Spanish Emergency Departments Research Articles

Characteristics and outcomes of older adults presented to Spanish emergency departments after a fall.

To study patient profile, fall-related characteristics and immediate outcomes according to age and to determine the effect of age in the outcomes among older patients presenting to ED after a fall. Cross-sectional analysis of the FALL-ER registry that included patients aged ≥ 65years old that presented to five Spanish EDs after a fall. Patients were classified into three age categories, and demographic, comorbidity, chronic medication, fall-related characteristics, health care resources and immediate outcomes data were analysed. We included 1610 patients, 541 (28%) aged 65-74, 647 (40.2%) aged 74-84 and 512 (31.8%) aged ≥ 85years old. Indoor falls, with no witnesses, at night and due to non-identified causes were significantly more likely among the oldest old. Medications related to risk of falling and antithrombotic therapy significantly increased with age category. Physical, functional and psychological consequences and healthcare resource use increased significantly with age group. Age was independently associated with severe injury (adjusted OR 1.02; IC 95% 1.01-1.04), fear of falling (adjusted OR 1.02; IC 95% 1.01-1.04) and acute functional impairment (adjusted OR 1.02; IC 95% 1.00-1.04). Indoor falls, with no witnesses, at night and due to non-identified causes were significantly more likely among the oldest old. The probability of presenting with severe injury, fear of falling and acute functional impairment increases with age.

Preparation of sedation–analgesia procedures in Spanish paediatric emergency departments: A descriptive study

Abstract Introduction The objective of this study was to describe the current practice regarding the preparation of the sedation–analgesia (SA) procedures performed in the paediatric emergency centres in Spain. Material and methods A multicentre, observational and prospective analytical study was carried out on the SA procedures that were performed on children under 18 years old in 18 paediatric emergency departments between February 2015 and January 2016. Results A total of 658 SA procedures were registered in 18 hospitals of Spain, most of them to children older than 24 months. The type of the procedure was: simple analgesia in 57 (8.6%), sedation in 44 (6.7%), SA for a not very painful procedure in 275 (41.8%), and SA for a very painful procedure in 282 (42.9%). Informed consent was requested in 98.6% of the cases. The written form was more frequently preferred in the group of patients that received SA for a very painful procedure (76.6%) in comparison to a painful procedure or to simple analgesia (62.9% and 54.4%, respectively, p Conclusion The majority of the SA procedures analysed in this study have been carried out correctly and prepared in accordance with the current guidelines.

Long-term prognostic value of functional status and delirium in emergency patients with decompensated heart failure.

Heart failure (HF) is prevalent in older adults and is associated with impaired physical and cognitive function. However, these factors are rarely included in studies about long-term prognosis of HF. The aim of the study was to determine whether functional status and delirium at admission (prevalent delirium) would predict 1-year mortality in patients with decompensated HF (DHF). We performed a prospective observational study in adult patients with DHF attended at two Spanish Emergency Departments (ED) in the context of the Epidemiology Acute HF Emergency project. Functional status was assessed by Barthel Index (BI) and prevalent delirium by the Brief Confusion Assessment Method within the first 24h of admission. We used Kaplan-Meier survival curves for delirium and multivariable Cox regression models to estimated hazard ratio (HR) and survival probability for death while adjusting for six potential confounders. We enrolled 239 patients (age 81.7 ± 9.4years, women 61.1%). BI < 60 was 23.4 and 14.6% of patients had delirium. Age (HR 1.046 CI 95% 1.014-1.080, p < 0.004) and BI (HR 0.979 CI 95% 0.972-0.979, p < 0.001) were independently associated with 1-year mortality. In patients without severe functional dependence at admission, delirium (HR 3.579 CI 95% 1.730-7.403, p < 0.001) and age (HR 1.051 CI 95% 1.014-1.090, p = 0.007) independently predicted long-term mortality. Age and functional dependence are strong predictors of long-term mortality in patients with DHF. In patients without severe functional dependence, delirium-a potentially modifiable risk factor-identified a subgroup of patients with higher mortality. Evaluating functional status and delirium in ED could improve decision-making and future care of patients with DHF.

Occult bacteremia etiology following the introduction of 13-valent pneumococcal conjugate vaccine: a multicenter study in Spain.

