Tertiary Emergency Department Research Articles

Emergency medicine pharmacists' interventions in the tertiary hospitals' emergency departments in Malaysia.

The emergency medicine (EM) pharmacist is an integrated part of the Emergency Department (ED) interdisciplinary team in many countries, including Malaysia. The presence of EM pharmacists in the ED has positively impacted patient outcomes. Data on EM pharmacists' interventions is scarce in the Asian region. In Malaysia, data on interventions done by EM pharmacists in the EDs was unavailable. This study aimed to assess the type of interventions done by EM pharmacists in the ED of tertiary public hospitals in Malaysia. This cross-sectional, multicenter study involved EM pharmacists from 14 tertiary hospitals in Malaysia. All accepted interventions done by EM pharmacists in the ED for patients admitted to the Red (critical) and Yellow (semi-critical) zones from January to June 2022 were extracted from the Clinical Pharmacy Report Form. All data were analyzed descriptively. The EM pharmacists documented 1659 accepted interventions on 1584 patients during the study period. Inappropriate regimens (n = 1117, 67.3%) and incomplete prescriptions (n = 339, 20.4%) were the main categories of accepted interventions in ED. Inappropriate drug (n = 574, 34.6%), dose (n = 292, 17.6%), and frequency (n = 176, 10.6%) were the top three subcategory interventions documented under inappropriate regimens. Antimicrobials, antihypertensives, and proton pump inhibitors were the commonest drug intervened under the categories of inappropriate drug intervention. There were 272 (16.4%) accepted interventions on high-alert medications (HAMs). Insulin, enoxaparin, and noradrenaline were the most intervened HAMs. Inappropriate treatment regimens were the most common intervention category done by EM pharmacists in Malaysia. The significant number of interventions done by EM pharmacists demonstrated the importance of EM pharmacists as integral members of the EM team. This data can help improve the quality of clinical pharmacy services in the ED and is important for the future expansion of clinical pharmacy services in all EDs across Malaysia, neighbouring countries, and other developing countries.

Impact of WHO-Recommended TB Control Measures on Occupational TB Risk Among Healthcare Workers in a High-Burden Tertiary Hospital in Brazil: A 24-Year Retrospective Analysis.

Tuberculosis (TB) remains a significant public health concern, particularly in low-to-middle-income countries. Healthcare workers (HCWs) are at a higher risk due to prolonged exposure. The World Health Organization (WHO) has proposed guidelines focusing on administrative interventions, structural interventions, and personal protective equipment (PPE) usage to mitigate this risk. Despite these recommendations, data on their efficiency in reducing occupational TB risk in Brazil is lacking. Evaluate the effectiveness of the WHO-recommended measures regarding the risk of developing TB among the HCWs. We conducted a retrospective analysis of TB incidence among patients admitted to a tertiary public Emergency Department (ED), and HCWs from 2000 to 2023. We extracted TB notifications among HCWs and the general population of Ribeirão Preto from a public database. We comparatively analysed the incidence rates between patients and HCWs to evaluate the effectiveness of WHO-recommended measures. From 2000 to 2023, the ED handled an average of 148,496 patients per quadrennium, with 202 TB patients per quadrennium. The prevalence ratio of TB per 100,000 patients increased from 80 to 170 (p=0.035) and the incidence rates rose from 39 to 157 per 100,000 patients (p=0.046). The incidence rate of TB among HCWs in our institution started at 412.0 (85.0;1201.0) and decreased to 179.0 (20.0;619.0). In total, 11 HCWs were diagnosed with TB. The relative risk of having TB between HCWs and the general population was significantly higher before the Program implementation and became equivalent after it. Implementing WHO-recommended TB control measures was demonstrated effective in reducing the incidence rate ratios between HCWs and the general population in a high-burden tertiary hospital in Brazil.

Prognostic nutritional index as a predictor of mortality in acute ischemic stroke.

Nutritional and immune status have been recognized as important factors influencing the prognosis of acute ischemic stroke. This study aims to evaluate the prognostic value of the Prognostic Nutritional Index (PNI) in predicting 30-day mortality in patients with acute ischemic stroke. A retrospective cohort study was conducted in a tertiary care hospital emergency department. Patients diagnosed with acute ischemic stroke between January 1, 2019, and January 1, 2024, were included. PNI was calculated using serum albumin levels and total lymphocyte count. Data on demographics, clinical parameters, laboratory results, and 30-day mortality were collected from electronic medical records and patient follow-up via phone calls. Appropriate statistical tests were applied based on the data distribution, and p-values < 0.05 were considered statistically significant. A total of 169 patients were included in the study, with a mean age of 74.2 ± 10.5 years, and 55 % were male. Of these patients, 25 (14.8 %) did not survive within the 30-day follow-up period. PNI was significantly lower in deceased patients compared to survivors (p < 0.001). The area under the receiver operating characteristic (AUROC) curve was 0.831, indicating good predictive accuracy for 30-day mortality. The optimal PNI cut-off of 37.21 demonstrated a sensitivity of 72.0 % and a specificity of 81.2 %. The PNI is a reliable predictor of 30-day mortality in acute ischemic stroke patients. Lower PNI values were associated with higher mortality, highlighting the importance of nutritional and immune status in stroke outcomes. PNI could be used in clinical practice to help identify high-risk patients and inform more appropriate treatment decisions.

