Medical Emergency Department Research Articles

Engagement in GI Behavioral Health Is Associated with Reduced Portal Messages, Phone Calls, and ED Visits.

Chronic digestive disorders are associated with increased costs for healthcare systems and often require provision of both urgent care and non-face-to-face (non-F2F) care, such as responding to patient messages. Numerous benefits of integrated gastroenterology (GI) behavioral health have been identified; however, it is unclear if integrated care impacts healthcare utilization, including urgent care and non-F2F contact. We sought to investigate the association between patient engagement with GI behavioral health and healthcare utilization. We performed a retrospective chart review study of adult patients who were referred for and completed at least one behavioral health appointment between January 1, 2019 and December 21, 2021 in the Gastroenterology and Hepatology department of a large academic medical center. Data on electronic medical record (EMR) messages, phone calls, and Emergency Department utilization were collected 6months before and 9months after patient engagement with GI behavioral health. 466 adult patients completed at least one behavioral health visit from 2019 to 2021. Overall, messages, phone calls, and ED visits all decreased significantly from the 6months before behavioral health treatment to 6months after (all P values < 0.001). Engagement with integrated GI behavioral health is associated with reduced non-F2F care and emergency department utilization in patients with chronic digestive disorders. Increasing access to GI behavioral health may result in reduced provider workload and healthcare system costs.

Clinical Impact of Routine Assessment of Patient-Reported Health Status in Heart Failure Clinic: The PRO-HF Trial.

The impact of routine clinic use of patient-reported outcome (PRO) measures on clinical outcomes in patients with heart failure (HF) has not been well-characterized. We tested if clinic-based use of a disease-specific PRO improves patient-reported quality of life at 1 year. The PRO-HF trial (Patient-Reported Outcome Measurement in Heart Failure Clinic) was an open-label, parallel, patient-level randomized clinical trial of routine PRO assessment or usual care at an academic HF clinic between August 30, 2021, and June 30, 2022, with 1 year of follow-up. In the PRO assessment arm, participants completed the Kansas City Cardiomyopathy Questionnaire-12 (KCCQ-12) at each HF clinic visit, and results were shared with their treating clinician. The usual care arm completed the KCCQ-12 at randomization and 1 year later, which was not shared with the treating clinician. The primary outcome was the KCCQ-12 overall summary score (OSS) between 12 and 15 months after randomization. Secondary outcomes included domains of the KCCQ-12, hospitalization and emergency department visit rates, HF medication therapy, clinic visit frequency, and testing rates. Across 17 clinicians, 1248 participants were enrolled and randomized to PRO assessment (n=624) or usual care (n=624). The median age was 63.9 years (interquartile range [IQR], 51.8-72.8), 38.9% were women, and the median baseline KCCQ-12 OSS was 82.3 (IQR, 58.3-94.8). Final KCCQ-12 (available in 87.9% of the PRO arm and 85.1% in usual care; P=0.16) median OSS were 87.5 (IQR, 68.8-96.9) in the PRO arm and 87.6 (IQR, 69.7-96.9) in the usual care arm with a baseline-adjusted mean difference of 0.2 ([95% CI, -1.7 to 2.0]; P=0.85). The results were consistent across prespecified subgroups. A post hoc analysis demonstrated a significant interaction with greater benefit among participants with a baseline KCCQ-12 OSS of 60 to 80 but not in less or more symptomatic participants. No significant differences were found in 1-year mortality, hospitalizations, emergency department visits, medication therapy, clinic follow-up, or testing rates between arms. Routine PRO assessment in HF clinic visits did not impact patient-reported quality of life or other clinical outcomes. Alternate strategies and settings for embedding PROs into routine clinical care should be tested. URL: https://www.clinicaltrials.gov; Unique identifier: NCT04164004.

Pediatric Epistaxis-Effectiveness of Conservative Management.

