Antiviral treatment for SARS-CoV-2 infection in the current situation: a position paper of the Spanish Society of Emergency Medicine (SEMES). / Posicionamiento de la Sociedad Española de Medicina de Urgencias y Emergencias (SEMES) ante el tratamiento antiviral frente al SARS-CoV-2 en la situación epidemiológica actual.

SUMMARY: COVID-19 continues to pose a significant threat: mortality stands at nearly twice that of influenza, and the incidence rate is growing as the population's vaccination rate decreases, particularly in Spain and other areas of Europe. Given this situation, it is vitally important know whether medical protocols are consistent and appropriately implemented by health care staff in the interest of preventing possible inefficiency or inequity. Physicians from hospital emergency departments met to study their hospitals' usual clinical practices for managing SARS-CoV-2 infection and to determine their expert opinions on the use of antiviral agents. The participating physicians then reached consensus on evidencebased recommendations for strategies that would optimize emergency treatment.

RESUMEN: Actualmente, la COVID-19 sigue representando una amenaza significativa, con una mortalidad cercana al doble de la ocasionada por la gripe y con una incidencia variable debido a una disminución en la tasa de vacunación de la población, especialmente en el contexto europeo y español. Ante este panorama, es de vital importancia comprobar que los protocolos médicos están consolidados y son debidamente implementados por los profesionales sanitarios, con la finalidad de evitar posibles ineficiencias o inequidades. A través de reuniones con profesionales de urgencias se han observado las prácticas clínicas habituales en los servicios de urgencias hospitalarios para pacientes con infección por SARS-CoV-2, con la finalidad de comprender la perspectiva de estos profesionales acerca del uso de antivirales y, tras un consenso de expertos basados en la evidencia actual, se han generado estas de recomendaciones para poder enfocar estrategias que optimicen el tratamiento de los pacientes en estos servicios.

Impact of dementia on 30-, 180-, and 365-day mortality during the first pandemic wave in older adults seen in spanish emergency departments diagnosed with or without COVID-19.

OBJECTIVES: To assess whether dementia is an independent predictor of death after a hospital emergency department (ED) visit by older adults with or without a COVID-19 diagnosis during the first pandemic wave. METHOD: We used data from the EDEN-Covid (Emergency Department and Elderly Needs during Covid) cohort formed by all patients ≥65 years seen in 52 Spanish EDs from March 30 to April 5, 2020. The association of prior history of dementia with mortality at 30, 180 and 365 d was evaluated in the overall sample and according to a COVID-19 or non COVID diagnosis. RESULTS: We included 9,770 patients aged 78.7 ± 8.3 years, 51.1% men, 1513 (15.5%) subjects with prior history of dementia and 3055 (31.3%) with COVID-19 diagnosis. 1399 patients (14.3%) died at 30 d, 2008 (20.6%) at 180 days and 2456 (25.1%) at 365 d. The adjusted Hazard Ratio (aHR) for age, sex, comorbidity, disability and diagnosis for death associated with dementia were 1.16 (95% CI 1.01-1.34) at 30 d; 1.15 at 180 d (95% CI 1.03-1.30) and 1.19 at 365 d (95% CI 1.07-1.32), p < .001. In patients with COVID-19, the aHR were 1.26 (95% CI: 1.04-1.52) at 30 days; 1.29 at 180 d (95% CI: 1.09-1.53) and 1.35 at 365 d (95% CI: 1.15-1.58). CONCLUSION: Dementia in older adults attending Spanish EDs during the first pandemic wave was independently associated with 30-, 180- and 365-day mortality. This impact was lower when adjusted for age, sex, comorbidity and disability, and was greater in patients diagnosed with COVID-19.

Analysis of the reasons for requesting HIV serology in the emergency department other than those defined in the targeted screening strategy of the "Urgències VIHgila" program and its potential inclusion in a future consensus document.

OBJECTIVE: To describe other reasons for requesting HIV serology in emergency departments (ED) other than the 6 defined in the SEMES-GESIDA consensus document (DC-SEMES-GESIDA) and to analyze whether it would be efficient to include any of them in the future. METHODS: Review of all HIV serologies performed during 2 years in 20 Catalan EDs. Serologies requested for reasons not defined by the DC-SEMES-GESIDA were grouped by common conditions, the prevalence (IC95%) of seropositivity for each condition was calculated, and those whose 95% confidence lower limit was >0.1% were considered efficient. Sensitivity analysis considered that serology would have been performed on 20% of cases attended and the remaining 80% would have been seronegative. RESULTS: There were 8044 serologies performed for 248 conditions not recommended by DC-SEMES-GESIDA, in 17 there were seropositive, and in 12 the performance of HIV serology would be efficient. The highest prevalence of detection corresponded to patients from endemic countries (7.41%, 0.91-24.3), lymphopenia (4.76%, 0.12-23.8), plateletopenia (4.37%, 1.20-10.9), adenopathy (3.45%, 0.42-11.9), meningoencephalitis (3.12%, 0.38-10.8) and drug use (2.50%, 0.68-6.28). Sensitivity analysis confirmed efficiency in 6 of them: endemic country origin, plateletopenia, drug abuse, toxic syndrome, behavioral-confusional disorder-agitation and fever of unknown origin. CONCLUSION: The DC-SEMES-GESIDA targeted HIV screening strategy in the ED could efficiently include other circumstances not previously considered; the most cost-effective would be origin from an endemic country, plateletopenia, drug abuse, toxic syndrome, behavioral-confusional-agitation disorder and fever of unknown origin.

Usefulness of combining inflammatory biomarkers and clinical scales in an emergency department to stratify risk in patients with infections. / Utilidad de la combinación de biomarcadores de respuesta inflamatoria y escalas clínicas para la estratificación del riesgo en pacientes atendidos en urgencias por sospecha de infección.

