Impact of the COVID-19 pandemic, its related social restriction measures and vaccination campaign on emergency department attendances for epileptic seizures: An interrupted time-series analysis.

AIM: To investigate the impact of the outbreak of the COVID-19 pandemic, its related social restriction measure (national lockdown) and vaccination campaign on emergency department (ED) accesses for epileptic seizures. METHODS: Retrospective observational analysis conducted on a consecutive cohort of patients who sought medical care at the ED of the General Hospital of Merano, Italy, from January 1, 2015, to December 31, 2021. We investigated the monthly ED attendances for epileptic seizures between the periods before and after the outbreak of the COVID-19 pandemic and the national lockdown (March 2020) using an interrupted time-series analysis with data standardized for 1000 accesses/month. As a further temporal cutoff, we used the start of the national vaccination campaign. RESULTS: Between January 1, 2015, and December 31, 2021, a total of 415,005 ED attendances were recorded; 1,254 (0.3 %) were due to epileptic seizures. No significant difference was found in the rate of standardized ED accesses for epileptic seizures in March 2020 (time point of interest) to the pre-pandemic trend (0.33/1000; 95 %CI: -1.05 to 1.71; p = 0.637). Similarly, there was no difference between the pre- and post-pandemic trends (-0.02/1000; 95 %CI: -0.11 to 0.06; p = 0.600). When adopting January 2021 as time point of interest, we found no difference to the pre-vaccination trend (0.83/1000; 95 %CI: -0.48 to 2.15), and no difference in the pre- and post-vaccination trends (-0.12/1000; 95 %CI: -0.27 to 0.04). CONCLUSIONS: The COVID-19 pandemic and its related social restrictions (lockdown), as well as the COVID-19 national vaccination campaign, had little impact on ED accesses for epileptic seizures.

Prognostic role of albumin, lactate-to-albumin ratio and C-reactive protein-to-albumin ratio in infected patients.

INTRODUCTION: The prognostic evaluation of the septic patient has recently been enriched by some predictive indices such as albumin concentration, lactate/albumin ratio (LAR) and C-reactive protein/albumin ratio (CAR). The performance of these indices has been evaluated in septic patients in intensive care, but until now their performance in infected patients in the Emergency Department (ED) has not been evaluated. AIM: To investigate the potential prognostic role of albumin, LAR and CAR in patients with infection in the ED. METHODS: Single-centre prospective study performed between 1 January 2021 and 31 December 2021 at the ED of the Merano Hospital (Italy). All patients with infection were enrolled. The study outcome was death within 30 days. The predictive ability of albumin, LAR and CAR was assessed by area under the receiver operating characteristic curves (AUROCs). A multivariate logistic regression model was used to examine the association of the indices with 30-day mortality, with comorbidity, acute urgency and severity of infection as covariates. RESULTS: The study enrolled 962 patients with an infectious status. The overall 30-day mortality rate was 8.9% (86/962). The AUROC of albumin was 0.831 (95% CI 0.795-868), while for LAR this was 0.773 (CI95% 0.719-0.827) and for CAR 0.718 (CI95% 0.664-0.771). The odds ratio for 30-day mortality for albumin was 3.362 (95% CI 1.904-5.936), for ln(LAR) 2.651 (95% CI 1.646-4.270) and for ln(CAR) 1.739 (95% CI 1.326-2.281). CONCLUSIONS: All three indices had a good discriminatory ability for the risk of short-term death in patients with infection, indicating their promising use in the ED as well as in the ICU. Further studies are needed to confirm the better performance of albumin compared to LAR and CAR.

Human intelligence versus Chat-GPT: who performs better in correctly classifying patients in triage?