Emergency department early mortality model for patients admitted after presenting to a tertiary medical center emergency department.

Identifying patients in the emergency department (ED) at higher risk for in-hospital mortality can inform shared decision making and goals-of-care discussions. Electronic health record systems allow for integrated multivariable logistic regression (LR) modeling, which can provide early predictions of mortality risk in time for crucial decision making during a patient's initial care. Many commonly used LR models require blood gas analysis values, which are not frequently obtained in the ED. The goal of this study was to develop an all-cause mortality prediction model, derived from commonly collected ED data, which can assess mortality risk early in ED care. Data were obtained for all patients, age 18 and older, admitted from the ED to Atrium Health Wake Forest Baptist from April 1, 2016, through March 31, 2020. Initial vital signs including heart rate, respiratory rate, systolic blood pressure, diastolic blood pressure, mean arterial pressure, pulse oximetry, weight, body mass index, comprehensive metabolic panel, and a complete blood count were electronically retrieved for all patients. The prediction model was developed using LR. The ED early mortality (EDEM) model was compared with the rapid Emergency Medicine Score (REMS) for performance analysis. A total of 45,004 patients met inclusion criteria, comprising a total of 77,117 admissions. In this cohort, 52.8% of patients were male and 47.2% were female. The model used 35 variables and yielded an area under the receiver operating characteristic curve (AUC) of 0.889 (95% CI 0.874-0.905) with a sensitivity of 0.828 (95% CI 0.791-0.860), a specificity of 0.788 (95% CI 0.783-0.794), a negative predictive value of 0.995 (95% CI 0.994-0.996), and a positive predictive value of 0.084 (95% CI 0.076-0.092). This outperformed REMS in this data set, which yielded an AUC of 0.500 (95% CI 0.455-0.545). The EDEM model was predictive of in-hospital mortality and was superior to REMS.

Procedural Sedation in the Emergency Department – An Observational Study: Does Nil Per Os Status Matter?

Introduction: Procedural sedation (PS) is commonly performed in the emergency department (ED). Nil per os (nothing by mouth) (NPO) guidelines extrapolated from standards for patients undergoing elective procedures in the operating room have been applied to ED PS patients. There has been no large study of ED PS patients comparing differences in adverse events and PS success rates based on NPO status. Methods: From a cohort of consecutive ED PS patients of all ages in the 20 EDs of one hospital system—one quaternary ED, four tertiary EDs, six community hospital EDs, one rural ED, two pediatric EDs, and six freestanding EDs in two states in the Midwest and South—we conducted a retrospective analysis on a prospective database over 183 months from April 2000–June 2015. Primary outcome was the incidence of side effects and complications, which comprised the adverse effects. The side effects were nausea, vomiting, itching/rash, emergence reaction, myoclonus, paradoxical reaction, cough, and hiccups. Complications were oxygen desaturation &amp;lt;90%, respiratory depression (respiratory rate &amp;lt;8), apnea, tachypnea, hypotension, hypertension, bradycardia, and tachycardia. Normal vital signs were age dependent. Secondary outcome was successful sedation defined as completion of the procedure. We examined the association between adverse events and successful sedation with NPO status. Results: Of 3,274 visits, exact NPO status was known in 2,643 visits. Comparison of NPO &amp;lt;8 hours in 1,388 patients vs ≥ 8 hours in 1,255 patients revealed side effects 5.5% vs 4.5% (P = 0.28); complications 11.9% vs 17.7% (P &amp;lt; 0.001); adverse events 16.3% vs 21.5% (P &amp;lt; 0.001), interventions 4.1% vs 4.4% (P = 0.73), and procedural completions 94.3% vs 89.7% (P &amp;lt; 0.001). After adjustment for age, sex, transfer status, American Society of Anesthesiology physical status classification, race, primary sedative, multiple sedatives, sedative plus analgesic, and primary analgesic, we found no association betweenNPOstatus and side effects (P = 0.68), complications (P = 0.48), or adverse effects (P = 0.26); however, procedural completion rate remained significantly higher for NPO &amp;lt; 8 hours (P = 0.007). Conclusion: A nil per os status ≥8 hours may have similar or worse outcomes than NPO &amp;lt;8 hours, which is contrary to many suggested guidelines. Strict adherence to NPO guidelines in ED procedural sedation patients may not be necessary.