OBJECTIVES: To determine whether combining biomarkers of inflammatory response and clinical scales can improve risk stratification of patients with suspected infection in a hospital emergency department (ED). MATERIAL AND METHODS: Prospective observational study of ED patients treated for infections. We collected the following information on arrival: demographic and baseline clinical data, comorbidities, the focus of infection, and values for the following inflammatory biomarkers: leukocyte counts, and C-reactive protein, procalcitonin, and midregional proadrenomedullin (MR-proADM) concentrations. Scores on the following clinical scales were recorded based on the variables gathered: the SIRS (Systemic Inflammatory Response Syndrome) criteria, the qSOFA (Quick Sequential Organ Failure Assessment), and the NEWS (National Early Warning Score). The main outcome was a composite measure that included 30-day death or need for intensive care unit (ICU) admission. RESULTS: A total of 473 patients with a mean (SD) age of 70.3 (19.2) years were included. The majority were men (257, 54.3%). Thirty-one (6.6%) died within 30 days and 16 (3.4%) were admitted to the ICU. The composite outcome (death or ICU admission) occurred in 45 patients (9.5%). The MR-proADM concentration, with an area under the receiver operating characteristic curve of 0.739 (95% CI, 0671-0.809) was a better predictor than the other biomarkers or clinical scales, although the differences between MR-proADM and either lactate concentration or the NEWS were not significant in the comparisons (P = .064). Combining the MR-proADM concentration with any of the scales did not significantly improve risk prediction. CONCLUSION: Risk stratification of patients with infection is a key part of ED decision-making. MR-proADM concentration is superior to other biomarkers and clinical prediction scales for predicting short-term prognosis in the ED. Combining MR-proADM measurement with other scales or measures does not improve the yield.

OBJETIVO: Investigar si la combinación de biomarcadores de respuesta inflamatoria (BMRI) y escalas clínicas mejora la estratificación pronóstica de pacientes atendidos en servicios de urgencias hospitalarios (SUH) por sospecha de infección. METODO: Estudio analítico, observacional y prospectivo que incluyó pacientes con sospecha de infección atendidos en un SUH. Se recogieron variables demográficas, comorbilidades, datos clínicos a la llegada al SUH, foco de infección y los siguientes BMRI: leucocitos, proteína C reactiva, procalcitonina, lactato y región medial de la proadrenomodulina (MR-proADM). Se calcularon los valores de las escalas SIRS (síndrome de respuesta inflamatoria sistémica), qSOFA (quick Sequential Organ Failure Assessment) y NEWS (National Early Warning Score). La variable de resultado principal fue una compuesta que incluía mortalidad a 30 días o necesidad de ingreso en la unidad de cuidados intensivos (UCI). RESULTADOS: Se incluyeron 473 pacientes, con una edad media de 70 (DE 19) años y el 54,3% (257). Hubo 31 fallecimientos (6,6%) y 16 (3,4%) ingresos en UCI. La variable de resultado se produjo en 45 (9,5%) pacientes. La MR-proADM mostró la mejor área bajo la curva de la característica operativa del receptor (ABC-COR) en comparación con el resto de biomarcadores y escalas clínicas [0,739 (IC 95% 0,671-0,809)], aunque sin diferencias respecto a lactato (p = 0,144) ni a la escala NEWS (p = 0,064). Al combinar MR-proADM con los diferentes biomarcadores y escalas clínicas, no se obtuvo ninguna combinación que mejore significativamente la precisión pronóstica individual del MR-proADM. CONCLUSIONES: La estratificación del riesgo de los pacientes con infección es una cuestión clave para la toma de decisiones en los SUH. La determinación de MR-proADM supera a otros BMRI y escalas clínicas para la estratificación pronóstica de los pacientes a corto plazo en los SUH. La combinación con otros biomarcadores o escalas clínicas no mejora su capacidad pronóstica.

Value of the soluble urokinase-type plasminogen activator receptor as a predictor of prognosis in patients attended in hospital emergency departments. / Capacidad del biomarcador suPAR para estratificar el pronóstico en pacientes atendidos en servicios de urgencias hospitalarios.

OBJECTIVES: To determine the value of the soluble urokinase-type plasminogen activator receptor (suPAR) for predicting outcomes in emergency department (ED) patients. Secondary objectives were 1) to measure the predictive value of the usual decision points, 2) to identify patients at low risk for mortality who could be safely discharged from the ED, and 3) to measure the correlation between suPAR and other biomarkers. MATERIAL AND METHODS: Prospective observational cohort study of patients attended in the EDs of participating hospitals. We recorded sociodemographic variables, comorbidity, variables related to the acute episode, prognostic markers commonly used in EDs, and suPAR concentration. Outcome variables were the need for hospital admission during the index episode, ED revisits within 90 days, and 90-day mortality. RESULTS: A total of 990 patients with a median (interquartile range) age of 68 (53-81 years) were studied; 50.8% were men. The median suPAR concentration was 3.8 (2.8-6.0) ng/mL, and 112 patients (11.31%) required admission. At 90 days there were 276 revisits (27.9% of the cohort), and 47 patients (4.74%) had died. Mortality was lower (1%) in patients with suPAR concentrations less than 4 ng/mL (52.5%), and fewer of these patients revisited (24.4%) or required hospitalization (20.6%) than patients with suPAR concentrations higher than 6 ng/mL (mortality, 13.5%; revisits, 39.6%; admissions, 56.3%). A suPAR concentration over 6 ng/mL was associated with 90-day mortality and revisits (adjusted hazard ratios and 95% CIs of 4.61 [1.68-12.67] and 1.59 [1.13-2.10]), respectively. The high suPAR concentration was also associated with hospital admission (odds ratio, 1.62 [0.99-2.62]). CONCLUSION: A suPAR concentration of less than 4 ng/mL identifies patients at low risk of 90-day mortality and revisits or need for hospitalization, whereas a suPAR concentration higher than 6 ng/mL is associated with higher risk for these outcomes.