INTRODUCTION: Chat-GPT is rapidly emerging as a promising and potentially revolutionary tool in medicine. One of its possible applications is the stratification of patients according to the severity of clinical conditions and prognosis during the triage evaluation in the emergency department (ED). METHODS: Using a randomly selected sample of 30 vignettes recreated from real clinical cases, we compared the concordance in risk stratification of ED patients between healthcare personnel and Chat-GPT. The concordance was assessed with Cohen's kappa, and the performance was evaluated with the area under the receiver operating characteristic curve (AUROC) curves. Among the outcomes, we considered mortality within 72 h, the need for hospitalization, and the presence of a severe or time-dependent condition. RESULTS: The concordance in triage code assignment between triage nurses and Chat-GPT was 0.278 (unweighted Cohen's kappa; 95% confidence intervals: 0.231-0.388). For all outcomes, the ROC values were higher for the triage nurses. The most relevant difference was found in 72-h mortality, where triage nurses showed an AUROC of 0.910 (0.757-1.000) compared to only 0.669 (0.153-1.000) for Chat-GPT. CONCLUSIONS: The current level of Chat-GPT reliability is insufficient to make it a valid substitute for the expertise of triage nurses in prioritizing ED patients. Further developments are required to enhance the safety and effectiveness of AI for risk stratification of ED patients.

Techniques improving electrical cardioversion success for patients with atrial fibrillation: a systematic review and meta-analysis.

AIMS: Electrical cardioversion is commonly used to restore sinus rhythm in patients with atrial fibrillation (AF), but procedural technique and clinical success vary. We sought to identify techniques associated with electrical cardioversion success for AF patients. METHODS AND RESULTS: We searched MEDLINE, EMBASE, CENTRAL, and the grey literature from inception to October 2022. We abstracted data on initial and cumulative cardioversion success. We pooled data using random-effects models. From 15 207 citations, we identified 45 randomized trials and 16 observational studies. In randomized trials, biphasic when compared with monophasic waveforms resulted in higher rates of initial [16 trials, risk ratio (RR) 1.71, 95% CI 1.29-2.28] and cumulative success (18 trials, RR 1.10, 95% CI 1.04-1.16). Fixed, high-energy (≥200 J) shocks when compared with escalating energy resulted in a higher rate of initial success (four trials, RR 1.62, 95% CI 1.33-1.98). Manual pressure when compared with no pressure resulted in higher rates of initial (two trials, RR 2.19, 95% CI 1.21-3.95) and cumulative success (two trials, RR 1.19, 95% CI 1.06-1.34). Cardioversion success did not differ significantly for other interventions, including: antero-apical/lateral vs. antero-posterior positioned pads (initial: 11 trials, RR 1.16, 95% CI 0.97-1.39; cumulative: 14 trials, RR 1.01, 95% CI 0.96-1.06); rectilinear/pulsed biphasic vs. biphasic truncated exponential waveform (initial: four trials, RR 1.11, 95% CI 0.91-1.34; cumulative: four trials, RR 0.98, 95% CI 0.89-1.08) and cathodal vs. anodal configuration (cumulative: two trials, RR 0.99, 95% CI 0.92-1.07). CONCLUSIONS: Biphasic waveforms, high-energy shocks, and manual pressure increase the success of electrical cardioversion for AF. Other interventions, especially pad positioning, require further study.

Effect of perioperative benzodiazepine use on intraoperative awareness and postoperative delirium: a systematic review and meta-analysis of randomised controlled trials and observational studies.

