Emergency Department Presentation Research Articles

Urinary Retention After GreenLight Laser Photoselective Vaporization of the Prostate (GLL.PVP) Surgery for Benign Prostatic Hyperplasia (BPH): A 3-6 Month Retrospective Follow-Up Study.

Objective Our study was designed to evaluate the postoperative urinary retention (UR) and success rate of the GreenLight Laser (Boston Scientific, Marlborough, MA, USA) photoselective vaporization of the prostate (GLL.PVP) procedure for Benign Prostatic Hyperplasia (BPH) patients, both with and without high-risk factors. Methodology We conducted a retrospective follow-up study of postoperative patients who underwent GLL.PVP for BPH. We collected data from clinical health records, including notes from the lower urinary tract symptoms (LUTS) clinic, trial without catheter (TWOC) clinic, and emergency department presentations with UR. The analysis examined several parameters, including the patient's age, high-risk factors, prostate volume, and both preoperative and postoperative objective voiding parameters. These voiding parameters included post-void residual (PVR) and maximum flow rate (Qmax). Additionally, the analysis looked into whether the patient had a catheter or experienced urinary retention prior to the surgery. Results A total of 50 GreenLight Laser PVP surgeries were performed over a 14-month period from May 2023 to July 2024 at West Middlesex University Hospital in London. Most of the patients were between the ages of 60 and 80. Prior to the surgery, data indicated that 17 patients (34%) were using long-term catheters, whereas 33 patients (66%) were not. Additionally, 25 patients (50%) were identified as having high-risk factors, which included being on anticoagulation therapy, a history of urinary retention, and a prostate volume exceeding 100 cc.Notably, the patient without h/o urinary retention had an average preoperative PVR of 150 mL and an averageQmaxof 7 mL/second In our 3-6 month retrospective postoperative follow-up study, we found that eight cases (16%) developed urinary retention, while 42 cases (84%) did not, with an average PVR volume of 105 mL and an average Qmax of 13.5 mL/second. In patients with preoperative urinary retention, 13 cases (76%) did not develop UR postoperatively whereas four cases (24%) developed. Conclusion Our study conclusively found that 42 cases (84%) of patients did not experience urinary retention (UR) in the follow-up after undergoing the GLL PVP operation, irrespective of any history of urinary retention or other high-risk factors. This unequivocally demonstrates the operation's efficacy. Furthermore, our findings revealed that three-quarters of patients with a preoperative history of urinary retention also did not develop UR post-surgery. The GLL.PVP procedure is safe and effective, leading to rapid improvements in voiding parameters.

Evaluation of a youth-focused suicide prevention HOPE aftercare service: protocol for a non-randomized hybrid effectiveness-implementation type I design.

Suicide is the fourth leading cause of death among young people aged 15-29 worldwide. Young people often present to emergency departments (EDs) with self-harm and suicide-related behaviors. The period following discharge from the ED is recognized as one of elevated risk for both repeated self-harm and suicide. During this critical time, suicide prevention aftercare services are recommended. Despite their increased popularity, evidence demonstrating the effectiveness of these models is very limited. Using a hybrid effectiveness-implementation type I design, this evaluation will assess the effectiveness and implementation of a suicide prevention aftercare (Hospital Outreach Post-suicidal Engagement; HOPE) service designed to reduce risk of self-harm and suicide in young people aged 12-25 who are referred to the service following an ED presentation for self-harm or suicide attempt. Two complementing theoretical frameworks will guide this evaluation, specifically the design, data collection, analysis, and interpretation of results. The RE-AIM evaluation framework will be used to assess Reach, Effectiveness (including cost-effectiveness), Adoption, Implementation and Maintenance of the HOPE aftercare service. The PRISM implementation framework will be used to assess multi-level contextual factors hypothesized to affect the RE-AIM outcomes. Several data sources will be used to assess the changes in primary and secondary outcomes from baseline to post-intervention, and at follow-up, including user and provider self-report surveys, semi-structured interviews, and routinely collected hospital data. An historical control study will also be conducted using data from the Self-Harm Monitoring System for Victoria to examine the impact of the service on rates of self-harm and suicide-related presentations to ED, and compare trends prior to and following commencement of the HOPE aftercare service. In addition, dynamic systems modelling will be used to assess the future scalability of the service. Findings from this evaluation will determine the effectiveness, including cost-effectiveness, of the HOPE aftercare service and describe the implementation context. They will inform the future development and sustainability of this and other similar services across Australia and internationally. This trial was prospectively registered with the Australian New Zealand Clinical Trials Registry (ANZCTR) on the19th December 2023 (Registration number ACTRN12623001332617). We do not foresee any amendments to this protocol however, if any unforeseen modifications are required, they will be submitted to ANZCTR. Orygen, 35 Poplar Road, Parkville, VIC, 3052, Australia.