Little is known about occult bacteremia (OB) in Spain following the introduction of the 13-valent pneumococcal conjugated vaccine (PCV13). Our aim was to describe the microbiologic characteristics and management of OB among children aged 3-36months in Spain in the era of PCV13. Data were obtained from a multicenter registry of positive blood cultures collected at 22 Spanish emergency departments (ED). Positive blood cultures performed on patients aged 3-36months from 2011 to 2015 were retrospectively identified. Immunocompetent infants with a final diagnosis of OB were included. Non-well-appearing patients and patients with fever > 72h were excluded. We analyzed 67 cases (median age 12.5months [IQR 8.7-19.4]). Thirty-seven (54.4%) had received ≥ 1 dose of PCV. Overall, 47 (70.1%) were initially managed as outpatients (38.3% of them with antibiotic treatment). Phone contact was established with 43 (91.5%) of them after receiving the blood culture result and 11 (23.4%) were hospitalized with parenteral antibiotic. All patients did well. Streptococcus pneumoniae was isolated in 79.1% of the patients (42.2% of the isolated serotypes were included in the PCV13). S. pneumoniae remains the first cause of OB in patients attended in the ED, mainly with non-PCV13 serotypes. Most of the patients with OB were initially managed as outpatients with no adverse outcome.

Time trends in characteristics, clinical course, and outcomes of 13,791 patients with acute heart failure.

To analyse time trends in patient characteristics, clinical course, hospitalisation rate, and outcomes in acute heart failure along a 10-year period (2007-2016). The EAHFE registry has prospectively collected 13,971 consecutive AHF patients diagnosed in 41 Spanish emergency departments (EDs) at five different time points (2007/2009/2011/2014/2016). Eighty patient-related variables and outcomes were described and statistically significant changes along time were evaluated. We also compared our data with large ED- and hospital-based registries. Compared to other large registries, our patients were older [80 (10)years], more frequently women (55.5%), and had a higher prevalence of hypertension (83.5%) and a lower prevalence of ischaemic cardiomyopathy (29.4%). De novo AHF was observed in 39.6%. 63.6% showed some degree of functional dependence and 56.1% had preserved left ventricular ejection fraction (LVEF). 56.8% of the patients arrived at the ED by ambulance, 4.5% arrived hypotensive, and 21.3% hypertensive. Direct discharge from the ED home was seen in 24.9%, and internal medicine (32.5%) and cardiology (15.8%) were the main hospital destinations. Triggers for decompensation were identified in 75.4%, the most being frequent infection (35.2%) and rapid atrial fibrillation (14.7%). The AHF phenotypes were: warm/wet 82.0%, warm/dry 6.2%, cold/wet 11.1%, and cold/dry 0.7%. The length of hospitalisation was 9.3 (8.6)days, and in-hospital, 30-day, and 1-year all-cause mortality were 7.8, 10.2 and 30.3%, respectively; and 30-day re-hospitalisation and ED revisit due to AHF were 16.9 and 24.8%, respectively. Thirty-nine of the eighty characteristics studied showed significant changes over time, while all outcomes remained unchanged along the 10-year period. The EAHFE Registry is the first European ED-based registry describing the characteristics, clinical course, and outcomes of a cohort resembling the universe of patients with AHF. Significant changes were observed over time in some aspects of AHF characteristics and management, but not in outcomes.

Short-term outcomes of heart failure patients with reduced and preserved ejection fraction after acute decompensation according to the final destination after emergency department care