BACKGROUND: Benzodiazepine use is associated with delirium, and guidelines recommend avoiding them in older and critically ill patients. Their perioperative use remains common because of perceived benefits. METHODS: We searched CENTRAL, MEDLINE, CINAHL, PsycInfo, and Web of Science from inception to June 2021. Pairs of reviewers identified randomised controlled trials and prospective observational studies comparing perioperative use of benzodiazepines with other agents or placebo in patients undergoing surgery. Two reviewers independently abstracted data, which we combined using a random-effects model. Our primary outcomes were delirium, intraoperative awareness, and mortality. RESULTS: We included 34 randomised controlled trials (n=4354) and nine observational studies (n=3309). Observational studies were considered separately. Perioperative benzodiazepines did not increase the risk of delirium (n=1352; risk ratio [RR] 1.43; 95% confidence interval [CI]: 0.9-2.27; I2=72%; P=0.13; very low-quality evidence). Use of benzodiazepines instead of dexmedetomidine did, however, increase the risk of delirium (five studies; n=429; RR 1.83; 95% CI: 1.24-2.72; I2=13%; P=0.002). Perioperative benzodiazepine use decreased the risk of intraoperative awareness (n=2245; RR 0.26; 95% CI: 0.12-0.58; I2=35%; P=0.001; very low-quality evidence). When considering non-events, perioperative benzodiazepine use increased the probability of not having intraoperative awareness (RR 1.07; 95% CI: 1.01-1.13; I2=98%; P=0.03; very low-quality evidence). Mortality was reported by one randomised controlled trial (n=800; RR 0.90; 95% CI: 0.20-3.1; P=0.80; very low quality). CONCLUSIONS: In this systematic review and meta-analysis, perioperative benzodiazepine use did not increase postoperative delirium and decreased intraoperative awareness. Previously observed relationships of benzodiazepine use with delirium could be explained by comparisons with dexmedetomidine. SYSTEMATIC REVIEW PROTOCOL: PROSPERO CRD42019128144.

Can triage nurses accurately interpret the electrocardiogram in the emergency department to predict acute cardiovascular events? A prospective observational study.

AIMS: The prompt recording of the electrocardiogram (ECG) and its correct interpretation is crucial to the management of patients who present to the emergency department (ED) with cardiovascular symptoms. Since triage nurses represent the first healthcare professionals evaluating the patient, improving their ability in interpreting the ECG could have a positive impact on clinical management. This real-world study investigates whether triage nurses can accurately interpret the ECG in patients presenting with cardiovascular symptoms. DESIGN: Prospective, single-centre observational study conducted in a general ED of General Hospital of Merano in Italy. METHODS: For all patients included, the triage nurses and the emergency physicians were asked to independently interpret and classify the ECGs answering to dichotomous questions. We correlated the interpretation of the ECG made by the triage nurses with the occurrence of acute cardiovascular events. The inter-rater agreement in ECG interpretation between physicians and triage nurses was evaluated with Cohen's kappa analysis. RESULTS: Four hundred and ninety-one patients were included. The inter-rater agreement between triage nurses and physicians in classifying an ECG as abnormal was good. Patients who developed an acute cardiovascular event were 10.6% (52/491), and in 84.6% (44/52) of them, the nurse accurately classified the ECG as abnormal, with a sensitivity of 84.6% and a specificity of 43.5%. CONCLUSION: Triage nurses have a moderate ability in identifying alterations in specific components of the ECG but a good ability in identifying patterns indicative of time-dependent conditions correlated with major acute cardiovascular events. IMPACT FOR NURSING: Triage nurses can accurately interpret the ECG in the ED to identify patients at high risk of acute cardiovascular events. REPORTING METHOD: The study was reported according to the STROBE guidelines. NO PATIENT OR PUBLIC CONTRIBUTION: The study did not involve any patients during its conduction.

Daily triage audit can improve nurses' triage stratification: A pre-post study.

