Unscheduled Emergency Department Research Articles

Lactate Levels as a Predictor of Emergency Department Revisits in Infants With Acute Bronchiolitis.

This study aimed to identify predictive biomarkers for unscheduled emergency department (ED) revisits within 24 hours of discharge in infants diagnosed with acute bronchiolitis (AB). A retrospective observational study was conducted on infants diagnosed with AB who visited 3 emergency medical centers between January 2020 and December 2022. The study excluded infants with comorbidities, congenital diseases, and prematurity and infants who revisited the ED after 24 hours of discharge. Demographic data, vital signs, and laboratory results were collected from the medical records. Univariable and multivariable logistic regression analyses were performed on factors with P of less than 0.1 in univariable analysis. Receiver operator curve analysis was used to assess the accuracy of lactate measurements in predicting ED revisits within 24 hours of discharge. Out of 172 participants, 100 were in the revisit group and 72 in the discharge group. The revisit group was significantly younger and exhibited higher lactate levels, lower pH values, and higher pCO2 levels compared to the discharge group. Univariable logistic regression identified several factors associated with revisits. Multivariable analysis found that only lactate was a variable correlated with predicting ED revisits (odds ratio, 18.020; 95% confidence interval [CI], 5.764-56.334). The receiver operator curve analysis showed an area under the curve of 0.856, with an optimal lactate cutoff value of 2.15. Lactate value in infants diagnosed with AB were identified as a potential indicator of predicting unscheduled ED revisits within 24 hours of discharge. The predictive potential of lactate levels holds promise for enhancing prognosis prediction, reducing health care costs, and alleviating ED overcrowding. However, given the study's limitations, a more comprehensive prospective investigation is recommended to validate these findings.

Postpartum Emergency Department Use Following Midwifery-Model vs Obstetrics-Model Care

Emergency department (ED) use postpartum is a common and often-preventable event. Unlike traditional obstetrics models, the Ontario midwifery model offers early care postpartum. To assess whether postpartum ED use differs between women who received perinatal care in midwifery-model care vs in traditional obstetrics-model care. This retrospective population-based cohort study took place in Ontario, Canada, where public health care is universally funded. Participants included women who were low risk and primiparous and gave birth to a live baby in an Ontario hospital between 2012 and 2018. Data were collected from April 2012 to March 2018 and analyzed from June 2022 to April 2023. Perinatal care clinician, namely, a midwife or obstetrician. : Any unscheduled ED visit 42 days postpartum or less. Poisson regression models compared ED use between women with midwifery-model care vs obstetrics-model care, weighting by propensity score-based overlap weights. Among 104 995 primiparous women aged 11 to 50 years, those in midwifery-model care received a median (IQR) of 7 (6-8) postpartum visits, compared with 0 (0-1) visits among those receiving obstetrics-model care. Unscheduled ED visits 42 days or less postpartum occurred for 1549 of 23 124 women (6.7%) with midwifery-model care compared with 6902 of 81 871 women (8.4%) with traditional obstetrics-model care (adjusted relative risks [aRR], 0.78; 95% CI, 0.73-0.83). Similar aRRs were seen in women with a spontaneous vaginal birth (aRR, 0.71; 95% CI, 0.65-0.78) or assisted vaginal birth (aRR, 0.70; 95% CI, 0.59-0.82) but not those with a cesarean birth (aRR, 0.94; 95% CI, 0.86-1.03) or those with intrapartum transfer of care between a midwife and obstetrician (aRR, 0.94; 95% CI, 0.87-1.04). ED use 7 days or less postpartum was also lower among women receiving midwifery model care (aRR, 0.70; 95% CI, 0.65-0.77). In this cohort study, midwifery-model care was associated with less postpartum ED use than traditional obstetrics-model care among women who had low risk and were primiparous, which may be due to early access to postpartum care provided by Ontario midwives.

Unscheduled Emergency Department Revisits Within 48 Hours of Discharge.