OGC SO23 - Audit on Enhanced Recovery After Surgery (ERAS) in Oesophago-gastric Resections for Cancers

Abstract Background Enhanced Recovery After Surgery (ERAS) protocols, have been designed to guide clinicians in managing patients post-operatively, reducing hospital stay, complications and readmissions. Our trust’s ERAS protocol includes guidance on oral intake initiation, drain, catheter and epidural removal, investigation frequency, medications required on discharge and early mobilization. However, implementation of ERAS protocols in complex oncological surgery can be challenging, due to the multiple factors included and increasing complexity. We aimed to assess the compliance of ERAS implementation in a high volume resectional oesophago-gastric unit, and subsequent impact on morbidity. Method A retrospective review of all patients who underwent oesophago-gastric resections during March-April 2024 was performed. Patients were included if they completed an oesophagectomy, or subtotal/total gastrectomy resection for cancer. Electronic records and medical notes were reviewed and compared to all aspects of the trust’s ERAS protocol. The adherence percentage to the protocol was calculated. Results 20 patients underwent surgery. 85% started their oral diet on time per ERAS protocol. Adherence to ERAS was lowest for epidural (52.6%, 95% within 24-hours of target), catheter (55%, 90% within 24-hours of target), apical (55.6%, 100% within 24-hours of target), basal (53.8%, 85.7% within 24-hours of target), and abdominal drain removals (81.8%, 90.9% within 24-hours of target). All patients mobilized within four days post-op, with 65% achieving daily mobilization. VTE prophylaxis was prescribed for all, and discharge medication adherence ranged from 86.7% to 100%. The mean hospital stay was 9 days post-oesophagectomy, with a 3.2% emergency department return rate. Conclusion Implementation of an ERAS protocol is feasible in complex oesophago-gastric cancer surgery. Effective involvement and training of allied health, specialist pain services and the whole surgical team can decrease morbidity and length of stay in oesophagectomy, while avoiding excess emergency department presentations. Ongoing training and feedback of allied health, pain services, and surgical team at all levels is important to ensure adequate compliance.

MS O10 - BN Case Report: Aberrant Right Subclavian Artery As A Rare Differential For Dysphagia

Abstract Background Dysphagia lusoria (DL) is characterised by swallowing difficulty due to external oesophageal compression from congenital aortic arch malformations. It is clinically rare and affects less than 2.5% of the population. The most prevalent form of DL is the aberrant right subclavian artery (ARSA) where approximately 10% of patients experience dysphagia. Despite AL being congenital, dysphagia often manifests later in life, likely due to age-related atherosclerotic changes in the vasculature and decreased oesophageal flexibility. Method Presented is a case report of a female in her seventies where, despite repeat hiatal hernia repair and maximal medical management, her index symptoms of dyspepsia and retrosternal discomfort persisted when reviewed in specialist upper gastrointestinal clinic. She underwent extensive investigation; however, her symptoms were unremitting, manifesting in numerous emergency department presentations to exclude acute coronary syndrome. This case report details the anatomical differences via diagrams and documents the comprehensive investigation and multi-disciplinary approach to the management of dysphagia in ARSA. Results Prior to referral to our team, the patient had a laparoscopic hiatus hernia repair and Nissen fundoplication undertaken. Oesophageal manometry revealed weak oesophageal motility and 24-hour pH monitoring did not demonstrate pathological acid-reflux. Recurrence of hiatus hernia was observed on oral contrast swallow and gastroscopy. Subsequently, the patient underwent laparoscopic revision of hiatus hernia and conversion of Nissen to a Dor. Post-operatively her symptoms required complete fundoplication reversal. Following reversal, assessment demonstrated improved distal oesophageal emptying. Her CT emphasised an ARSA causing significant compression and deviation of the proximal oesophagus. The patient was referred onwards to vascular surgery. Conclusion Initial diagnostic workup for patients presenting with dysphagia in the upper gastrointestinal clinic seeks to encompass several common aetiologies including oesophageal motility disorders, malignant compression and benign strictures. Clinicians must consider less common causes of extrinsic compression, such as ARSA, particularly in patients with unrelenting and persistent symptoms despite appropriate implementation of both medical and surgical interventions. Treatment approaches for ARSA reflect symptom severity, with both conservative and surgical options considered.

Management of COVID-19 in the community using virtual care: An Australian perspective.

Virtual care and remote monitoring were widely used during the COVID-19 pandemic. However, early evaluations of effectiveness were often inconclusive due to low rates of enrolment and limited data. The aim of this study was to evaluate the effectiveness of virtual care in managing individuals in community-based self-isolation and quarantine in Australia during this pandemic. A retrospective cross-sectional study was conducted of individuals admitted to a virtual hospital in Sydney who either tested positive for COVID-19 and required self-isolation, or tested negative but still needed to self-isolate, amidst the Delta wave of the COVID-19 pandemic. Outcome measures included health service utilisation, in-hospital mortality, patient-reported experience measures (PREM), and cost savings resulting from avoided emergency department (ED) presentations. Out of 9571 individuals admitted, 8544 (89.3%) had COVID-19. Clinical deterioration or acute illness occurred in 2477 (25.9%) individuals, of whom 890 (9.3%) were referred to ED for further assessment or investigation, and 614 (6.4%) were admitted for inpatient treatment. Overall mortality was 0.2%. Out of 1020 individuals who completed the PREM survey, 846 (82.9%) rated the overall virtual care experience as 'good' or 'very good'. Avoided ED presentations possibly resulted in cost savings estimated between AU$691,214 and AU$2,994,540. Virtual care was successfully used to manage a large number of individuals in community-based self-isolation and quarantine during the COVID-19 pandemic. Scalable pathways for triage, monitoring and clinical escalation via telehealth ensured patient safety and acceptability, and alleviated strain on the broader health system.

