We conducted a single-center retrospective cohort study of children aged younger than 18 years evaluated in the emergency department (ED) from May 1, 2014 to February 28, 2020 with tICH and initial Glasgow Coma Scale (GCS) score of higher than 8. We determined rates of clinically important tICH after injury and within 96 hours of ED arrival, defined as immediate ED interventions (intubation, hyperosmotic agents, or neurosurgery within 4 hours of arrival) or clinically important deterioration (signs/symptoms with change in management). Associations between outcome and clinical and neuroradiographic characteristics were calculated using individual logistic regression models. Our sample included 135 children. Clinically important tICH was observed in 13.3% (n = 18); 9 (6.7%) underwent immediate ED interventions and 9 (6.7%) developed deterioration. Most (93.3%, n = 127) presented with an initial GCS ≥ 14, including all children who later deteriorated. Initial GCS ( P = 0.001) and nonaccidental trauma ( P = 0.024) mechanism were associated with the outcome. None of the 71 (52.6%) children with initial GCS ≥ 14, isolated, nonepidural hemorrhage after accidental injury developed clinically important tICH. Clinically important tICH occurred in 13% of children with nonsevere tICH, and 7% of children who did not undergo immediate ED interventions later deteriorated, all of whom had an initial GCS ≥ 14. However, a subgroup of children was identified as low risk based on clinical and neuroradiographic characteristics.

Association of Whole Blood With Survival Among Patients Presenting With Severe Hemorrhage in US and Canadian Adult Civilian Trauma Centers

Whole-blood (WB) resuscitation has gained renewed interest among civilian trauma centers. However, there remains insufficient evidence that WB as an adjunct to component therapy-based massive transfusion protocol (WB-MTP) is associated with a survival advantage over MTP alone in adult civilian trauma patients presenting with severe hemorrhage. To assess whether WB-MTP compared with MTP alone is associated with improved survival at 24 hours and 30 days among adult trauma patients presenting with severe hemorrhage. This retrospective cohort study using the American College of Surgeons Trauma Quality Improvement Program databank from January 1, 2017, and December 31, 2018, included adult trauma patients with a systolic blood pressure less than 90 mm Hg and a shock index greater than 1 who received at least 4 units of red blood cells within the first hour of emergency department (ED) arrival at level I and level II US and Canadian adult civilian trauma centers. Patients with burns, death within 1 hour of ED arrival, and interfacility transfers were excluded. Data were analyzed from February 2022 to September 2022. Resuscitation with WB-MTP compared with MTP alone within 24 hours of ED presentation. Primary outcomes were survival at 24 hours and 30 days. Secondary outcomes selected a priori included major complications, hospital length of stay, and intensive care unit length of stay. A total of 2785 patients met inclusion criteria: 432 (15.5%) in the WB-MTP group (335 male [78%]; median age, 38 years [IQR, 27-57 years]) and 2353 (84.5%) in the MTP-only group (1822 male [77%]; median age, 38 years [IQR, 27-56 years]). Both groups included severely injured patients (median injury severity score, 28 [IQR, 17-34]; median difference, 1.29 [95% CI, -0.05 to 2.64]). A survival curve demonstrated separation within 5 hours of ED presentation. WB-MTP was associated with improved survival at 24 hours, demonstrating a 37% lower risk of mortality (hazard ratio, 0.63; 95% CI, 0.41-0.96; P = .03). Similarly, the survival benefit associated with WB-MTP remained consistent at 30 days (HR, 0.53; 95% CI, 0.31-0.93; P = .02). In this cohort study, receipt of WB-MTP was associated with improved survival in trauma patients presenting with severe hemorrhage, with a survival benefit found early after transfusion. The findings from this study are clinically important as this is an essential first step in prioritizing the selection of WB-MTP for trauma patients presenting with severe hemorrhage.

Racial Disparities in Opioid Analgesia Administration Among Adult Emergency Department Patients with Abdominal Pain.