This study aimed to analyze early revisits (within 48 hours of discharge) in an Emergency Department. Among the 178,295 visits, 11,686 were revisits, resulting in a rate of 6.55% (95%CI 6.43-6.67). A total of 1,410 revisits required hospitalization, and 252 were due to preventable errors (17.87%). These errors were mainly related to an inadequate therapeutic plan at discharge (47.22%), an incomplete diagnostic process (29.37%), and misdiagnoses (13.10%). These findings represent a technology-enabled clinical audit tool. Electronic Healthcare Records have the potential to: provide quality metrics of hospital performance, help to keep revisit rates updated (assessment through a real-time dashboard), and improve clinical management (by transparency initiatives about errors, and a supportive learning environment regarding lessons learned).

A simplified scoring model for predicting bacteremia in the unscheduled emergency department revisits: The SADFUL score

Bacteremia is a severe complication of infectious disease. Patients with a high bacteremia risk in the emergency department (ED) but misidentified would lead to the unscheduled revisits. This study aimed to develop a simplified scoring model to predict bacteremia in patients with unscheduled ED revisits. Adult patients with unscheduled ED revisits within 72h with a final diagnosis of infectious disease were retrospectively included. The development cohort included patients visiting the ED from January 1, 2019 to December 31, 2021. Internal validation was performed in patients visiting the ED from January 1, 2022 to March 31, 2022. Variables including demographics, pre-comorbidities, triage levels, vital signs, chief complaints, and laboratory data in the index visit were analyzed. Bacteremia was the primary outcome determined by blood culture in either index visits or revisits. The SADFUL score for predicting bacteremia comprised the following predictors: "S"egmented neutrophil percentage (+3 points), "A"ge>55 years (+1 point), "D"iabetes mellitus (+1 point), "F"ever (+2 points), "U"pper respiratory tract symptoms (-2 points), and "L"eukopenia (2 points). The area under receiver operating characteristic curve with 95% confidence interval in the development (1802 patients, 190 [11%] with bacteremia) and the validation cohort (134 patients, 17 [13%] with bacteremia) were 0.78 (0.74-0.81) and 0.79 (0.71-0.88), respectively. The SADFUL score is a simplified useful tool for predicting bacteremia in patients with unscheduled ED revisits. The scoring model could help ED physicians decrease misidentification of patients at a high risk for bacteremia and potential complications.

Outpatient parenteral antimicrobial therapy (OPAT) in a safety-net hospital: Opportunities for improvement

Background: Parkland Health is a 900-bed safety-net hospital that serves Dallas County, Texas. It has an OPAT program in which patients are managed via self-administration (S-OPAT), home-health/hemodialysis (H-OPAT), and skilled nursing facilities (SNF-OPAT). We evaluated the reasons for unscheduled emergency department (ED) visits by patients in these groups to identify strategies to decrease unexpected healthcare utilization and to improve safety. Methods: We performed a retrospective chart review of all adult patients discharged from Parkland Health on OPAT between April and June 2021. Demographic, medical, and healthcare utilization information, including the date and reason of first unscheduled ED visit after discharge, was collected utilizing a standardized instrument. The institutional review board approved this study. Results: In total, 184 patients were discharged with OPAT. Among them, 32% were female and 55% identified as Hispanic; 41% were non-English speakers, and 45% were treated for a musculoskeletal infection. Among all OPAT models of care, 43.4% were S-OPAT patients, 31.5% were H-OPAT patients, and 25% were SNF-OPAT patients (Table 1). The groups differed, and fewer African Americans received H-OPAT. Also, 45% were being treated for musculoskeletal infections and were more likely to be discharged with H- or SNF-OPAT. In addition, 41% were being treated for endovascular infections and 21.7% were being treated for genitourinary infections. The total length of stay in the hospital was longer for SNF-OPAT patients and shorter for S-OPAT patients (Table 2). Among 184 OPAT patients, 41 patients (22.2%) had an ED visit: 17.3% SNF-OPAT patients, 27.6% H-OPAT patients, and 21.3% S-OPAT patients (Table 2). ED visits were attributed to intravenous (IV) access–related problems (12 of 41, 29.0%), worsening of known infection (3 of 41, 7.3%), and abnormal blood test results (2 of 41, 4.9%). Also, 24 ED visits (58%) were not related to underlying infection or OPAT. However, when examined by the OPAT care model, 41% of ED visits among S-OPAT patients, 20% among H-OPAT visits, and 25% among SNF-OPAT visits were related to IV access issues. Among S-OPAT ED visits pertaining to IV access, 71% were for minor issues such as dressing changes or line occlusion or malfunction. Conclusions: One-fifth of OPAT patients had an unscheduled ED visit, of whom 20%–41% had issues with IV access. Many of these visits could be avoided with enhanced outreach to patients discharged with OPAT and improved ambulatory capabilities to provide standard services related to maintenance of IV access.Disclosures: None