To compare short-term outcomes after an episode of acute heart failure (AHF) in patients with reduced and preserved ejection fractions (HFrEF, < 40%; and HFpEF, > 49%; respectively) according to their destinations after emergency department (ED) care. This secondary analysis of the EAHFE Registry (consecutive AHF patients diagnosed in 41 Spanish EDs) investigated 30-day all-cause mortality, in-hospital all-cause mortality, prolonged hospitalisation (> 7 days), and 30-day post-discharge ED revisit due to AHF, all-cause death, and combined endpoint (ED revisit/death) in 5829 patients with echocardiographically documented HFrEF and HfpEF (HFrEF/HFpEF: 1,442/4,387). Adjusted ratios were calculated for patients admitted to internal medicine (IM), short stay unit (SSU), and discharged from the ED without hospitalisation (DEDWH) and compared with those admitted to cardiology. For HFrEF, the only significant differences were lower in-hospital mortality (OR = 0.26; 95% CI 0.08-0.81; p = 0.021) and prolonged hospitalisation (OR = 0.07; 95% CI 0.04-0.13; p < 0.001) related to SSU admission. For HFpEF, IM admission had a higher post-discharge 30-day mortality (HR = 1.85; 95% CI 1.05-3.25; p = 0.033) and combined endpoint (HR = 1.24; 95% CI 1.01-1.64; p = 0.044); SSU admission had a lower in-hospital mortality (OR = 0.43; 95% CI 0.23-0.80; p = 0.008) and prolonged hospitalisation (OR = 0.17; 95% CI 0.13-0.23; p < 0.001) but a higher post-discharge 30-day combined endpoint (HR = 1.29; 95% CI 1.01-1.64; p = 0.041); and DEDDWH had a lower 30-day mortality (HR = 0.46; 95% CI 0.28-0.75; p = 0.002) but higher post-discharge ED revisit (HR = 1.62; 95% CI 1.31-2.00; p < 0.001). While HFrEF patients have similar short-term outcomes irrespective of the destination after ED care for an AHF episode, HFpEF patients present worse short-term outcomes when managed by non-cardiology departments, despite adjustment for different clinical patient profiles. Reasons for this heterogeneous specialty-related performance should be investigated.

Effects on short term outcome of non-invasive ventilation use in the emergency department to treat patients with acute heart failure: A propensity score-based analysis of the EAHFE Registry

ObjectiveTo assess the effects of non-invasive ventilation (NIV) in emergency department (ED) patients with acute heart failure (AHF) on short term outcomes. MethodsPatients from the EAHFE Registry (a multicenter, observational, multipurpose, cohort-designed database including consecutive AHF patients in 41 Spanish EDs) were grouped based on NIV treatment (NIV+ and NIV–groups). Using propensity score (PS) methodology, we identified two subgroups of patients matched by 38 covariates and compared regarding 30-day survival (primary outcome). Interaction was investigated for age, sex, ischemic cardiomyopathy, chronic obstructive pulmonary disease, AHF precipitated by an acute coronary syndrome (ACS), AHF classified as hypertensive or acute pulmonary edema (APE), and systolic blood pressure (SBP). Secondary outcomes were intensive care unit (ICU) admission; mechanical ventilation; in-hospital, 3-day and 7-day mortality; and prolonged hospitalization (>7 days). ResultsOf 11,152 patients from the EAHFE (age (SD): 80 (10) years; 55.5% women), 718 (6.4%) were NIV+ and had a higher 30-day mortality (HR = 2.229; 95%CI = 1.861–2.670) (p < 0.001). PS matching provided 2 groups of 490 patients each with no significant differences in 30-day mortality (HR = 1.239; 95%CI = 0.905–1.696) (p = 0.182). Interaction analysis suggested a worse effect of NIV on elderly patients (>85 years, p < 0.001), AHF associated with ACS (p = 0.045), and SBP < 100 mmHg (p < 0.001). No significant differences were found in the secondary endpoints except for more prolonged hospitalizations in NIV+ patients (OR = 1.445; 95%CI = 1.122–1.862) (p = 0.004). ConclusionThe use of NIV to treat AHF in ED is not associated with improved mortality outcomes and should be cautious in old patients and those with ACS and hypotension.

Asimetrías en el tratamiento hospitalario del ictus isquémico en fase aguda

ObjectiveTo analyze the degree of implementation of the protocolized care for acute stroke in the Spanish emergency departments and to discuss the territorial differences in the treatment of stroke. Material and methodsMulticenter national survey conducted to evaluate the current treatment of ischemic stroke in emergency departments. The main variables analyzed were focused at evaluating the participation of ERs in the performance of thrombolysis, interventional treatment and destination of patients with stroke. Results42 emergency services participated. 90.5% have stroke protocol. In 52.4% is identified an emergency physician referent in cerebrovascular pathology. In 2016 2090 thrombolysis were performed, we observe a great variability in the number of treatments per hospital [0-222]. 11.9% were admitted in the Observation area. Only one-third of the hospitals currently treat stroke with thrombectomy. 31% have a telemedicine service available. ConclusionsUrgencies plays a fundamental role in the chain of care of stroke treatment. There is a worrying variability between centers in the management of the stroke.