Racial disparities in pain management have been reported among emergency department (ED) patients. In this study we evaluated the association between patients' self-identified race/ethnicity and the administration of opioid analgesia among ED patients with abdominal pain, the most common chief complaint for ED presentations in the United States. This was a retrospective cohort study of adult (age ≥18 years) patients who presented to the ED of a single center with abdominal pain from January 1, 2019-December 31, 2020. We collected demographic and clinical information, including patients' race and ethnicity, from the electronic health record. The primary outcome was the ED administration of any opioid analgesic (binary). Secondary outcomes included the administration of non-opioid analgesia (binary) and administration of any analgesia (binary). We used logistic regression models to estimate odds ratios (OR) of the association between a patient's race/ethnicity and analgesia administration. Covariates included age, sex, initial pain score, Emergency Severity Index, and ED visits in the prior 30 days. Subgroup analyses were performed in non-pregnant patients, those who underwent any imaging study, were admitted to the hospital, and who underwent surgery within 24 hours of ED arrival. We studied 7,367 patients: 45% (3,314) were non-Hispanic (NH) White; 28% (2,092) were Hispanic/Latinx; 19% (1,384) were NH Black, and 8% (577) were Asian. Overall, 44% (3,207) of patients received opioid analgesia. In multivariable regression models, non-White patients were less likely to receive opioid analgesia compared with White patients (OR 0.73, 95% CI 0.65-0.83 for Hispanic/Latinx patients; OR 0.62, 95% CI 0.54-0.72 for Black patients; and OR 0.64, 95% CI 0.52-0.78 for Asian patients). Black patients were also less likely to receive non-opioid analgesia, and Black and Hispanic/Latinx patients were less likely than White patients to receive any analgesia. The associations were similar across subgroups; however, the association was attenuated among patients who underwent surgery within 24 hours of ED arrival. Hispanic/Latinx, Black, and Asian patients were significantly less likely to receive opioid analgesia than White patients when presenting to the ED with abdominal pain. Black patients were also less likely than White patients to receive non-opioid analgesia.

Trauma team leader and early mortality: An interrupted time series analysis

BackgroundThe trauma team leader (TTL) is a “model” of a specifically dedicated team leader in the emergency department (ED), but its benefits are uncertain. The primary objective was to assess the impact of the TTL on 72-hour mortality. Secondary objectives included 24-hour mortality and admission delays from the ED. MethodsMajor trauma admissions (Injury Severity Score (ISS)≥12) in 3 Canadian Level-1 trauma centres were included from 2003 to 2017. The TTL program was implemented in centre 1 in 2005. An interrupted time series (ITS) analysis was performed. Analyses account for the change in patient case-mix (age, sex, and ISS). The two other centres were used as control in sensitivity analyses ResultsAmong 20,193 recorded trauma admissions, 71.7% (n=14,479) were males. The mean age was 53.5 ± 22.0 years. The median [IQR] ISS was 22 [16–26]. TTL implementation was not associated with a change in the quarterly trends of 72-hour or 24-hour mortality: adjusted estimates with 95% CI were 0.32 [−0.22;0.86] and −0.07 [−0.56;0.41] percentage-point change. Similar results were found for the proportions of patients admitted within 8 hours of ED arrival (0.36 [−1.47;2.18]). Sensitivity analyses using the two other centres as controls yielded similar results. ConclusionTTL implementation was not associated with changes in mortality or admission delays from the ED. Future studies should assess the potential impact of TTL programs on other patient-centred outcomes using different quality of care indicators.

Incidence and risk factors associated with early death in patients with emergency department septic shock.

BackgroundLimited research has explored early mortality among patients presenting with septic shock. The objective of this study was to determine the incidence and factors associated with early death following emergency department (ED) presentation of septic shock.MethodsA prospective registry of patients enrolled in an ED septic shock clinical pathway was used to identify patients. Patients were compared across demographic, comorbid, clinical, and treatment variables by death within 72 hours of ED presentation.ResultsAmong the sample of 2,414 patients, overall hospital mortality was 20.6%. Among patients who died in the hospital, mean and median time from ED presentation to death were 4.96 days and 2.28 days, respectively. Death at 24, 48, and 72 hours occurred in 5.5%, 9.5%, and 11.5% of patients, respectively. Multivariate regression analysis demonstrated that the following factors were independently associated with early mortality: age (odds ratio [OR], 1.04; 95% confidence interval [CI], 1.03–1.05), malignancy (OR, 1.53; 95% CI, 1.11–2.11), pneumonia (OR, 1.39; 95% CI, 1.02–1.88), urinary tract infection (OR, 0.63; 95% CI, 0.44–0.89), first shock index (OR, 1.85; 95% CI, 1.27–2.70), early vasopressor use (OR, 2.16; 95% CI, 1.60–2.92), initial international normalized ratio (OR, 1.14; 95% CI, 1.07–1.27), initial albumin (OR, 0.55; 95% CI, 0.44–0.69), and first serum lactate (OR, 1.21; 95% CI, 1.16–1.26).ConclusionsAdult septic shock patients experience a high rate of early mortality within 72 hours of ED arrival. Recognizable clinical factors may aid the identification of patients at risk of early death.

