Antimicrobial stewardship, procalcitonin testing, and rapid blood-culture identification to optimize sepsis care in critically ill adult patients: A quality improvement initiative.

We examined the effect of an antimicrobial stewardship program (ASP), procalcitonin testing and rapid blood-culture identification on hospital mortality in a prospective quality improvement project in critically ill septic adults. Secondarily, we have reported antimicrobial guideline concordance, acceptance of ASP interventions, and antimicrobial and health-resource utilization.

Screening tools to identify patients with unmet palliative care needs in the emergency department: A systematic review.

OBJECTIVES: This systematic review identified and assessed psychometric properties of the available screening tools to identify patients with unmet palliative care (PC) needs in the emergency department (ED). METHODS: A comprehensive search of electronic databases and the gray literature was conducted. Two independent reviewers completed study screening and inclusion, data extraction, and quality assessment. A descriptive summary of the results was reported using median of medians and interquartile ranges (IQRs). RESULTS: A total of 35 studies were included, involving the assessment of 14 unique screening tools. The most commonly used screening tool was the surprise question (SQ; n = 12 studies), followed by the Palliative Care and Rapid Emergency Screening (P-CaRES) tool (n = 8), and the screening for palliative and end-of-life care needs in the emergency department (SPEED) instrument (n = 4). Twelve of the included studies reported on the psychometric properties of the screening tools, of which eight of these studies assessed the performance of the SQ to predict patient mortality. Overall, the median sensitivity (63%, IQR 38%-78%) and specificity (75%, IQR 57%-84%) of the SQ to predict mortality at 1 or 12 months was moderate. While the median positive predictive value of the SQ was low (32%, IQR 16%-40%), the median negative predictive value was high (91%, IQR 88%-95%). Across the studies, the proportion of patients identified as having unmet PC based on the criteria of the screening tools ranged from 5% to 83%. CONCLUSIONS: This review identified 14 unique screening tools used to identify adult patients with unmet PC needs in the ED. One screening tool, the SQ, was found to have moderate sensitivity and specificity to accurately predict future patient mortality. Additional research is needed to better understand the clinical value of this and the other available tools prior to their widespread implementation.

Comparison of characteristics and management of emergency department presentations between patients with met and unmet palliative care needs.

INTRODUCTION: This study examined emergency department (ED) presentations of patients with end of life (EOL) conditions and patients having met and unmet palliative care needs were compared. METHODS: Presentations for EOL conditions were prospectively identified and screened for palliative care needs. Descriptive data were reported as proportions, means or medians. Bi-variable analysis for dichotomous and continuous variables were performed by chi-squared and T-tests (p≤0.01), respectively. A multivariable logistic regression model identified factors associated with having unmet palliative needs and reported adjusted odds ratios (aOR) with 95% confidence intervals (CI). RESULTS: Overall, 663 presentations for EOL conditions were identified; 518 (78%) involved patients with unmet palliative care needs. Presentations by patients with unmet palliative needs were more likely to involve consultations (80% vs. 67%, p = 0.001) and result in hospitalization (69% vs. 51%, p<0.001) compared to patients whose palliative needs were met. Patients with unmet palliative care needs were more likely to have previous ED visits (73% unmet vs. 48% met; p<0.001). While medication, procedures, investigations and imaging ordering were high across all patients with EOL conditions, there were no significant differences between the groups. Consultations with palliative specialists in the ED (6% unmet vs. 1% met) and following discharge (29% unmet vs. 18% met) were similarly uncommon. Patients having two or more EOL conditions (aOR = 2.41; 95% CI: 1.16, 5.00), requiring hospitalization (aOR = 1.93; 95% CI: 1.30, 2.87), and dying during the ED visit (aOR = 2.15; 95% CI: 1.02, 4.53) were strongly associated with having unmet palliative care needs. CONCLUSIONS: Most ED presentations for EOL conditions were made by patients with unmet palliative care needs, who were significantly more likely to require consultation, hospitalization, and to die. Referrals to palliative care services during and after the ED visit were infrequent, indicating important opportunities to promote these services.

Correction to: Preventing emergency department visits among patients with cancer: a scoping review.

Table 2 is incorrect in the original manuscript. The correct table 2 is shown below.

Preventing emergency department visits among patients with cancer: a scoping review.

PURPOSE: The objective of this scoping review was to examine the effectiveness of supportive care interventions designed to reduce ED visits among patients receiving active cancer treatment. METHODS: Literature search involving nine electronic databases and grey literature. Inclusion criteria considered studies assessing the impact of any intervention to reduce ED utilization among patients with active cancer. Dichotomous and continuous outcomes were summarized as risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CIs) using a random-effects model, wherever appropriate. RESULTS: A total of 25 studies were included. Interventions identified in these studies comprised the following: routine and symptom-based patient follow-up, oncology outpatient clinics, early symptom detection, comprehensive inpatient management, hospital at home, and patient navigators. Six out of eight studies assessing oncology outpatient clinics reported a decrease in the proportion of patients presenting to the ED. A meta-analysis of three of these studies did not demonstrate reduction in ED utilization (RR 0.78; 95% CI 0.56 to 1.08; I2 = 77%) when comparing oncology outpatient clinics with standard care; however, sensitivity analysis supported a decrease in ED visits (RR 0.86; 95% CI 0.74 to 0.99; I2 = 47%). Three studies assessing patient follow-up interventions showed no difference in ED utilization (RR 0.69; 95% CI 0.38 to 1.25; I2 = 86%). CONCLUSION: A variety of supportive care interventions designed to mitigate ED presentations by patients receiving active cancer treatment have been developed and evaluated. Limited evidence suggests that an oncology outpatient clinic may be an effective strategy to reduce ED utilization; however, additional high-quality studies are needed.

Effectiveness of a multidisciplinary educational intervention in patients with hip fracture: SWEET HOME study. / Efectividad de una intervención educativa multidisciplinar en pacientes con fractura de fémur: estudio SWEET HOME.

BACKGROUND AND OBJECTIVE: Hip fracture is a common injury among elderly patients. The main goal of our study was to assess the effectiveness of a multidisciplinary educational intervention aimed at hip fracture patients to promote home discharges and reduce in-hospital complications. MATERIAL AND METHOD: A quasi-experimental study was performed by taking repeated measurements at hospital admission, at hospital discharge, and at both 30days and one year of discharge. Patients aged ≥65years with hip fracture who were admitted to the Orthogeriatric Service between February 2016 and January 2017 were included in the study. The educational intervention consisted in two coordinated actions: patient education administered during their hospitalization and multimodal support provided during their discharge home. RESULTS: A total of 67 patients were included in the study (77.6% of whom were women; 84.19±7,78 years old). Of these, 70.1% were discharged home, which doubles the figures recorded in the 2014-2015 period. The rate of readmission at 30days and one year of the discharge was 8.5%. At the one-year follow-up, the patient's dependence to perform basic activities of daily living was nearer to the pre-fracture level (Barthel: 86.67±19.31; 94.33±14.66), their mobility had improved in comparison with the time of discharge (Parker: 4.73±1.84; 6.73±2.76; Timed Up and Go Test: 38.29±21.27; 21.91±10.97), and their cognitive function had not worsened significantly. The patient education measures improved the patients' autonomy as perceived by the patients, the caregivers, and the healthcare providers. Satisfaction with the healthcare received was high. CONCLUSIONS: As a novelty to the already described benefits in orthogeriatric care models, this study would contribute by proving an increase of the number of patients discharged home in a safe condition.