Risk stratification of patients with chest pain who have an unscheduled revisit to the emergency department

AimsAcute cardiovascular (CV) emergencies are critical conditions that require urgent attention in the emergency department (ED). Failure to make a timely diagnosis may result in unscheduled ED revisits and severe outcomes. Therefore, this study aimed to investigate the risk factors associated with potentially missed acute CV emergencies. Methods and resultsThis retrospective study enrolled adult patients who presented with chest pain and returned to the ED within 72 h. Demographic information, pre-existing medical conditions, chief complaints, triage level and vital signs, electrocardiography (ECG) reports, and laboratory data were collected from medical charts by independent physicians. The primary outcome was the diagnosis of acute CV diseases, including ACS, pulmonary embolism, unstable arrhythmia, acute decompensated heart failure, and aortic dissection. Multivariable logistic regression was used to analyze the association between variables and acute CV emergencies. A total of 453 eligible patients were included, with 60 (13.2%) patients diagnosed as acute CV emergencies at the ED revisit. Risk factors for acute CV emergencies included male gender (adjusted odds ratio [aOR] = 2.71, 95% confidence interval [CI] = 1.17–6.25), abnormal ECG rhythm (aOR = 10.33, 95% CI = 4.68–22.83), and abnormal changes in high sensitivity Troponin-T (hs-cTnT) during sequential follow-up (aOR = 6.52, 95% CI = 2.19–19.45). ConclusionsMale gender, abnormal ECG rhythm, and a significant increase in sequential follow-up hs-cTnT levels were identified as significant risk factors for acute CV emergencies. ED physicians should recognize these high-risk patients with chest pain to prevent misdiagnosis and potential severe complications.

Risk factors associated with 1-week revisit among emergency department patients with alcohol withdrawal

Approximately one-quarter of emergency department (ED) visits for alcohol withdrawal result in unscheduled 1-week ED return visits, but it is unclear what patient and clinical factors may impact this outcome METHODS: From January 1, 2015, to December 31, 2018, at three urban EDs in Vancouver, Canada, we studied patients who were discharged with a primary or secondary diagnosis of alcohol withdrawal. We performed a structured chart review to ascertain patient characteristics, ED treatments, and the outcome of an ED return within 1week of discharge. We used univariable and multivariable Bayesian binomial regression to identify characteristics associated with being in the upper quartile of 1-week ED revisits. We collected 935 ED visits among 593 unique patients. Median age was 45years (interquartile range 34 to 55years) and 71% were male. The risk of a 1-week ED revisit was 15.0% (IQR 12.3; 19.5%). After adjustment, factors independently associated with a high risk for return included any prior ED visit within 30days, no fixed address, initial blood alcohol level > 45mmol/L, and initial Clinical Institute Withdrawal Assessment-alcohol revised score > 23. These factors explained 41% of the overall variance in revisits. Among discharged ED patients with alcohol withdrawal, we describe high-risk patient characteristics associated with 1-week ED revisits, and these findings may assist clinicians to facilitate appropriate discharge planning with access to integrated follow-up support.

Организация помощи пациентам с тяжелой бронхиальной астмой, нуждающимся в лечении генно-инженерными биологическими препаратами, в Санкт-Петербурге