Focused assessment with sonography for trauma in predicting early surgical intervention in hemodynamically unstable children with blunt abdominal trauma.

ObjectivesThe predictive accuracy and clinical role of the focused assessment with sonography for trauma (FAST) exam in pediatric blunt abdominal trauma are uncertain. This study investigates the performance of the emergency department (ED) FAST exam to predict early surgical intervention and subsequent free fluid (FF) in pediatric trauma patients.MethodsPediatric level 1 trauma patients ages 0 to 15 years with blunt torso trauma at a single trauma center were retrospectively reviewed. After stratification by initial hemodynamic (HD) instability, the association of a positive FAST with (1) early surgical intervention, defined as operative management (laparotomy or open pericardial window) or angiography within 4 hours of ED arrival and (2) presence of FF during early surgical intervention was determined.ResultsAmong 508 salvageable pediatric trauma patients with an interpreted FAST exam, 35 (6.9%) had HD instability and 98 (19.3%) were FAST positive. A total of 42 of 508 (8.3%) patients required early surgical intervention, and the sensitivity and specificity of FAST predicting early surgical intervention were 59.5% and 84.3%, respectively. The specificity and positive predictive value of FF during early surgical intervention in FAST‐positive HD unstable patients increased from 50% and 90.9% at 4 hours after ED arrival to 100% and 100% at 2 hours after ED arrival, respectively.ConclusionsIn this large series of injured children, a positive FAST exam improves the ability to predict the need for early surgical intervention, and accuracy is greater for FF in HD unstable patients 2 hours after arrival to the ED.

Emergent cardiac outcomes in patients with normal electrocardiograms in the emergency department.

Emergency physicians (EP) are frequently interrupted to screen electrocardiograms (ECG) from Emergency Department (ED) patients undergoing triage. Our objective was to identify discrepancies between the computer ECG interpretation and the cardiologist ECG interpretation and if any patients with normal ECGs underwent emergent cardiac intervention. We hypothesized that computer-interpreted normal ECGs do not require immediate review by an EP. This was a retrospective study of adult (≥ 18years old) ED patients with computer-interpreted normal ECGs. Laboratory, diagnostic testing and clinical outcomes were abstracted following accepted methodologic guidelines. The primary outcome was emergent cardiac catheterization (within four hours of ED arrival). All ECGs underwent final cardiologist interpretation. When cardiology interpretation differed from the computer (discrepant ECG interpretation), the difference was classified as potentially clinically significant or not clinically significant. Data was described with simple descriptive statistics. 989 ECGs interpreted as normal by the computer were analyzed with a mean age of 50.4±16.8years (range 18-96years) and 527 (53%) female. Discrepant ECG interpretations were identified in 184 cases including 124 (12.5%, 95% CI 10.4, 14.7%) not clinically significant and 60 (6.1%, 95% CI 4.6, 7.7%) potentially clinically significant. The 60 potentially clinically significant changes included: ST/T wave changes 45 (75%), T wave inversions 6 (10%), prolonged QT 3 (5%), and possible ischemia 10 (17%). Of these 60, 21 (35%) patients were admitted. Six patients had potassium levels >6.0mEq/L, with one having a potentially clinically significant ECG change. No patient (0%, 95% CI 0, 0.3%) underwent immediate (within four hours) cardiac catherization whereas two underwent delayed cardiac interventions. Cardiologists frequently disagree with a computer-interpreted normal ECG. Patients with computer-interpreted normal ECGs, however, rarely had significant ischemic events. A rare number of patients will have important cardiac outcomes regardless of the computer-generated normal ECG interpretation. Immediate EP review of the ECG, however, would not have changed these patients' ED courses.

An emergency department-based intensive care unit is associated with decreased hospital length of stay for upper gastrointestinal bleeding.