OBJETIVO: Determinar la capacidad del receptor soluble del activador del plasminógeno tipo uroquinasa (suPAR) para la estratificación pronóstica en pacientes atendidos en servicios de urgencias hospitalarios (SUH). Los objetivos secundarios son: 1) medir la capacidad de los `puntos de decisión habituales, 2) identificar una población de bajo riesgo de mortalidad que puede darse de alta de forma segura desde el SUH, y 3) medir la correlación entre suPAR y otros biomarcadores. METODO: Estudio observacional de cohortes prospectivo de pacientes atendidos en SUH. Se registraron variables sociodemográficas, de comorbilidad, datos del episodio agudo, biomarcadores de uso común en urgencias y suPAR. Las variables de resultado fueron la necesidad de ingreso en el episodio índice, reconsulta al SUH y mortalidad a los 90 días. RESULTADOS: Se incluyeron 990 pacientes, la edad fue de 68 (53-81) años, 50,8% eran hombres, la mediana de suPAR fue de 3,8 (2,8-6,0) ng/ml, 112 pacientes (11,31%) requirieron ingreso. En el seguimiento a 90 días hubo 276 reconsultas (27,9%) y 47 pacientes (4,74%) fallecieron. Los pacientes con suPAR 4 ng/ml (52,5%) tenían menor mortalidad (1%), menor reconsulta (24,4%) y menor necesidad de ingreso hospitalario (20,6%), que pacientes con suPAR 6 ng/ml (mortalidad 13,5%, reconsulta 39,6% e ingreso 56,3%). Un suPAR 6 ng/ml mostró una hazard ratio (IC 95%) ajustada de 4,61 (1,68-12,67) para predecir mortalidad a 90 días y de 1,59 (1,13-2,10) para la reconsulta, y una odds ratio de 1,62 (0,99-2,62) para la necesidad de ingreso hospitalario. CONCLUSIONES: Un valor de suPAR 4 ng/ml identifica pacientes con riesgo bajo de mortalidad a 90 días, de reconsulta y de necesidad de ingreso, mientras que los pacientes con suPAR 6 ng/ml tienen mayor mortalidad, reconsulta y necesidad de ingreso.

Short-term prognosis of polypharmacy in elderly patients treated in emergency departments: results from the EDEN project.

Background: Polypharmacy is a growing phenomenon among elderly individuals. However, there is little information about the frequency of polypharmacy among the elderly population treated in emergency departments (EDs) and its prognostic effect. This study aims to determine the prevalence and short-term prognostic effect of polypharmacy in elderly patients treated in EDs. Methods: A retrospective analysis of the Emergency Department Elderly in Needs (EDEN) project's cohort was performed. This registry included all elderly patients who attended 52 Spanish EDs for any condition. Mild and severe polypharmacy was defined as the use of 5-9 drugs and ⩾10 drugs, respectively. The assessed outcomes were ED revisits, hospital readmissions, and mortality 30 days after discharge. Crude and adjusted logistic regression analyses, including the patient's comorbidities, were performed. Results: A total of 25,557 patients were evaluated [mean age: 78 (IQR: 71-84) years]; 10,534 (41.2%) and 5678 (22.2%) patients presented with mild and severe polypharmacy, respectively. In the adjusted analysis, mild polypharmacy and severe polypharmacy were associated with an increase in ED revisits [odds ratio (OR) 1.13 (95% confidence interval (CI): 1.04-1.23) and 1.38 (95% CI: 1.24-1.51)] and hospital readmissions [OR 1.18 (95% CI: 1.04-1.35) and 1.36 (95% CI: 1.16-1.60)], respectively, compared to non-polypharmacy. Mild and severe polypharmacy were not associated with increased 30-day mortality [OR 1.05 (95% CI: 0.89-2.26) and OR 0.89 (95% CI: 0.72-1.12)], respectively. Conclusion: Polypharmacy was common among the elderly treated in EDs and associated with increased risks of ED revisits and hospital readmissions ⩽30 days but not with an increased risk of 30-day mortality. Patients with polypharmacy had a higher risk of ED revisits and hospital readmissions ⩽30 days after discharge.

Short-term prognosis of polypharmacy in elderly patients treated in emergency departments: results from the EDEN project Management elderly patients with polypharmacy is becoming a major challenge to the emergency services. The progressive aging of the population is producing a progressive increase in the number of patients treated with multiple comorbidities and chronic medications. It's well known that polypharmacy is associated with an increase in hospital admissions and health care system costs. However, the impact of polypharmacy over the risk of new visits to the emergency rooms is not well defined. Understanding the impact of polypharmacy on the frequency of new visits to the emergency room and on patient mortality is the first step to establish prevention measures for new visits, proposing improvements in chronic treatment at discharge. This study aimed to determine the prevalence and effect on short-term prognosis of polypharmacy in elderly patients treated in Emergency departments. The authors used a retrospective multipurpose registry in 52 hospitals in Spain. This study includes 25,557 patients with a mean age of 78 years. On admission, the median number of drugs was 6 (IQR: 3­9), with 10,534 (41.2%) patients taking 5­9 drugs and 5,678 (22.2%) taking ⩾10 drugs. In these patients comorbidities were associated with an increase in the number of drugs. In the patients with severe polypharmacy (⩾10 drugs), diuretics were the most frequently drugs prescribed, followed by antihypertensives and statins. The results obtained indicate that polypharmacy is a frequent phenomenon among the elderly population treated in Emergency departments, being antihypertensives the most frequently used drugs in this population. Those patients who takes ⩾10 drugs have a higher risk of new visits to the emergency room and hospital readmissions in short term period.

Epidemiological and clinical management aspects of pneumonias diagnosed in the emergency department in elderly patients in Spain: Results of the EDEN-29 study.

OBJECTIVES: To estimate the incidence of pneumonia diagnosis in elderly patients in Spanish emergency departments (ED), need for hospitalization, adverse events and predictive capacity of biomarkers commonly used in the ED. METHODS: Patients ≥65 years with pneumonia seen in 52 Spanish EDs were included. We recorded in-hospitaland 30-day mortality as adverse events, as well as intensive care unit (ICU) admission among hospitalizedpatients. Association of 10 predefined variables with adverse events was calculated and expressed as odds ratio (OR) with 95% confidence interval (CI), as well as predictive capacity of 5 commonly used biomarkers in the ED (leukocytes, hemoglobin, C-reactive protein, glucose, creatinine) was investigated using area under the receiver operating characteristic curve (AUC-ROC). RESULTS: 591 patients with pneumonia attended in the ED were included (annual incidence of 18,4 per 1000 inhabitants). A total of 78.0% were hospitalized. Overall, 30-day mortality was 14.2% and in-hospital mortality was 12.9%. Functional dependency was associated with both events (OR=4.453, 95%CI=2.361-8.400; and OR=3.497, 95%CI=1.578-7.750, respectively) as well as severe comorbidity (2.344, 1.363-4.030, and 2.463, 1.252-4.846, respectively). Admission to the ICU during hospitalization occurred in 3.5%, with no associated factors. The predictive capacity of biomarkers was only moderate for creatinine for ICU admission (AUC-ROC=0.702, 95% CI=0.536-0.869) and for leukocytes for post-discharge adverse event (0.669, 0.540-0.798). CONCLUSIONS: Pneumonia is a frequent diagnosis in elderly patients consulting in the ED. Their functional dependence and comorbidity is the factor most associated with adverse events. The biomarkers analyzed do not have a good predictive capacity for adverse events.