The proportion of patients with severe asthma among asthma patients is approximately 5–10%. Severe asthma is associated with a heavy economic burden and remains a major public health problem. Patients with severe asthma require significant use of healthcare resources, i.e., the rate of exacerbation-related hospital admissions and unscheduled emergency department visits is two- and three-fold, respectively, higher than that in non-severe asthma. The discovery of the molecular mechanisms of asthma pathogenesis allowed the development of biological genetically engineering therapies that provide an effective therapeutic option for severe asthma by improving the quality of life by reducing the rate of exacerbations, improving lung function, and reducing the need for systemic steroids with a good safety profile. Targets for existing biological agents include IgE, interleukins (IL)-4, 5, and 13, and thymic stromal lymphopoietin. These drugs include omalizumab, mepolizumab, reslizumab, benralizumab, dupilumab, and tezepelumab, which were recently registered in Russia. Pharmacoeconomic analysis demonstrates a reduction in the costs of managing patients with severe asthma who receive targeted therapy despite the financial costs of its implementation. The choice of targeted drug is always a complex task that requires careful assessment of clinical, anamnestic, and laboratory parameters. In addition, monoclonal antibodies are an expensive treatment option. Currently, centers for genetically engineering biological therapies are being created to achieve effective routing and continuity in the management of these patients and to minimize financial costs. KEYWORDS: severe asthma, eosinophilic phenotype, genetically engineered biological therapy (GEBT), registry, medical commission, targeted therapy, monoclonal antibodies, type 2 immune response. FOR CITATION: Titova O.N., Volchkov V.A., Kuzubova N.A., Sklyarova D.B. Organization of medical care for patients with severe asthma requiring genetically engineered biological therapies in St. Petersburg. Russian Medical Inquiry. 2023;7(8):493–497 (in Russ.). DOI: 10.32364/2587-6821-2023-7-8-3.

Unscheduled emergency department presentations with diabetes: Identifying high risk characteristics

BackgroundUnscheduled emergency department (ED) presentation by patients with diabetes has seldom been examined. This study aimed to determine the frequency and associated characteristics of presentations in this population. MethodsUsing a prospective cross-sectional design, data were collected from patients with diabetes presenting and/or admitted to a tertiary metropolitan hospital in New South Wales, Australia (December 2016-September 2017). A screening interview including brief measures of cognitive and executive function, and clinical details from healthcare records were utilised; details around unscheduled presentations within 90 days were extracted. Independent associations with ED presentation were determined. ResultsUnscheduled ED presentations were common; 35.4% had at least one within 90 days, and for 20.1% this occurred within 28 days. The screening tool contributed little towards identifying risk of unscheduled presentation. Those attending any community or outpatient follow-up appointment within the first 28 (OR 0.42, 95% CI 0.23–0.76; p = 0.004) or 90 days (OR 0.25; 0.13–0.47; p < 0.001) from the index presentation were less likely to present within that same period. ConclusionsFindings indicated the magnitude of unscheduled ED presentation, care complexity and the value of targeted and timely follow-up. Alternative service support may help maintain and improve diabetes self-management and will require effectiveness and cost-effectiveness evaluation.

Comprehensive geriatric assessment in the emergency department: A protocol for a prospective cohort study.

Background: Comprehensive geriatric assessment (CGA) has been shown to improve outcomes in hospitalised older adults; however, there is currently no compelling evidence to support CGA interventions within the Emergency Department (ED). The aim of this study is to explore the clinical and process outcomes of older adults who receive ED-CGA over a period of six months after their initial ED attendance. Design: Prospective cohort study. Methods: The STrengthening the Reporting of the OBservational studies in Epidemiology (STROBE) standardised reporting guidelines will be adhered to. Older adults aged ≥65 years who score ≥2 on the Identification of Seniors at Risk (ISAR) tool and present to the ED with a medical complaint during the operational hours of the dedicated interdisciplinary team, will be considered eligible for recruitment. Demographic and health assessment information will be obtained at the ED index attendance followed by completion of an interdisciplinary CGA. A dedicated research nurse will complete follow-up telephone interviews with participants at 30 days and six months. The primary outcome will be incidence of hospital admission from the ED index attendance. Secondary outcomes will include functional decline, patient satisfaction with the ED index attendance, unscheduled ED reattendance(s), unscheduled hospital (re)admission(s), nursing home admission(s), healthcare utilisation, and death. Descriptive statistics will be used to profile the characteristics of the study participants and multivariate logistic and linear regression analysis will be used to analyse risk of adverse outcomes. Ethics and dissemination: Ethical approval was granted by the University of Limerick Hospital Group Research Ethics Committee (107/2021). The authors will disseminate study findings through publication in a peer-reviewed journal and presentation at national and international conferences. Patient and public involvement will be sought from a panel of older adults at the Ageing Research Centre in the University of Limerick. Clinicaltrials.gov Identifier: NCT05252182.