Effects of the intensity of prehospital treatment on short-term outcomes in patients with acute heart failure: the SEMICA-2 study.

Little is known about treatments provided by advanced life support (ALS) ambulance teams to patients with acute heart failure (AHF) during the prehospital phase, and their influence on short-term outcome. We evaluated the effect of prehospital care in consecutive patients diagnosed with AHF in Spanish emergency departments (EDs). We selected patients from the EAHFE registry arriving at the ED by ALS ambulances with available follow-up data. We recorded specific prehospital ALS treatments (supplemental oxygen, diuretics, nitroglycerin, non-invasive ventilation) and patients were grouped according to whether they received low- (LIPHT; 0/1 treatments) or high-intensity prehospital therapy (HIPHT; >1 treatment) for AHF. We also recorded 46 covariates. The primary endpoint was all-cause 7-day mortality, and secondary endpoints were prolonged hospitalisation (> 10days) and in-hospital and 30-day mortality. Unadjusted and adjusted odds ratios were calculated to compare the groups. We included 1493 patients [mean age 80.7 (10) years; women 54.8%]. Prehospital treatment included supplemental oxygen in 71.2%, diuretics in 27.9%, nitroglycerin in 13.5%, and non-invasive ventilation in 5.3%. The LIPHT group included 1041 patients (70.0%) with an unadjusted OR for 7-day mortality of 1.770 (95% CI 1.115-2.811; p = 0.016), and 1.939 (95% CI 1.114-3.287, p = 0.014) after adjustment for 16 discordant covariables. The adjusted ORs for all secondary endpoints were always > 1 in the LIPHT group, but none reached statistical significance. Patients finally diagnosed with AHF at then ED that have received LIPHT by the ALS ambulance teams have a poorer short-term outcome, especially during the first 7days.

Adherence to Mediterranean Diet and All-Cause Mortality After an Episode of Acute Heart Failure: Results of the MEDIT-AHF Study

ObjectivesThe authors sought to evaluate clinical outcomes of patients after an episode of acute heart failure (AHF) according to their adherence to the Mediterranean diet (MedDiet). BackgroundIt has been proved that MedDiet is a useful tool in primary prevention of cardiovascular diseases. However, it is unknown whether adherence to MedDiet is associated with better outcomes in patients who have already experienced an episode of AHF. MethodsWe designed a prospective study that included consecutive patients diagnosed with AHF in 7 Spanish emergency departments (EDs). Patients were included if they or their relatives were able to answer a 14-point score of adherence to the MedDiet, which classified patients as adherents (≥9 points) or nonadherents (≤8 points). The primary endpoint was all-cause mortality at the end of follow-up, and secondary endpoints were 1-year ED revisit without hospitalization, rehospitalization, death, and a combined endpoint of all these variables for patients discharged after the index episode. Unadjusted and adjusted hazard ratios (HRs) were calculated. ResultsWe included 991 patients (mean age of 80 ± 10 years, 57.8% women); 523 (52.9%) of whom were adherent to the MedDiet. After a mean follow-up period of 2.1 ± 1.3 years, no differences were observed in survival between adherent and nonadherent patients (HR of adherents [HRadh] = 0.86; 95% confidence interval [CI]: 0.73 to 1.02). The 1-year cumulative ED revisit for the whole cohort was 24.5% (HRadh = 1.10; 95% CI: 0.84 to 1.42), hospitalization 43.7% (HRadh = 0.74; 95% CI: 0.61 to 0.90), death 22.7% (HRadh = 1.05; 95% CI: 0.8 to 1.38), and combined endpoint 66.8% (HRadh = 0.89; 95% CI: 0.76 to 1.04). Adjustment by age, hypertension, peripheral arterial disease, previous episodes of AHF, treatment with statins, air-room pulsioxymetry, and need for ventilation support in the ED rendered similar results, with no statistically significant differences in mortality (HRadh = 0.94; 95% CI: 0.80 to 1.13) and persistence of lower 1-year hospitalization for adherents (HRadh = 0.76; 95% CI: 0.62 to 0.93). ConclusionsAdherence to the MedDiet did not influence long-term mortality after an episode of AHF, but it was associated with decreased rates of rehospitalization during the next year.