Reasons and Features of Patients Who Leave the Emergency Department Without Being Seen.

Background: Emergency medicine practitioners encounter significant challenges related to patients who leave emergency departments (EDs) without being seen (LWBS) in the ED. We aimed to assess the characteristics, reasons, and rate of patients who left without being seen in the tertiary teaching hospital ED of King Khalid University Hospital in Riyadh, Saudi Arabia. Methods: A qualitative prospective observational study was conducted from January 4, 2023, to May 17, 2023, among patients who left the ED without being seen in the King Khalid University Hospital, King Saud University Medical City, a tertiary hospital in Riyadh, Saudi Arabia. Data were collected from the ED administrative database, phone surveys, and electronic files of the identified patients. Phone interviews with questionnaires were conducted with patients participating in the study within 1 week of their ED visit. Results: During the study period, 16,682 patients visited the adult ED and 636 (3.81%) remained unseen; 300 patients met the study criteria. Of these, 288 (96%) arrived at the hospital via private car and 12 (4%) used ambulances. Trauma and gastrointestinal, neurological, and cardiovascular complaints were the most common, reported by 24.33%, 18.33%, 12%, and 10% of patients, respectively. In our study, 55 patients (18.3%) experienced prolonged waiting times of more than four hours before leaving the ED. Most patients (75%) inquired about the reasons for not being seen by a physician while waiting; 137 (45.6%) asked a receptionist, 117 (39%) asked a nurse, and 28 (9.3%) asked a doctor. According to 76 (25.3%) patients, they should not have to wait, whereas 82 (27.3%) said that they should wait for an hour. When asked whether they would visit the same ED in the future, 213 (71%) answered yes and 87 (29%) answered no. Conclusion: We conclude that in our center, prolonged waiting time and ED overcrowding are the main reasons why patients leave the ED without seeing a physician. Younger patients are more prone to LWBS, with trauma and gastroenterological complaints being the most common presenting symptoms. The LWBS rate was 3.81% of the total ED visits during the study period.

Information Mode-Dependent Success Rates of Obtaining German Medical Informatics Initiative-Compliant Broad Consent in the Emergency Department: Single-Center Prospective Observational Study.

The broad consent (BC) developed by the German Medical Informatics Initiative is a pivotal national strategy for obtaining patient consent to use routinely collected data from electronic health records, insurance companies, contact information, and biomaterials for research. Emergency departments (EDs) are ideal for enrolling diverse patient populations in research activities. Despite regulatory and ethical challenges, obtaining BC from patients in ED with varying demographic, socioeconomic, and disease characteristics presents a promising opportunity to expand the availability of ED data. This study aimed to evaluate the success rate of obtaining BC through different consenting approaches in a tertiary ED and to explore factors influencing consent and dropout rates. A single-center prospective observational study was conducted in a German tertiary ED from September to December 2022. Every 30th patient was screened for eligibility. Eligible patients were informed via one of three modalities: (1) directly in the ED, (2) during their inpatient stay on the ward, or (3) via telephone after discharge. The primary outcome was the success rate of obtaining BC within 30 days of ED presentation. Secondary outcomes included analyzing potential influences on the success and dropout rates based on patient characteristics, information mode, and the interaction time required for patients to make an informed decision. Of 11,842 ED visits, 419 patients were screened for BC eligibility, with 151 meeting the inclusion criteria. Of these, 68 (45%) consented to at least 1 BC module, while 24 (15.9%) refused participation. The dropout rate was 39.1% (n=59) and was highest in the telephone-based group (57/109, 52.3%) and lowest in the ED group (1/14, 7.1%). Patients informed face-to-face during their inpatient stay following the ED treatment had the highest consent rate (23/27, 85.2%), while those approached in the ED or by telephone had consent rates of 69.2% (9/13 and 36/52). Logistic regression analysis indicated that longer interaction time significantly improved consent rates (P=.03), while female sex was associated with higher dropout rates (P=.02). Age, triage category, billing details (inpatient treatment), or diagnosis did not significantly influence the primary outcome (all P>.05). Obtaining BC in an ED environment is feasible, enabling representative inclusion of ED populations. However, discharge from the ED and female sex negatively affected consent rates to the BC. Face-to-face interaction proved most effective, particularly for inpatients, while telephone-based approaches resulted in higher dropout rates despite comparable consent rates to direct consenting in the ED. The findings underscore the importance of tailored consent strategies and maintaining consenting staff in EDs and on the wards to enhance BC information delivery and consent processes for eligible patients. German Clinical Trials Register DRKS00028753; https://drks.de/search/de/trial/DRKS00028753.

Pediatric non-traumatic dental presentations to the emergency department: a ten year retrospective study in an Australian tertiary hospital.