Epistaxis is an emergency medical condition that sometimes requires admission to the emergency department. Pediatric epistaxis differs from epistaxis in the older population in terms of etiology, severity, and management. Our objective was to identify the distinctive features of pediatric epistaxis and determine the appropriate management. This was a retrospective study of 231 medical records of children (<18 years old) with epistaxis of a total of 1171 cases in the general population who presented to our medical center's emergency department between 2013 and 2018. Among 231 admissions, 10 children (4.3%) presented more than once. Male patients accounted for the majority of cases (64.5%), and the average age was 9.4 years. Two children were treated with aspirin because of cardiac valve disease. Anterior bleeding was detected in 101 cases (43.7%), whereas posterior origin was observed in 8 cases (3.5%). In 122 cases (52.8%), there was no active bleeding observed. Nose injury was the cause of epistaxis in 24 cases (10.4%), and 16 admissions (6.9%) followed nasal surgical interventions. Nineteen children (8%) had abnormal coagulation tests, and 7 patients (3%) received blood transfusions. Chemical cauterization was performed in 89 cases (39.3%), and anterior packing was needed in only 9 cases (3.9%). Nine children required hospitalization (3.9%), and 2 needed surgical intervention to control bleeding. Compared with the adult population, there were significantly fewer cases of active bleeding, recurrent epistaxis, anterior packing, or need for hospitalization in the pediatric population. Epistaxis is significantly less severe in the pediatric population, with only a few cases requiring major intervention. Endoscopic examination of the entire nasal cavity and routine coagulation tests are not mandatory unless there is a history of recurrent epistaxis, known coagulopathy, antiplatelet/anticoagulation therapy, or a suspicion of juvenile idiopathic angiofibroma. We suggest using absorbable packs, which offer advantages over cauterization or nonabsorbable packs.

Dementia-Related Disparities in Adult Day Centers: Results of a Bivariate Analysis.

Adult day services (ADS) are a valuable resource for people living with Alzheimer's disease and Alzheimer's disease and related dementias (AD/ADRD) and serve a large population of late-life immigrants, often with limited English proficiency (LEP). This secondary data analysis examined potential disparities in diagnosis, dementia severity, medical complexity, and dementia-related behavioral problems in persons with AD/ADRD with LEP within the ADS setting. The current study used data from TurboTAR, the electronic health record for ADS in California. Bivariate analyses were conducted to examine differences in clinical management for those with and without LEP. Of 3,053 participants included in the study, 42.3% had LEP. Participants with LEP had higher rates of emergency department use and medication mismanagement. However, due to non-standard data collection, there was a significant amount of missing data on language preference (38.1%) and race/ethnicity (46.5%). Although these findings suggest LEP may play a role in the clinical management of persons with AD/ADRD in ADS, missing data caused by lack of standardized collection compromise the results. It is essential to improve data collection practices in ADS on language, race, and ethnicity to help identify health disparities and promote equitable care for marginalized older adults. [Journal of Gerontological Nursing, 50(4), 42-47.].

Development of Predictive Models Based on Biochemical Parameters to Triage COVID-19 Patients: A Study Conducted in a Tertiary Care Hospital.

Background The COVID-19 disease continues to cause severe mortality and morbidity. Biochemical parameters are being used to predict the severity of the infection. This study aims to predict disease severity and mortality to help reduce mortality through timely intervention in a cost-effective way. Methods A total of 324 COVID-19 casesadmitted at our hospital (All India Institute of Medical Sciences, Patna, BR, India) betweenJune 2020 to December 2020 (phase 1: 190 patients) and April 2021 to May 2021 (phase 2: 134 patients) were recruited for this study. Statistical analysis was done using SPSS Statistics version 23 (IBM Corp., Armonk, NY, USA) and model prediction using Python (The Python Software Foundation, Wilmington, DE, USA). Results There were significant differences in biochemical parameters at the time of admission among COVID-19 patients between phases 1 and 2, ICU and non-ICU admissions, and expired and discharged patients. Thereceiver operating characteristic (ROC)curves predicted mortality solely based on biochemical parameters. Using multiple logistic regression in Python, a total of four models (two each) were developed to predict ICU admission and mortality. A total of 92 out of 96 patients were placed into the correct management category by our model. This model would have allowed us to preserve 17 of the 21 patients we lost. Conclusions We developed predictive models for admission (ICU or non-ICU) and mortality based on biochemical parameters at the time of admission. A predictive model with a significant predictive capability for IL-6 and procalcitonin values using normal biochemical parameters was proposed. Both can be used as machine learning tools to prognosticate the severity of COVID-19 infections. This study is probably the first of its kind to propose triage for admission in the ICU or non-ICU at the medical emergency department during the first presentation for the necessary optimal treatment of COVID-19 based on a predictive model.