Risk profile, management, and outcomes of patients with venous thromboembolism attended in Spanish Emergency Departments: The ESPHERIA registry.

The objective of this study was to determine the clinical profile of and diagnostic and therapeutic approach to patients with venous thromboembolism (VTE) in Spanish Emergency Departments (EDs). Risk factors, adherence to clinical practice guidelines, and outcomes were also evaluated.Patients with VTE diagnosed in 53 Spanish EDs were prospectively and consecutively included. Demographic data, comorbidities, risk factors for VTE, index event characteristics, hemorrhagic risk, and mortality were evaluated. Adherence to clinical practice guidelines was assessed based on clinical probability scales, requests for determination of D-dimer, use of anticoagulant treatment before confirmation of diagnosis, and assessment of bleeding and prognostic risk. Recurrence, bleeding, and death during admission and at 30, 90, and 180 days after diagnosis in the EDs were recorded.From 549,840 ED visits made over a mean period of 40 days, 905 patients were diagnosed with VTE (incidence 1.6 diagnoses per 1000 visits). The final analysis included 801 patients, of whom 49.8% had pulmonary embolism. The most frequent risk factors for VTE were age (≥70 years), obesity, and new immobility. Clinical probability, prognosis, and bleeding risk scales were recorded in only 7.6%, 7.5%, and 1% of cases, respectively. D-dimer was determined in 87.2% of patients with a high clinical probability of VTE, and treatment was initiated before confirmation in only 35.9% of these patients. In patients with pulmonary embolism, 31.3% had a low risk of VTE. Overall, 98.7% of patients with pulmonary embolism and 50.2% of patients with deep venous thrombosis were admitted. During follow-up, total bleeding was more frequent than recurrences: the rates of any bleeding event were 4.4%, 3.9%, 5.3%, and 3.5% at admission and at 30 and 90, and 180 days, respectively; the rates of VTE recurrence were 2.3%, 1.3%, 1.7%, and 0.6%, respectively. Mortality rates were 3.4%, 3.1%, 4.1%, and 2.6% during hospitalization and at 30, 90, and 180 days, respectively.VTE had a substantial impact on Spanish EDs. The clinical presentation and risk profile for the development of VTE in patients diagnosed in the EDs was similar to that recorded in previous studies. During follow-up, bleeding (overall) was more frequent than recurrences. Adherence to clinical practice guidelines could improve significantly.

Mortality in Spanish pediatric emergency departments: a 5-year multicenter survey.

Analysis of the causes of death in children in the pediatric emergency department (ED) may aid the development of management and prevention practices. To identify the causes of death in Spanish pediatric EDs and to analyze the management of these children in the prehospital and hospital settings. This was a retrospective descriptive multicenter survey including all patients whose death was certified in 18 Spanish pediatric EDs between 2008 and 2013. During the study period, 3 542 426 episodes were registered in the EDs. Of these, 54 patients died (mortality rate: 1.5/100 000 visits). Data of 53 patients are analyzed (male 36, 67%, 31 younger than 2 years old and 43.3% nonpreviously healthy children). The main causes of death were related to their previous illnesses (24.5%), sudden infant death syndrome (20.7%), and traumatism (18.8%).Prehospital cardiopulmonary resuscitation (CPR) was performed in 31 patients, and exclusively by health workers in 19 patients. In 35 patients, the parents witnessed the event and seven began CPR.Thirty children were transferred to the pediatric EDs by medical transport (56.6%) and all of them received prehospital CPR (vs. one patient out of 23 arrived in a nonmedical transportation).In 37 patients, CPR was performed in the pediatric EDs. Overall, CPR lasted 40±23 min (range, 10-120 min). CPR was not performed in seven patients at any time. The main causes of death in Spanish pediatric EDs are related to previous illnesses, sudden infant death syndrome, and nonintentional lesions. Several actions have to be considered to improve the quality of care of these children in prehospital and emergency settings.

Predicting 30-Day Mortality for Patients With Acute Heart Failure in the Emergency Department: A Cohort Study.