Non-traumatic dental conditions (NTDC) that present to the emergency department of a tertiary hospital tend to be related to dental caries, including facial cellulitis, abscess and toothache. This study aimed to report the types of dental conditions and the characteristics of children that presented to an urban tertiary hospital emergency department for NTDC. Medical records were reviewed for children less than 19years of age who presented to the emergency department over a 10-year period with a NTDC. Principal diagnosis, sociodemographic data and source of referral was obtained with treatment and investigations collated for those who were subsequently admitted. Across the total 4483 dental presentations, 2481 were NTDC. The most common age group was from 0 to 3years of age (average 6.3) and 57.2% of children were male. Dental caries related diagnoses were the most common reasons for emergency department presentations. A total of 297 children were admitted for investigations and treatment. Children present to emergency departments with caries related conditions more often than traumatic injuries. Targeted interventions are needed to ensure adequate oral health care access for children to avoid overburdening the emergency services in tertiary hospitals with NTDC.

Spinal Anatomy Ultrasound in Young Infants With Implications for Lumbar Puncture.

Lumbar puncture (LP) in young infants may challenge clinicians due to the infrequency of the procedure and anatomic variability. The use of ultrasound (US) to characterize young infant spinal anatomy prior to performing an LP may help determine the most favorable site for intervention. 1) Evaluate potential sites for LP in young infants with US at L2/L3 through L5/S1 to determine differences in needle insertion depth (NID), spinal canal width (SCW), and subarachnoid fluid width (SAW).2) Describe the location of the conus medullaris.3) Predict NID of L2/L3 through L5/S1 based on variables including age, gestational age, height, and weight. We studied a convenience sample of participants aged 0-6 months in a tertiary children's emergency department. We recorded characteristic data and used a Sonosite PX US with a linear 15-MHz transducer to image each participant's spine. We used the paired t-test to examine univariate differences in NID, SCW, and SAW and multiple linear regression models to derive predictive equations for NID. Among 50 participants, the mean NID for sites L2/L3 through L5/S1 did not differ significantly; however, at sites L2/L3 through L5/S1, there were statistically significant differences in the mean SCW and mean SAW, which were both consistently measured to be larger the more cephalad the site. Weight was the only statistically significant variable associated with NID after adjusting for other covariates. Spinal canal width and SAW were consistently measured to be larger at more cephalad sites, suggesting there is a larger target fluid volume available at higher interspaces. Subarachnoid fluid width was measured to be small, highlighting the importance of precise movements. Location of the needle site did not change expected needle depth (approximately 1 cm across all sites). The conus medullaris was not often visualized while scanning the L2/L3-L5/S1 interspaces. Weight can be used to estimate optimal NID; although, it is unclear such small differences would have clinical significance.

Assessment of Continuous Pulse Oximetry Monitoring in Infants With Bronchiolitis in the Pediatric Emergency Department: A Cross-Sectional Study.

Purpose Bronchiolitis guidelines recommend intermittent pulse oximetry monitoring for stable infants. Continuous pulse oximetry can lead to harm for some infants with bronchiolitis but is still frequently used in emergency departments (EDs) for infants who do not require oxygen supplementation. Measuring continuous pulse oximetry use from medical charts can be challenging. This study aimed to (1) develop a feasible method for documenting the use of continuous pulse oximetry in infants with bronchiolitis and (2) explore factors influencing its use in this population. Methods We conducted a cross-sectional observational study in a tertiary pediatric ED. Infants 60 days and 12 months old with possible bronchiolitis and not requiring oxygen were included. The patients were recruited from January 11 to March 21, 2023. Research assistants directly observed the use of pulse oximetry monitors. The primary outcome was the proportion of infants placed on continuous pulse oximetry. The secondary outcomes included disease severity, admission, unplanned return visits, the use of supplemental oxygen, and the need for investigationsand interventions. Results Eighteen infants were included in this study, with six (33.3%) placed on continuous pulse oximetry. The median disease severity score was similar between infants who were continuously monitored (6.5 (IQR 5.3, 10.8)) and those in the intermittent pulse oximetry group (4.5 (IQR 2, 9)). Infants in the continuous pulse oximetry group underwent more investigations and interventions than those in the intermittent pulse oximetry group: chest radiograph and bloodwork in 50% versus 8.3%, antibiotics in 33.3% versus 8.3%, bronchodilators in 33.3% versus 16.7%, and steroids in 16.7% versus 0%. In the continuous pulse oximetry group, four infants (66.7%), all of whom were placed on supplemental oxygen, were admitted, compared to one infant (8.3%) in the intermittent pulse oximetry group. Conclusion The decision to use continuous pulse oximetry may be influenced by provider characteristics. Objectiveparameters should be developed to guide its applicationand minimize potential harms associated with it.