Comprehensive geriatric assessment in the emergency department: A protocol for a prospective cohort study

Background: Comprehensive geriatric assessment (CGA) has been shown to improve outcomes in hospitalised older adults; however, there is currently no compelling evidence to support CGA interventions within the Emergency Department (ED). The aim of this study is to explore the clinical and process outcomes of older adults who receive ED-CGA over a period of six months after their initial ED attendance. Design: Prospective cohort study. Methods: The STrengthening the Reporting of the OBservational studies in Epidemiology (STROBE) standardised reporting guidelines will be adhered to. Older adults aged ≥65 years who score ≥2 on the Identification of Seniors at Risk (ISAR) tool and present to the ED with a medical complaint during the operational hours of the dedicated interdisciplinary team, will be considered eligible for recruitment. Demographic and health assessment information will be obtained at the ED index attendance followed by completion of an interdisciplinary CGA. A dedicated research nurse will complete follow-up telephone interviews with participants at 30 days and six months. The primary outcome will be incidence of hospital admission from the ED index attendance. Secondary outcomes will include functional decline, patient satisfaction with the ED index attendance, unscheduled ED reattendance(s), unscheduled hospital (re)admission(s), nursing home admission(s), healthcare utilisation, and death. Descriptive statistics will be used to profile the characteristics of the study participants and multivariate logistic and linear regression analysis will be used to analyse risk of adverse outcomes. Ethics and dissemination: Ethical approval was granted by the University of Limerick Hospital Group Research Ethics Committee (107/2021). The authors will disseminate study findings through publication in a peer-reviewed journal and presentation at national and international conferences. Patient and public involvement will be sought from a panel of older adults at the Ageing Research Centre in the University of Limerick. Clinicaltrials.gov Identifier: NCT05252182.

Does medical disparity exist while treating severe mental illness patients with acute appendicitis in emergency departments? A real-world database study

BackgroundPatients with severe mental illness (SMI) have a shorter life expectancy and have been considered by the World Health Organization (WHO) as a vulnerable group. As the causes for this mortality gap are complex, clarification regarding the contributing factors is crucial to improving the health care of SMI patients. Acute appendicitis is one of the most common indications for emergency surgery worldwide. A higher perforation rate has been found among psychiatric patients. This study aims to evaluate the differences in appendiceal perforation rate, emergency department (ED) management, in-hospital outcomes, and in-hospital expenditure among acute appendicitis patients with or without SMI via the use of a multi-centre database.MethodsRelying on Chang Gung Research Database (CGRD) for data, we selectively used its data from January 1st, 2007 to December 31st, 2017. The diagnoses of acute appendicitis and SMI were confirmed by combining ICD codes with relevant medical records. A non-SMI patient group was matched at the ratio of 1:3 by using the Greedy algorithm. The outcomes were appendiceal perforation rate, ED treatment, in-hospital outcome, and in-hospital expenditure.ResultsA total of 25,766 patients from seven hospitals over a span of 11 years were recruited; among them, 11,513 were excluded by criteria, with 14,253 patients left for analysis. SMI group was older (50.5 vs. 44.4 years, p < 0.01) and had a higher percentage of females (56.5 vs. 44.4%, p = 0.01) and Charlson Comorbidity Index. An analysis of the matched group has revealed that the SMI group has a higher unscheduled 72-hour revisit to ED (17.9 vs. 10.4%, p = 0.01). There was no significant difference in appendiceal perforation rate, ED treatment, in-hospital outcome, and in-hospital expenditure.ConclusionsOur study demonstrated no obvious differences in appendiceal perforation rate, ED management, in-hospital outcomes, and in-hospital expenditure among SMI and non-SMI patients with acute appendicitis. A higher unscheduled 72-hour ED revisit rate prior to the diagnosis of acute appendicitis in the SMI group was found. ED health providers need to be cautious when it comes to SMI patients with vague symptoms or unspecified abdominal complaints.

Factors Associated with Unscheduled Emergency Department Revisits in Children with Acute Lower Respiratory Tract Diseases.