Physicians in the emergency department (ED) need additional tools to stratify patients with acute heart failure (AHF) according to risk. To predict mortality using data that are readily available at ED admission. Prospective cohort study. 34 Spanish EDs. The derivation cohort included 4867 consecutive ED patients admitted during 2009 to 2011. The validation cohort comprised 3229 patients admitted in 2014. 88 candidate risk factors and 30-day mortality. Thirteen independent risk factors were identified in the derivation cohort and were combined into an overall score, the MEESSI-AHF (Multiple Estimation of risk based on the Emergency department Spanish Score In patients with AHF) score. This score predicted 30-day mortality with excellent discrimination (c-statistic, 0.836) and calibration (Hosmer-Lemeshow P = 0.99) and provided a steep gradient in 30-day mortality across risk groups (<2% for patients in the 2 lowest risk quintiles and 45% in the highest risk decile). These characteristics were confirmed in the validation cohort (c-statistic, 0.828). Multiple sensitivity analyses did not find important amounts of confounding or bias. The study was confined to a single country. Participating EDs were not selected randomly. Many patients had missing data. Measurement of some risk factors was subjective. This tool has excellent discrimination and calibration and was validated in a different cohort from the one that was used to develop it. Physicians can consider using this tool to inform clinical decisions as further studies are done to determine whether the tool enhances physician decision making and improves patient outcomes. Instituto de Salud Carlos III, Spanish Ministry of Health; Fundació La Marató de TV3; and Catalonia Govern.

OBESICA study: relationship between BMI and acute heart failure outcome.

The objective of this study was to investigate the relationship between BMI and outcome of acute heart failure (AHF). We carried out a secondary analysis of the Epidemiology of Acute Heart Failure in Emergency department Registry (prospective, multicenter registry following a cohort of AHF patients from 34 Spanish emergency departments). Follow-up was at 3 months and 1 year after enrolment over the telephone and included medical history review. We analyzed revisits to the emergency department and death in relation to BMI. Significant differences were analyzed using proportional risk models including data on demographic variables, basal status, the acute episode, and patient outcome. We included 1562 patients: low weight 1.3%, normal weight 26.1%, overweight 45.3%, obese 24.3%, and morbidly obese 3.1%. BMI was inversely associated with mortality (P<0.001) but not with revisit (P=0.70). Compared with patients with normal weight, the proportional risk of death among patients with low weight was increased [hazard ratio (HR) 1.75, 95% confidence interval (CI) 0.95-3.23], being reduced in overweight, obese and morbidly obese patients (HR 0.72, 95% CI 0.59-0.89; HR 0.75, 95% CI 0.58-0.96; and HR 0.42, 95% CI 0.20-0.85, respectively). These differences disappeared after adjusting the model for confounding factors and other predictive variables of mortality. BMI seems to be related to AHF and death, although this relationship disappeared on considering other prognostic factors and confounding variables. This finding limits the use of BMI by emergency physicians when estimating the risk of emergency department reconsultation or death in AHF patients.

Emergency physician sex and emergency department resource use.

We investigated whether there are differences in emergency department (ED) patient management associated with emergency physician (EP) sex, specifically in terms of ordering investigations and hospital admissions. We included all EPs working as consultants for at least 24 consecutive months at a Spanish ED during an 8-year period. Every annual period was considered independently. The classificatory variable was EP sex. For every annual period we compiled age and years of experience of each EP, the number of patients who attended, and patient distribution in triage categories. To analyze ED resource use by each EP and period, we recorded percentages of blood tests, radiography, ultrasonography, computerized tomography (CT) scan, and hospital admission orders. Fifty EPs (27 women and 23 men) were included, 291 annual periods were analyzed (132 for women and 159 for men) and 256 524 patient attendances were recorded (114 086 by women and 142 438 by men). Blood tests were ordered in 57.2% of cases, radiography in 58.0%, ultrasounds in 5.0%, CT scans in 7.0%, and hospitalizations in 28.4%. Compared with men, women ordered 6.8% (95% confidence interval 6.1-7.5%) more blood tests, 4.6% (4.3-5.3%) more radiographies, 15.2% (11.6-18.9%) more ultrasonographies, 11.1% (8.1-14.1%) more CT scans, and 12.1% (10.8-13.4%) more hospitalizations. These differences maintained statistical significance in the stratified analysis by EP experience, and were observed for most of the years analyzed. Female EPs order more investigations and admit more patients, although from our results the reason for this is unclear, and the impact on healthcare effectiveness and patient outcome is unknown.