Unplanned revisits of older patients to the emergency department

IntroductionOlder patients currently represent up to 12%−24% of all emergency department (ED) visits. While increasing in number, they are also at high risk of revisits once discharged. The rate of ED revisits within 72 h is a key indicator of the quality of care in emergency medicine and varies between 1% and 15%. The reasons for ED revisits are natural course of illness, misdiagnosis, lack of homecare, and self-discharge against medical advice. However, the risk factors for ED revisits have not been fully investigated. Therefore, this study aimed to analyze the incidence of ED revisits and identify the risk factors for ED revisits within 72 h after ED discharge.MethodsIn this retrospective study, older patients (≥70 years) were consecutively enrolled if they presented with an Emergency Severity Index of 2 or 3 in a tertiary care ED in 2019, with discharge after the ED visit. The primary endpoint was the frequency of unplanned ED revisits within 72 h after ED discharge. The secondary endpoints were the reasons and potential risk factors for ED revisits. Univariate and multivariate logistic regression models were used.ResultsA total of 592 older patients were enrolled, of whom 30 (5.1%) revisited the ED within 72 h. Gastrointestinal diagnosis [odds ratio (OR), 2.9; 95% confidence interval [CI], 1.04–8.2; p = 0.043) and nausea in particular (OR, 3.5; 95% CI, 1.3–9.4; p = 0.016) were significant risk factors for ED revisits. Furthermore, discharge against medical advice (OR, 5.6; 95% CI, 1.7–18.1; p = 0.004) and ED presentation during the night (OR, 2.7; 95% CI, 1.2–6.1; p = 0.014) were significant risk factors for ED revisits within 72 h after discharge, respectively.ConclusionAlthough the frequency of ED revisits among older patients at 72 h after discharge tends to be low and most revisits were illness-related, all older patients need to be assessed for risk factors for ED revisits. Discharge should be carefully evaluated to improve patient safety and provide the best healthcare to this frail population.

Pattern of the medical emergency department admissions in a tertiary hospital: Ahospital-based prospective study