Predictive usefulness of qSOFA, NEWS and GYM scores in the elderly patient: EDEN-5 study.

OBJECTIVE: To analyze the prognostic accuracy of the scores NEWS, qSOFA, GYM used in hospital emergency department (ED) in the assessment of elderly patients who consult for an infectious disease. METHODS: Data from the EDEN (Emergency Department and Elderly Need) cohort were used. This retrospective cohort included all patients aged ≥65 years seen in 52 Spanish EDs during two weeks (from 1-4-2019 to 7-4-2019 and 30/3/2020 to 5/4/2020) with an infectious disease diagnosis in the emergency department. Demographic variables, demographic variables, comorbidities, Charlson and Barthel index and needed scores parameters were recorded. The predictive capacity for 30-day mortality of each scale was estimated by calculating the area under the receiver operating characteristic (ROC) curve, and sensitivity and specificity were calculated for different cut-off points. The primary outcome variable was 30-day mortality. RESULTS: 6054 patients were analyzed. Median age was 80 years (IQR 73-87) and 45.3% women. 993 (16,4%) patients died. NEWS score had better AUC than qSOFA (0.765, 95CI: 0.725-0.806, versus 0.700, 95%CI: 0.653-0.746; P < .001) and GYM (0.716, 95%CI: 0.675-0.758; P = .024), and there was no difference between qSOFA and GYM (P = .345). The highest sensitivity scores for 30-day mortality were GYM ≥ 1 point (85.4%) while the qSOFA score ≥2 points showed high specificity. In the case of the NEWS scale, the cut-off point ≥4 showed high sensitivity, while the cut-off point NEWS ≥ 8 showed high specificity. CONCLUSION: NEWS score showed the highest predictive capacity for 30-day mortality. GYM score ≥1 showed a great sensitivity, while qSOFA ≥2 scores provide the highest specificity but lower sensitivity.

Design of a panel of indicators for antibiotic stewardship programs in the Emergency Department. / Diseño de un panel de indicadores para programas de optimización del uso de antimicrobianos en los Servicios de Urgencias.

OBJECTIVE: To develop a panel of indicators to monitor antimicrobial stewardship programs activity in the emergency department. METHODS: A multidisciplinary group consisting of experts in the management of infection in emergency departments and the implementation of antimicrobial stewardship programs (ASP) evaluated a proposal of indicators using a modified Delphi methodology. In the first round, each expert classified the relevance of each proposed indicators in two dimensions (healthcare impact and ease of implementation) and two attributes (prioritization level and frequency). The second round was conducted based on the modified questionnaire according to the suggestions raised and new indicators suggested. Experts modified the prioritization order and rated the new indicators in the same manner as in the first round. RESULTS: 61 potential indicators divided into four groups were proposed: consumption indicators, microbiological indicators, process indicators, and outcome indicators. After analyzing the scores and comments from the first round, 31 indicators were classified as high priority, 25 as intermediate priority, and 5 as low priority. Moreover, 18 new indicators were generated. Following the second round, all 61 initially proposed indicators were retained, and 18 new indicators were incorporated: 11 classified as high priority, 3 as intermediate priority, and 4 as low priority. CONCLUSIONS: The experts agreed on a panel of ASP indicators adapted to the emergency services prioritized by level of relevance. This is as a helpful tool for the development of these programs and will contribute to monitoring the appropriateness of the use of antimicrobials in these units.

Feasibility of a selective targeted strategy of HIV testing in emergency departments: a before-after study.

BACKGROUND AND IMPORTANCE: The rates of hidden infection and late diagnosis of HIV still remain high in Western countries. Missed diagnostic opportunities represent the key point in changing the course of the epidemic. OBJECTIVE: To evaluate the feasibility and results of implementation of a selective strategy to test for HIV in the emergency department (ED) in patients with six pre-defined medical situations: sexually transmitted infections, herpes zoster, community-acquired pneumonia, mononucleosis syndrome, practice of chemsex (CS) or request of post-exposure prophylaxis. DESIGN: This quasi-experimental longitudinal study evaluated the pre- and post-implementation results of HIV testing in the six aforementioned clinical scenarios. SETTINGS AND PARTICIPANTS: Patients attended 34 Spanish EDs. INTERVENTION OR EXPOSURE: The intervention was an intensive educational program and pathways to facilitate and track orders and results were designed. We collected and compared pre- and post-implementation ED census and diagnoses, and HIV tests requested and results. OUTCOME MEASURES AND ANALYSIS: The main outcome was adherence to the recommendations. Secondary outcomes were to evaluate the effectiveness of the program by the rate of positive test and the new HIV diagnoses. Differences between first and second periods were assessed. The magnitude of changes (absolute and relative) was expressed with the 95% confidence interval (CI). MAIN RESULTS: HIV tests increasing from 7080 (0.42% of ED visits) to 13 436 (relative increase of 75%, 95% CI from 70 to 80%). The six conditions were diagnosed in 15 879 and 16 618 patients, and HIV testing was ordered in 3393 (21%) and 7002 (42%) patients (increase: 97%; 95% CI: 90-104%). HIV testing significantly increased for all conditions except for CS. The positive HIV test rates increased from 0.92 to 1.67%. Detection of persons with undiagnosed HIV increased from 65 to 224, which implied a 220% (95% CI: 143-322%) increase of HIV diagnosis among all ED comers and a 71% (95% CI: 30-125%) increase of positive HIV tests. CONCLUSION: Implementation of a strategy to test for HIV in selective clinical situations in the ED is feasible and may lead to a substantial increase in HIV testing and diagnoses.

Sex- and age-related patterns in the use of analgesics in older patients in the emergency department.