Oral Ketamine and Midazolam for Procedural Sedation in the Pediatric Emergency Department: A Retrospective Study.

Needle-free procedural sedation (PS) is an attractive option for children presenting to the emergency department (ED) who require a painful procedure, as it avoids inflicting additional pain either with intravenous line placement or intramuscular injection. While use of oral (PO) ketamine has been reported in the literature, limited information is available to guide ED-based use in children. This is a descriptive study of the patient experience receiving PS with the following regimen: PO ketamine 6 mg/kg (max of 200 mg) with or without PO midazolam 0.5 mg/kg (max 15 mg) approximately 30 minutes before a procedure. We performed a retrospective chart review of children younger than 18 years receiving this PS regimen at a tertiary care children's hospital ED and an affiliated community hospital ED from January 1 through September 30, 2023. Fifty-eight children were sedated with PO ketamine during the study period. The most common procedure performed was laceration repair (46.5%), followed by incision and drainage (17.3%). All but 2 children received PO midazolam along with PO ketamine. Eight patients received additional medications due to inadequate sedation. Sedation depth was clinician-reported as moderate in 74.1% (43), mild in 15.5% (9), and deep in 10.3% (6). Procedures were completed in 98.3% (57) cases. 93.1% (54) of patients had no adverse event (AE) of any kind and no patient had a significant adverse event (SAE). PO ketamine with or without midazolam resulted in procedure completion of a variety of procedures in the pediatric ED with minimal AE, no SAE, and without need for additional sedative medications in 86.2% (50). This regimen is an option for needle-free moderate PS in this setting. Further study is needed to clarify the benefit of the addition of midazolam to PO ketamine, rates of AE and SAE, sedation duration, and recovery times.

MicroRNA Biomarkers on Day of Injury Among Patients with Post Concussive Symptoms at 28-Days: A Prospective Cohort Study.

After mild traumatic brain injury (mTBI), some patients experience symptoms that persist for weeks to months. Recovery from mTBI is primarily assessed using selfreported symptom questionnaires. Blood biomarkers, including microRNA species, have shown promise to assist diagnosis of mTBI, however, little is known about how blood microRNA measures might predict symptom recovery. The aim of this study was to investigate the variances in plasma microRNAs on the day of injury between individuals with mTBI who report post-concussive symptoms at the 28- day mark and those who do not. Patients who presented to an adult, tertiary referral hospital emergency department on the day of the injury and were diagnosed with isolated mTBI (n=35) were followed up for 28 days. Venous blood samples were collected and symptom severity was assessed using the Rivermead Post-Concussion Symptom Questionnaire (RPQ) on the day of injury and at 28 days. Patients who reported ongoing symptoms of total RPQ score ≥10 or at least one symptom severity ≥2, were compared to those with lesser symptom severity or symptom resolution. There were 9 (25.7%; 95%CI: 12.5-43.3) patients who reported persistent symptoms. Day of injury plasma miR-223-3p levels were significantly higher in individuals with ongoing symptoms compared to those without, however, no such differences were observed for miRs 142- 3p, 423-3p, 32-5p, 144-3p, and let-7f-5p. Acute plasma miR-223-3p levels appear to detect patients who later have persistent symptoms after mTBI. The results demonstrate the potential utility for such biomarkers to assist in decisions towards early referral for therapy after mTBI.

The impact of reduced pediatric emergency care hours on the patterns of emergency department utilization

Purpose: The declining recruitment rate of pediatric residents in Korea has led to a decrease in the number of emergency departments (EDs) offering a 24/7 pediatric emergency care (PEC). This study evaluated the impact of reduced PEC hours on the utilization patterns of a single ED.Methods: We reviewed medical records of pediatric patients who were defined as individuals aged 14 years or younger undergoing pediatricians’ practices in a tertiary hospital ED in Korea. Given the reduction of PEC hours from full-time to 08:00-24:00 on September 27, 2022, the patients were grouped as those who visited during March 27, 2022-September 26, 2022 (“control”), and those who visited during September 27, 2022-March 26, 2023 (“reduction”). The following variables were analyzed between the 2 periods: the number of patients, age, sex, visits via ambulances, severity by the Korean Triage and Acuity Scale with high acuity (a level 1-2 of the scale), disease-related visits, time of visit, ED length of stay (EDLOS), disposition, chief complaints, and diagnoses.Results: Among 3,577 pediatric patients, 1,315 visited the ED during the reduction period, down by 41.9% in numbers from the control period. From the control to reduction periods, we observed an increase in the median age (from 3.0 years [interquartile range, 1.0-7.0] to 4.0 years [1.0-8.0]; P = 0.005) and decreases in the median EDLOS (from 140.0 minutes [80.0-217.0] to 104.0 minutes [54.0-169.8]; P &lt; 0.001) and proportion of hospitalization (from 22.1% to 12.6%; P &lt; 0.001). No change was observed in the proportions of highacuity cases or chief complaints. We noted decreases in infection-related diagnoses during the reduction.Conclusion: Reducing PEC hours was associated with shorter EDLOS, fewer hospitalizations, and older age, with no difference in the severity. Even with reduced PEC hours, relevant resources should be redistributed to ensure the accessibility to PEC.