Introduction: Most emergency departments in Nigeria are usually merged (Surgical and Medical). The recently established Adult medical emergency unit of the University of Benin Teaching hospital (UBTH) is novel in Southern Nigeria. We sought to determine the pattern of purely medical emergency cases seen over a 6 months' period in our hospital.&#x0D; Methods: It was a cross-sectional descriptive study involving all patients treated in the medical ED at University of Benin Teaching Hospital, Benin city over a six month period (August 2019-January 2020). An interviewer administered questionnaire was used to collect data on sociodemographic characteristics, presenting complaints, diagnosis, sub-specialty involved in management and outcome (discharge, admission, referral or death).&#x0D; Results: A total of 875 patients were recruited for the study. There were 410(46.9%) males and 465(53.1%) females. The mean age was 57.8±19.94 years (range: 17 - 107 years). The top 10 clinical diagnosis included stroke 146(16.7%), chronic kidney disease 59(6.7%), diabetic emergency 59(6.7%), pneumonia 57(6.5%), congestive cardiac failure 53(6.1%), type- 2 Diabetes mellitus with chronic complications50(5.7%), malaria49(5.6%), retroviral disease 33(3.8%), hypertensive emergency29(3.3%) and Tuberculosis28(3.2%).&#x0D; Conclusion: Neurological and infectious diseases were the most frequent reason for consultation. Stroke was the singular most common diagnosis in the medical emergency. A prior consultation to a peripheral center was high amongst patients observed during the study period &#x0D; &#x0D; French title: Modèle d'admissions aux services d'urgence médicale dans un hôpital tertiaire : une étude prospective en milieu hospitalierIntroduction: La plupart des services d'urgence au Nigeria sont généralement fusionnés (chirurgicaux et médicaux). L'unité d'urgence médicale pour adultes récemment créée à l'hôpital universitaire du Bénin (UBTH) est une nouveauté dans le sud du Nigeria. Nous avons cherché à déterminer la répartition des cas d’urgence purement médicale vus sur une période de 6 mois dans notre hôpital.&#x0D; Méthodes:Il s'agissait d'une étude descriptive transversale portant sur tous les patients traités à l'urgence médicale de l'hôpital universitaire du Bénin, ville de Benin, sur une période de six mois (août 2019-janvier 2020). Un questionnaire administré par un intervieweur a été utilisé pour collecter des données sur les caractéristiques sociodémographiques, la présentation des plaintes, le diagnostic, la sous-spécialité impliquée dans la gestion et les résultats (sortie, admission, référence ou décès).&#x0D; Résultats: Au total, 875 patients ont été recrutés pour l'étude. Il y avait 410 (46,9 %) hommes et 465 (53,1 %) femmes. L'âge moyen était de 57,8 ± 19,94 ans (extrêmes : 17 - 107 ans). Les 10 principaux diagnostics cliniques comprenaient un accident vasculaire cérébral 146 (16,7 %), une maladie rénale chronique 59 (6,7 %), une urgence diabétique 59 (6,7 %), une pneumonie 57 (6,5 %), une insuffisance cardiaque congestive 53 (6,1 %), un diabète de type 2. sucré avec complications chroniques50(5,7%), paludisme49(5,6%), maladie rétrovirale 33(3,8%), urgence hypertensive29(3,3%) et tuberculose28(3,2%).&#x0D; Conclusion: Les maladies neurologiques et infectieuses étaient le motif de consultation le plus fréquent. L’accident vasculaire cérébral était le diagnostic le plus courant en cas d’urgence médicale. Une consultation préalable dans un centre périphérique était élevée parmi les patients observés pendant la période d'étude.

Preoperative Depression Screening for Primary Total Knee Arthroplasty: An Evaluation of Its Modifiability on Outcomes in Patients Who Have Depression

BackgroundFew studies have evaluated preoperative depression screenings in patients who have depression. We studied whether depression screenings before total knee arthroplasty (TKA) were associated with lower: 1) medical complications; 2) emergency department (ED) utilizations and readmissions; 3) implant complications; and 4) costs. MethodsA nationwide sample from January 1, 2010, to April 30, 2021, was collected using an insurance database. Depression patients were 1:1 propensity-score matched based on those who had (n = 29,009) and did not have (n = 29,009) preoperative depression screenings or psychotherapy visits within 3 months of TKA. A case-matched population who did not have depression was compared (n = 144,994). A 90-day period was used to compare complications and health-care utilization and 2-year follow-up for periprosthetic joint infections (PJIs) and implant survivorship. Costs were 90-day reimbursements. Logistic regression models computed odds ratios (ORs) of depression screening on dependent variables. P values less than .001 were significant. ResultsPatients who did not receive preoperative screening were associated with higher medical complications (18.7 versus 5.2%, OR: 4.15, P < .0001) and ED utilizations (11.5 versus 3.2%, OR: 3.93, P < .0001) than depressed patients who received screening. Patients who had screening had lower medical complications (5.2 versus 5.9%, OR: 0.88, P < .0001) and ED utilizations compared to patients who did not have depression (3.2 versus 3.8%, OR: 0.87, P = .0001). Two-year PJI incidences (3.0 versus 1.3%, OR: 2.63, P < .0001) and TKA revisions (4.3 versus 2.1%, OR: 2.46, P < .0001) were greater in depression patients who were not screened preoperatively versus screened patients. Depression patients who had screening had lower PJIs (1.3 versus 1.8%, OR: 0.74, P < .0001) compared to nondepressed patients. Reimbursements ($13,949 versus $11,982; P < .0001) were higher in depression patients who did not have screening. ConclusionsPreoperative screening was associated with improved outcomes in depression patients. Level of evidenceIII.