BACKGROUND: Treatment of acute pain in older patients is a common challenge faced in emergency departments (EDs). Despite many studies that have investigated chronic analgesic use in the elderly, data on patterns of acute use, especially in EDs, of analgesics according to patient characteristics is scarce. OBJECTIVE: To investigate sex- and age-related patterns of analgesic use in the Spanish EDs and determine differences in age-related patterns according to patient sex. DESIGN: A secondary analysis of the Emergency Department and Elderly Needs (EDEN) multipurpose cohort. SETTING: Fifty-two Spanish EDs (17% of Spanish EDs covering 25% of Spanish population). PARTICIPANTS: All patients' ≥65 years attending ED during 1 week (April 1-7, 2019). Patient characteristics recorded included age, sex, chronic treatment with non-steroidal anti-inflammatory drugs (NSAIDs) and opiates, comorbidity, dependence, dementia, depression, ability to walk and previous falls. Analgesics used in the ED were categorized in three groups: non-NSAID non-opioids (mainly paracetamol and metamizole, PM), NSAIDs, and opiates. OUTCOME MEASURES: Frequency of analgesic use was quantified, and the relationship between sex and age and analgesic use (in general and for each analgesic group) was assessed by unadjusted and adjusted logistic regression and restricted cubic spline models. Interaction between sex and age was explored. MAIN RESULTS: We included 24 573 patients, and 6678 (27.2%) received analgesics in the ED: 5551 (22.6%) PM, 1661 (6.8%) NSAIDs and 937 (3.8%) opiates (1312 received combinations). Analgesics were more frequently used in women (adjusted OR = 1.076, 95%CI = 1.014-1.142), as well as with NSAID (1.205, 1.083-1.341). Analgesic use increased with age, increasing PM and decreasing NSAIDs use. Opiate use remained quite constant across age and sex. Interaction of sex with age was present for the use of analgesics in general ( P  = 0.006), for PM ( P  < 0.001) and for opiates ( P  = 0.033), with higher use of all these analgesics in women. CONCLUSION: Use of analgesics in older individuals in EDs is mildly augmented in women and increases with age, with PM use increasing and NSAIDs decreasing with age. Conversely, opiate use is quite constant according to sex and age. Age-related patterns differ according to sex, with age-related curves of women showing higher probabilities than those of men to receive any analgesic, PM or opiates.

Impact of First Wave of COVID-19 Pandemic on Mortality at Emergency Department in Older Patients with COVID and Non-COVID Diagnoses.

INTRODUCTION: Mortality in emergency departments (EDs) is not well known. This study aimed to assess the impact of the first-wave pandemic on deaths accounted in the ED of older patients with COVID and non-COVID diseases. METHODS: We used data from the Emergency Department and Elderly Needs (EDEN) cohort (pre-COVID period) and from the EDEN-COVID cohort (COVID period) that included all patients ≥65 years seen in 52 Spanish EDs from April 1 to 7, 2019, and March 30 to April 5, 2020, respectively. We recorded patient characteristics and final destination at ED. We compared older patients in the pre-COVID period, with older patients with non-COVID and with COVID-19. ED-mortality (before discharge or hospitalization) is the prior outcome and is expressed as an adjusted odds ratio (aOR) with 95% interval confidence. RESULTS: We included 23,338 older patients from the pre-COVID period (aged 78.3 [8.1] years), 6,715 patients with non-COVID conditions (aged 78.9 [8.2] years) and 3,055 with COVID (aged 78.3 [8.3] years) from the COVID period. Compared to the older patients, pre-COVID period, patients with non-COVID and with COVID-19 were more often male, referred by a doctor and by ambulance, with more comorbidity and disability, dementia, nursing home, and more risk according to qSOFA, respectively (p < 0.001). Compared to the pre-COVID period, patients with non-COVID and with COVID-19 were more often to be hospitalized from ED (24.8% vs. 44.3% vs. 79.1%) and were more often to die in ED (0.6% vs. 1.2% vs. 2.2%), respectively (p < 0.001). Compared to the pre-COVID period, aOR for age, sex, comorbidity and disability, ED mortality in elderly patients cared in ED during the COVID period was 2.31 (95% confidence interval [CI]: 1.76-3.06), and 3.75 (95% CI: 2.77-5.07) for patients with COVID. By adding the variable qSOFA to the model, such OR were 1.59 (95% CI: 1.11-2.30) and 2.16 (95% CI: 1.47-3.17), respectively. CONCLUSIONS: During the early first pandemic wave of COVID-19, more complex and life-threatening older with COVID and non-COVID diseases were seen compared to the pre-COVID period. In addition, the need for hospitalization and the ED mortality doubled in non-COVID and tripled in COVID diagnosis. This increase in ED mortality is not only explained by the complexity or severity of the elderly patients but also because of the system's overload.

[Translated article] Design of a panel of indicators for antibiotic stewardship programs in the Emergency Department.

OBJECTIVE: To develop a panel of indicators to monitor antimicrobial stewardship programs activity in the emergency department. METHODS: A multidisciplinary group consisting of experts in the management of infection in emergency departments and the implementation of antimicrobial stewardship programs (ASP) evaluated a proposal of indicators using a modified Delphi methodology. In the first round, each expert classified the relevance of each proposed indicators in two dimensions (healthcare impact and ease of implementation) and two attributes (prioritisation level and frequency). The second round was conducted based on the modified questionnaire according to the suggestions raised and new indicators suggested. Experts modified the prioritisation order and rated the new indicators in the same manner as in the first round. RESULTS: 61 potential indicators divided into four groups were proposed: consumption indicators, microbiological indicators, process indicators, and outcome indicators. After analysing the scores and comments from the first round, 31 indicators were classified as high priority, 25 as intermediate priority, and 5 as low priority. Moreover, 18 new indicators were generated. Following the second round, all 61 initially proposed indicators were retained, and 18 new indicators were incorporated: 11 classified as high priority, 3 as intermediate priority, and 4 as low priority. CONCLUSIONS: The experts agreed on a panel of ASP Indicators adapted to the emergency services prioritised by level of relevance. This is as a helpful tool for the development of these programs and will contribute to monitoring the appropriateness of the use of antimicrobials in these units.