PurposeTo identify factors associated with unscheduled emergency department (ED) revisits within 72 hours in children with acute dyspnea from lower respiratory tract diseases.Patients and MethodsThis retrospective cohort study included pediatric patients (age group: one month to 15 years old) who visited the ED with acute lower respiratory tract diseases between January 1st, 2017 and February 28th, 2019. The medical records were reviewed and discharged patients were dichotomized into revisit and non-revisit groups, based on whether the patients needed a revisit or not. Baseline characteristics, vital signs, diagnosis, treatment, pediatrician consultation, ED length of stay, and primary doctor of both groups were compared. Univariate and multivariate analyses by logistic regression were used to determine the significant factors associated with the revisits.ResultsMedical records of 918 eligible pediatric patients (1417 visits) were reviewed. Factors significantly associated with the revisits were history of asthma or current controller use (odds ratio [OR]: 3.08: 95% confidence interval [CI]: 1.86–5.1). Not prescribing systemic corticosteroids (P < 0.001), or prescribing them upon discharge without first dose in the ED (P = 0.022) were significantly associated with revisits.ConclusionNo prescription of systemic corticosteroids or prescription upon discharge, without an immediate dose at the ED, in children with history of asthma or current controller use were associated with revisits.

Parental beliefs and practices in childhood asthma – A hospital based cross-sectional study

Childhood asthma represents a significant burden, not only in terms of morbidity and reduced quality of life but also in terms of healthcare costs, as reflected by the high rates of unscheduled emergency department visits, hospitalization, and school absenteeism. Parents play a key link in asthma management and adherence to treatment regimen in the early years of childhood before children can manage their asthma independently. However, some parents have misconceptions regarding asthma and its medication, which could in turn influence children’s control of asthma.To find out the effect of parental beliefs and practices with respect to their knowledge about etiology, folk beliefs, home remedies, alternative therapies, etiology and pharmacotherapy in childhood asthma influence the pharmacotherapy and outcome of asthma management.The hospital based cross sectional study was carried out on a convenience sample of 82 parents of children, 5-14 years of age and clinically diagnosed with asthma of any form in the Department of Pediatrics, F.M. Medical College &amp; Hospital, a tertiary care teaching hospital in Balasore town in the eastern part of India. The parents’ beliefs and practices were captured with the help of a pre-designed and validated questionnaire. Descriptive analytical statictics was used to analyse the demographic data. Chi square test was used to find out the association of beliefs, use of home remedies, folk beliefs and alternative therapies and the use of prescribed asthma medications as per standard reference. GraphPad Prism free trial version 7.0 was used for statistical analysis. Statistical significance was taken at a level of p ≤ 0.05.Majority of the children were in the age group of 10-14 years with a male predominance. Most of the primary care givers less than 40 years age and literate, 30 (36.6%) having more than two children and a family history of asthma. The common beliefs were that asthma was chest allergy, of hereditary origin. Exposure to dust, indoor smoke believed to be a significant potential triggering factor for asthma attack The participants (68.2%) believed that inhaled steroids had more side effects lead to dependency also believed using inhaler only when serious. Domiciliary treatment was preferred. 𝛽-agonist were the commonest medications.Parental beliefs and practices have a predominant role in the management of asthma in children. In order to enhance the level of perceptions among caregivers, education should include knowledge about asthma and its management, as there might be misperceptions about the use of inhalers and the safety of inhaled corticosteroids.

Characteristics of an Unscheduled Emergency Department Revisit Within 72 hours of Discharge.

BackgroundAn unscheduled emergency department (ED) revisit is defined as a patient presenting to the ED with the same problem within 72 hours of discharge. The revisits result in overcrowding and compromise the care provided by the ED. We assume that the poor quality of care provided by the ED is the reason for revisiting. However, the circumstances surrounding these revisits are not well-understood. We conducted this study to understand the characteristics associated with the revisits.ObjectivesWe aimed to identify the common causes of ED revisits within 72 hours of discharge and determine the outcome of these patients during the revisit.MethodsWe conducted a prospective observational study at a tertiary care center from July 2015 to June 2017, including patients presenting at the ED within 72 hours after their first visit. Our study selected 50 patients using a simple random sampling method and identified the leading causes of revisit as doctor-related, patient-related, and illness-related.ResultsWe found that 56% (28/50) of patients returned to the ED for illness-related reasons, 26% (13/50) for doctor-related reasons, and 18% (9/50) for patient-related reasons. In addition, we found that 62% (31/50) of patients who returned to the ED within 72 hours required in-patient admission.ConclusionThe most common cause of ED revisit was illness-related causes, and more than half of the patients during a revisit required in-patient admission. The modifiable causes of the ED revisit, such as doctor-related and patient-related factors, were discovered in this study. These findings may aid in reducing ED revisits and improving the ED quality.

