Safety and Revisit Related to Discharge the Sixty-one Spanish Emergency Department Medical Centers Without Hospitalization in Patients with COVID-19 Pneumonia. A Prospective Cohort Study UMC-Pneumonia COVID-19.

BACKGROUND: Information is needed on the safety and efficacy of direct discharge from the emergency department (ED) of patients with COVID-19 pneumonia. OBJECTIVES: The objectives of the study were to study the variables associated with discharge from the ED in patients presenting with COVID-19 pneumonia, and study ED revisits related to COVID-19 at 30 days (EDR30d). METHODS: Multicenter study of the SIESTA cohort including 1198 randomly selected COVID patients in 61 EDs of Spanish medical centers from March 1, 2020, to April 30, 2020. We collected baseline and related characteristics of the acute episode and calculated the adjusted odds ratios (aOR) for ED discharge. In addition, we analyzed the variables related to EDR30d in discharged patients. RESULTS: We analyzed 859 patients presenting with COVID-19 pneumonia, 84 (9.8%) of whom weredischarged from the ED. The variables independently associated with discharge were being a woman (aOR 1.890; 95%CI 1.176 3.037), age < 60 years (aOR 2.324; 95%CI 1.353-3.990), and lymphocyte count > 1200/mm3 (aOR 4.667; 95%CI 1.045-20.839). The EDR30d of the ED discharged group was 40.0%, being lower in women (aOR 0.368; 95%CI 0.142-0.953). A totalof 130 hospitalized patients died (16.8%) as did two in the group discharged from the ED (2.4%) (OR 0.121; 95%CI 0.029-0.498). CONCLUSION: Discharge from the ED in patients with COVID-19 pneumonia was infrequent and was associated with few variables of the episode. The EDR30d was high, albeit with a low mortality.

Evaluation of the safety of medication-use systems in hospital emergency services. / Evaluación de la seguridad del sistema de utilización de los medicamentos en los servicios de urgencias hospitalarios.

INTRODUCTION: The aim of this study was to assess the implementation of safe medication practices in hospital emergency services, in order to understand the points of greatest risk as well as the safety challenges faced by these departments, and to plan collaboratively improvement initiatives. METHOD: Multicentric and descriptive study based on completion of the "Medication safety self-assessment of emergency services" from 5/16/2023 to 11/16/2023, at voluntarily participating emergency services. The survey contained 93 items grouped into 10 key elements. Mean score and mean percentages based on the maximum possible values for the overall survey, for the key elements and for each individual item of evaluation, were assessed. RESULTS: A total of 72 emergency services completed the questionnaire. The mean score obtained for the overall questionnaire was 428.3 points (51.1% of the maximum score). Results showed a large variation among the scores of the participating services (range: 164-620.5). Four key elements had values below 50%, corresponding to competence and training of professionals in safety practices (38.4%); incorporation of pharmacists in emergency departments (42.1%), availability and accessibility of information about patients (43.1%), and patient education (48.1%). The highest values corresponded to labeling, packaging, and naming of medications (69.2%) and communication of prescriptions and other medication information (64%). No differences were found between emergency services in the key elements according to the dependency or size of the hospital, or the type of service, except for the item referring to the incorporation of pharmacists in the emergency service, where differences were observed between hospitals with less than 200 beds (28.9%) and those with more than 500 (52.2%). CONCLUSION: The application of the specific self-assessment questionnaire has made it possible to identify safety practices that are insufficiently implemented into emergency services in our country and to identify critical points for improvement for which planning collaborative initiatives to reduce medication errors in these departments should become a priority.

Prophylaxis of venous thromboembolism in hospitalized patients admitted from Spanish emergency departments: the PROTESU II study. / Profilaxis de la enfermedad tromboembólica venosa en pacientes hospitalizados por patología médica desde los servicios de urgencias españoles: estudio PROTESU II.

OBJECTIVE: To estimate the prevalence of inappropriate use of prophylaxis to prevent venous thromboembolism (VTE) in patients with medical diseases admitted to hospital from the emergency department. To explore variables associated with inappropriate thromboprophylaxis. METHODS: Prospective multicenter cohort study in 15 hospital emergency departments. We included patients admitted for a medical condition during 7 days in the first quarter of 2022. We assessed risk for VTE with the Padua Prediction Score (PPS). Inappropriate thromboprophylaxis was defined by failure to prescribe prophylaxis in patients with a high-risk PPS assessment unless there were absolute contraindications (active bleeding or severe thrombopenia) or, alternatively, the prescription of prophylaxis in patients with a low-risk PPS assessment or absolute contraindications. A logistic regression model was adjusted for risk level to identify variables associated with inappropriate use of thromboprophylaxis. RESULTS: Of a total of 630 patients included, 450 (71.4%) had PPS scores indicating high risk for VTE; 180 patients were at low risk. Thromboprophylaxis was inappropriate in 248 patients (39.4%): 165 high-risk patients who received no prophylaxis, 82 low-risk patients who were nonetheless treated, and 1 patient who was treated in spite of severe thrombopenia. Odds ratios (ORs) revealed that the variables associated with inappropriate use of thromboprophylaxis were trauma or recent surgery (OR, 5.53; 95% CI, 1.58-19.34), presence of factors indicating risk for bleeding (OR, 2.61; 95% CI, 1.44-4.73), and hospital admission for either urinary tract infection (OR, 2.29; 95% CI, 1.07-4.87) or gastrointestinal disease (OR, 4.30; 95% CI, 1.71-10.85). CONCLUSIONS: The inappropriate use of thromboprophylaxis in Spanish emergency departments is high and associated with certain clinical characteristics.