Implementation of Extracorporeal CPR Programs for Out-of-Hospital Cardiac Arrest: Another Tale of Two County Hospitals

Extracorporeal cardiopulmonary resuscitation (ECPR) is a form of intensive life support that has seen increasing use globally to improve outcomes for patients who experience out-of-hospital cardiac arrest (OHCA). Hospitals with advanced critical care capabilities may be interested in launching an ECPR program to offer this support to the patients they serve; however, to do so, they must first consider the significant investment of resources necessary to start and sustain the program. The existing literature describes many single-center ECPR programs and often focuses on inpatient care and patient outcomes in hospitals with cardiac surgery capabilities. However, building a successful ECPR program and using this technology to support an individual patient experiencing refractory cardiac arrest secondary to a shockable rhythm depends on efficient out-of-hospital and emergency department (ED) management. This article describes the process of implementing 2 intensivist-led ECPR programs with limited cardiac surgery capability. We focus on emergency medical services and ED clinician roles in identifying patients, mobilizing resources, initiation and management of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in the ED, and ongoing efforts to improve ECPR program quality. Each center experienced a significant learning curve to reach goals of arrest-to-flow times of cannulation for ECPR. Building consensus from multidisciplinary stakeholders, including out-of-hospital stakeholders; establishing shared expectations of ECPR outcomes; and ensuring adequate resource support for ECPR activation were all key lessons in improving our ECPR programs.

The organization of emergency medical care for the children's population during the COVID-19 pandemic

Objective. To analyze the work of the emergency medical care department (EMCD) of the largest children's polyclinic of the city in 2020-2022 and to evaluate the organization of the EMC for the attached children during the Covid-19 pandemic. Materials and methods. Mathematical and statistical analysis of quantitative and qualitative indicators of EMCD activity based on a continuous sample of primary accounting and reporting medical documentation. Results. A significant increase in the number of EMCD visits was demonstrated. In 2022, the growth was 40,96 % and 28,12 % compared to 2020 and 2021. It was found out that in 97,4–98,0 % of all cases provided with EMC, were the children with respiratory diseases. Their number in 2022 increased 1,3 times compared to 2021, and 1,43 times compared to 2020. In this group of patients, the number of children with pneumonia increased by 63.5 % in 2021 compared to 2020. Conclusions. The proper organization of the work of the EMCD made it possible to provide children with available, timely and rapid primary medical social and emergency medical care during an increased workload in the context of the COVID-19 pandemic.

Potential drug-drug interactions between discharge medication from the emergency department and home medication in tertiary hospital

Objective: This retrospective analysis aimed to comprehensively examine the age distribution, gender prevalence, comorbidity patterns, and potential drug-drug interactions among discharged emergency department (ED) patients. By elucidating these factors, the study would contribute valuable insights for improving patient care and medication safety. Methods: The study used retrospective data collection and analyzed cross-sectional data of patients discharged from the ED at King Abdullah Medical City from January to February 2023. Results: The results showed that the majority of discharged patients were between the ages of 36 and 50 years (56.4%) and had a balanced gender distribution. The most common department of discharge was cardiology (42.1%). The analysis also revealed that 68.5% of patients had 3 to 6 comorbidities. The study found significant associations between discharge status and potential drug-drug interactions (DDIs), with patients discharged against medical advice having a higher incidence of potential DDIs (p = 0.037). Conclusion: The study highlighted the importance of training emergency physicians to use hospital systems to identify and prevent potential DDIs. The prevalence of DDIs between prescribed ED medication and home medication was found to be high. The study suggested that discharge status and DDI severity are significant factors influencing the frequency of potential DDIs.