AIMS: The objective was to evaluate whether the error rate in the application of the triage system decreased after the introduction of daily auditing, and it was also evaluated if the agreement rate between physician and nurse on triage priority levels increased after the introduction of daily auditing and if the error-related variables in the pre-intervention period changed in the post-intervention period. DESIGN: A quasi-experimental study was performed with a pre-post design, between June 2019 and June 2021 in one emergency department. METHODS: The accuracy and error rate of triage in the pre- and post-intervention period were compared. Univariate and multivariate logistic regression analyses were performed to explore the relationships between the variables related to the error. The comparison between the priority level assigned by the physician and the triage nurse was analysed using Cohen's K. RESULTS: Nine hundred four patients were enrolled in the pre-intervention period and 869 in the post-intervention period. The error rate in the pre-intervention period was 23.3% and in the post-intervention period was 9.7%. The concordance between the degree of priority expressed by the physician and the nurse varied from a quadratically weighted Cohen's K of 0.447 in the pre-intervention period to 0.881 in the post-intervention period. CONCLUSION: Daily auditing is a clinical procedure that improves the nurse's application of the triage system. Daily auditing has reduced errors by the nurse, improving performance and concordance with the physician. IMPACT: Triage systems are a key point for the stratification of the priority level of patients and it is therefore evident that they maintain high-quality standards. Through the practice of daily auditing, not only a reduction in the error rate, which ensures patient safety, but also an improvement in triage performance has been demonstrated. NO PATIENT OR PUBLIC CONTRIBUTION: The study did not involve any patients during its conduction.

The triage Nurse's ability in electrocardiogram interpretation in real clinical practice.

AIMS AND OBJECTIVE: The study aimed to assess the triage nurse's skill in the recognition of abnormal electrocardiogram during actual clinical practice and to identify nurse- and patient-related factors associated with errors in electrocardiogram interpretation. BACKGROUND: The nurse's ability to interpret the electrocardiogram has only been evaluated in simulation settings and has reported conflicting results. DESIGN: A prospective single-centre observational study. METHODS: During the evaluation of a patient with a cardiovascular symptom, the triage nurses were asked to define whether the 12-lead electrocardiogram performed during the triage evaluation was pathological or non-pathological for the presenting symptom. Patient characteristics and some nurse-related variables were recorded. Inter-rater agreement between the physician and nurse in the electrocardiogram interpretation was considered the primary outcome, while the association of a major acute cardiovascular event related to patient access in the Emergency Department was the secondary outcome. We have followed the STROBE checklist for the preparation of this manuscript. RESULTS: Twenty nurses agreed to participate to the study and collect data. Of the 644 patients enrolled, 21.6% (139/644) reported a pathological electrocardiogram according to the ED Physician. The concordance between nurse and physician was modest with Cohen's Kappa of 0.666. An error in the electrocardiogram interpretation was present in 11% of the patients. Nurses who performed an electrocardiogram course within 1 year and studied electrocardiogram interpretation autonomously presented a lower error rate, while older patients and patients with more previous cardiovascular disease were found to be more associated with an error in electrocardiogram interpretation. CONCLUSIONS: The study demonstrates that triage nurses have a fair ability to interpret the electrocardiogram. RELEVANCE TO CLINICAL PRACTICE: Specific educational programmes for electrocardiogram interpretation could improve the skill of electrocardiogram interpretation by the nurse and enable this instrument to become an indispensable tool in triage assessment.

Direct Oral Anticoagulation Versus Warfarin in Patients with Atrial Fibrillation and Bioprosthetic Heart Valves: a Retrospective, Real-World Cohort Study.

OBJECTIVE: In this retrospective cohort study of consecutive patients with atrial fibrillation and surgical or transcatheter bioprosthetic valve, we compared the efficacy and safety of direct oral anticoagulants with warfarin. METHODS: Using linked health administrative databases housed at the Institute for Clinical Evaluative Sciences, we identified consecutive patients in Ontario (Canada) 65 years of age or older with AF who underwent bioprosthetic valve replacement between 1 April 2012 and 31 March 2017. We created a time-varying Cox model to examine the relationship between the type of anticoagulant and time to thrombotic or bleeding events after adjustment for baseline risk of thrombosis using the CHA2DS2-VASc score and risk of bleeding using the HAS-BLED scores. We conducted prespecified subgroup analyses according to whether valve implantation was surgical or transcatheter. RESULTS: We identified 2245 eligible patients. The mean age was 79 years, 41% were female, and 39% had transcatheter aortic valve replacement. Risk of death or thrombosis was not different between direct oral anticoagulants and warfarin after adjustment for CHA2DS2-VASc score (hazard ratio [HR] 1.02, 95% confidence interval [CI], 0.83-1.25). Risk of death or bleeding was not different between direct oral anticoagulants and warfarin after adjustment for HAS-BLED score (HR 0.89, 95% CI 0.75-1.07). Subgroup analyses of surgical or transcatheter valves were consistent with overall results. CONCLUSIONS: In a real-world population of patients with atrial fibrillation and bioprosthetic valve replacement, we found no difference between direct oral anticoagulants and warfarin with regard to the risk of thrombosis or bleeding.