OBJETIVO: Evaluar la inadecuación de la tromboprofilaxis farmacológica, según la escala Padua (PPS), para prevenir la enfermedad tromboembólica venosa (ETV) entre los pacientes que ingresan desde el servicio de urgencias hospitalario (SUH) por patología médica, así como las variables asociadas a su uso inadecuado. METODO: Estudio de cohortes, prospectivo, multicéntrico donde participaron 15 SUH. Se incluyeron los pacientes atendidos que requirieron ingreso por enfermedad médica durante 7 días del primer trimestre de 2022. La inadecuación de la tromboprofilaxis farmacológica se definió como la no utilización en pacientes clasificados por PPS de alto riesgo sin contraindicaciones absolutas para su uso (hemorragia activa o trombopenia grave) o su utilización en pacientes de riesgo bajo o con contraindicaciones absolutas. Se ajustó, para cada grupo de riesgo, un modelo de regresión logística para identificar las variables asociadas a la inadecuación. RESULTADOS: Se incluyeron 630 pacientes, 450 (71,4%) tenían riesgo alto y 180 (28,6%) riesgo bajo para ETV según la PPS. De ellos, la tromboprofilaxis fue inadecuada en 248 pacientes (39,4%) (165 tenían riesgo alto pero no recibieron tromboprofilaxis, 1 la recibió teniendo trombopenia grave y 82 tenían riesgo bajo pero recibieron tromboprofilaxis). Las variables asociadas con la inadecuación en pacientes de alto riesgo fueron trauma o cirugía recientes con odds ratio (OR) de OR 5,53 (IC 95%: 1,58-19,34), presencia de factores de riesgo hemorrágico con OR de 2,61 (IC 95%: 1,44-4,73), e infección del tracto urinario con OR de 2,29 (IC 95%: 1,07-4,87) y enfermedad gastrointestinal con OR de 4,30 (IC 95%: 1,71-10,85) como motivos de ingreso. CONCLUSIONES: En los SUH españoles, el uso inadecuado de la tromboprofilaxis farmacológica es elevado. Algunas características clínicas se asocian al uso inadecuado de dicha tromboprofilaxis.

Immune thrombotic thrombocytopenic purpura: clinical suspicion and basic management in emergency departments - an expert review and consensus statement from the Spanish societies of hematology and hemotherapy (SEHH) and emergency medicine (SEMES). / Púrpura trombocitopénica trombótica inmune: sospecha y manejo básico en los servicios de urgencias. Revisión y consenso de un grupo de expertos de las sociedades científicas SEHH y SEMES.

TEXT: Acquired or immune thrombotic thrombocytopenic purpura (TTP) are thrombotic microangiopathies associated with high mortality if treatment is not started early. Onset is usually sudden, meaning that the condition is often diagnosed in hospital emergency departments, where TTP must be suspected as early as possible. These guidelines were drafted by specialists in emergency medicine and hematology to cover the diagnosis, referral, and treatment of patients suspected of immune-mediated TTP who require emergency care. Immune TTP should be suspected whenever a patient presents with hemolytic microangiopathy and has a negative Coombs test, and thrombocytopenia, possibly in conjunction with fever and neurologic and cardiac alterations. If one of the existing diagnostic algorithms indicates there is a high probability that the patient has immune TTP, plasma exchange therapy should be started along with immunosuppressants. Treatment with caplacizumab should also be considered. The patient should be referred immediately to the hematology department within the same hospital or a referral hospital.

TEXTO: La púrpura trombótica trombocitopénica adquirida o inmune (PTTi) es una microangiopatía trombótica (MAT) con una elevada mortalidad si no se instaura un tratamiento precoz. El inicio habitualmente brusco de la enfermedad hace que, en la mayoría de los pacientes, el diagnóstico inicial se haga en los servicios de urgencias hospitalarios (SUH), donde se debe sospechar esta entidad con la mayor inmediatez posible. Esta guía, elaborada por profesionales de Medicina de Urgencias y de Hematología, establece unas recomendaciones en cuanto al diagnóstico, derivación y tratamiento de los pacientes con sospecha de PTTi en los SUH. Se debe sospechar PTTi en todo paciente que presente una anemia hemolítica microangiopática, prueba de Coombs directo negativa y trombocitopenia pudiendo asociar, además, fiebre, alteraciones neurológicas y cardiacas. Si tras la aplicación de alguno de los algoritmos diagnósticos existentes, hay una alta probabilidad de que el paciente presente una PTTi, debería iniciarse tratamiento con recambio plasmático, inmunosupresores y valorar el inicio de caplacizumab. Además, debe gestionarse el traslado inmediato de los pacientes al Servicio de Hematología, bien del mismo centro o a uno de referencia.

Impact of emergency department management of isolated superficial vein thrombosis of the lower limbs: a secondary analysis of data from the ALTAMIRA study. / Impacto del manejo en urgencias en la evolución de los pacientes con trombosis venosa superficial aislada de miembros inferiores: subanálisis del estudio ALTAMIRA.