Influence of income on in-hospital mortality in older adults during the first wave of the COVID-19 pandemic: results from the EDEN-33 study. / Influencia de la renta económica en la mortalidad intrahospitalaria de las personas mayores durante la primera ola de la pandemia por COVID-19: resultados del estudio EDEN-33.

OBJECTIVES: To determine whether income was associated with unexpected in-hospital mortality in older patients treated in Spanish public health system hospital emergency departments. MATERIAL AND METHODS: Fifty-one public health system hospital emergency departments in Spain voluntarily participated in the study. Together the hospitals covered 25% of the population aged 65 years or older included in all patient registers during a week in the pre-pandemic period (April 1-7, 2019) and a week during the COVID-19 pandemic (March 30 to April 5, 2020). We estimated a patient's gross income as the amount published for the postal code of the patient's address. We then calculated the standardized gross income (SGI) by dividing the patient's estimated income by the mean for the corresponding territory (Spanish autonomous community). The existence and strength of an association between the SGI and in-hospital mortality was evaluated by means of restricted cubic spline (RCS) curves adjusted for 10 patient characteristics at baseline. Odds ratios (ORs) for each income level were expressed in relation to a reference SGI of 1 (the mean income for the corresponding autonomous community). We compared the COVID-19 and pre-pandemic periods by means of first-order interactions. RESULTS: Of the 35 280 patients attended in the 2 periods, gross income could be ascertained for 21 180 (60%), 15437 in the pre-pandemic period and 5746 during the COVID-19 period. SGIs were slightly higher for patients included before the pandemic (1.006 vs 0.994; P = .012). In-hospital mortality was 5.6% overall and higher during the pandemic (2.8% pre-pandemic vs 13.1% during COVID-19; P .001). The adjusted RCS curves showed that associations between income and mortality differed between the 2 periods (interaction P = .004). Whereas there were no significant income-influenced differences in mortality before the pandemic, mortality increased during the pandemic in the lowest-income population (SGI 0.5 OR, 1.82; 95% CI, 1.32-3.37) and in higher-income populations (SGI 1.5 OR, 1.32; 95% CI, 1.04-1.68, and SGI 2 OR, 1.92; 95% CI, 1.14-3.23). We found no significant differences between patients with COVID-19 and those with other diagnoses (interaction P = .667). CONCLUSION: The gross income of patients attended in Spanish public health system hospital emergency departments, estimated according to a patient's address and postal code, was associated with in-hospital mortality, which was higher for patients with the lowest and 2 higher income levels. The reasons for these associations might be different for each income level and should be investigated in the future.

OBJETIVO: Determinar si el nivel económico durante la primera ola pandémica tuvo una influencia diferente a la esperable en la mortalidad intrahospitalaria de los pacientes mayores atendidos en los servicios de urgencias (SU) de los hospitales públicos españoles. METODO: Cincuenta y un SU públicos españoles que participaron voluntariamente y que dan cobertura al 25% de la población incluyeron todos los registros de pacientes de edad 65 años atendidos durante una semana del periodo preCOVID (1-4-2019 a 7-4-2019) y una semana del periodo COVID (30-3-2020 a 5-4-2020). Se identificó la renta bruta (RB) asignada al código postal de residencia de cada paciente y se calculó la RB normalizada (RBN) dividiendo aquella por la RB media de su comunidad autónoma. La existencia y fuerza de la relación entre RBN y mortalidad intrahospitalaria se determinó mediante curvas spline cúbicas restringidas (SCR) ajustadas por 10 características basales del paciente. Las OR para cada situación económica se expresó en relación con una RBN de 1 (referencia, renta correspondiente a la media de la comunidad autónoma). La comparación entre periodo COVID y no COVID se realizó mediante el estudio de interacción de primer grado. RESULTADOS: De los 35.280 registros de pacientes atendidos en ambos periodos, se disponía de la RB en 21.180 (60%): 15.437 del periodo preCOVID y 5.746 del periodo COVID. La RBN de los pacientes incluidos fue discretamente superior en el periodo preCOVID (1,006 versus 0,994; p = 0,012). La mortalidad intrahospitalaria fue del 5,6%, y fue superior durante el periodo COVID (2,8% versus 13,1%; p 0,001). Las curvas SCR ajustadas mostraron una asociación entre nivel económico y mortalidad diferente entre ambos periodos (p interacción = 0,004): en el periodo preCOVID no hubo diferencias significativas de mortalidad en función de la RBN, mientras que en el periodo COVID la mortalidad se incrementó en rentas bajas (OR = 1,82, IC 95% = 1,32-3,37 para RBN de 0,5) y en rentas altas (OR = 1,32, IC 95% = 1,04-1,68 y OR = 1,92, IC 95% = 1,14-3,23 para RBN de 1,5 y 2, respectivamente), sin diferencias significativas entre pacientes con COVID y con otros diagnósticos (p interacción = 0,667). CONCLUSIONES: Durante la primera ola de la pandemia COVID, la RB asignada al código postal de residencia de los pacientes atendidos en los SU públicos españoles se asoció con la mortalidad intrahospitalaria, que aumentó en pacientes de rentas bajas y altas. Las razones de estas asociaciones pueden ser distintas para cada segmento económico y deben ser investigadas en el fututo.

Factors related to bladder catheterization in older patients and its possible association with prognosis: results of the EDEN-30 study. / Factores relacionados con la práctica de sondaje vesical en urgencias en pacientes ancianos y su relación con el pronóstico: resultados del estudio EDEN-30.