Comprehensive geriatric assessment in the emergency department: A protocol for a prospective cohort study.

Background: Comprehensive geriatric assessment (CGA) has been shown to improve outcomes in hospitalised older adults; however, there is currently no compelling evidence to support CGA interventions within the Emergency Department (ED). The aim of this study is to explore the clinical and process outcomes of older adults who receive ED-CGA over a period of six months after their initial ED attendance. Design: Prospective cohort study. Methods: The STrengthening the Reporting of the OBservational studies in Epidemiology (STROBE) standardised reporting guidelines will be adhered to. Older adults aged ≥65 years who score ≥2 on the Identification of Seniors at Risk (ISAR) tool and present to the ED with a medical complaint during the operational hours of the dedicated interdisciplinary team, will be considered eligible for recruitment. Demographic and health assessment information will be obtained at the ED index attendance followed by completion of an interdisciplinary CGA. A dedicated research nurse will complete follow-up telephone interviews with participants at 30 days and six months. The primary outcome will be incidence of hospital admission from the ED index attendance. Secondary outcomes will include functional decline, patient satisfaction with the ED index attendance, unscheduled ED reattendance(s), unscheduled hospital (re)admission(s), nursing home admission(s), healthcare utilisation, and death. Descriptive statistics will be used to profile the characteristics of the study participants and multivariate logistic and linear regression analysis will be used to analyse risk of adverse outcomes. Ethics and dissemination: Ethical approval was granted by the University of Limerick Hospital Group Hospital Research Ethics Committee (107/2021). The authors will disseminate study findings through publication in a peer-reviewed journal and presentation at national and international conferences. Patient and public involvement will be sought from a panel of older adults at the Ageing Research Centre in the University of Limerick. Clinicaltrials.gov Identifier: NCT05252182.

Successful Same-Day Discharge for Robot-Assisted Radical Prostatectomy: A Systematic Review and Meta-Analysis.

Same-day discharge (SDD) following robot-assisted radical prostatectomy (RARP) is emerging as the standard of care. We conducted a systematic review and meta-analysis to evaluate the differences in perioperative characteristics, complication/readmissions rates and satisfaction/cost data between inpatient (IP) RARP and SDD RARP. This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and was prospectively registered with PROSPERO (CRD42021258848). A comprehensive search of PubMed®, Embase®, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov and conference abstract publications was performed. A leave-one-out sensitivity analysis was performed to control for heterogeneity and risk of bias. A total of 14 studies were included with a pooled population of 3,795 patients, including 2,348 (61.9%) IP RARPs and 1,447 (38.1%) SDD RARPs. SDD pathways varied, though many commonalities were present in patient selection, perioperative recommendations and postoperative management. When compared to IP RARP, SDD RARP had no differences in ≥grade 3 Clavien-Dindo complications (RR: 0.4, 95% CI 0.2, 1.1, p=0.07), 90-day readmission rates (RR: 0.6, 95% CI 0.3, 1.1, p=0.10) or unscheduled emergency department visits (RR: 1.0, 95% CI 0.3, 3.1, p=0.97). Cost savings per patient ranged between $367 and $2,109, and overall satisfaction was high at 87.5%-100%. SDD following RARP is both feasible and safe, while potentially offering health care cost savings with high patient satisfaction rates. Data from this study will inform the uptake and development of future SDD pathways in contemporary urological care such that it may be offered to a broader patient population.