OBJECTIVES: To describe the management of superficial vein thrombosis (SVT) of the lower limbs in patients treated in Spanish hospital emergency departments (EDs). To evaluate the impact of ED management of venous thromboembolic complications on outcomes and to determine the characteristics of patients who develop complications. MATERIAL AND METHODS: The retrospective multicenter ALTAMIRA study (Spanish acronym for risk factors, complications, and assessment of Spanish ED management of SVT) used recorded data for consecutive patients with a diagnosis of isolated SVT treated in 18 EDs. We gathered data on symptomatic venous thromboembolic disease (deep vein thrombosis, pulmonary embolism, or the extension or recurrence of SVT), clinically significant bleeding, and 180-day mortality. Cox regression analysis was used to explore variables associated with complications. RESULTS: A total of 703 patients were included. Anticoagulation was prescribed for 84.1% of the patients for a median of 30 days (interquartile range, 15-42 days); 81.3% were treated with low molecular weight heparin. A prophylactic dose was prescribed for 48% and an intermediate therapeutic dose for 52%. Sixty-four patients (9.2%) developed symptomatic thromboembolic disease within 180 days, 12 (1.7%) experienced clinically significant bleeding, and 4 (0.6%) died. Complications developed later in patients receiving anticoagulant therapy than in those not taking an anticoagulant (66 vs 11 days , P=.009), and 76.6% of those developing complications were not on anticoagulant when symptoms appeared. A history of thromboembolic disease was associated with developing complications (adjusted hazard ratio, 2.20; 95% confidence interval, 1.34-3.62). CONCLUSION: ED treatment of SVT varies and is often suboptimal. The incidence of thromboembolic complications after SVT is high. Starting anticoagulation in the ED delays the development of complications. Patients with a history of thromboembolic disease are more at risk of complications.

OBJETIVO: Describir el manejo terapéutico de los pacientes con trombosis venosa superficial (TVS) aislada de miembros inferiores en servicios de urgencias hospitalarios (SUH) españoles. Evaluar el impacto del tratamiento instaurado en urgencias en la evolución, en términos de complicaciones de enfermedad tromboembólica venosa (ETV), y conocer las características de los pacientes que sufren complicaciones. METODO: El estudio multicentrico (18 SUH) ALTAMIRA (fActores de riesgo, compLicaciones y evaluación del manejo de la TVS de Miembros Inferiores en hospitales españoles atendidos en los seRvicios de urgenciAs) creó un cohorte retrospectivo de pacientes consecutivos con diagnóstico objetivo de TVS aislada. Se recogieron las complicaciones de ETV sintomáticas (trombosis venosa profunda, tromboembolia pulmonar y extensión o recurrencia de TVS), sangrados clínicamente relevantes y defunciones a 180 días. Se evaluaron las variables asociadas a las complicaciones mediante una regresión de Cox. RESULTADOS: Se incluyeron 703 pacientes. El 84,1% recibieron anticoagulación durante 30 días (rango intercuartil 15-42), 81,3% con heparina de bajo peso molecular (48% dosis profilácticas, 52% intermedias-terapéuticas). En 180 días, 64 pacientes (9,1%) tuvieron complicación de ETV, 12 (1,7%) tuvieron sangrado clínicamente relevante, y 4 fallecieron (0,6%). Los pacientes en que se instauró anticoagulación en urgencias tardaron más tiempo en desarrollar complicaciones (66 vs 11 días, p = 0,009). El 76,6% de los que se complicaron no estaban anticoagulados en ese momento. La ETV previa se asoció de forma independiente con el desarrollo de complicaciones (hazard ratio ajustada 2,20; intervalo de confianza del 95%: 1,34-3,62). CONCLUSIONES: El tratamiento en urgencias de la TVS aislada es heterogéneo y con frecuencia subóptimo. La incidencia de complicaciones de ETV es elevada. El tratamiento anticoagulante iniciado en urgencias supone un retraso en el desarrollo de complicaciones. Los pacientes con ETV previa tienen más riesgo de complicaciones.

Profiles of patients with venous thromboembolic disease in the emergency department and their medium-term prognosis: data from the ESPHERIA registry. / Registro ESPHERIA: perfiles de pacientes con enfermedad tromboembólica venosa en urgencias y su asociación con el pronóstico a medio plazo.

OBJECTIVES: To assess the 180-day prognosis for patients of different profiles diagnosed with venous thromboembolism (VTE) in emergency departments (EDs). Secondary aims were to assess all-cause mortality and readmission rates and to describe the clinical characteristics and forms of presentation of deep vein thrombosis (DVT) and pulmonary thromboembolism (PTE) in each patient profile. MATERIAL AND METHODS: Secondary analysis of data from the ESPHERIA registry (Spanish acronym for Risk Profile of Patients with VTE Attended in Spanish Emergency Departments), which includes consecutive patients with symptomatic VTE treated in 53 EDs. The cases were divided according to 4 profiles: 1) unprovoked DVT, 2) DVT provoked by transient risk factors, 3)patients with cancer, and 4) patients with low cardiopulmonary reserve. The primary outcome was a composite of 180-day all-cause mortality or readmission. RESULTS: We studied 773 patients: 450 (58.2%) were classified as profile 1, 128 (16.6%) as profile 2, 115 (14.9%) as profile 3 , a nd 8 0 ( 10.3%) a s p rofile 4. We fo und di fferences be tween th e 4 pr ofiles in demographics, com orbidity, clinical presentation, type of DVT and location, management, and outcomes. One hundred ninety-five p atients (25.2%) had at least one of the adverse events included in the composite within 180 days: 69 (8.9%) died and 179 (23.2%) were readmitted. Hazard ratios (HR) indicated that DVT with low cardiopulmonary reserve (HR, 1.73; 95% CI, 1.12-2.68; P = .01)) or DVT with cancer (HR, 3.10; 95% CI, 2.22-4.34; P .001) were the profiles t hat w ere independently associated with the 180-day composite outcome. CONCLUSION: Classifying patients with DVT according to 4 profiles ( unprovoked, provoked by t ransient r isk f actors, associated with cancer, and associated with low cardiopulmonary reserve) when making the diagnosis is useful for assessing prognosis for all-cause mortality or readmission within 180 days. This classification could be useful for establishing a care and follow-up plan when discharging patients with DVT from the ED.

