A novel scale for triage assessment of frailty in the emergency department (ED-FraS): a prospective videotaped study.

BACKGROUND: Rapid recognition of frailty in older patients in the ED is an important first step toward better geriatric care in the ED. We aimed to develop and validate a novel frailty assessment scale at ED triage, the Emergency Department Frailty Scale (ED-FraS). METHODS: We conducted a prospective cohort study enrolling adult patients aged 65 years or older who visited the ED at an academic medical center. The entire triage process was recorded, and triage data were collected, including the Taiwan Triage and Acuity Scale (TTAS). Five physician raters provided ED-FraS levels after reviewing videos. A modified TTAS (mTTAS) incorporating ED-FraS was also created. The primary outcome was hospital admission following the ED visit, and secondary outcomes included the ED length of stay (EDLOS) and total ED visit charges. RESULTS: A total of 256 patients were included. Twenty-seven percent of the patients were frail according to the ED-FraS. The majority of ED-FraS was level 2 (57%), while the majority of TTAS was level 3 (81%). There was a weak agreement between the ED-FraS and TTAS (kappa coefficient of 0.02). The hospital admission rate and charge were highest at ED-FraS level 5 (severely frail), whereas the EDLOS was longest at level 4 (moderately frail). The area under the Receiver Operating Characteristic curve (AUROC) in predicting hospital admission for the TTAS, ED-FraS, and mTTAS were 0.57, 0.62, and 0.63, respectively. The ED-FraS explained more variation in EDLOS (R2 = 0.096) compared with the other two methods. CONCLUSIONS: The ED-Fras tool is a simple and valid screening tool for identifying frail older adults in the ED. It also can complement and enhance ED triage systems. Further research is needed to test its real-time use at ED triage internationally.

Acute exacerbation of chronic obstructive pulmonary disease in United States emergency departments, 2010-2018.

OBJECTIVES: Little is known about the recent status of acute exacerbation of chronic obstructive pulmonary disease (AECOPD) in the U.S. emergency department (ED). This study aimed to describe the disease burden (visit and hospitalization rate) of AECOPD in the ED and to investigate factors associated with the disease burden of AECOPD. METHODS: Data were obtained from the National Hospital Ambulatory Medical Care Survey (NHAMCS), 2010-2018. Adult ED visits (aged 40 years or above) with AECOPD were identified using International Classification of Diseases codes. Analysis used descriptive statistics and multivariable logistic regression accounting for NHAMCS's complex survey design. RESULTS: There were 1,366 adult AECOPD ED visits in the unweighted sample. Over the 9-year study period, there were an estimated 7,508,000 ED visits for AECOPD, and the proportion of AECOPD visits in the entire ED population remained stable at approximately 14 per 1,000 visits. The mean age of these AECOPD visits was 66 years, and 42% were men. Medicare or Medicaid insurance, presentation in non-summer seasons, the Midwest and South regions (vs. Northeast), and arrival by ambulance were independently associated with a higher visit rate of AECOPD, whereas non-Hispanic black or Hispanic race/ethnicity (vs. non-Hispanic white) was associated with a lower visit rate of AECOPD. The proportion of AECOPD visits that were hospitalized decreased from 51% to 2010 to 31% in 2018 (p = 0.002). Arrival by ambulance was independently associated with a higher hospitalization rate, whereas the South and West regions (vs. Northeast) were independently associated with a lower hospitalization rate. The use of antibiotics appeared to be stable over time, but the use of systemic corticosteroids appeared to increase with near statistical significance (p = 0.07). CONCLUSIONS: The number of ED visits for AECOPD remained high; however, hospitalizations for AECOPD appeared to decrease over time. Some patients were disproportionately affected by AECOPD, and certain patient and ED factors were associated with hospitalizations. The reasons for decreased ED admissions for AECOPD deserve further investigation.

Rigid-to-Flexible Transition in a Molecular Brush in a Good Solvent at a Semidilute Concentration.