Upper gastrointestinal bleeding (UGIB) is associated with substantial morbidity, mortality, and intensive care unit (ICU) utilization. Initial risk stratification and disposition from the Emergency Department (ED) can prove challenging due to limited data points during a short period of observation. An ED-based ICU (ED-ICU) may allow more rapid delivery of ICU-level care, though its impact on patients with UGIB is unknown. A retrospective observational study was conducted at a tertiary U.S. academic medical center. An ED-ICU (the Emergency Critical Care Center [EC3]) opened in February 2015. Patients presenting to the ED with UGIB undergoing esophagogastroduodenoscopy within 72 h were identified and analyzed. The Pre- and Post-EC3 cohorts included patients from 9/2/2012-2/15/2015 and 2/16/2015-6/30/2019. We identified 3788 ED visits; 1033 Pre-EC3 and 2755 Post-EC3. Of Pre-EC3 visits, 200 were critically ill and admitted to ICU [Cohort A]. Of Post-EC3 visits, 682 were critically ill and managed in EC3 [Cohort B], whereas 61 were critically ill and admitted directly to ICU without care in EC3 [Cohort C]. The mean interval from ED presentation to ICU level care was shorter in Cohort B than A or C (3.8 vs 6.3 vs 7.7 h, p < 0.05). More patients in Cohort B received ICU level care within six hours of ED arrival (85.3 vs 52.0 vs 57.4%, p < 0.05). Mean hospital length of stay (LOS) was shorter in Cohort B than A or C (6.2 vs 7.3 vs 10.0 days, p < 0.05). In the Post-EC3 cohort, fewer patients were admitted to an ICU (9.3 vs 19.4%, p < 0.001). The rate of floor admission with transfer to ICU within 24 h was similar. No differences in absolute or risk-adjusted mortality were observed. For critically ill ED patients with UGIB, implementation of an ED-ICU was associated with reductions in rate of ICU admission and hospital LOS, with no differences in safety outcomes.

304 Lack of Early Left Ventricular Outflow Tract Velocity Time Integral Estimated Volume Responsiveness is Associated With Increased Morbidity and Mortality

Fluid boluses are amongst the strongest recommendations for the management of septic patients, and they are generally administered with the goal increasing cardiac output and improving tissue perfusion. Early identification of volume responsiveness is challenging and dependent on many patient factors, but it may prevent the harmful consequences of hypervolemia. Left ventricular outflow tract (LVOT) velocity time integral (VTI) has been used as a predictor of volume responsiveness. The purpose of this study was to determine whether lack of volume responsiveness, defined as ≤15% change in LVOT VTI, is associated with increased risk of mortality, admission to an intensive care unit (ICU), or rapid response team activation within 24 hours of hospital arrival (composite outcome measure). We hypothesize that septic patients who are not volume responders will be more critically ill and therefore at greater risk of experiencing the composite outcome. This is a prospective observation study of septic patients conducted in an academic emergency department (ED). Patients were eligible for enrollment if they met Sepsis 3 definition and were receiving intravenous fluids. Patients received a point-of-care echocardiogram to measure LVOT VTI. Three measurements were taken and the average was recorded. After patients received a 500mL fluid bolus, a repeat ultrasound was conducted to re-measure VTI. Volume responsiveness was defined as >15% increase in VTI. Chart review was performed on all enrolled patients to determine whether the composite outcome occurred within 24 hours of ED arrival. At total of 126 patients with repeat ultrasound exams were included in this analysis; 49.2% were female and median age was 74 years. Overall, 56 (44.4%) patients experienced the composite primary outcome within 24 hours, and 30 (23.8%) patients had a delta VTI of >15%. Among the patients who experienced the composite outcome, 82.1% of them had a delta VTI of ≤15%, compared with 71.4% of patients who did not experience the composite outcome (p-value = 0.160). In a multivariable logistic regression modeling adjusting for lactate and systolic blood pressure, delta VTI of ≤15%, compared with delta VTI >15%, was significantly associated with higher odds of mortality, ICU admission, or rapid response team activation within 24 hours (OR: 2.643; 95% CI: 1.002, 6.967). Septic ED patients who are not volume responsive, based on percent change in VTI, are more likely to experience mortality, be admitted to an ICU, or have a rapid response team activation within 24 hours of ED arrival. Our findings suggest that early VTI may be used in septic patients to predict their clinical course. Future endeavors may evaluate if initial change in VTI could be used to help emergency physicians identify this critically ill cohort and facilitate earlier ICU disposition and vasopressor administration.