OBJETIVO: Evaluar el pronóstico a 180 días de los pacientes diagnosticados de enfermedad tromboembólica venosa (ETV) en urgencias, en función de una clasificación por perfiles clínicos. Los objetivos secundarios fueron evaluar la mortalidad y el reingreso por todas las causas de manera individual, y describir las características clínicas y formas de presentación de trombosis venosa profunda (TVP) y tromboembolismo pulmonar (TEP), según dichos perfiles. METODO: Análisis secundario del registro ESPHERIA que incluye pacientes consecutivos con ETV sintomática de 53 servicios de urgencias (SU). Se dividió la muestra en 4 perfiles: ETV no provocada (perfil 1), ETV provocada por factores de riesgo transitorios (perfil 2), cáncer (perfil 3) y baja reserva cardiopulmonar (perfil 4). La variable de resultado primaria fue la compuesta mortalidad o reingreso por cualquier causa a 180 días. RESULTADOS: Se incluyeron 773 pacientes de los cuales 450 (58,2%) fueron clasificados en el perfil 1, 128 (16,6%) en el perfil 2, 115 pacientes (14,9%) en el perfil 3 y 80 (10,3%) en el perfil 4. Se documeô€‚˜taron diferencias demográficas, de comorbilidad, presentación clínica, tipo de ETV, manejo, ubicación y resultados entre los perfiles clínicos. Ciento noventa y cinco pacientes (25,2%) presentaron un resultado adverso compuesto a los 180 días, de los cuales 69 (8,9%) fallecieron y 179 (23,2%) sufrieron un nuevo ingreso por cualquier causa. La ETV asociada a baja reserva cardiopulmonar (HR 1,73; IC 95% 1,12-2,68; p = 0,01) y la ETV asociada a cáncer (HR 3,10; IC 95% 2,22-4,34; p 0,001) se asociaron de forma independiente con sufrir un resultado adverso en los primeros 180 días. CONCLUSIONES: Clasificar a los pacientes con ETV según factores de riesgo y comorbilidades en 4 perfiles (no provocada, provocada por factores transitorios, asociada a cáncer y asociada a baja reserva cardiopulmonar) resulta útil al momento del diagnóstico de la ETV para estimar el pronóstico en términos de mortalidad y reingreso a 180 días. Esta clasificación podría ayudar a establecer un plan de cuidados y seguimiento al alta en la ETV diagnosticada en urgencias.

Characteristics of isolated superficial vein thrombosis and diagnostictherapeutic management in Spanish hospital emergency departments: the ALTAMIRA study. / Características y manejo diagnóstico-terapéutico de los pacientes con trombosis venosa superficial aislada en los servicios de urgencias hospitalarios españoles. Estudio ALTAMIRA.

OBJECTIVES: To describe the characteristics of patients with isolated lower-limb superficial vein thrombosis (SVT) treated in hospital emergency departments and to evaluate adherence to clinical practice guidelines on diagnosis (vein ultrasound imaging) and therapeutic management (start of anticoagulant therapy). MATERIAL AND METHODS: Retrospective cohort study in 18 Spanish emergency departments. We included all patients with a final emergency department diagnosis of lower-limb SVT aged 18 years or older between January 2016 and May 2017. Backward stepwise multiple logistic regression analysis was used to evaluate adherence to clinical practice guidelines on ordering vein ultrasound imaging and starting anticoagulant therapy. RESULTS: A total of 1166 patients were included. The mean patient age was 59.6 years, and 67.9% were women. About a quarter of the patients (24.4%) had a history of venous thromboembolic disease. Complications developed in 8.9% within 180 days: 4.6% experienced a recurrence and 3.6% progressed to SVT and 1.8% to deep vein thrombosis; pulmonary thromboembolism occurred in 0.9%. Hemorrhagic complications developed in 17 patients (1.5%). Sixteen patients (1.4%) died. Vein ultrasound imagine was ordered for 703 patients (60.3%). Anticoagulant agents were prescribed for 898 (77%) for a median period of 22 days. Variables associated with a decision to order anticoagulants were a history of venous thromboembolic disease (odds ratio [OR], 1.60; 95% CI, 1.12-2.30), varicose veins (OR, 1.40; 95% CI, 1.12-2.30); limb pain (OR, 1.44; 95% CI, 1.08-1.91); painful cord (OR, 1.30; 95% CI, 0.97-1.73); and availability of vein ultrasound images (OR, 1.60; 95% CI, 1.94-3.45). CONCLUSION: Adherence to clinical practice guidelines for the diagnosis and treatment of isolated lower-limb SVT is low in Spanish emergency departments. Ultrasound imaging is not ordered for 1 out of every 2 to 3 patients, and anticoagulant treatment is not started in 1 out of 4 patients. There is great room for improvement.