SmartEUS: An Integrated Dynamic Platform For The Innovation Of Healthcare Emergency-Urgency Services

The SmartEUS project aims to design, develop, and test a highly innovative model for the provision of Emergency Urgency Services (EUS) based on the concept of clinical pathway (i.e., the entire emergency care chain). The project is innovative both from an organizational and technological point of view. It is based on an e-Health approach, capable of exploiting new digital technologies in a coordinated way to support the evolution of emergency health systems towards dynamic and safer processes. The paper presents the SmartEUS platform which can integrate the information from all the key players in medical emergency response (emergency operation center, emergency medical service, hospital emergency department) improving their coordination. The most relevant innovations of the proposed solution are data integration and interoperability, advanced communication and collaboration, knowledge-based resource allocation, telemedicine integration to support decision making in dispatching and resource assignment. In fact, a Decision Support System is integrated into SmartEUS cloud platform to suggest to the emergency operation center which emergency medical service and hospital emergency department. In fact, information on the patient status can include results from ambulance’s on board telediagnosis equipment, alerting the hospital emergency department even before the arrive of the patient, thus guaranteeing the appropriateness of care according to patient needs (e.g., patient pre-triage index, potential pre-hospital diagnosis) and reducing emergency department overcrowding and resources saturation.

Child Victims of Road Traffic Accidents: Epidemiological and Clinical Aspects in the Medical and Surgical Emergency Department of the Donka National Hospital

Child Victims of Road Traffic Accidents: Epidemiological and Clinical Aspects in the Medical and Surgical Emergency Department of the Donka National Hospital

Collaborative Advanced Trauma Care (CATC): Evaluation of a trauma education program developed in Pakistan in an Ethiopian context

Trauma globally represents an overwhelming burden of morbidity and mortality. Effective management with trauma teams has proven to reduce time to resuscitation and definitive care leading to decreased mortality and length of stay of trauma patients. Building upon previous partnership we undertook to implement and evaluate Collaborative Advanced Trauma Care (CATC) at a public teaching hospital in Ethiopia, based on course developed in Pakistan. A total of 140 participants were trained in CATC (83 physicians, 57 nurses), with improvement in fundamental trauma knowledge and leadership and teamwork. These findings are similarly reflective of evaluation scores of CATC in Pakistan, demonstrating that CATC can be expanded in settings that share similar medical education and emergency department structures.

The association of inflammatory bowel disease with postoperative complications, re-admissions and emergency department visits following primary total hip arthroplasty.

Inflammatory bowel disease (IBD) is a systemic inflammatory disorder of the gut. Few studies have evaluated whether patients with a history of IBD have worse outcomes following primary total hip arthroplasty (THA). Therefore, the purpose of this study was to evaluate whether IBD is associated with increased: (1) medical complications; (2) readmissions; and (3) emergency department (ED) visits. Using a nationwide claims database, patients with IBD undergoing primary THA were identified and matched to a comparison group according to age, sex and the Charlson Comorbidity Index. Outcomes assessed included the development of 90-day medical complications, 90-day re-admissions and 90-day ED visit rates. A p-value <0.0001 was considered statistically significant. Patients with IBD had a greater incidence and odds ratio of total medical complications (31.90% vs. 11.47%; OR 2.89; p < 0.0001) compared with matched controls. IBD patients had significantly higher incidence and odds ratio of developing acute kidney injury (5.46 vs. 1.46%; OR 3.92; p < 0.0001), cerebrovascular accident (1.32 vs. 0.35%; OR 3.79; p < 0.0001), pneumonia (4.02 vs. 1.30%; OR 3.19; p < 0.0001), respiratory failure (1.21 vs. 0.41%; OR 2.94; p < 0.0001), deep vein thrombosis (0.89% vs. 0.30%; OR 2.93; p < 0.0001), and other adverse events. IBD patients also had higher incidence and odds ratio of 90-day re-admissions (4.20% vs. 3.23%; OR 1.31; p < 0.0001) and ED visits (6.56% vs. 3.99%; OR 1.69; p < 0.0001). This study found that patients with IBD are at increased risk of 90-day medical complications, re-admissions, and ED visits. Due to its systemic nature, surgeons operating on these patients should be aware of the disease's extra-intestinal manifestations, and the potential postoperative risks in IBD patients. Providers should use this investigation when educating patients on potential risks of elective THA.