From triage to treatment

Background: The COVID-19 pandemic has had a significant impact on healthcare systems worldwide, leading to changes in presentation types, service utilization, and admission rates to emergency departments (ED). This study examines changes in ED visit patterns and triage misclassifications during the pandemic in Alberta, Canada. Methods: We conducted a retrospective population-level time-series analysis of all patients who presented to 12 EDs in the Edmonton Alberta Zone between March 3, 2019, and March 3, 2022. Routinely collected electronic health record data were analyzed and with primary categories of reporting including Canadian Triage Acuity Scale (CTAS), age, Canadian Emergency Department Information System (CEDIS) presenting complaint, admission status, triage misclassifications, and time markers for patient care. Results: 1.24 million cases from 12 hospitals were included. When we compare the patterns of presentation to the pre-pandemic period, we found a relative increase of 12.5% in EMS volumes, a 43.2% relative reduction in the proportion of patients presenting to tertiary EDs, 17.2% relative reduction in the number of patients under the age of 18, and a global increase in acuity with the highest relative increase 19.7% coming from patients in the highest acuity level: CTAS 1. Complaint distributions during these periods demonstrated that mental health, substance use, and environmental complaints experienced 15.5%, 22.4%, and 26.7% relative increases in volume, respectively; pediatric specific complaints experienced a 56.5% relative reduction. By the end of the study period, patients spent an average of 59 minutes longer in the ED compared to the pre-pandemic period. The proportion of patients triaged using Epic increased from 7.8% of all patients triaged in the pre-pandemic period to over 66.1% during the pandemic, and there was a 22.9% and 24.2% relative reduction in high-risk triage misclassifications (22.9%) and pain related triage misclassifications (24.2%) by the end of the period compared to the before the pandemic. Conclusion: Our study adds to the pandemic-related emergency care knowledge base by describing ED visit trends, changes in presenting complaint categories and time markers for patient care over a big-data pre and post pandemic dataset. Nursing-specific ED quality indicators that have not been previously described over a three-year duration between March 3rd 2019 and March 3rd 2022. are also presented. Our study findings have significant implications for healthcare professionals and policymakers in understanding both the impact of the pandemic on ED care delivery as well as future pandemic and post-pandemic ED operations.

Do vaginal swabs alter empirical clinical management in obstetrics and gynaecology: A retrospective case-series and activity-based costing of the vaginal swab.

Vaginal swab microbiological testing is commonly performed as routine clinical management for various obstetric and gynaecological presentations. The clinical utility and cost-effectiveness of vaginal swab microscopy, culture and susceptibilities (MCS) in altering empirical management is ill-defined. To describe the clinical use of vaginal swabs in a tertiary women's hospital emergency department (ED), measure the impact of vaginal swabs on altering empirical clinical management, and to determine the economic cost of vaginal swab MCS. Retrospective case-series of vaginal swabs collected at a single, tertiary women's ED between January 2021 and July 2021. Symptomatology, clinical diagnosis, test results, and pre-swab and post-swab clinical management were determined upon medical record review. Economic costs of vaginal swab MCS were retrospectively determined via internal accounting records, permitting unit-level activity-based costing. A total of 660 vaginal swabs from 584 clinical episodes were included. Vulvovaginitis was the most common indication for swab collection (34.5%, 167 samples). Altered empirical management was observed in 9.8% of all swabs (95% CI 7.4-12.2%), with marked variability between clinical indications. Antimicrobial initiation was the most common alteration in management (8.9%, 95% CI 8.7-9.1%). The estimated cost of vaginal swab MCS was $29.71 AUD; labour, consumables and disposal costs accounted for 69.3, 29.8 and 0.9%, respectively. The impact of vaginal swab MCS on empirical clinical management is context-specific and variable. The majority of swabs performed do not impact upon empirical management. Antimicrobial initiation is appreciably more common than antimicrobial cessation with vaginal swab results.