OBJETIVO: Describir las características de los pacientes diagnosticados de trombosis venosa superficial (TVS) aislada de miembros inferiores en servicios de urgencias hospitalarios (SUH), y evaluar la adherencia a las guías de práctica clínica en el manejo diagnóstico y terapéutico (realización de ecografía venosa e instauración de tratamiento anticoagulante). METODO: . Estudio de cohortes retrospectivo en 18 SUH españoles. Se incluyeron todos los pacientes atendidos en los SUH con diagnóstico final de TVS en miembros inferiores, con edad $ 18 años, de enero de 2016 a mayo de 2017. Para evaluar la no adherencia a las recomendaciones de las guías de práctica clínica (realización de ecografía venosa, e instauración de tratamiento anticoagulante) se ajustó un modelo de regresión logística múltiple por pasos hacia atrás. RESULTADOS: . Mil ciento sesenta y seis pacientes fueron incluidos. La edad media fue de 59,6 años, el 67,9% eran mujeres. El 24,4% tenían antecedentes de enfermedad tromboembólica venosa (ETV). El 8,9% tuvieron alguna complicación a 180 días [4,6% recurrencia y 3,6% progresión de TVS, 1,8% trombosis venosa profunda (TVP) y 0,9% tromboembolia pulmonar (TEP)]. Hubo 17 pacientes (1,5%) con hemorragia y 16 (1,4%) muertes. Se realizó ecografía venosa a 703 (60,3%) pacientes. Recibieron tratamiento anticoagulante 898 (77%), con una mediana de 22 días. Las variables asociadas con la decisión de anticoagular fueron: antecedentes ETV (OR 1,60; IC 95%: 1,12-2,30), varices (OR 1,40; IC 95%: 1,12-2,30), dolor de la extremidad (OR 1,44; IC 95%: 1,08-191), presencia de cordón doloroso (OR 1,30; IC 95%: 0,97-1,73) y realización de ecografía venosa (OR 1,60; IC 95%: 1,94-3,45). CONCLUSIONES: Existe una baja adherencia a las recomendaciones de las guías de práctica clínica en el manejo diagnóstico y terapéutico de los pacientes con diagnóstico de TVS aislada de miembros inferiores en los SUH españoles: no se realiza ecografía venosa en uno de cada 2-3 pacientes, y no se instaura tratamiento anticoagulante en 1 de cada 4. Esto constituye un margen de mejora muy relevante.

Clinical characteristics and course in emergency department patients with chronic obstructive pulmonary disease and symptomatic acute venous thromboembolic disease: secondary analysis of the ESPHERIA registry. / Características y evolución de los pacientes con enfermedad pulmonar obstructiva crónica y enfermedad tromboembólica venosa aguda sintomática en urgencias: subanálisis del registro ESPHERIA.

OBJECTIVES: To determine the impact of chronic obstructive pulmonary disease (COPD) on prognosis in patients diagnosed with venous thromboembolic disease (VTED) in Spanish emergency departments. MATERIAL AND METHODS: Secondary analysis of data from the ESPHERIA (Spanish acronym for Risk Profile of Patients VTED Attended in Spanish Emergency Departments) registry. RESULTS: A total of 801 patients, 71 (9%) with COPD, were included. Pulmonary thromboembolism was recorded in 77.%% of the patients with COPD (vs in 47.1% of patients without COPD; P<.001). Patients with COPD had evidence of right ventricular dysfunction on computed tomography angiography more often than other VTED patients (18.2% vs 13.1%; P<.001) and more often required ventilatory support (7% vs 0.5%; P<.001). VTED patients with COPD also had a higher rate of readmission or mortality at 180 days (hazard ratio, 1.52; 95% CI, 1.00-2.29; P = .048)] than patients without COPD. CONCLUSION: COPD affects the prognosis of patients diagnosed with VTED in Spanish emergency departments as evidenced by hospital readmission and mortality.

OBJETIVO: Determinar el impacto pronóstico de la enfermedad pulmonar obstructiva crónica (EPOC) en los pacientes diagnosticados de enfermedad tromboembólica venosa (ETV) en servicios de urgencias (SU) españoles. METODO: Análisis secundario del registro ESPHERIA que incluyó pacientes consecutivos con ETV sintomática en 53 SU. RESULTADOS: Se incluyeron 801 pacientes de los que 71 (9%) tenían EPOC, siendo la tromboembolia pulmonar la forma de presentación más frecuente de ETV en este subgrupo de pacientes (77,5% vs 47,1%, p < 0,001). Los pacientes con EPOC tuvieron con más frecuencia disfunción de ventrículo derecho en la angiotomografía pulmonar (18,2% vs 13,1%; p < 0,001) y necesidad de soporte ventilatorio (7% vs 0,5%; p < 0,001). Los pacientes con ETV y EPOC tuvieron mayor incidencia de reingreso o mortalidad en el seguimiento a 180 días [HR 1,52 (IC 95% 1,00-2,29; p = 0,048)], comparados con los pacientes con ETV sin EPOC. CONCLUSIONES: La EPOC tiene impacto pronóstico en los pacientes diagnosticados de ETV en SU españoles, en términos de mortalidad y reingreso hospitalario.