Antenatal counselling at the cusp of viability and parental decision-making in the zone of parental discretion: A cohort study.

Safer Care Victoria updated a clinical guideline on extreme prematurity in 2020, reducing the threshold for offering resuscitation from 23 to 22 weeks gestation. The zone of parental discretion is the interval of shared decision-making between parents and doctors regarding resuscitation decisions. It is especially relevant at this periviable gestation. Our study aimed to establish current practices in antenatal counselling and steroid administration at this cusp of viability, and examine the decisions made during the zone of parental discretion. Single centre retrospective cohort study. Sixteen thousand three hundred fifty-four admissions and emergency department presentations between January 2021 and July 2023 were retrieved from Birthing Outcomes System (BOS) and patient details were imported and manually reviewed on Microsoft Excel, with particular note to the gestation at admission/emergency department presentation and duration of admission. Eighty-seven patients were identified as present in the hospital between 21 + 0 and 22 + 6 weeks gestation. These 87 scanned records on Clinical Patient Folder (CPF) were then manually reviewed to identify if antenatal counselling occurred during this window. Thirty-six patients were included who received antenatal counselling between 21 + 0 and 22 + 6 weeks gestation (the remaining patients did not receive antenatal counselling during this window), and relevant data was subsequently extracted from the scanned medical record and analysed using SPSS software (IBM SPSS Statistics 29). Thirty-six women received antenatal counselling between 21 + 0 and 22 + 6 weeks. 58% decided on full resuscitation and 39% opted for comfort care if their infant was to be born between 22 + 0 and 22 + 6 weeks. All but one baby born premature were exposed to steroids, with 83.3% receiving a full course. Twenty-eight infants (62.2%) were fully steroid loaded at the time of delivery. In those fully steroid loaded, 31.1% of the time steroids were initiated prior to transfer, 50% of the time deferred until neonatal review and a decision regarding the resuscitation status of the baby, and on one occasion requested by the neonatologist before counselling. Patients at risk for premature birth who attended our hospital at the cusp of viability were generally counselled about the opportunity for resuscitation between 22 + 0 and 22 + 6 weeks gestational age, and offered steroids. Further studies are required to establish whether the content of antenatal counselling, and the timing of steroids, are consistent in this population.

Convergence insufficiency as a predictor of poor prognosis after acute mild traumatic brain injury

BackgroundMild traumatic brain injury (mTBI) is becoming a more common emergency department (ED) presentation. Towards this end, many types of testing in the acute setting are being investigated. One of these is screening for convergence insufficiency (CI) symptoms. These are common problems reported by patients with mTBI, but such oculomotor testing is rarely performed in the ED.ObjectiveTo assess the feasibility of convergence insufficiency screening in the ED and investigate whether CI is associated with adverse events such as post-concussive symptoms or hospital admission.MethodsWritten informed consent was obtained from patients age 18 years or older who experienced a mild head injury from any mechanism resulting in an mTBI. Patients underwent screening for CI symptoms using a standardized instrument of 15 questions, known as the convergence insufficiency symptom survey (CISS), with responses based on the Likert scale. These data were correlated to outcomes of hospital admission, occurrence of post-concussive symptoms, and 30-day hospital re-admission.ResultsA total of 116 patients were prospectively enrolled, of which 58 were male. The median age was 31 years, with a range of 18 to 95 years of age. The median CISS score was 13, with an interquartile range (IQR) of 6 to 21 and an overall range of 0 to 53. Females presented with a median CISS score of 14, which was higher compared to the male median score of 10. The higher the CISS score, the more likely the patient was to be admitted to the hospital (p = 0.0378), develop symptoms of post-concussive syndrome at 30-day follow up (p = 0.0322), and be readmitted within 30 days (p = 0.0098).ConclusionsScreening for CI symptoms using the CISS can be a solid adjunct in the evaluation of mTBI in the ED. The CISS is easy and fast to administer, and it is a useful tool to stratify patients in terms of who is at the highest risk of developing complications related to the mTBI.

The Association of the Child Opportunity Index with Emergency Department Presentations for Pediatric Poisonings: A Case-Control Study

The Association of the Child Opportunity Index with Emergency Department Presentations for Pediatric Poisonings: A Case-Control Study

Implementing a pathway for patients diagnosed with cancer in the emergency department.