50 Emergency Department Management and Outcomes of COVID-19 Acute Hypoxemic Respiratory Failure During the New York City Surge

Delays in intensive care unit (ICU) admission for critically ill patients are associated with worse outcomes, but the effect of “boarding” during the COVID-19 pandemic has not been well characterized. This study describes the emergency department (ED)-based care for patients presenting with COVID-19-related acute hypoxemic respiratory failure (AHRF) to five hospitals in a large, academic health system during the initial surge in New York City, examining both respiratory modality choice and settings. For those managed with noninvasive respiratory support, we also aimed to explore the association between ED boarding time and patient morbidity and mortality. We conducted a retrospective cohort study of ED patients presenting from 3/1/2020 to 7/10/2020 with COVID-19-related AHRF and requiring ICU admission at any time during their hospitalization. Patient demographics, comorbidities, severity of illness (Mortality Probability Model III on admission), clinical course, including the use, settings (initial and changes), and duration of respiratory support modalities (ie, noninvasive ventilation [NIV], high flow nasal cannula [HFNC], invasive mechanical ventilation [IMV]), as well as hospital site, were collected through validated electronic query and standardized manual chart abstraction. AHRF severity was defined using a PaO2/FiO2 ratio (PF): 200-300 (mild), 100-199 (moderate), and <100 (severe). For patients without a PaO2, the PF was imputed using SpO2/FiO2 ratio using previously validated non-linear conversion. Boarding was defined as the time interval from ED request for admission to ED departure. The primary outcome was a composite outcome of ICU admission, intubation, or mortality within 48 hours of ED arrival. Descriptive analyses stratified by boarding duration and AHRF were completed. Multivariable logistic regression modelling was used to determine the association between ED boarding and the primary outcome. A total of 679 ED patients with COVID-19 AHRF required ICU admission during the study period. They were managed with low flow oxygen only (261, 38.4%), or with NIV (120, 17.7%), HF (51, 7.5%), and/or IMV (99, 14.6%), with setting ranges detailed in Table 1. Of the patients with a known PF ratio (N=418), 110 (26.35%) had mild, 34 (5.0%) had moderate, and 274 (40.4%) had severe AHRF. Of these patients, 279 (41.1%) had a change documented to their settings, with increased likelihood of adjustments with longer boarding time (p<0.001) and higher AHRF severity (p<0.001). Median boarding duration across all site was 9.5 hours (IQR 5.3-16.9 hours) with site variation. AHRF severity and support modality were not associated with differences of boarding time (p = 0.77 and p=0.54). Controlling for age, sex, race, and severity of illness, boarding time was not associated with worse patient outcomes in 48 hours (OR 0.85, 95% CI 0.67-1.08, p=0.17) During the COVID-19 pandemic, critically ill patients presented to the ED and boarded for long periods of time, requiring prolonged ventilatory management. Despite the surge state and resource limitations, boarding times did not worsen post-ED outcomes for patients managed with non-invasive modalities.

Association Between Hyperoxia, Supplemental Oxygen, and Mortality in Critically Injured Patients.

Hyperoxia is common among critically ill patients and may increase morbidity and mortality. However, limited evidence exists for critically injured patients. The objective of this study was to determine the association between hyperoxia and in-hospital mortality in adult trauma patients requiring ICU admission. This multicenter, retrospective cohort study was conducted at two level I trauma centers and one level II trauma center in CO between October 2015 and June 2018. All adult trauma patients requiring ICU admission within 24 hours of emergency department arrival were eligible. The primary exposure was oxygenation during the first 7 days of hospitalization. None. Primary outcome was in-hospital mortality. Secondary outcomes were hospital-free days and ventilator-free days. We included 3,464 critically injured patients with a mean age of 52.6 years. Sixty-five percent were male, and 66% had blunt trauma mechanism of injury. The primary outcome of in-hospital mortality occurred in 264 patients (7.6%). Of 226,057 patient-hours, 46% were spent in hyperoxia (oxygen saturation > 96%) and 52% in normoxia (oxygen saturation 90-96%). During periods of hyperoxia, the adjusted risk for mortality was higher with greater oxygen administration. At oxygen saturation of 100%, the adjusted risk scores for mortality (95% CI) at Fio2 of 100%, 80%, 60%, and 50% were 6.4 (3.5-11.8), 5.4 (3.4-8.6), 2.7 (1.7-4.1), and 1.5 (1.1-2.2), respectively. At oxygen saturation of 98%, the adjusted risk scores for mortality (95% CI) at Fio2 of 100%, 80%, 60%, and 50% were 7.7 (4.3-13.5), 6.3 (4.1-9.7), 3.2 (2.2-4.8), and 1.9 (1.4-2.7), respectively. During hyperoxia, higher oxygen administration was independently associated with a greater risk of mortality among critically injured patients. Level of evidence: Cohort study, level III.