Clinical findings, risk factors, and final outcome in patients diagnosed with pulmonary thromboembolism and COVID-19 in hospital emergency departments. / Características clínicas, factores de riesgo y resultados finales de pacientes con COVID-19 diagnosticados de tromboembolia de pulmón en urgencias.

OBJECTIVES: To analyze clinical, laboratory, and radiologic findings and final health outcomes in patients with pulmonary embolism and coronavirus disease 2019 (COVID-19). To compare them to findings and outcomes in patients with pulmonary embolism without COVID-19. MATERIAL AND METHODS: Multicenter, observational, retrospective study in 4 Spanish hospital emergency departments (EDs) from January 15 to April 15, 2020. Cases were located by reviewing all ED requests for pulmonary computed tomography angiography (CTA) procedures. Clinical, laboratory, and radiologic findings; medical histories and comorbidity; risk factors; and outcomes were compared between the 2 groups of patients (with or without COVID-19). RESULTS: A total of 399 CTAs were ordered; 88 pulmonary embolisms were diagnosed, 28 of them (32%) in patients with COVID-19. This group had more men, and a history of thromboembolic disease was more common. We found no between-group differences in clinical presentation, laboratory, or radiologic findings; nor were there differences in final outcomes. In-hospital mortality was 7% (2 cases) in patients with COVID-19 and 17% (10 cases) in patients without the virus (odds ratio for death in patients with pulmonary embolism and COVID-19, 0.38; 95% CI, 0.08-1.89). CONCLUSION: We found no clinically important differences in the clinical, laboratory, or radiologic findings between patients with or without COVID-19 who were treated for pulmonary embolism in our hospital EDs. Final outcomes also did not differ.

OBJETIVO: Analizar las características clínicas, analíticas, radiológicas y los resultados finales de salud en una cohorte de pacientes con embolia pulmonar (EP) y COVID-19, y compararlas con un grupo de pacientes con EP sin COVID-19. METODO: Estudio multicéntrico, observacional y retrospectivo realizado en cuatro servicios de urgencias hospitalarios (SUH) españoles del 15 de enero al 15 de abril de 2020. La detección de EP se hizo mediante la revisión de todas las angiografías por tomografía computarizada (angioTC) pulmonares solicitadas desde los SUH. Se han analizado dos grupos de pacientes con EP, con o sin enfermedad por COVID-19, y se comparan las características clínicas, analíticas, radiológicas, antecedentes y comorbilidad, factores de riesgo y resultados finales. RESULTADOS: Se realizaron 399 angioTC y se diagnosticaron 88 EP, 28 (32%) en pacientes con COVID-19. Estos pacientes fueron con más frecuencia hombres y tenían más antecedentes de enfermedad tromboembólica previa. No hubo diferencias en la presentación clínica, características analíticas o radiológicas ni en los resultados finales entre ambos grupos. La mortalidad intrahospitalaria fue del 7% (2 casos) en pacientes COVID y del 17% (10 casos) en pacientes sin COVID (OR de muerte en pacientes COVID con EP: 0,38, IC 95%: 0,08-1,89). CONCLUSIONES: No se han observado diferencias clínicamente relevantes en las características clínicas, analíticas, radiológicas y los resultados finales de salud en una cohorte de pacientes con EP y COVID-19 respecto a los pacientes con EP sin esta enfermedad atendidos en los SUH.

Ultrasound imaging obtained by emergency department physicians to diagnose deep vein thrombosis: accuracy, safety, and efficiency. / Precisión, seguridad y eficiencia de la ecografía realizada por urgenciólogos en el diagnóstico de la trombosis venosa profunda en servicios de urgencias hospitalarios.

OBJECTIVES: To assess the accuracy, safety, and efficiency of ultrasound images obtained by emergency physician to diagnose deep vein thrombosis (DVT). patients with acute heart failure (AHF) attended in a hospital emergency department (ED). MATERIAL AND METHODS: Prospective multicenter cohort study. We assigned patients suspected of having DVT to an intervention or control group. Emergency physicians took ultrasound images that were later evaluated by a radiologist in the intervention group. In the control group, images were evaluated only by the radiologist. We analyzed patient, physician, and episode variables. Test results, times until imaging, and 30-day adverse events were also analyzed. Sensitivity, specificity, positive and negative likelihood ratios, and agreement between physicians and radiologists (κ statistic) were calculated. RESULTS: A total of 304 patients (209 in the intervention group and 95 controls) were included. The groups were comparable. The overall prevalence of DVT was 35.5% (95% CI, 30.3-41.0). The sensitivity of ultrasound images obtained by emergency physicians was superior in relation to experience: 71.4 (95% CI, 50.0-86.0) for those in a training course, 75.0 (95% CI, 80.0-95.4) for those with at least 2 months' practical experience, and 94.7 (95% CI, 82.7-98.5) for routine users. Specificity statistics for the 3 levels of physician experience were 83.3 (95% CI 55.2- 95.2), 100 (95% CI 83.0-100), and 96.6 (95% CI 88.4-99.0), respectively. The positive and negative likelihood ratios for ultrasound imaging by physicians were 27.94 and 0.054, respectively. The κ statistic was 0.80. Mean (SD) time until a physician took ultrasound images was 1.81 (1.46) hours versus 4.39 (1.81) hours until a radiologist obtained images (P = .007). Three deaths occurred within 30 days. They were not attributable to recurrence or bleeding. CONCLUSION: Ultrasound images taken by emergency physicians to diagnose DVT are accurate and safe and may be efficient. However, routine experience with ultrasound is necessary.