33 Use of CHU Ste. Justine online resources prior to visiting the Emergency Department for less-urgent, acute febrile illness

Abstract Background Over the past 20 years, visits to paediatric emergency departments (EDs) across Canada have steadily increased, with a higher proportion of presentations for lower acuity symptoms. Many paediatric institutions’ websites now provide information and recommendations for caregivers on common illnesses and reasons for seeing healthcare providers or going to the ED. Increasing the use of internet resources may improve health literacy and hopefully decrease ED use for lower acuity presentations like uncomplicated viral illness. Objectives The objective of this study was to assess whether caregivers presenting with children with lower acuity at triage were aware of and using the online resources provided by our paediatric institution to help with at-home management of febrile illnesses and to guide their decision to present to the ED. Design/Methods This was a cross-sectional study in a tertiary care university-affiliated paediatric ED in an urban setting. Participants were a convenience sample of caregivers of children 6 months to 17 years old with a fever 72 hours or less and triaged low acuity (Canadian Triage and Acuity Scale levels 3 to 5). Caregivers of children with underlying significant systemic illness were excluded. Consenting participants completed two questionnaires. The first questionnaire included demographic data, information on baseline internet utilisation, use of general online health information and our institutions’ website specifically, and whether use of those resources influenced their decision to present to the ED. After browsing dedicated web materials developed by our institution (“Before going to the emergency room” and “Fever”), questionnaire 2 asked for feedback on the website. Results From April to July 2023, 100 caregivers participated in the study (response rates questionnaires 1 and 2: 80% and 70%, respectively) (Table 1). Half (49%) of caregivers researched their child’s symptoms prior to coming to the ED (Table 2). Approximately one third (39%) of respondents were aware that our institution provided online information for caregivers about common symptoms and when to present to the ED. Half (51%) of caregivers who completed questionnaire 2 said they would not have come to the ED if they had read these resources prior (Table 3). Many (66%) respondents reported they would be “likely/very likely” to look up their child’s symptoms on the institutional website before going to the ED in the future. Conclusion Half of caregivers presenting to the ED for their child’s lower-acuity febrile illness conducted research on their child’s symptoms prior to visiting the ED and most were influenced in their decision to come to ED by what they found. Most caregivers were not aware that our institution had online resources available. Promotion of the institutional resources available to parents may empower parents to manage common symptoms at home and prevent ED visits for lower-acuity illness.

Unmasking bocavirus: is it a co-infectious agent or an actual respiratory pathogen?

ABSTRACT Objectives Although human bocavirus (HBoV) is primarily linked to respiratory tract infections, its exact role as a respiratory pathogen remains unclear. This study aims to investigate HBoV detection rates, as well as clinical, laboratory, microbiological, and radiological characteristics, length of stay in the emergency department (ED), rate of hospitalization, and severity of illness in cases where HBoV is detected in respiratory secretions. Methods We conducted a retrospective analysis of all consecutive patients under 18 years who visited a large-volume tertiary pediatric ED from January to December 2023 and tested positive for HBoV in their respiratory viral panel (RVP). Results Among the 14,315 patients who underwent RVP testing during the study period, 591 (4%) tested positive for HBoV. After excluding those with incomplete data, 528 patients (57% male) were included in the analyses. The median age was 2.8 [1.2–4.9] years. The most common symptoms were cough (67%), fever (58%), runny nose/nasal congestion/sore throat (34%), and respiratory distress (24%). Thirty percent of the patients had a history of antibiotic use before admission. Thirteen percent of the patients had at least one chronic illness. Co-infection with HBoV occurred in 37% of the patients, with respiratory syncytial virus (RSV) being the most frequently co-detected virus (45%). Lymphopenia was documented in 12% of patients, and 36% had elevated C-reactive protein levels (median 21 [12–38] g/dl). Abnormal chest X-rays were noted in 85% of patients. The management approach included outpatient care for more than half of the patients (69%). Clinical severity was classified as high in 11% of patients (n = 60), necessitating ICU admission. Conclusion Although typically mild, HBoV infections can escalate to severe respiratory illnesses, requiring respiratory support and intensive care.

Predictability of adult patient medical emergency condition from triage vital signs and comorbidities: a single-center, observational study

BackgroundVital signs and comorbid diseases are the first information evaluated in patients admitted to the emergency department (ED). In most EDs, triage of patients takes place with vital signs and admission complaints only. Comorbidities are generally underestimated when determining the patient’s status at the triage area. This study aims to assess the relationship between initial vital signs, comorbid diseases, and medical emergency conditions (MEC) in patients admitted to the ED.MethodsThis prospective study was designed as a single-center observational study, including patients admitted to a tertiary ED between 16.06.2022 and 09.09.2022. Patients younger than 18, readmitted to the ED within 24 h, or absence of vital signs due to cardiac arrest were excluded from the study. Vital signs and comorbid diseases of all patients were recorded. The mortality within 24 h, the need for intensive care unit admission, emergency surgery, and life-saving procedures were considered “medical emergency conditions”. The role of vital signs and comorbid diseases in predicting emergencies was analyzed by binary logistic regression.ResultsA total of 10,022 patients were included in the study; 5056 (50.4%) were female, and 4966 (49.6%) were male. Six hundred four patients presented with an MEC. All vital signs -except diastolic hypertension and tachycardia- and comorbidities were found statistically significant. Hypoxia (Odd’s Ratio [OR]: 1.73), diastolic hypotension (OR: 3.71), tachypnea (OR: 8.09), and tachycardia (OR: 1.61) were associated with MECs. Hemiplegia (OR: 5.7), leukemia (OR: 4.23), and moderate-severe liver disease (OR: 2.99) were the most associated comorbidities with MECs. In our study, an MEC was detected in 3.6% (186 patients) of the patients with no abnormal vital signs and without any comorbidities.ConclusionAmong the vital signs, hypoxia, diastolic hypotension, tachypnea, and tachycardia should be considered indicators of an MEC. Hemiplegia, leukemia, and moderate-severe liver disease are the most relevant comorbidities that may accompany the MECs.