Patients diagnosed with cancer or suspected cancer during an emergency department (ED) presentation are often signposted back to their GP for urgent referral to cancer services. However, this can result in delays in patients receiving specialist support, confirmation of diagnosis and, vitally, starting treatment. A quality improvement initiative that aimed to address these issues through the introduction of an ED suspected cancer diagnosis pathway was implemented by the acute oncology service in two EDs in Oxford University Hospitals NHS Foundation Trust in April 2023. Data collected during the first year of implementation of the pathway show there has been a significant increase in the numbers of patients meeting the NHS England 62-day referral to treatment standard and in the numbers of patients receiving support from an acute oncology named cancer clinical nurse specialist from the point of discharge from the ED. This article details the initiative, which is ongoing, and shares some of the results from the first year of data collection.

Estimating the impact of the COVID-19 vaccination programme in Ireland: December 2021-March 2023

Abstract Background In Autumn 2023, COVID-19 booster vaccines were offered to all those aged ≥50 years in Ireland. There was concern that vaccine fatigue would impact uptake. We aimed to quantify the direct impact of the COVID-19 vaccination programme on averted outcomes in individuals aged ≥50 years, during a period of Omicron variant dominance, to inform vaccination strategy and public health communication. Methods We conducted a retrospective observational study from December 2021 to March 2023 in Ireland. We considered as averted outcomes symptomatic SARS-CoV-2 presentations to primary care, emergency department (ED) presentations, hospitalisations, intensive care unit (ICU) admissions and deaths due to COVID-19. We used an adapted formula from other vaccine impact published studies, including national data on notified outcomes, vaccine coverage data and vaccine effectiveness (VE) estimates, sourced from the WHO’s live systematic VE review, to estimate the count and prevented fraction of outcomes in ≥ 50-year-olds averted by the COVID-19 vaccination programme. The number of expected outcomes in the absence of vaccination was calculated by summing the counts of outcomes observed and outcomes averted. Results Between December 2021 and March 2023, the COVID-19 vaccination programme averted 48,551 symptomatic presentations to primary care (36% of expected), 9,517 ED presentations (53% of expected), 102,160 hospitalisations (81% of expected), 3,303 ICU admissions (89% of expected) and 15,985 deaths (87% of expected). Conclusions During Omicron dominance, the COVID-19 vaccination programme averted symptomatic and severe outcomes, including deaths due to COVID-19, underscoring the benefits of COVID-19 vaccination. In the context of vaccine fatigue emerging as an important public health issue in Ireland and internationally, these findings can inform future COVID-19 booster vaccination programmes and communication about the reason for and importance of COVID-19 vaccination. Key messages • The COVID-19 vaccination programme in Ireland prevented illness and death in people aged ≥50-years. Vaccination therefore protected population health and the healthcare system. • These findings can be used to inform future COVID-19 vaccination policies, planning for winter, pandemic preparedness and communisation about the importance of ongoing COVID-19 vaccination programmes.

Growth differentiation factor-15 and 5-years cardiovascular risk in chest pain patients presenting to the emergency department: a multicenter cohort study

Abstract Background Growth differentiation factor 15 (GDF-15) has been explored as a prognostic biomarker in multiple disease entities, including ischemic heart disease and heart failure (HF), but its role as a prognostic marker in chest pain patients presenting to the emergency department (ED) is unknown. Purpose To investigate the association between GDF-15 and 5-year all-cause mortality, cardiovascular mortality, and major adverse cardiac events (MACE), and to evaluate its prognostic incremental value. Methods Patients presenting to the ED with acute chest pain were prospectively enrolled in an international multicenter diagnostic study. GDF-15 concentrations were measured in a blinded fashion upon ED presentation. Follow-ups were performed at 3 months, 1-, 2- and 5-years. MACE was defined as the composite of cardiovascular mortality, acute myocardial infarction, stroke, and HF rehospitalization. Associations between GDF-15 and each prognostic outcome were modeled using multivariable Cox proportional hazard regression fitting restricted cubic splines to continuous variables. The magnitude of the effect of each GDF-15 unit change on multivariable-adjusted models was assessed graphically using dose-response plots. To compute an HR for the dose-response plots we chose a GDF-15 value of 1200 pg/mL as a reference value as this has been chosen in previous literature1. For the restricted cubic splines three knots were used. The added prognostic value of GDF-15 was evaluated by the increase in the C-statistic between a base and an extended model and the fraction of new information (FNI) provided by GDF-15. Results A total of 4779 chest pain patients had baseline GDF-15 values available. The median age was 61 [48-74] and 33% were female. Higher GDF-15 levels were more strongly associated with heart failure, kidney dysfunction, older age, hypertension, diabetes and coronary artery disease. GDF-15 was independently associated with 5-years all-cause mortality, cardiovascular mortality and MACE (Figure). When adding GDF-15 to a rich-for-prior-information base model which included age, sex, cardiovascular risk factors, creatinine, cardiac troponin and NT-proBNP, GDF-15 provided relevant incremental prognostic discrimination for 5-years all-cause death and cardiovascular death. (Table). Conclusions In chest pain patients presenting to the emergency department, GDF-15 concentration on admission was associated with 5-years all-cause mortality, cardiovascular mortality, and MACE. In addition, it provided relevant incremental prognostic information when added on top of troponin and NT-proBNP, the two current prognostic gold standard biomarkers.FigureTable