The structures of a molecular brush in a good solvent are investigated using synchrotron small-angle X-ray scattering in a wide range of concentrations. The brush under study, PiPOx239-g-PnPrOx14, features a relatively long poly(2-isopropenyl-2-oxazoline) (PiPOx) backbone and short poly(2-n-propyl-2-oxazoline) (PnPrOx) side chains. As a solvent, ethanol is used. By model fitting, the overall size and the persistence length as well as the interaction length and interaction strength are determined. At this, the interplay between form and structure factor is taken into account. The conformation of the molecular brush is traced upon increasing the solution concentration, and a rigid-to-flexible transition is found near the overlap concentration. Finally, the results of computer simulations of the molecular brush solutions confirm the experimental results.

Pain trajectories in the emergency department: Patient characteristics and clinical outcomes.

BACKGROUND: Little is known about pain trajectories in the emergency department (ED), which could inform the heterogeneous response to pain treatment. We aimed to identify clinically relevant subphenotypes of pain resolution in the ED and their relationships with clinical outcomes. METHODS: This retrospective cohort study used electronic clinical warehouse data from a tertiary medical center. We retrieved data from 733,398 ED visits over a 7-year period. We selected one ED visit per person and retrieved data including patient demographics, triage data, repeated pain scores evaluated on a numeric rating scale, pain characteristics, laboratory markers, and patient disposition. The primary outcome measures were hospitalization and ED revisit. RESULTS: 28,105 adult ED patients were included with a total of 154,405 pain measurements. Three distinct pain trajectory groups were identified: no pain (57.1%); moderate-to-severe pain, fast resolvers (17.9%); and moderate pain, slow resolvers (24.9%). The fast resolvers responded well to treatment and were independently associated with a lower risk of hospitalization (adjusted odds ratio [aOR], 0.75; 95% confidence interval [CI], 0.70-0.81). By contrast, the slow resolvers had lingering pain in the ED and were independently associated with a higher risk of ED revisit (aOR, 2.65; 95%CI, 1.85-3.69). This group also had higher levels of inflammatory markers, including a higher leukocyte count and a higher level of C-reactive protein. CONCLUSIONS: We identified three novel pain subphenotypes with distinct patterns in clinical characteristics and patient outcomes. A better understanding of the pain trajectories may help with the personalized approach to pain management in the ED.

All-In-One "Schizophrenic" Self-Assembly of Orthogonally Tuned Thermoresponsive Diblock Copolymers.

Smart, fully orthogonal switching was realized in a highly biocompatible diblock copolymer system with variable trigger-induced aqueous self-assembly. The polymers are composed of nonionic and zwitterionic blocks featuring lower and upper critical solution temperatures (LCSTs and UCSTs). In the system investigated, diblock copolymers from poly( N-isopropyl methacrylamide) (PNIPMAM) and a poly(sulfobetaine methacrylamide), systematic variation of the molar mass of the latter block allowed for shifting the UCST of the latter above the LCST of the PNIPMAM block in a salt-free condition. Thus, successive thermal switching results in "schizophrenic" micellization, in which the roles of the hydrophobic core block and the hydrophilic shell block are interchanged depending on the temperature. Furthermore, by virtue of the strong electrolyte-sensitivity of the zwitterionic polysulfobetaine block, we succeeded to shift its UCST below the LCST of the PNIPMAM block by adding small amounts of an electrolyte, thus inverting the pathway of switching. This superimposed orthogonal switching by electrolyte addition enabled us to control the switching scenarios between the two types of micelles (i) via an insoluble state, if the LCST-type cloud point is below the UCST-type cloud point, which is the case at low salt concentrations or (ii) via a molecularly dissolved state, if the LCST-type cloud point is above the UCST-type cloud point, which is the case at high salt concentrations. Systematic variation of the block lengths allowed for verifying the anticipated behavior and identifying the molecular architecture needed. The versatile and tunable self-assembly offers manifold opportunities, for example, for smart emulsifiers or for sophisticated carrier systems.