Prognostic accuracy of SIRS criteria, qSOFA score and GYM score for 30-day-mortality in older non-severely dependent infected patients attended in the emergency department

The aim of this study was to determine the accuracy of systemic inflammatory response syndrome (SIRS), quick Sepsis-related Organ Failure Assessment (qSOFA) score and GYM score to predict 30-day mortality in older non-severely dependent patients attended for an episode of infection in the emergency department (ED). We performed an analytical, observational, prospective cohort study including patients 75years of age or older, without severe functional dependence, attended for an infectious process in 69 Spanish EDs for 2-day three-seasonal periods. Demographic, clinical and analytical data were collected. The primary outcome was 30-day mortality after the index event. We included 1071 patients, with a mean age of 83.6 [standard deviation (SD) 5.6] years; 544 (50.8%) were men. Seventy-two patients (6.5%) died within 30days. SIRS criteria ≥ 2 had a sensitivity of 65% [95% confidence interval (CI) 53.1-75.9] and a specificity of 49% (95% CI 46.0-52.3), a qSOFA score≥2 had a sensitivity of 28% (95% CI 18.2-39.8) and a specificity of 94% (95% CI 91.9-95.1), and a GYM score≥1 had a sensitivity of 81% (95% CI 69.2-88.6) and a specificity of 45% (95% CI 41.6-47.9). A GYM score≥1 and a qSOFA score≥2 were the cut-offs with the highest sensitivity (p<0.001) and specificity (p<0.001), respectively. The area under the curve (AUC) was 0.73 (95% CI 0.66-0.79; p<0.001) for the GYM score, 0.69 (95% CI 0.61-0.76; p<0.001) for the qSOFA score and 0.65 (95% CI 0.59-0.72; p<0.001) for SIRS. A GYM score≥1 may be the most sensitive score and a qSOFA score≥2 the most specific score to predict 30-day mortality in non-severely dependent older patients attended for acute infection in EDs.

Impact of Frailty and Disability on 30-Day Mortality in Older Patients With Acute Heart Failure

The objectives were to determine the impact of frailty and disability on 30-day mortality and whether the addition of these variables to HFRSS EFFECT risk score (FBI-EFFECT model) improves the short-term mortality predictive capacity of both HFRSS EFFECT and BI-EFFECT models in older patients with acute decompensated heart failure (ADHF) atended in the emergency department. We performed a retrospective analysis of OAK Registry including all consecutive patients ≥65 years old with ADHF attended in 3 Spanish emergency departments over 4 months. FBI-EFFECT model was developed by adjusting probabilities of HFRSS EFFECT risk categories according to the 6 groups (G1: non frail, no or mildly dependent; G2: frail, no or mildly dependent; G3: non frail, moderately dependent; G4: frail, moderately dependent; G5: severely dependent; G6: very severely dependent).We included 596 patients (mean age: 83 [SD7]; 61.2% females). The 30-day mortality was 11.6% with statistically significant differences in the 6 groups (p < 0.001). After adjusting for HFRSS EFFECT risk categories, we observed a progressive increase in hazard ratios from groups G2 to G6 compared with G1 (reference). FBI-EFFECT had a better prognostic accuracy than did HFRSS EFFECT (log-rank p < 0.001; Net Reclassification Improvement [NRI] = 0.355; p < 0.001; Integrated Discrimination Improvement [IDI] = 0.052; p ;< 0.001) and BI-EFFECT (log-rank p = 0.067; NRI = 0.210; p = 0.033; IDI = 0.017; p = 0.026). In conclusion, severe disability and frailty in patients with moderate disability are associated with 30-day mortality in ADHF, providing additional value to HFRSS EFFECT model in predicting short-term prognosis and establishing a care plan.