Remote monitoring and prioritisation for patients awaiting transcatheter aortic valve implantation safely mitigates longer waiting times

Abstract Background • The UK National Health Service (NHS) faces an unprecedented backlog of over 400,000 patients awaiting critical cardiac procedures, incurring thousands of excess deaths (1). • Longer waiting times to transcatheter aortic valve implantation (TAVI) can increase rates of unplanned hospitalisation and death (2). • Remote patient monitoring (RPM) can improve cardiovascular clinical outcomes (3), but its effectiveness in detecting and managing TAVI waiting list deterioration is untested. Purpose 1. Measure the systemic increase in waiting time to TAVI 2. Determine if RPM and prioritisation: · Is acceptable to patients · Detects clinical deterioration · Mitigates the expected increase in adverse events associated with longer waiting times · Does not unfairly disadvantage patients who are not prioritised Methods • We performed an observational cohort study including all patients awaiting TAVI at one UK regional centre between 24th April and 15th November 2023. • Patients were supported to complete an online or telephone-based weekly symptom questionnaire. • Responses were monitored by non-specialist nurses staffing a 'hub', with rule-based escalation to the TAVI team, who could prioritise treatment (Figure 1). • A historical control cohort who did not receive RPM was identified, as sequential unselected patients on the TAVI waiting list in reverse order, from 24th April 2023 to 1st January 2023. This cohort was propensity score-matched to adjust for age, sex, ethnicity and comorbidities. • Waiting time was defined as the date difference between a patient being placed on the waiting list and TAVI completion. • We defined patient acceptability as >80% engagement with at least one symptom questionnaire. • Sensitivity was calculated as the percentage of escalations to the TAVI Consultant resulting in prioritisation. • Kaplan-Meier survival analysis was performed for the primary endpoint of adverse events, defined as emergency department presentation, unplanned hospitalisation or death. Results • The median waiting time to TAVI increased by one month (104 days versus 75 days, p<0.001). • There was 99% (200/202) engagement with RPM • Despite the increased waiting time, there was no significant difference in rate of adverse events between the propensity score-matched RPM and historical control groups (12.5% versus 13.7%, p=0.86) (Figure 2) • 87% (27/31) of escalations to the TAVI Consultant resulted in treatment prioritisation • There was a non-significant difference in median waiting time between prioritised and non-prioritised patients during the study period, but with no clinical consequence to the delay (97 versus 120 days, p=0.16). Conclusions • An RPM pathway can detect patient deterioration on TAVI waiting lists with high sensitivity • RPM-based prioritisation for patients awaiting TAVI can mitigate the increased risk of adverse events associated with longer waiting times, without unfairly disadvantaging non-prioritised patients.Figure 1.RPM pathwayFigure 2

The prevalence and impact of changes in the severity of secondary TR during hospitalization in acute heart failure

Abstract Background Secondary tricuspid regurgitation (TR) is a prevalent entity in patients hospitalized for acute heart failure (AHF), and concomitant moderate or severe TR at admission has been demonstrated to be associated with a poor prognosis. However, no study has described the trajectories of the severity of secondary TR during admission, and the prognostic implications of changes in the severity of secondary TR. Purpose This study aimed to investigate the dynamism of secondary TR observed during hospitalization due to worsening heart failure, and its prognostic impact in patients with AHF. Methods A post-hoc analysis of 1,061 consecutive patients hospitalized with AHF was performed, enrolled in the prospective, multicenter Registry Focused on Very Early Presentation and Treatment in Emergency Department of Acute Heart Failure (REALITY-AHF). Patients included in the study underwent a comprehensive echocardiographic examination within 24 hours of admission and again prior to discharge. Patients were divided into four groups based on the TR severity at admission and discharge: none to mild TR at both admission and discharge (no/no group), moderate to severe TR at admission but improved to none to mild TR at discharge (resolution group), none to mild TR at admission but moderate to severe TR at discharge (worsening group), and moderate to severe TR at both admission and discharge (persistent group). The primary endpoint was the composite of 1-year all-cause mortality and HF re-hospitalization after discharge. Results The no/no, resolution, worsening, and persistent groups included 479 (45%), 275 (26%), 85 (8%), and 222 patients (21%), respectively. The no/no group and the resolution group had significantly lower tricuspid regurgitant pressure gradients prior to discharge compared to the worsening and persistent groups (P<0.001). Also, right ventricular dysfunction evaluated at discharge, defined by tricuspid annular plane systolic excursion <17 mm, was more prevalent in the worsening (65.7%) and persistent groups (66.4%) compared to the no/no (43.7%) and resolution (53.2%) groups (P<0.001). Compared to the no/no group, the worsening and persistent groups, but not the resolution group, were associated with a higher incidence of the primary endpoint (Log-rank: P<0.001). This association remained significant in an adjusted Cox regression analysis, with the worsening group (hazard ratio: 1.48, 95% confidence interval [CI]: 1.01–2.20) and persistent group (hazard ratio: 1.35, 95% CI: 1.01–1.83) independently associated with the primary endpoint, but not the resolution group (hazard ratio: 1.10, 95% CI: 0.81–1.49). Conclusions In patients hospitalized for AHF, the severity of secondary TR is dynamic, and changes in the severity of TR are significantly associated with prognosis. Our study results underscore the importance of repetitive evaluation of TR in hospitalized patients with AHF.