Rapid antigen test to identify COVID-19 infected patients with and without symptoms admitted to the Emergency Department.

PURPOSE: Early detection of SARS-CoV-2 patients is essential to contain the pandemic and keep the hospital secure. The rapid antigen test seems to be a quick and easy diagnostic test to identify patients infected with SARS-CoV-2. To assess the possible role of the antigen test in the Emergency Department (ED) assessment of potential SARS-CoV-2 infection in both symptomatic and asymptomatic patients. METHODS: Between 1 July 2020 and 10 December 2020, all patients consecutively assessed in the ED for suspected COVID-19 symptoms or who required hospitalisation for a condition not associated with COVID-19 were subjected to a rapid antigen test and RT-PCR swab. The diagnostic accuracy of the antigen test was determined in comparison to the SARS-CoV-2 PCR test using contingency tables. The possible clinical benefit of the antigen test was globally evaluated through decision curve analysis (DCA). RESULTS: A total of 3899 patients were subjected to antigen tests and PCR swabs. The sensitivity, specificity and accuracy of the antigen test were 82.9%, 99.1% and 97.4% (Cohen's K = 0.854, 95% CI 0.826-0.882, p < 0.001), respectively. In symptomatic patients, sensitivity was found to be 89.8%, while in asymptomatic patients, sensitivity was 63.1%. DCA appears to confirm a net clinical benefit for the preliminary use of antigen tests. CONCLUSIONS: The antigen test performed in the ED, though not ideal, can improve the overall identification of infected patients. While it appears to perform well in symptomatic patients, in asymptomatic patients, although it improves their management, it seems not to be definitive.

Triage assessment of transitory loss of consciousness in the emergency department-A retrospective observational study.

AIM: To establish how the Manchester Triage System can correctly prioritize patients admitted to the emergency department for transitory loss of consciousness in relation to their risk of presenting severe acute disease. DESIGN: A observational retrospective study. METHODS: A total of 2291 patients who required a triage evaluation for a transitory loss of consciousness at the emergency department of Merano Hospital between 1 January 2017 and 30 June 2019 were considered. Transitory loss of consciousness was classified according to European Society of Cardiology guidelines. The baseline characteristics of the patients were collected and divided according to the priority level assigned at triage into two different study groups: high priority (red/orange) and low priority (blue/green/yellow). The composite outcome of the study was defined as the diagnosis of a severe acute disease. RESULTS: Of the patients enrolled, 17% (390/2291) had a high-priority code and 83% (1901/2291) received a low-priority code. Overall, a severe acute disease was present in 16.9% of patients (387/2291). The Manchester Triage System had a sensitivity of 42.4%, a specificity of 88.1% and an accuracy of 80.4% for predicting severe acute disease. The discriminatory ability had an area under the receiver operating characteristic curve of 0.651 (CI 95%: 0.618-0.685). CONCLUSIONS: Despite the good specificity, the low sensitivity does not currently allow the Manchester Triage System to completely exclude patients with a severe acute disease who presented in the emergency department for a transitory loss of consciousness. Therefore, it is important to develop precise nursing tools or assessments that can improve triage performance. IMPACT: The assessment of a complex symptom can create difficulties in the stratification of patients in triage, assigning low-priority codes to patients with a severe disease. Additional tools are needed to allow the correct triage assessment of patients presenting with transitory loss of consciousness.