The effect of coronavirus disease 2019 on asthma visits

Unscheduled emergency department (ED) and inpatient (IP) visits for pediatric asthma have been found to be decreased during coronavirus disease 2019 (COVID-19). Nevertheless, each of these reports has had their limitations. Arsenault et al1 compared asthma ED visits for 2020 with 2019 only. It is difficult to make an inference from this single-year comparison because 2019 could have been an abnormal year. Kenyon et al2 compared visits for the first 4 months of 2020 with those months from 4 previous years.

Predicting Unscheduled Emergency Department Revisits Leading to Acute Hospital Admissions Among Older Adults

Background: Unscheduled emergency department (ED) revisits leading to acute hospital admission (RVA) are tantamount to a failed discharge, associated with physician error, mis-prognosis, and inadequate care planning. Previous research has shown RVA to be associated with adverse outcomes such as ICU admissions, long hospitalizations and mortality. Given the limited impact of pre-existing screening tools for older adults, we developed and validated a machine learning model to predict individual patient risk of RVA within 72 hours and 9 days of index ED visits. Method: A machine learning model was applied to retrospective electronic health record (EHR) data of patients presenting to 2 geographically and demographically divergent urban EDs in 2019. 478 clinically meaningful EHR data variables were included: socio-demographics, ED and comorbidity diagnoses, therapeutics, laboratory test orders and test results, diagnostic imaging test orders, vital signs, and utilization and operational data. Multiple machine learning algorithms were constructed; models were compared against a pre-existing adult ED-RVA risk score as a baseline. Results: A total of 62,154 patients were included in the analysis, with 508 (0.82%) and 889 (1.4%) having 72-hour and 9-day RVA. The best-performing model, combining deep significance clustering (DICE) and regularized logistic regression, achieved AUC of 0.86 and 0.79 for 72-hour and 9-day ED-RVA for older adult patients, respectively, outperforming the pre-existing RVA risk score (0.704 and 0.694). Discussion: Machine learning models to screen for and predict older adults at high-risk for ED-RVA may be useful in directing interventions to reduce adverse events in older adults discharged from the ED.

Predictive Factors of 30-day Adverse Events in Acute Heart Failure after Discharge from Emergency Department; a Historical Cohort Study.

Introduction:The rates of unscheduled emergency department (ED) visits and readmissions after discharge from the ED in acute heart failure (AHF) patients are high. This study aimed to identify the predictive factors of 30-day adverse events after discharge from the ED. Methods: A retrospective study was conducted from 2017 to 2019 in patients diagnosed with AHF and discharged from the ED at a tertiary university hospital. Thirty-day adverse events were defined as (i) unscheduled revisit to the ED with AHF, (ii) hospital admission from AHF, and, (iii) death after discharge from the ED. The predictive factors of 30-day adverse events were examined using multivariate analyses by logistic regression. Results:421 patients with the median age of 73 (IQR: 63-81) years were studied (52.3% male). 81 (19.2%) patients had 30-day adverse events. Significant predictive factors of 30-day adverse events consisted of underlying valvular heart disease (OR = 2.46; 95%CI: 1.27-4.78; p = 0.008), chronic obstructive pulmonary disease (COPD) (OR = 0.08; 95%CI: 0.01-0.64; p=0.001), malignancy (OR=3.63; 95%CI: 1.17-11.24; p = 0.031), New York Heart Association functional class III (OR = 4.88; 95%CI: 0.93-25.59) and IV (OR = 7.23; 95% CI: 1.37-38.08) at the ED (p = 0.035), and serum sodium <135 mmol/L (OR = 2.20; 95%CI: 1.17-4.14; p = 0.014). Precipitating factors were anemia (OR = 2.42; 95%CI: 1.16-5.02; p = 0.021), progressive valvular heart disease (OR = 3.52; 95%CI: 1.35-7.85; p = 0.009), acute kidney injury (OR = 6.98; 95%CI: 2.32-20.96; p < 0.001), time to diuretic administration >60 minutes after ED arrival (OR = 3.89; 95%CI: 2.16-7.00; p < 0.001), and no discharge advice for follow-up (OR = 2.30; 95%CI: 1.10-4.77; p = 0.028). Conclusion:AHF patients who had good response to intravenous diuretics and were discharged from the ED were at high risk for 30-day adverse events. Ten factors predicted 30-day adverse events after discharge from the ED.