Can a chest pain virtual ward be used to safely manage patients with low-risk acute coronary syndrome?

Abstract Background Acute coronary syndrome (ACS) accounts for approximately 2-6% of emergency department (ED) presentations and contributes at least 20% of the overall acute hospital admissions(1-3). Patients presenting with low-risk ACS may be suitable for remote monitoring(4) while awaiting angiogram in chest pain virtual ward(CPVW) thereby improving patient flow and resource utilisation. Purpose We aimed to assess outcomes for patients with low-risk ACS admitted in a district general hospital with a view to establish an onboarding pathway for CPVW whilst ensuring a safe monitoring without effecting the readmission rate or all-cause mortality. Methods We retrospectively analysed the Myocardial Ischaemia National Audit Project (MINAP) registry of from March 2022 to April 2023 for patients who presented to ED with a diagnosis of confirmed ACS. Patients were stratified into low-risk (GRACE score <140, HEART score <4, non-dynamic ECG, non-dynamic troponin, without ongoing chest pain), all other patients were deemed intermediate-to-high-risk ACS. Baseline demographics, the total length of acute admission days, waiting time before and after coronary investigation ,adverse events (escalation of therapy, death)whilst awaiting for invasive inpatient angiogram were calculated. The primary endpoint was 30-day readmission and all-cause mortality. Results 1077 patients were coded as ACS diagnosis in ED. 561(52.1%) had a confirmed diagnosis of ACS. Data to allow stratification was available for 538 patients, included in final analysis. 377(70.1%) were male with a mean age of 66.8 ± SD 13.1 years. A significant number of patients had other comorbidities, including hypertension (66.1%), diabetes (45.3%), hyperlipidaemia (51.3%), and previous history of IHD (46.5%). Total number of patients stratified into low-risk ACS was 55(10.2%), intermediate-to-high-risk group contained 483(89.8%) patients. The median total-length-of-stay (LOS) for low-risk ACS patients was 4 days(IQR 2-7), waiting time to have an inpatient angiogram was 3 days(IQR 0-5), and discharge time post-angiogram was 1 day(IQR 0-2). 4 patients(7.3%) in low-risk cohort required CCU admission for GTN infusion due to ongoing chest pain, among them 3 patients(5.5%) had abnormal coronary angiogram. 5 patients(9.1%) in low-risk cohort were readmitted due to chest pain post-angiogram and no patients had 30-days or 1-year all-cause mortality. The result depicts 51 patients from low-risk cohort would have been eligible for CPVW reducing the LOS from median 4 days to 1-2 days, this is a saving of 102-153 acute bed days per year. Assuming the costing of a bed day is £320 this equates to £32,640 - £48,960 cost saving without any adverse outcomes. Conclusion Our data suggests that there is a large cost saving with minimal risk in managing patients with low-risk ACS via a CPVW. This pathway of management is likely to have benefit in patient flow and resource utilisation in our district general hospital trust.Comparison of different ACS cohortsCPVW flow-diagram

Chronic Coronary Syndromes with/without obstructive coronary arteries: are there differences in ongoing chest pain?

Abstract Background Stable coronary artery disease (CAD) is the archetype chronic coronary syndrome, clinically manifesting as angina with obstructive CAD on angiography and managed via evidence-based guidelines. In contrast, patients with Angina with Non-Obstructive Coronary Arteries (ANOCA) are often diagnosed with ‘non-specific chest pain’ and not appropriately managed. Purpose To compare the Seattle Angina Questionnaire (SAQ) responses and 3-year rates of chest pain hospital presentations in patients with ANOCA compared to Stable CAD. Methods Consecutive angina patients undergoing elective coronary angiography enrolled in the CADOSA (Coronary Angiogram Database of South Australia) Registry between 2012-18 were included. Consenting patients participated in a longitudinal health status assessment utilising the SAQ. In-hospital clinical data was extracted from CADOSA and mortality and hospitalisation data over 12-months was extracted via administrative records. Results Of 6,372 consecutive patients undergoing elective angiography for the investigation of chest pain 2,287 had ANOCA and 4,085 Stable CAD. ANOCA patients were younger (61±11 vs 66±11, p<0.05) and more often female (59% vs 27%, p<0.05) compared to Stable CAD. The SAQ health status assessment was completed at baseline, 1 and 12-months for 377 patients (ANOCA n=156, Stable CAD n=221). At 12-month follow-up, there were no differences in SAQ scores amongst all domains (physical limitation- 92±16 vs 92±15, angina stability- 64±25 vs 62 ±24, angina frequency- 91±17 vs 92±16, treatment satisfaction- 94±13 vs 94±13 and quality of life- 78±22 vs 81±21) between ANOCA and Stable CAD, all p>0.05. However, in the 12-month follow-up, ANOCA patients were less likely to have a chest pain hospital emergency department presentation (10% vs 15%, p<0.001) or admission (6% vs 12%, p<0.005) compared to the Stable CAD cohort. Conclusion Although patient-reported outcomes were identical between Stable CAD and ANOCA patients, the latter were less likely to present to emergency department or be admitted to hospital than their Stable CAD counterparts, reflecting the clinical nihilism encountered in the ANOCA patient journey.