The incidence, predictors, and causes of cardiac arrest in United States emergency departments.

Background: Emergency department cardiac arrest (EDCA) is a global public health challenge associated with high mortality rates and poor neurological outcomes. This study aimed to describe the incidence, risk factors, and causes of EDCA during emergency department (ED) visits in the U.S. Methods: This retrospective cohort study used data from the 2019 Nationwide Emergency Department Sample (NEDS). Adult ED visits with EDCA were identified using the cardiopulmonary resuscitation code. We used descriptive statistics and multivariable logistic regression, considering NEDS's complex survey design. The primary outcome measure was EDCA incidence. Results: In 2019, there were approximately 232,000 ED visits with cardiac arrest in the U.S. The incidence rate of EDCA was approximately 0.2%. Older age, being male, black race, low median household income, weekend ED visits, having Medicare insurance, and ED visits in non-summer seasons were associated with a higher risk of EDCA. Hispanic race was associated with a lower risk of EDCA. Certain comorbidities (e.g., diabetes and cancer), trauma centers, hospitals with a metropolitan and/or teaching program, and hospitals in the South were associated with a higher risk of EDCA. Depression, dementia, and hypothyroidism were associated with a lower risk of EDCA. Septicemia, acute myocardial infarction, and respiratory failure, followed by drug overdose, were the predominant causes of EDCA. Conclusions: Some patients were disproportionately affected by EDCA. Strategies should be developed to target these modifiable risk factors, specifically factors within ED's control, to reduce the subsequent disease burden.

Prospective study of pain and patient outcomes in the emergency department: a tale of two pain assessment methods.

BACKGROUND: Accurate pain assessment is essential in the emergency department (ED) triage process. Overestimation of pain intensity, however, can lead to unnecessary overtriage. The study aimed to investigate the influence of pain on patient outcomes and how pain intensity modulates the triage's predictive capabilities on these outcomes. METHODS: A prospective observational cohort study was conducted at a tertiary care hospital, enrolling adult patients in the triage station. The entire triage process was captured on video. Two pain assessment methods were employed: (1) Self-reported pain score in the Taiwan Triage and Acuity Scale, referred to as the system-based method; (2) Five physicians independently assigned triage levels and assessed pain scores from video footage, termed the physician-based method. The primary outcome was hospitalization, and secondary outcomes included ED length of stay (EDLOS) and ED charges. RESULTS: Of the 656 patients evaluated, the median self-reported pain score was 4 (interquartile range, 0-7), while the median physician-rated pain score was 1.5 (interquartile range, 0-3). Increased self-reported pain severity was not associated with prolonged EDLOS and increased ED charges, but a positive association was identified with physician-rated pain scores. Using the system-based method, the predictive efficacy of triage scales was lower in the pain groups than in the pain-free group (area under the receiver operating curve, [AUROC]: 0.615 vs. 0.637). However, with the physician-based method, triage scales were more effective in predicting hospitalization among patients with pain than those without (AUROC: 0.650 vs. 0.636). CONCLUSIONS: Self-reported pain seemed to diminish the predictive accuracy of triage for hospitalization. In contrast, physician-rated pain scores were positively associated with longer EDLOS, increased ED charges, and enhanced triage predictive capability for hospitalization. Pain, therefore, appears to modulate the relationship between triage and patient outcomes, highlighting the need for careful pain evaluation in the ED.

Pulmonary embolism in United States emergency departments, 2010-2018.