RECREATIONAL DRUG USE IN ALGERIA: A SHORT COHORT STUDY

In the Middle East and worldwide, drug abuse is a growing problem for authorities Defined as the ingestion of substance for their psychoactive effect .it is a main reason for cardiovascular neuronal avoidable comorbidities The aim of this study is to settle the prevalence of Recreational drug (RD) and the tendency of consumption METHOD: We analyzed the data of 40 cases that came to the medical and surgery emergency department units in 03 months starting from July,1st 2023 The data were analyzed by IBM SPSS RESULTS: Among the 40 included cases, 7 were female. The median age was 30 years. The patient presented at night (20:00– 07:59) in 25 cases, and during the weekend in19 cases (47.5%). The average length of stay is 57h34 minutes. The drugs most commonly involved were Cocaine 35.5% followed by buprenorphine 27.5% and pregabalin 22.5% then cannabis 17.5% Drugs were combined with other toxic agents in 20 cases (50%) to cocaine In 3 cases, the patient died during his hospitalization (7.5%) 8 cases (20%) required naloxone use CONCLUSION: The trend of drug consumption is different from the European model. Cocaine is 35.5% KEY-WORDS: Recreational drug use, intoxication, emergency medical department, prevalence, North Africa, substance abuse

The consequence of the closure of primary care dental services on secondary care during the COVID-19 pandemic – A national outlook

BackgroundAfter the global pandemic of COVID-19 in March 2020, restrictions were implemented on all aspects of routine dental-care with a primary focus to urgent care only. AimTo investigate the impact on secondary care medical facilities and Emergency Department (ED) admissions for the management of severe dental infections as a result of restricted access to routine primary dental-care during the period of COVID-19 restrictions. DesignNational level Hospital Episode Statistics was used to describe the number of inpatient admissions for the drainage of a dental abscess and the attendance for dental related to ED. Data was stratified across ethnicity, sex and deprivation. ResultsThere was a decrease in admission to secondary care for dental infection and total admissions during the initial period of national lockdown due to COVID-19. Incidence of dental abscess drainage equalled 4.51 per100,000 person years from 2018 to 2021. There was a 209 % increase in admissions in patients with greatest deprivation. This was much more exaggerated compared to that of non-dental comparison conditions and total inpatient admissions. Using subsequent inpatient admission as a marker of severity, 4.2 % dentally related ED attendance required onward admission. ConclusionA large proportion of ED attendances with dental related conditions did not require inpatient admission, therefore a large proportion of ED attendances could be managed more appropriately in specific dental services. Dental infections requiring surgical admission disproportionality affects the most deprived communities of the population which is much more exaggerated compared to peri-anal and total inpatient admissions. This highlights the inequalities and links with deprivation that exist in oral and dental health in England, which is much greater than that of general health if total admissions are used as maker for this. This research highlights the need to improve access to primary dental-care services.