OBJETIVO: Evaluar la precisión, la seguridad y la eficiencia de la ecografía realizada por urgenciólogos para el diagnóstico de la trombosis venosa profunda (TVP). METODO: Estudio prospectivo multicéntrico de cohortes que incluyó pacientes con sospecha de TVP asignados a un grupo intervención (evaluados ecográficamente por el urgenciólogo y posteriormente por el radiólogo) y a un grupo control (evaluados únicamente por el radiólogo). Se analizaron las variables relacionadas con el paciente, el urgenciólogo, el episodio, el resultado de la prueba y los tiempos de estancia y acontecimientos a 30 días. Se calcularon la sensibilidad, la especificidad, las razones de verosimilitud positiva y negativa, y el índice kappa. RESULTADOS: Se incluyeron 304 pacientes (95 control, 209 intervención). Ambos grupos fueron comparables. La prevalencia de TVP en la cohorte global fue de 35,5% (IC 95% 30,3-41,0). La sensibilidad de la ecografía realizada por urgenciólogos fue superior según la experiencia-curso vs meses vs uso habitual: 71,4 (IC 95% 50,0-86,0) vs 75,0 (IC 95% 80,0-95,4) vs 94,7 (IC 95% 82,7-98,5), así como la especificidad 83,3 (IC 95% 55,2-95,2) vs 100 (IC 95% 83,0- 100) vs 96,6 (IC 95% 88,4-99,0). Las razones de verosimilitud positiva y negativa para la ecografía realizada por urgenciólogos fueron del 27,94 y del 0,054, respectivamente. El índice de kappa fue de 0,80. El tiempo hasta la realización de la ecografía por el urgenciólogo fue de 1,81 (DE 1,46) frente a 4,39 (DE 1,81) horas del radiólogo (p = 0,007). Durante el seguimiento a 30 días, se registraron 3 muertes, ninguna de ellas por recurrencia o hemorragia. CONCLUSIONES: La ecografía realizada por urgenciólogos para el diagnóstico de TVP es precisa, segura y podría resultar eficiente. Sin embargo, se requiere de experiencia basada en el uso habitual de esta técnica.

[Nontherapeutic international normalized ratio results in hospital emergency patients on vitamin K antagonists: prevalence and associated factors]. / Prevalencia y factores asociados a un International Normalized Ratio (INR) fuera de rango en pacientes en tratamiento con antivitamina K atendidos en servicios de urgencias hospitalarios.

OBJECTIVES: To determine the prevalence of international normalized ratio (INR) findings outside the normal range in hospital emergency department patients on vitamin K antagonists (VKAs). To identify factors associated with abnormal anticoagulant levels in these patients. MATERIAL AND METHODS: Observational, cross-sectional, multicentric study in 4 hospital emergency departments. We included a convenience sample of patients on VKA treatment for whom INR levels were on record and who had sought emergency care for complications unrelated to anticoagulant treatment. RESULTS: We included 376 patients with a mean (SD) age of 76.8 (10.1) years; 50.3% were women and 86.7% had atrial fibrillation. We found that 60.4% (95% CI, 55.3%-65.2%) had INRs outside the reference range. Multivariate analysis showed that changes in the patients' other long-term medications were independently associated with nontherapeutic INR results (odds ratio, 1.6; 95% CI, 1.02-2.79; P=.035). CONCLUSION: Over 60% of patients on VKA treatment who come to hospital emergency departments with complaints unrelated to anticoagulant therapy have INR values outside the normal range. Changes in a patient's usual medications are significantly associated with nontherapeutic INR findings.

OBJETIVO: Determinar la prevalencia de un International Normalized Ratio (INR) fuera de rango entre los pacientes que acuden a los servicios de urgencias hospitalarios (SUH) y se encuentran en tratamiento con fármacos antivitamina K (AVK). Identificar los factores que se asocian con unos valores inadecuados de anticoagulación en estos pacientes. METODO: Estudio multicéntrico, observacional y transversal en cuatro SUH. Se incluyeron pacientes en tratamiento con AVK a los que se les realizó una analítica con determinación de INR, que no acudían por complicaciones asociadas al tratamiento anticoagulante. La inclusión se realizó mediante un muestreo de oportunidad. RESULTADOS: Se incluyeron en el estudio un total de 376 pacientes. Edad media de 76,8 (10,1) años, 50,3% fueron mujeres. El 86,7% de los pacientes presentaban fibrilación auricular. El 60,4% (IC 95%: 55,3%-65,2%) de los pacientes tuvieron un INR fuera de rango. El análisis multivariado demostró que los cambios en los medicamentos habituales con odss ratio (OR) de 1,6 (IC 95%: 1,02-2,79; p = 0,035) se asociaron de forma independiente a la presencia de un INR fuera de rango. CONCLUSIONES: El 60,4% de los pacientes en tratamiento con AVK que acuden a un SUH sin complicaciones asociadas al tratamiento anticoagulante presenta un INR fuera de rango. Los cambios en el tratamiento habitual del paciente se relacionaron significativamente con un INR fuera de rango.