The ROX index can be a useful tool for the triage evaluation of COVID-19 patients with dyspnoea.

AIM: To assess whether the application of a non-invasive tool, such as ratio of oxygen saturation (ROX) index, during triage can identify patients with COVID-19 at high risk of developing acute respiratory distress syndrome (ARDS). DESIGN: A multi-centre, observational, retrospective study. METHODS: Only COVID-19 positive patients who required an emergency department evaluation for dyspnoea were considered. The primary objective of the study was to compare the ROX value obtained during triage with the medical diagnosis of ARDS and intubation in 72 h of the triage evaluation. The ROX index value was also compared with objective outcomes, such as the pressure of arterial O2 (PaO2 )/fraction of inspired oxygen (FiO2 ) ratio and the lung parenchyma volume involved in COVID-19-related inflammatory processes, based on 3D reconstructions of chest computed tomography (CT). RESULTS: During the study period, from 20 March 2020 until 31 May 2020, a total of 273 patients with confirmed SARS-CoV-2 infection were enrolled. The predictive ability of ROX for the risk of developing ARDS in 72 h after triage evaluation was associated with an area under the receiver operating characteristic (AUROC) of 0.845 (0.797-0.892, p < 0.001), whereas the AUROC value was 0.727 (0.634-0.821, p < 0.001) for the risk of intubation. ROX values were strongly correlated with PaO2 /FiO2 values (r = 0.650, p < 0.001), decreased ROX values were associated with increased percentages of lung involvement based on 3D CT reconstruction (r = -0.371, p < 0.001). CONCLUSION: The ROX index showed a good ability to identify triage patients at high evolutionary risk. Correlations with objective but more invasive indicators (PaO2 /FiO2 and CT) confirmed the important role of ROX in identifying COVID-19 patients with extensive pathological processes. IMPACT: During the difficult triage evaluation of COVID-19 patients, the ROX index can help the nurse to identify the real severity of the patient. The triage systems could integrate the ROX in the rapid patient assessment to stratify patients more accurately.

Outcomes after Ross procedure in adult patients: A meta-analysis and microsimulation.

OBJECTIVE: We conducted a meta-analysis to estimate the risk of adverse events, life expectancy, and event-free life expectancy after the Ross procedure in adults. METHODS: We searched databases for reports evaluating the Ross procedure in patients aged more than or equal to 16 years of age. A microsimulation model was used to evaluate age- and gender-specific life expectancy for patients undergoing the Ross procedure. RESULTS: Data were pooled from 63 articles totaling 19 155 patients from 20 countries. Perioperative mortality was 2.5% (95% confidence interval [CI]: 1.9-3.1; N = 9978). We found a mortality risk of 5.9% (95% CI: 4.8-7.2) at a mean follow-up of 7.2 years (N = 7573). The rate of perioperative clinically significant bleeding was 1.0% (95% CI: 0.1-3.0); re-exploration for bleeding 4.6% (95% CI: 3.1-6.3); postoperative clinically significant bleeding from 30 days until a mean of 7.1 years was 0.5% (95% CI: 0.2-1.0). At a mean of 6.9 years of follow-up, reintervention rate of any operated valve was 7.9% (95% CI: 5.7-10.3). The risk of valve thrombosis was 0.3% (95% CI: 0.2-0.5) at 7.6 years; peripheral embolism 0.3% (95% CI: 0.2-0.4) at 6.4 years; stroke 0.9% (95% CI: 0.7-1.2) at 6.5 years; and endocarditis 2.1% (95% CI: 1.6-2.6) at 8.0 years. Microsimulation reported a 40-year-old undergoing the Ross procedure to have a life expectancy of 35.4 years and event-free life expectancy of 26.6 years. CONCLUSIONS: Ross procedure in nonelderly adults is associated with low mortality and low risk of adverse events both at short- and long-term follow-up. The surgical community must prioritize a large, expertize-based randomized controlled trial to definitively address the risks and benefits of the Ross procedure compared to conventional aortic valve replacement.