Emergency Nurse Competence in Electrocardiographic Interpretation in Spain: A Cross-Sectional Study

IntroductionElectrocardiographic interpretation skills are key to provide a fast attention to patients with thoracic pain. The aim of the study was to determine the current level of competence in electrocardiographic interpretation of nurses in emergency departments. MethodsCross-sectional, multicenter study via an ad hoc questionnaire. Subjects were nurses from three Spanish emergency departments with at least a year experience in this area. A two-part questionnaire was created consisting of a professional profile, and 12 questions (2 theoretical questions and 10 questions on practical cases with electrocardiographic register [readout]). A pilot test was carried out to evaluate the validity of the questionnaire, the content validity index. The reliability of the questionnaire was also tested on a subsample through intraclass correlation coefficient with a value of 0.869 (CI 95% 0.712-0.941). Descriptive and bivariate analyses were conducted using an independent t-test or one-way ANOVA as appropriate. A statistical significance of P < .05 was assumed. ResultsFifty-seven usable questionnaires were obtained (47.2% response rate). Women comprised 84.2% of the sample and the mean age of the sample was 40.5 (SD = 9.3) years. Slightly more than 91% had taken electrocardiographic interpretation training courses, the main modality for which was face-to-face (84.2%). The average score on our questionnaire was 8.6 (SD=1.1) points. No significant differences between nursing experience and hospitals were observed. Nurses who had received training within the previous five years scored significantly higher than those who had not (P = .031). DiscussionThe electrocardiographic knowledge of emergency nurses is high. Level of knowledge was not influenced by experience or hospital but was influenced by training when provided in the previous 5 years. Therefore, refreshing courses should be taken at least every 5 years.Contribution to Emergency Nursing Practice:•Refresher courses in electrocardiography should be run at least every 5 years.•Recognizing the most relevant pathologies in the electrocardiogram (ECG) is the key to hastening patient care.•Nurses are the first step in patient care. To provide patients with the best care possible, nurses need to be highly competent in recognizing alarming symptoms.

Benefits of Emergency Departments' Contribution to Stroke Prophylaxis in Atrial Fibrillation: The EMERG-AF Study (Emergency Department Stroke Prophylaxis and Guidelines Implementation in Atrial Fibrillation).

Long-term benefits of initiating stroke prophylaxis in the emergency department (ED) are unknown. We analyzed the long-term safety and benefits of ED prescription of anticoagulation in atrial fibrillation patients. Prospective, multicenter, observational cohort of consecutive atrial fibrillation patients was performed in 62 Spanish EDs. Clinical variables and thromboprophylaxis prescribed at discharge were collected at inclusion. Follow-up at 1 year post-discharge included data about thromboprophylaxis and its complications, major bleeding, and death; risk was assessed with univariate and bivariate logistic regression models. We enrolled 1162 patients, 1024 (88.1%) at high risk according to CHA2DS2-VASc score. At ED discharge, 935 patients (80.5%) were receiving anticoagulant therapy, de novo in 237 patients (55.2% of 429 not previously treated). At 1 year, 48 (4.1%) patients presented major bleeding events, and 151 (12.9%) had died. Anticoagulation first prescribed in the ED was not related to major bleeding (hazard ratio, 0.976; 95% confidence interval, 0.294-3.236) and was associated with a decrease in mortality (hazard ratio, 0.398; 95% confidence interval, 0.231-0.686). Adjusting by the main clinical and sociodemographic characteristics, concomitant antiplatelet treatment, or destination (discharge or admission) did not affect the results. Prescription of anticoagulation in the ED does not increase bleeding risk in atrial fibrillation patients at high risk of stroke and contributes to decreased mortality.

The Effect of Frailty on 30-day Mortality Risk in Older Patients With Acute Heart Failure Attended in the Emergency Department.

The objective was to determine the effect of frailty on risk of 30-day mortality in nonseverely disabled older patients with acute heart failure (AHF) attended in emergency departments (EDs). The Frailty-AHF Study is a retrospective analysis of a multicenter, observational, prospective, cohort study (Older-AHF Register). This study included consecutive patients ≥ 65 years of age without severe functional dependence or dementia attended for AHF in three Spanish EDs for 4 months. Frailty was defined by frailty phenotype as the presence of three or more domains. Baseline and episode characteristics and 30-day mortality were collected in all the patients. A total of 465 patients with a mean (±SD) age of 82 (±7) years were included, 283 (61.0%) being female and 225 (51.3%) with severe comorbidity (Charlson index ≥ 3). Frailty was present in 169 (36.3%). The rate of 30-day mortality was 7.3%. Frailty adjusted for potential confounding factors was an independent factor associated with 30-day mortality (adjusted hazard ratio=2.5; 95% confidence interval= 1.0 to 6.0; p=0.047). The presence of frailty is an independent risk factor of 30-day mortality in nonsevere dependent older patients attended with AHF in EDs.