Little is known about pulmonary embolism (PE) in the United States emergency department (ED). This study aimed to describe the disease burden (visit rate and hospitalization) of PE in the ED and to investigate factors associated with its burden. Data were obtained from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2010 to 2018. Adult ED visits with PE were identified using the International Classification of Diseases codes. Analyses used descriptive statistics and multivariable logistic regression accounting for the NHAMCS's complex survey design. Over the 9-year study period, there were an estimated 1,500,000 ED visits for PE, and the proportion of PE visits in the entire ED population increased from 0.1% in 2010-2012 to 0.2% in 2017-2018 (P for trend = 0.002). The mean age was 57 years, and 40% were men. Older age, obesity, history of cancer, and history of venous thromboembolism were independently associated with a higher proportion of PE, whereas the Midwest region was associated with a lower proportion of PE. The utilization of chest computed tomography (CT) scan appeared stable, which was performed in approximately 43% of the visits. About 66% of PE visits were hospitalized, and the trend remained stable. Male sex, arrival during the morning shift, and higher triage levels were independently associated with a higher hospitalization rate, whereas the fall and winter months were independently associated with a lower hospitalization rate. Approximately 8.8% of PE patients were discharged with direct-acting oral anticoagulants. The ED visits for PE continued to increase despite the stable trend in CT use, suggesting a combination of prevalent and incident PE cases in the ED. Hospitalization for PE remains common practice. Some patients are disproportionately affected by PE, and certain patient and hospital factors are associated with hospitalization decisions.

In-Hospital Cardiac Arrest in United States Emergency Departments, 2010-2018.

Background: Little is known about the in-hospital cardiac arrest (IHCA) in the US emergency department (ED). This study aimed to describe the incidence and mortality of ED-based IHCA visits and to investigate the factors associated with higher incidence and poor outcomes of IHCA. Materials and Methods: Data were obtained from the National Hospital Ambulatory Medical Care Survey (NHAMCS) between 2010 and 2018. Adult ED visits with IHCA were identified using the cardiopulmonary resuscitation code, excluding those with out-of-hospital cardiac arrest. We used descriptive statistics and multivariable logistic regression accounting for NHAMCS's complex survey design. The primary outcome measures were ED-based IHCA incidence rates and ED-based IHCA mortality. Results: Over the 9-year study period, there were approximately 1,114,000 ED visits with IHCA. The proportion of IHCA visits in the entire ED population (incidence rate, 1.2 per 1,000 ED visits) appeared stable. The mean age of patients who visited the ED with IHCA was 60 years, and 65% were men. Older age, male, arrival by ambulance, and being uninsured independently predicted a higher incidence of ED-based IHCA. Approximately 51% of IHCA died in the ED, and the trend remained stable. Arrival by ambulance, nighttime, or weekend arrival, and being in the non-Northeast were independently associated with a higher mortality rate after IHCA. Conclusion: The high burden of ED visits with IHCA persisted through 2010-2018. Additionally, ED-based IHCA survival to hospital admission remained poor. Some patients were disproportionately affected, and certain contextual factors were associated with a poorer outcome.

High-risk Return Visits to United States Emergency Departments, 2010-2018.

INTRODUCTION: Although factors related to a return visit to the emergency department (ED) have been reported, only a few studies have examined "high-risk" ED revisits with serious adverse outcomes. In this study we aimed to describe the incidence and trend of high-risk ED revisits in United States EDs and to investigate factors associated with these revisits. METHODS: We obtained data from the National Hospital Ambulatory Medical Care Survey (NHAMCS), 2010-2018. Adult ED revisits within 72 hours of a previous discharge were identified using a mark on the patient record form. We defined high-risk revisits as revisits with serious adverse outcomes, including intensive care unit admissions, emergency surgery, cardiac catheterization, or cardiopulmonary resuscitation (CPR) during the return visit. We performed analyses using descriptive statistics and multivariable logistic regression, accounting for NHAMCS's complex survey design. RESULTS: Over the nine-year study period, there were an estimated 37,700,000 revisits, and the proportion of revisits in the entire ED population decreased slightly from 5.1% in 2010 to 4.5% in 2018 (P for trend = 0.02). By contrast, there were an estimated 827,000 high-risk ED revisits, and the proportion of high-risk revisits in the entire ED population remained stable at approximately 0.1%. The mean age of these high-risk revisit patients was 57 years, and 43% were men. Approximately 6% of the patients were intubated, and 13% received CPR. Most of them were hospitalized, and 2% died in the ED. Multivariable analysis showed that older age (65+ years), Hispanic ethnicity, daytime visits, and arrival by ambulance during the revisit were independent predictors of high-risk revisits. CONCLUSION: High-risk revisits accounted for a relatively small fraction (0.1%) of ED visits. Over the period of the NHAMCS survey between 2010-2018, this fraction remained stable. We identified factors during the return visit that could be used to label high-risk revisits for timely intervention.