Estimated plasma volume status is a simple and quick tool that could help define the severity of patients with infection on arrival at the emergency department.

BACKGROUND: Infectious states are subtle and rapidly evolving conditions observed daily in the emergency department (ED), and their prognostic evaluation remains a complex clinical challenge. Recently, estimated plasma volume status (ePVS) has been suggested to have a prognostic role in conditions where volemic alteration is central to the pathophysiology. The aim of this study was to verify whether ePVS recorded at ED admission can provide prognostic indications of 30-day mortality in patients with infection. METHODS: A prospective observational study was performed between 1 January 2021 and 31 December 2021 at the ED of the Merano Hospital. All patients with infection were enrolled. ePVS values were derived from haemoglobin and haematocrit measured on the immediate arrival of patients in the ED. The predictive power of ePVS for 30-day mortality was assessed using a multivariate model adjusted for severity, comorbidity and urgency. Kaplan-Meier analysis was also performed. RESULTS: Of the 949 patients with infection enrolled in the study (47.9%, SOFA ≥2), 8.9% (84/949) died at 30 days. The median ePVS value was higher in patients who died at 30 days than in patients who survived (5.83 vs. 4.61, p < 0.001). Multivariate analysis revealed that ePVS in both continuous and categorical form around the median was an independent risk factor for 30-day mortality even after adjusting for severity, comorbidity and urgency. Kaplan-Meier analysis confirmed an increased risk of death in patients with high ePVS values. CONCLUSIONS: ePVS recorded on ED admission of patients with infection was an independent predictor of risk for 30-day mortality.

Development and validation of a nomogram for assessing comorbidity and frailty in triage: a multicentre observational study.

Assessing patient frailty in the Emergency Department (ED) is crucial; however, triage frailty and comorbidity assessment scores developed in recent years are unsatisfactory. The underlying causes of this phenomenon could reside in the nature of the tools used, which were not designed specifically for the emergency context and, thus, are difficult to adapt to the emergency environment. The objective of this study was to create and internally validate a nomogram for identifying different levels of patient frailty during triage. Multicenter, prospective, observational exploratory study conducted in two ED. The study was conducted from April 1 to October 31, 2022. Following the triage assessment, the nurse collected variables related to the patient's comorbidities and chronic conditions using a predefined form. The primary outcome was the 90-day mortality rate. A total of 1345 patients were enrolled in this study; 6% died within 90 days. In the multivariate analysis, the Charlson Comorbidity Index, an altered motor condition, an altered cognitive condition, an autonomous chronic condition, arrival in an ambulance, and a previous hospitalization within 90 days were independently associated with death. The internal validation of the nomogram reported an area under the receiver operating characteristic of 0.91 (95% CI 0.884-0.937). A nomogram was created for assessing comorbidity and frailty during triage and was demonstrated to be capable of determining comorbidity and frailty in the ED setting. Integrating a tool capable of identifying frail patients at the first triage assessment could improve patient stratification.

The role of lactate-to-albumin ratio to predict 30-day risk of death in patients with sepsis in the emergency department: a decision tree analysis.