Head-to-head comparison of 19 prediction models for short-term outcome in medical patients in the emergency department: a retrospective study

IntroductionPrediction models for identifying emergency department (ED) patients at high risk of poor outcome are often not externally validated. We aimed to perform a head-to-head comparison of the discriminatory performance of several prediction models in a large cohort of ED patients.MethodsIn this retrospective study, we selected prediction models that aim to predict poor outcome and we included adult medical ED patients. Primary outcome was 31-day mortality, secondary outcomes were 1-day mortality, 7-day mortality, and a composite endpoint of 31-day mortality and admission to intensive care unit (ICU).The discriminatory performance of the prediction models was assessed using an area under the receiver operating characteristic curve (AUC). Finally, the prediction models with the highest performance to predict 31-day mortality were selected to further examine calibration and appropriate clinical cut-off points.ResultsWe included 19 prediction models and applied these to 2185 ED patients. Thirty-one-day mortality was 10.6% (231 patients), 1-day mortality was 1.4%, 7-day mortality was 4.4%, and 331 patients (15.1%) met the composite endpoint. The RISE UP and COPE score showed similar and very good discriminatory performance for 31-day mortality (AUC 0.86), 1-day mortality (AUC 0.87), 7-day mortality (AUC 0.86) and for the composite endpoint (AUC 0.81). Both scores were well calibrated. Almost no patients with RISE UP and COPE scores below 5% had an adverse outcome, while those with scores above 20% were at high risk of adverse outcome. Some of the other prediction models (i.e. APACHE II, NEWS, WPSS, MEWS, EWS and SOFA) showed significantly higher discriminatory performance for 1-day and 7-day mortality than for 31-day mortality.ConclusionsHead-to-head validation of 19 prediction models in medical ED patients showed that the RISE UP and COPE score outperformed other models regarding 31-day mortality.

Descriptive evaluation of patients receiving one-time intravenous vancomycin doses at a large academic medical center emergency department

BackgroundIntravenous (IV) vancomycin is commonly used to treat a variety of infections caused by methicillin-resistant Staphylococcus aureus (MRSA). The practice of administering a single dose of IV vancomycin prior to emergency department (ED) discharge may be clinically ineffective and foster antimicrobial resistance. Furthermore, this practice introduces an unnecessary infection risk along with preventable adverse effects while potentially increasing ED length of stay (LOS). There is a paucity of literature identifying patient characteristics and objective findings in this patient population, which may foster future antimicrobial stewardship initiatives in the ED. MethodsThis was a single-center, retrospective, descriptive analysis of adult patients seen in the ED between January 2020 and January 2023 who received a single dose of IV vancomycin and were subsequently discharged from the ED without hospital admission. Information was collected on patient demographics and select comorbidities, vancomycin indication and dosing, ED LOS, initial vitals and labs, concomitant antibiotics administered, culture results, 30-day return ED visits and admissions, and antibiotics prescribed at ED discharge. ResultsA total of 295 patients met inclusion criteria. A total of 32.1% of patients met SIRS criteria. The most commonly selected order indication for IV vancomycin was “skin and skin structure infection” (41%). A total of 86.1% of patients received concomitant antibiotics in the ED and only 54.6% of patients were prescribed oral antibiotics at ED discharge. A total of 80% of patients had at least one culture obtained during the ED visit. In those who had at least one culture obtained, 78.4% of patients had negative cultures and 4.2% of patients had MRSA positive cultures, with MRSA skin cultures being the most common (3.1%). Return ED visits and admissions within 30 days were not statistically significantly different between patients who did and did not receive oral antibiotics at ED discharge. ConclusionsDespite a lack of clinical efficacy reported in prior literature and the potential risks, administration of a one-time dose of IV vancomycin prior to ED discharge is commonly encountered in clinical practice. There are opportunities for enhanced antimicrobial stewardship related to IV vancomycin use in the ED. Areas of future focus include the utilization of oral antimicrobials when clinically appropriate, particularly for skin and soft tissue infections, and clarification of antibiotic allergies.

Assessing medication self-management challenges and self-efficacy during emergency department medication reconciliation: An evidence-based quality improvement project

Assessing medication self-management challenges and self-efficacy during emergency department medication reconciliation: An evidence-based quality improvement project