The relationship of clinical presentation, d-dimer levels and previous SARS-CoV-2 positivity in outpatients with suspected pulmonary embolism

Abstract Introduction Elevated D-dimer levels can be detected in patients with pulmonary embolism (PE), but also in patients with the disease caused by the novel coronavirus (COVID-19). Aims To investigate relationship between clinical presentation, D-dimer levels and previous SARS-CoV-2 positivity in outpatients with suspected PE. Material and methods This retrospective study included 609 consecutive outpatients (mean age 68±15 years, 50% female) who underwent computed tomography pulmonary angiography for suspected PE from 2021 to 2023. By reviewing electronic databases, clinical and laboratory data were collected, as well data on previously documented SARS-CoV-2 infection. Results PE was confirmed in 130 (21%) patients who had higher D-dimer values than patients without PE (p<0.001). Patients with previous COVID-19 had significantly higher D-dimer values compared to those without prior COVID-19, but only during the first 8 months from infection to pulmonary angiography (Figure, upper panel). Clinical probability of PE, as indicated by Geneva score [odds ratio (OR) 2.36, 95% confidence interval (CI) 1.55 – 3.58)], and age-adjusted D-dimer (OR 4.52, 95%CI 1.58 – 12.90) were independently associated with PE, while previous COVID-19 was not. Main clinical reasons for emergency department presentation are shown in Figure (bottom panel). In 45/609 (7.4%) patients evaluated primarily for elevated D-dimer, the prevalence of COVID-19 in the previous 6 months was higher in those with PE compared to those without PE (100% vs. 49%, p=0.019). Conclusion Within 8 months of infection, patients with a history of COVID-19 had higher D-dimer levels than those without COVID-19. Age-adjusted D-dimer and standard clinical probability scores retained their predictive power in outpatients with suspected PE, regardless of COVID-19 history.

Early prediction of sepsis in emergency department patients using various methods and scoring systems.

Early recognition of sepsis, a common life-threatening condition in intensive care units (ICUs), is beneficial for improving patient outcomes. However, most sepsis prediction models were trained and assessed in the ICU, which might not apply to emergency department (ED) settings. To establish an early predictive model based on basic but essential information collected upon ED presentation for the follow-up diagnosis of sepsis observed in the ICU. This study developed and validated a reliable model of sepsis prediction among ED patients by comparing 10 different methods based on retrospective electronic health record data from the MIMIC-IV database. In-ICU sepsis was identified as the primary outcome. The potential predictors encompassed baseline demographics, vital signs, pain scale, chief complaints and Emergency Severity Index (ESI). 80% and 20% of the total of 425 737 ED visit records were randomly selected for the train set and the test set for model development and validation, respectively. Among the methods evaluated, XGBoost demonstrated an optimal predictive performance with an area under the curve (AUC) of 0.90 (95% CI: 0.90-0.91). Logistic regression exhibited a comparable predictive ability to XGBoost, with an AUC of 0.89 (95% CI: 0.89-0.90), along with a sensitivity and specificity of 85% (95% CI: 0.83-0.86) and 78% (95% CI: 0.77-0.80), respectively. Neither of the five commonly used severity scoring systems demonstrated satisfactory performance for sepsis prediction. The predictive ability of using ESI as the sole predictor (AUC: 0.79, 95% CI: 0.78-0.80) was also inferior to the model integrating ESI and other basic information. The use of ESI combined with basic clinical information upon ED presentation accurately predicted sepsis among ED patients, strengthening its application in ED. The proposed model may assist nurses in risk stratification management and prioritize interventions for potential sepsis patients, even in low-resource settings.

Pharmacotherapy of acute ST-elevation myocardial infarction and the pharmacist's role, part 2: Complications, postrevascularization care, and quality improvement.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Key pharmacotherapeutic modalities and considerations for the patient with ST-elevation myocardial infarction (STEMI) across the later phases of inpatient care are reviewed. Published descriptions and validation of clinical pharmacist roles specific to the acute management of STEMI are limited. This high-risk period from presentation through revascularization, stabilization, and hospital discharge involves complex pharmacotherapeutic decision points, many operational medication needs, and multiple layers of quality oversight. A companion article reviewed STEMI pharmacotherapy from emergency department presentation through revascularization. Herein we complete the pharmacotherapy review for the STEMI patient across the inpatient phases of care, including the management of peri-infarction complications with vasoactive and antiarrhythmic agents, considerations for postrevascularization antithrombotics, and assessments of supportive therapies and secondary prevention. Key guideline recommendations and literature developments are summarized from the clinical pharmacist's perspective alongside suggested pharmacist roles and responsibilities. Considerations for successful hospital discharge after STEMI and pharmacist involvement in associated institutional quality improvement efforts are also provided. We aim to support inpatient pharmacy departments in advancing clinical services for this critical patient population and call for further research delineating pharmacists' impact on patient and institutional STEMI outcomes.