BACKGROUND: Accurately estimating the prognosis of septic patients on arrival in the emergency department (ED) is clinically challenging. The lactate-to-albumin ratio (LAR) has recently been proposed to improve the predictive performance of septic patients admitted to the ICU. OBJECTIVES: This study aims to assess whether the LAR could be used as an early prognostic marker of 30-day mortality in patients with sepsis in the ED. METHODS: A prospective observational study was conducted in the ED of the Hospital of Merano. All patients with a diagnosis of sepsis were considered. The LAR was recorded on arrival in the ED. The primary outcome measure was mortality at 30 days. The predictive role of the LAR for mortality was evaluated with the area under the ROC curve, logistic regression adjusted for the Charlson Comorbidity Index value, National Early Warning Score, and Sequential Organ Failure score, and with decision tree analysis. RESULTS: 459 patients were enrolled, of whom 17% (78/459) died at 30 days. The median LAR of the patients who died at 30 days (0.78 [0.45-1.19]) was significantly higher than the median LAR of survivors (0.42 [0.27-0.65]) (p < 0.001). The discriminatory ability of the LAR for death at 30 days was 0.738, higher than that of lactate alone (0.692), and slightly lower than that of albumin alone (0.753). The decision trees confirmed the role of the LAR as an independent risk factor for mortality. CONCLUSION: The LAR can be used as an index to better predict the 30-day risk of death in septic patients.

Real requirements of nursing activities and patient-related factors related to nursing overload in an internal medicine department.

Adequate nursing care can be decisive for the outcome of a patient admitted to an internal medicine ward. Individual prediction of nursing activity at the time of a patient's admission could improve the work process. This study aimed to assess the objectively assessed nursing requirements of patients admitted to a medical setting and to identify clinical factors that correlate with high demands. This is a prospective and pragmatic observational study that enrolled patients admitted to the Internal Medicine ward at the Altovicentino Civil Hospital (Italy) between September 1 and December 31, 2022. Nursing activities were recorded for the first 3 days of hospitalization and standardized as performance/5 min/patient. Patients requiring more than the 75th percentile of performance/5 min/patient were considered nursing over-activities. Multivariable models were used to assess patient-related risk factors associated with nursing over-activity. This study enrolled 333 patients (mean age: 74.2; 55.6% male). Their mean Charlson Comorbidity Index (CCI), Clinical Frailty Scale (CFS), Chronic Barthel Index, and Sistema Informtativo della Performance Infermieristica (SIPI) scores were 5.3, 4.2, 62.4, and 53.7, respectively. Mean National Early Warning System (NEWS) on admission was 3.9 (standard deviation: 2.8). A median of 73 (interquartile range [IQR]: 54-109) nursing care activities/5 min/patient were performed. NEWS score (odds ratio [OR]: 1.372, 95% confidence interval [95%CI]: 1.216-1.547, p < 0.001) and Acute Barthel Index (OR: 0.983, 95%CI: 0.967-0.999, p = 0.041) were independent risk factors for nursing over-activities. NEWS and the Acute Barthel Index could help reorganize nursing resources within internal medicine wards, allowing for an equal distribution between patients who require more resources and those who require less.

Assessing the utility of frailty scores in triage: a comparative study of validated scales.

Currently, there is conflicting evidence regarding the efficacy of frailty scales and their ability to enhance or support triage operations. This study aimed to assess the utility of three common frailty scales (CFS, PRISMA-7, ISAR) and determine their utility in the triage setting. This prospective observational monocentric study was conducted at Merano Hospital's Emergency Department (ED) from June 1st to December 31st, 2023. All patients attending this ED during the 80-day study period were included, and frailty scores were correlated with three outcomes: hospitalization, 30-day mortality, and severity of condition as assessed by ED physicians. Patients were categorized by age, and analyses were performed for the entire study population, patients aged 18-64, and those aged 65 or older. Univariate analysis was followed by multivariable analysis to evaluate whether frailty scores were independently associated with the outcomes. In multivariable analysis, none of the frailty scores were found to be associated with the study outcomes, except for the CFS, which was associated with an increased risk of 30-day mortality, with an odds ratio of 1.752 (95% CI 1.148-2.674; p = 0.009) in the general population and 1.708 (95% CI 1.044-2.793; p = 0.033) in the population aged ≥ 65. Presently, available frailty scores do not appear to be useful in the triage context. Future research should consider developing new systems for accurate frailty assessment to support risk prediction in the triage assessment.