Is It Possible to Detect Return of Spontaneous Circulation during Chest Compression? Evaluation of a Novel Method: Carotid Artery Compression Ultrasound.

Objectives: To evaluate the diagnostic accuracy of carotid artery compression using a point-of-care ultrasound probe (POCUS-CAC) in reducing pulse check times and facilitating the detection of the return of spontaneous circulation (ROSC) during cardiopulmonary resuscitation (CPR) compared to manual palpation (MP). The secondary aim of the study is to assess the ability of POCUS-CAC to detect ROSC during ongoing chest compressions. Methods: This prospective study was conducted in a tertiary emergency department between January and June 2023. During CPR, POCUS-CAC was performed by placing a linear ultrasound probe transversely on the lateral neck to assess the compressibility of the carotid artery. Complete compression of the artery without any visible pulsation indicated no ROSC, while resistance to compression or partial compression suggested the presence of ROSC. Simultaneously, another clinician performed manual palpation of the femoral artery. The primary outcome assessed in this study was comparing ROSC detection between POCUS-CAC and traditional methods, and the secondary outcome was comparing the time taken to detect ROSC with each method, and the ability to detect ROSC during ongoing chest compressions. Results: The study included 41 cardiac arrest patients and analyzed 496 MP pulse and 1984 POCUS-CAC checks. The mean time to identify a pulse using POCUS-CAC was significantly shorter, at 2.3 (0.5-7.8, SD ± 1.2, 95% CI [2.25, 2.35]) s, compared to 4.7 (2.0-10.5, SD ± 1.8, 95% CI [4.54, 4.86]) s with MP (p = 0.004). Additionally, 52.9% of ROSC cases were detected earlier using POCUS-CAC, even during ongoing chest compressions. The sensitivity of POCUS-CAC was 100% (95% CI [80.5-100%]) and the specificity was 87.5% (95% CI [67.6-97.3%]). The POCUS-CAC method required less than 5 s in 99.996% of cases. Conclusions: POCUS-CAC significantly reduces pulse check times and enhances the early detection of ROSC during CPR, offering a reliable and rapid alternative to traditional manual palpation methods in emergency settings.

Procedural Sedation and Analgesia in an Australian Emergency Department: Results of the First 3 Months of a Procedural Sedation Registry

Background: Procedural sedation and analgesia (PSA) is commonly performed in emergency departments (EDs) to reduce anxiety, discomfort, or pain during a procedure. The primary goal of PSA is to produce a state of relaxation and drowsiness without eliminating the patient’s protective reflexes. Despite the discovery of new techniques and medications to deliver PSA, there is a paucity of research evaluating PSA in EDs over the last decade. We aim to describe the current practice of PSA in an Australian tertiary mixed ED with 75,000 presentations per year. Methods: A retrospective study of the initial 3 months of a PSA registry, which was part of the Tasmanian Emergency Care Outcomes Registry, was analyzed; Results: All told, 80 consecutive cases were entered over a 3-month period, with pediatric patients (&lt;14 years old) making up 35% of all cases. Joint reductions (17, 39%) and fracture reductions (13, 29%) were the most common indications for the adult population, whilst fracture reductions (9, 36%), laceration repairs (7, 28%), and other distressing procedures (7, 28%) were the most common indications in the pediatric cohort. Pharmacological approaches also differed between groups, with ketamine (25, 92%) preferred in the pediatric cohort whilst the combination of propofol and fentanyl (22, 42%) was preferred in the adult cohort. No adverse events were recorded in the pediatric cohort whilst 6 (8%) minor events occurred in the adult population, with no severe events occurring for either cohort. PSA also occurred more frequently at 0900–1000 and the incidence was reduced between 0000 and 0800. Conclusions: PSA is commonly performed in our tertiary mixed ED and is both safe and effective, with non-severe complication rates similar to those in the reported literature. Severe complications are rare and therefore a larger cohort will be required to assess this aspect. The approach to ED PSA is also different between pediatric and adult populations and therefore research needs to differentiate both populations.