OBJECTIVES: The aims of this study in the Emergency Department and Elder Needs (EDEN) series were to explore associations between clinical variables on arrival at the ED (baseline) and the insertion of a bladder catheter, and the relation between catheterization and deterioration to a more complex or serious clinical state. MATERIAL AND METHODS: Included were all patients aged 65 years or older attended during 1 week in 52 Spanish EDs. Patients were grouped according to whether a bladder catheter was or was not inserted in the ED. We used multivariable logistical regression to explore associations between catheterization and patient age, sex, 10 comorbidities, 7 baseline status variables, and 6 clinical variables. Progression was considered serious or complex if the patient died or required hospitalization, a prolonged hospital stay, or discharge to a care facility. We also explored the association between age and catheterization using adjusted restricted cubic spline (RCS) curves with a cutoff value of 65 years. RESULTS: Participating hospitals enrolled 24 573 patients; bladder catheters were inserted in 976 (4%). Of these, 44.3% were discharged from the ED. Fifteen of the 24 variables were independently associated with bladder catheterization. Factors with the strongest associations according to odds ratios (ORs) were impaired consciousness (OR, 2.50; 95% CI, 1.90-3.30), dehydration (OR, 2.24; 95% CI, 1.85-2.72), and male sex (OR, 2.12; 95% CI, 1.84- 2.44). Age 80 years or older was also associated with bladder catheterization (OR, 1.17; 95% CI, 1.01-1.358). The adjusted RCS curves showed a progressive linear increase in the probability of catheterization with age. The increase was constant in men and stabilized after the age of 85 years in women (P-interaction .001). Bladder catheterization was associated with hospitalization (OR, 2.31; 95% CI, 1.99-2.68), intensive care unit admission (OR, 4.64; 95% CI, 3.04-7.09), prolonged stay in the ED for discharged patients (OR, 2.28; 95% CI, 1.75-2.96), in-hospital death (OR, 1.99; 95% CI, 1.54-2.57), and 30-day death (OR, 1.66; 95% CI, 1.33-2.08). No associations were found between catheterization and prolonged hospital stay (OR, 1.11; 95% CI, 0.92-1.34) or need for a care facility on discharge (OR, 1.50; 95% CI, 0.98-2.29). CONCLUSION: Certain patient characteristics and baseline clinical conditions are associated with bladder catheterization in patients of advanced age. The main factors were decreased consciousness, dehydration, and male sex. Even after adjustment for related factors, catheterization is independently associated with progression to more complex or serious clinical states.

OBJETIVO: Estudiar las variables de estado basal y de situación clínica a la llegada a urgencias relacionadas con la práctica de sondaje vesical (SV) en pacientes mayores, y si el SV está asociado a una evolución más compleja o grave. METODO: Se incluyeron todos los pacientes de edad 65 años atendidos durante una semana en 52 servicios de urgencias (SU) españoles, que fueron clasificados en función de si se practicó o no SV en el SU. Se investigó la relación de SV con edad, sexo, 10 variables de comorbilidad, 7 de estado basal y 6 de situación clínica mediante un modelo de regresión logística multivariable. Se consideró la evolución como grave o compleja si existió necesidad de hospitalización, estancia prolongada, necesidad de residencia al alta o muerte. La relación entre edad y SV se exploró también mediante curvas spline cúbicas restringidas (SCR) ajustadas, tomando la edad de 65 años como referencia. RESULTADOS: Se incluyeron 24.573 pacientes, de los que 976 (4%) recibieron SV. De éstos, el 44,3% fueron dados de alta desde urgencias. De las 25 variables exploradas, 15 se relacionaron independientemente con el SV, y las más manifiestas fueron disminución de consciencia (OR = 2,50, IC 95% = 1,90-3,30), deshidratación (OR = 2,24, IC 95% = 1,85-2,72) y sexo masculino (OR = 2,12, IC 95% = 1,84-2,44). La edad 80 años también se asoció a SV (OR = 1,17, IC 95% = 1,01-1,358), y las curvas SCR ajustadas mostraron un incremento progresivo y lineal de la probabilidad de SV con la edad, constante en hombres y que se estabilizaba a partir de los 85 años en mujeres (p interacción 0,001). El SV se asoció a necesidad de hospitalización (OR = 2,31, IC 95% = 1,99-2,68), hospitalización en intensivos (OR = 4,64, IC 95% = 3,04-7,09), estancia prolongada en urgencias en los pacientes dados de alta (OR = 2,28, IC 95% = 1,75-2,96) y mortalidad intrahospitalaria (OR = 1,99, IC 95% = 1,54-2,57) y a 30 días (OR=1,66, IC 95% = 1,33-2,08), pero no con hospitalización prolongada (OR = 1,11, IC 95% = 0,92-1,34) ni con necesidad de residencia al alta (OR = 1,50, IC 95% = 0,98-2,29). CONCLUSIONES: Determinadas características del paciente mayor y de su estado clínico se asocian con realizar un SV en urgencias, entre las que destacan la disminución de consciencia, la deshidratación y el sexo masculino. Aun teniendo en cuenta los factores asociados a SV en urgencias, este procedimiento se asocia independientemente con evoluciones más complejas o graves.

[Impacto de la dependencia funcional de los pacientes mayores atendidos en los servicios de Urgencias españoles durante la primera ola pandémica de la COVID-19 sobre la mortalidad a 30, 180 y 365 días en función del diagnóstico (COVID versus no COVID).] / Impact of functional dependency of elderly patients seen in Spanish emergency departments during the first wave of the COVID-19 pandemic on mortality at 30, 180 and 365 days depending on the diagnosis (COVID versus non-COVID).

OBJECTIVE: Functional assessment is part of geriatric assessment. How it is performed in hospital Emergency Departments (ED) is poorly understood, let alone its prognostic value. The aim of this paper was to investigate whether baseline disability to perform basic activities of daily living (BADL) was an independent prognostic factor for death after the index visit to the ED during the first wave of the COVID-19 pandemic and whether it had a different impact on patients with and without diagnosis of COVID-19. METHODS: A retrospective observational study of the EDEN-Covid (Emergency Department and Elder Needs during COVID) cohort was carried out, consisting of all patients aged ≥65 years seen in 52 Spanish EDs selected by chance during 7 consecutive days (30/3/2020 to 5/4/2020). Demographic, clinical, functional, mental and social variables were analyzed. Dependence was categorized with the Barthel index (BI) as independent (BI=100), mild-moderate dependence (100>BI>60) and severe-total dependence (BI<60), and their crude and adjusted association was evaluated with mortality at 30, 180 and 365 days using COX proportional hazards models. RESULTS: Of 9,770 enrolled patients with a mean age of 79 years, 51% were men, 6,305 (64.53%) were independent, 2,340 (24%) had mild-moderate dependence, and 1,125 (11.5%) severe-total dependence. The number of deaths at 30 days in these three groups was 500 (7.9%), 521 (22.3%) and 378 (33.6%), respectively; at 180 days it was 757 (12%), 725 (30.9%) and 526 (46.8%); and at 365 days 954 (15.1%), 891 (38.1%) and 611 (54.3%). In relation to independent patients, the adjusted risks (hazard ratio) of dying within 30 days associated with mild-moderate and severe-total dependency were 1.91 (95% CI: 1.66-2.19) and 2.51. (2.11-2.98); at 180 days they were 1.88 (1.68-2.11) and 2.64 (2.28-3.05); and at 365 days they were 1.82 (1.64-2.02) and 2.47 (2.17-2.82). This negative impact of dependency on mortality was greater in patients diagnosed with COVID-19 than in non-COVID-19 (p interaction at 30, 180 and 365 days of 0.36, 0.05 and 0.04). CONCLUSIONS: The functional dependence of older patients who attend Spanish EDs during the first wave of the pandemic is associated with mortality at 30, 180 and 365 days, and this risk is significantly higher in patients treated for COVID-19.