Safety and Revisit Related to Discharge the Sixty-one Spanish Emergency Department Medical Centers Without Hospitalization in Patients with COVID-19 Pneumonia. A Prospective Cohort Study UMC-Pneumonia COVID-19

ABSTRACT Background: Information is needed on the safety and efficacy of direct discharge from the emergency department (ED) of patients with COVID-19 pneumonia. Objectives: The objectives of the study were to study the variables associated with discharge from the ED in patients presenting with COVID-19 pneumonia, and study ED revisits related to COVID-19 at 30 days (EDR30d). Methods: Multicenter study of the SIESTA cohort including 1198 randomly selected COVID patients in 61 EDs of Spanish medical centers from March 1, 2020, to April 30, 2020. We collected baseline and related characteristics of the acute episode and calculated the adjusted odds ratios (aOR) for ED discharge. In addition, we analyzed the variables related to EDR30d in discharged patients. Results: We analyzed 859 patients presenting with COVID-19 pneumonia, 84 (9.8%) of whom were discharged from the ED. The variables independently associated with discharge were being a woman (aOR 1.890; 95%CI 1.176-3.037), age < 60 years (aOR 2.324; 95%CI 1.353-3.990), and lymphocyte count > 1200/mm3 (aOR 4.667; 95%CI 1.045-20.839). The EDR30d of the ED discharged group was 40.0%, being lower in women (aOR 0.368; 95%CI 0.142-0.953). A total of 130 hospitalized patients died (16.8%) as did two in the group discharged from the ED (2.4%) (OR 0.121; 95%CI 0.029-0.498). Conclusion: Discharge from the ED in patients with COVID-19 pneumonia was infrequent and was associated with few variables of the episode. The EDR30d was high, albeit with a low mortality.

[Wells clinical prediction criteria in patients suspected of having deep vein thrombosis: evaluation of components and use in the emergency department]. / Evaluación de los componentes de la escala de probabilidad clínica de Wells en pacientes con sospecha de trombosis venosa profunda en el servicio de urgencias.

OBJECTIVES: To determine the applicability of the Wells clinical prediction criteria for deep vein thrombosis (DVT) in patients in hospital emergency departments and to evaluate the relevance of the score's components. MATERIAL AND METHODS: Prospective multicenter cohort study in consecutive hospital emergency department patients suspected of having DVT. Full-leg Doppler compression ultrasound imaging was performed on all patients. We recorded information on variables related to risk for DVT and the components of clinical prediction scales. Wells and Oudega clinical prediction scores were calculated. RESULTS: We studied 362 patients in 23 hospital emergency departments; the mean (SD) age was 65 (18) years and 52.8% were women. DVT was diagnosed in 254 patients (70.16%); 171 (47.2%) had proximal DVT. The clinical probability of DVT according to the Wells scale and the prevalence of proximal DVT were as follows: low probability, 57 patients (14 with DVT, 24.6%); intermediate probability, 124 (43 with DVT, 34.7%), and high probability, 181 (114 with DVT, 63%). Only 5 of the components of the Wells scale were associated with the presence of proximal DVT. CONCLUSION: The prevalence of DVT is very high in the 3 categories of clinical probability indicated by the Wells score. The prevalences do not correspond to those of the cohort used to validate the scale. It appears to be necessary to develop scales adjusted for use in hospital emergency departments when DVT is suspected.

OBJETIVO: Determinar la aplicabilidad y valorar la idoneidad de los componentes de la escala de Wells para la estimación de la probabilidad clínica de trombosis venosa profunda (TVP) en pacientes atendidos en los servicios de urgencias hospitalarios (SUH). METODO: Estudio multicéntrico prospectivo de cohortes, con inclusión de pacientes consecutivos atendidos en los SUH con sospecha de TVP. Se realizó una ecografía de compresión con Doppler de toda la extremidad a todos los pacientes. Se recogió la existencia de variables relacionadas con el riesgo de desarrollo de TVP y los componentes de las escalas de probabilidad. Finalmente se calculó la probabilidad clínica mediante las escalas de Wells y Oudega. RESULTADOS: Se incluyeron 362 pacientes de 23 SUH (edad media 65 (DE 18) años, 52,8% mujeres). Se diagnosticó TVP a un total de 254 pacientes (70,16%), de los que 171 (47,2%) fueron TVP proximales (TVPP). La distribución de los pacientes según las categorías de probabilidad de la escala de Wells y la prevalencia de TVPP fue: 57 pacientes con probabilidad baja (14 casos con TVP, 24,6%), 124 con probabilidad intermedia (43 casos con TVP, 34,7%) y 181 con probabilidad alta (114 casos con TVP, 63%). Sólo cinco de los componentes de la escala de Wells se asociaron a la presencia de TVPP. CONCLUSIONES: La prevalencia de TVP en las diferentes categorías de probabilidad de la escala de Wells es muy elevada y no corresponde a la señalada en las series de validación. Parece necesario desarrollar escalas adecuadas a la población con sospecha de TVP que acude a los SUH.