The Epidemiology of Pediatric Shoulder Dislocations in the United States.

Shoulder dislocations are the most common of all major joint dislocations and are a frequent cause of emergency department (ED) presentations. While the epidemiology of shoulder dislocations has been characterized in adults, it has not yet been done for children in the United States. The primary goal of this study was to calculate the incidence rate of pediatric shoulder dislocations in the United States. Secondary goals were to characterize the demographic information of children with shoulder dislocations as well as trends in management. The US Collaborative Network in TriNetX, a network of clinical data repositories containing patient data from over 100,000,000 unique individuals within the United States, was queried for patients younger than 18 years old diagnosed with shoulder dislocation from 2014 to 2024 using ICD codes. The demographic details were then extracted from the data set, and treatment approaches were determined by CPT coding. Over the past 10 years, there were 16,460 pediatric and adolescent patients diagnosed with a first-time shoulder dislocation in either an ED or ambulatory clinic. The overall incidence rate was 60.31 per 100,000 patients, while the incidence rate was 116.61 per 100,000 patients presenting in the ED and 33.95 per 100,000 patients presenting in ambulatory clinics that were under the age of 18 years. Most patients were male (73%), White (59%), and came from the southeastern region of the United States (36%). The most common treatment was a closed reduction (25%), followed by arthroscopic surgery (17%). The number of annual shoulder dislocations has increased over the past decade without an increase in the number of patients undergoing surgical treatment. There remains a high incidence rate of shoulder dislocations in the pediatric population of the United States. Despite evidence that early surgical treatment of shoulder dislocations offers improved outcomes, nonoperative treatment continues to be the most common modality without any increase in the percentage of patients undergoing surgical treatment. Level IV-descriptive epidemiological analysis.

11 Is emergency department transfer always required following anaphylaxis and epinephrine use?

Abstract Background Patients known for anaphylaxis are advised to always carry 2 epinephrine auto-injectors (EAI) with them. With epinephrine being the first-line treatment for anaphylaxis, current guidelines recommend prompt EAI administration, followed by observation in the emergency department (ED) for 4 hours. Data supporting transfer to the ED in all cases after epinephrine are sparse. Recent North American allergy guidelines no longer suggest that ED presentation after EAI use is required for all cases of anaphylaxis. Objectives We aimed to describe the need for additional ED treatment in children known for food-triggered anaphylaxis who received at least 1 EAI pre-hospital. Design/Methods Data on children under 18 years with food-induced anaphylaxis who received at least one dose of pre-hospital epinephrine was collected from the Cross-Canada Anaphylaxis REgistry (C-CARE) from seven hospitals. A standardized questionnaire obtained information on symptoms, allergens, comorbidities, and pre-hospital and in-hospital management. Multivariable logistic regression was performed to identify factors associated with ED management, among children who received 1, 2 or 3 or more doses of epinephrine pre-hospital. Results From 2011 to 2023, 1054 children with known food-triggered anaphylaxis and who used one or more EAIs pre-hospital were enrolled in C-CARE. The mean age at reaction was 8.2 (standard deviation [SD] 5.3) years, 648 (60.8%) were male and 82 (7.8%) of reactions were severe (defined as loss of bowel control, cyanosis, respiratory arrest, hypotension and/or circulatory collapse, dysrhythmia, severe bradycardia and/or cardiac arrest, confusion, and loss of consciousness). Primary triggers included peanuts (n=280; 26.6%) followed by tree nuts (n=173; 16.4%). 193 patients (18.3%) had known asthma and 201 received additional dose(s) of epinephrine in the ED, the majority of whom (177, 88.1%) received one dose. Only 2.9% of patients required admission. Among all patients, reactions to egg were less likely to require additional epinephrine (aOR 0.90; 95% CI 0.83, 0.99), and more likely with severe reactions (aOR 1.24; 95% CI 1.14-1.35). Among patients who received only one EAI pre-hospital, severe reactions (adjusted odds ratio [aOR] 1.19; 95% confidence interval [CI] 1.08-1.31) and reactions to tree nuts (aOR 1.12; 95% CI 1.04-1.20) were associated with increased odds of an additional dose of epinephrine in hospital. Conclusion One-fifth of anaphylaxis cases that used EAI require an additional dose of epinephrine in ED. Children with severe reactions and reactions to tree nuts are more likely to require additional doses; these cases should be considered for ED transfer and treatment following pre-hospital EAI use.