OBJETIVO: La valoración funcional forma parte de la valoración geriátrica. No se conoce bien cómo se realiza en los servicios de Urgencias hospitalarios (SUH) y menos aún su valor pronóstico. El objetivo de este trabajo fue investigar si la dependencia funcional basal para realizar las actividades básicas de la vida diaria (ABVD) era un factor pronóstico independiente de muerte tras la visita índice al SUH durante la primera ola pandémica de la COVID-19 y si tuvo un impacto diferente en pacientes con y sin diagnóstico de COVID-19. METODOS: Se realizó un estudio observacional retrospectivo de la cohorte EDEN-Covid (Emergency Department and Elder Needs during COVID) formada por todos los pacientes de edad mayor o igual a 65 años atendidos en 52 SUH españoles, seleccionados por oportunidad durante siete días consecutivos (del 30 de marzo al 5 de abril de 2020). Se analizaron variables demográficas, clínicas, funcionales, mentales y sociales. La dependencia se categorizó con el índice de Barthel (IB) en independiente (IB=100), dependencia leve-moderada (100>IB>60) y dependencia grave-total (IB<60), y se evaluó su asociación cruda y ajustada con la mortalidad a 30, 180 y 365 días mediante modelos de riesgos proporcionales de COX. RESULTADOS: De 9.770 pacientes incluidos con una media de edad de 79 años, un 51% eran hombres, 6.305 (64,53%) eran independientes, 2.340 (24%) tenían dependencia leve-moderada y 1.125 (11,5%) dependencia grave-total. El número de fallecidos a 30 días en estos tres grupos fue 500 (7,9%), 521 (22,3%) y 378 (33,6%), respectivamente; a 180 días fue 757 (12%), 725 (30,9%) y 526 (46,8%); y a 365 días 954 (15,1%), 891 (38,1%) y 611 (54,3%). En relación a los pacientes independientes, los riesgos (hazard ratio) ajustados de fallecer a 30 días, asociados a dependencia leve-moderada y grave-total, fueron 1,91 (IC 95%: 1,66-2,19) y 2,51 (2,11-2,98); a 180 días fueron de 1,88 (1,68-2,11) y 2,64 (2,28-3,05); y a 365 días fueron 1,82 (1,64-2,02) y 2,47 (2,17-2,82). Este impacto negativo de la dependencia sobre la mortalidad fue mayor en pacientes diagnosticados de COVID-19 que en los no COVID-19 (p interacción a 30, 180 y 365 días de 0,36, 0,05 y 0,04). CONCLUSIONES: La dependencia funcional de los pacientes mayores que acuden a SUH españoles durante la primera ola pandémica se asocia a mortalidad a 30, 180 y 365 días, y este riesgo es significativamente mayor en los pacientes atendidos por COVID-19.

Are there differences in the relationship between respiratory rate and oxygen saturation between patients with COVID-19 and those without COVID-19? Insights from a cohort-based correlational study.

BACKGROUND: Physicians have observed patients with COVID-19 without respiratory distress despite marked hypoxaemia and extensive radiographic abnormalities, a controversial phenomenon called 'silent hypoxaemia'. We aimed to compare the relationship between RR and peripheral oxygen saturation (SpO2) in patients with COVID-19 versus patients without COVID-19 when breathing air on admission. METHODS: We conducted a retrospective multicentre ED cohort correlational study.We used the Spanish Investigators on Emergency Situations TeAm network cohort of patients with COVID-19 admitted to 61 Spanish EDs between March and April 2020. The non-COVID-19 cohort included patients with lower respiratory tract bacterial infections admitted between January 2016 and April 2018.We built a multivariable linear model to investigate the independent predictive factors related to RR and a logistic multivariate regression model to analyse the presence of 'silent hypoxaemia'. RESULTS: We included 1094 patients with COVID-19 and 477 patients without COVID-19. On admission, RR was lower (20±7 vs 24±8/min, p<0.0001), while SpO2 higher (95±5% vs 90±7%, p<0.0001) in patients with COVID-19 versus patients without COVID-19. RR was negatively associated with SpO2 (RR decreasing with increasing age, beta=-0.37, 95% CI (-0.43; -0.31), p<0.0001), positively associated with age (RR increasing with increasing age, beta=0.05, 95% CI (0.03; 0.07), p<0.0001) and negatively associated with COVID-19 status (RR lower in patients with COVID-19, beta=-1.90, 95% CI (-2.65; -1.15), p<0.0001). The negative RR/SpO2 correlation differed between patients with COVID-19 aged <80 and ≥80 years old (p=0.04). Patients with COVID-19 aged ≥80 years old had lower RR than patients without COVID-19 aged ≥80 years old at SpO2 values <95% (22±7 vs 24±8/min, p=0.004). 'Silent hypoxaemia' defined as RR <20/min with SpO2 <95% was observed in 162 (14.8%) patients with COVID-19 and in 79 (16.6%) patients without COVID-19 (p=0.4). 'Silent hypoxaemia' was associated with age ≥80 years (OR=1.01 (1.01; 1.03), p<0.0001) but not with gender, comorbidities and COVID-19 status. CONCLUSION: The RR/SpO2 relationship before oxygen administration does not differ between patients with COVID-19 and those without COVID-19, except in elderly patients.