Physician gestalt for emergency department triage: A prospective videotaped study.

OBJECTIVE: Appropriate triage in patients presenting to the emergency department (ED) is often challenging. Little is known about the role of physician gestalt in ED triage. We aimed to compare the accuracy of emergency physician gestalt against the currently used computerized triage process. METHODS: We conducted a prospective observational study in the ED at an academic medical center. Adult patients aged ≥20 years were included and underwent a standard triage protocol. The patients underwent system-based triage using the computerized software the Taiwan Triage and Acuity Scale. The entire triage process was recorded, and triage data were collected. Five physician raters provided triage levels (physician-based) according to their perceived urgency after reviewing videos. The primary outcome was hospital admission. The secondary outcomes were ED length of stay (EDLOS) and charges. RESULTS: In total, 656 patients were recruited (mean age 52 years, 50% male). The median system-based triage level was 3. By contrast, the median physician-based triage level was 4. The physician raters tended to provide lower triage levels than the system, with an average difference of 1. There was modest concordance between the two triage methods (correlation coefficient 0.30), with a weighted kappa coefficient of 0.18. The area under the receiver operating curve for the system- and physician-based triage in predicting hospital admission were similar (0.635 vs. 0.631, p = 0.896). Attending physicians appeared to have better performance than residents in predicting admission. The variation explained (R2 ) in EDLOS and charges were similar between the two triage methods (R2  = 3% for EDLOS, 7%-9% for charges). CONCLUSIONS: Emergency physician gestalt for triage showed similar performance to a computerized system; however, physicians redistributed patients to lower triage levels. Physician gestalt has advantages for identifying low-risk patients. This approach may avoid undue time pressure for health care providers and promote rapid discharge.

Pain Assessment in the Emergency Department: A Prospective Videotaped Study.

INTRODUCTION: Research suggests that pain assessment involves a complex interaction between patients and clinicians. We sought to assess the agreement between pain scores reported by the patients themselves and the clinician's perception of a patient's pain in the emergency department (ED). In addition, we attempted to identify patient and physician factors that lead to greater discrepancies in pain assessment. METHODS: We conducted a prospective observational study in the ED of a tertiary academic medical center. Using a standard protocol, trained research personnel prospectively enrolled adult patients who presented to the ED. The entire triage process was recorded, and triage data were collected. Pain scores were obtained from patients on a numeric rating scale of 0 to 10. Five physician raters provided their perception of pain ratings after reviewing videos. RESULTS: A total of 279 patients were enrolled. The mean age was 53 years. There were 141 (50.5%) female patients. The median self-reported pain score was 4 (interquartile range 0-6). There was a moderately positive correlation between self-reported pain scores and physician ratings of pain (correlation coefficient, 0.46; P <0.001), with a weighted kappa coefficient of 0.39. Some discrepancies were noted: 102 (37%) patients were rated at a much lower pain score, whereas 52 (19%) patients were given a much higher pain score from physician review. The distributions of chief complaints were different between the two groups. Physician raters tended to provide lower pain scores to younger (P = 0.02) and less ill patients (P = 0.008). Additionally, attending-level physician raters were more likely to provide a higher pain score than resident-level raters (P <0.001). CONCLUSION: Patients' self-reported pain scores correlate positively with the pain score provided by physicians, with only a moderate agreement between the two. Under- and over-estimations of pain in ED patients occur in different clinical scenarios. Pain assessment in the ED should consider both patient and physician factors.