Validation of MEWS, NEWS, NEWS-2 and qSOFA for different infection foci at the emergency department, the acutelines cohort.

PURPOSE: Sepsis is a leading cause of morbidity and mortality globally. The lack of specific prognostic markers necessitates tools for early risk identification in patients with suspected infections in emergency department (ED). This study evaluates the prognostic accuracy of various Early Warning Scores (EWS)-MEWS, NEWS, NEWS-2, and qSOFA-for in-hospital mortality, 30-day mortality, and ICU admission, considering the site of infection. METHODS: A retrospective analysis was conducted using data from the Acutelines cohort, which included data collected from patients admitted to the University Medical Centre Groningen ED between September 2020 and July 2023. Patients were included if they had an ICD-10 code for infection. EWS were calculated using clinical data within 8 h post-admission. Predictive performance was assessed using AUC-ROC, calibration by the Hosmer-Lemeshow test and calibration curves, and operative characteristics like sensitivity and specificity. RESULTS: A total of 1661 patients were analyzed, with infections distributed as follows: lower respiratory tract (32.9%), urinary tract (30.7%), abdominal (12.5%), skin and soft tissue (9.5%), and others (8.2%). The overall in-hospital mortality was 6.7%, and ICU admission was 7.1%. The highest AUC-ROC for in-hospital mortality prediction was observed with NEWS and NEWS-2 in abdominal infections (0.86), while the lowest was for qSOFA in skin and soft tissue infections (0.57). Predictive performance varied by infection site. CONCLUSIONS: The study highlights the variability in EWS performance based on infection site, emphasizing the need to consider the source of infection in EWS development for sepsis prognosis. Tailored or hybrid models may enhance predictive accuracy, balancing simplicity and specificity.

Predictive performance of NEWS and qSOFA in immunocompromised sepsis patients at the emergency department.

PURPOSE: Sepsis has a high incidence and a poor prognosis. Early recognition is important to facilitate timely initiation of adequate care. Sepsis screening tools, such as the (quick) Sequential Organ Failure Assessment ((q)SOFA) and National Early Warning Score (NEWS), could help recognize sepsis. These tools have been validated in a general immunocompetent population, while their performance in immunocompromised patients, who are particularly at risk of sepsis development, remains unknown. METHODS: This study is a post hoc analysis of a prospective observational study performed at the emergency department. Inclusion criteria were age ≥ 18 years with a suspected infection, while ≥ two qSOFA and/or SOFA criteria were used to classify patients as having suspected sepsis. The primary outcome was in-hospital mortality. RESULTS: 1516 patients, of which 40.5% used one or more immunosuppressives, were included. NEWS had a higher prognostic accuracy as compared to qSOFA for predicting poor outcome among immunocompromised sepsis patients. Of all tested immunosuppressives, high-dose glucocorticoid therapy was associated with a threefold increased risk of both in-hospital and 28-day mortality. CONCLUSION: In contrast to NEWS, qSOFA underestimates the risk of adverse outcome in patients using high-dose glucocorticoids. As a clinical consequence, to adequately assess the severity of illness among immunocompromised patients, health care professionals should best use the NEWS.

Societal costs of sepsis in the Netherlands.

BACKGROUND: Sepsis is a life-threatening syndrome characterized by acute loss of organ function due to infection. Sepsis survivors are at risk for long-term comorbidities, have a reduced Quality of Life (QoL), and are prone to increased long-term mortality. The societal impact of sepsis includes its disease burden and indirect economic costs. However, these societal costs of sepsis are not fully understood. This study assessed sepsis's disease-related and indirect economic costs in the Netherlands. METHODS: Sepsis prevalence, incidence, sepsis-related mortality, hospitalizations, life expectancy, QoL population norms, QoL reduction after sepsis, and healthcare use post-sepsis were obtained from previous literature and Statistics Netherlands. We used these data to estimate annual Quality-adjusted Life Years (QALYs), productivity loss, and increase in healthcare use post-sepsis. A sensitivity analysis was performed to analyze the burden and indirect economic costs of sepsis under alternative assumptions, resulting in a baseline, low, and high estimated burden. The results are presented as a baseline (low-high burden) estimate. RESULTS: The annual disease burden of sepsis is approximately 57,304 (24,398-96,244; low-high burden) QALYs. Of this, mortality accounts for 26,898 (23,166-31,577) QALYs, QoL decrease post-sepsis accounts for 30,406 (1232-64,667) QALYs. The indirect economic burden, attributed to lost productivity and increased healthcare expenditure, is estimated at €416.1 (147.1-610.7) million utilizing the friction cost approach and €3.1 (0.4-5.7) billion using the human capital method. Cumulatively, the combined disease and indirect economic burdens range from €3.8 billion (friction method) to €6.5 billion (human capital method) annually within the Netherlands. CONCLUSIONS: Sepsis and its complications pose a substantial disease and indirect economic burden to the Netherlands, with an indirect economic burden due to production loss that is potentially larger than the burden due to coronary heart disease or stroke. Our results emphasize the need for future studies to prevent sepsis, saving downstream costs and decreasing the economic burden.

A clinical prediction model for safe early discharge of patients with an infection at the emergency department.

BACKGROUND: Every hospital admission is associated with healthcare costs and a risk of adverse events. The need to identify patients who do not require hospitalization has emerged with the profound increase in hospitalization rates due to infectious diseases during the last decades, especially during the COVID-19 pandemic. This study aimed to identify predictors of safe early discharge (SED) in patients presenting to the emergency department (ED) with a suspected infection meeting the Systemic Inflammatory Response Syndrome (SIRS) criteria. METHODS: We conducted a prospective cohort study on adult non-trauma patients with a suspected infection and at least two SIRS criteria. We defined SED as hospital discharge within 24 h (e.g. direct ED discharge or rapid ward discharge) without disease-related readmission to our hospital or death during the first seven days. A prediction model for SED was developed using multivariate logistic regression analysis and tested with k-fold cross-validation. RESULTS: We included 1381 patients, of whom 1027 (74.4 %) were hospitalized for longer than 24 h or re-admitted within seven days and 354 (25.6 %) met SED criteria. Parameters associated with SED were relatively young age, absence of comorbidities, living independently, yellow or green triage urgency, lack of ambulance transport or general practitioner referral, normal clinical impression scores, and risk scores (i.e., qSOFA, PIRO, MEDS, NEWS, and SIRS), normal vital sign measurements and absence of kidney and respiratory failure. The model performance metrics showed an area under the curve of 0.824. The validation showed a minimal drop in performance and indicated a good fit. CONCLUSION: We developed and validated a model to identify patients with an infection at the ED who can be safely discharged early.

Diagnostic accuracy of the Dutch version of the 4AT for delirium detection in a mixed patient population and setting.

BACKGROUND: Delirium is an acute disturbance in attention, awareness and cognition. Immediate detection in older adults is recommended because delirium is associated with adverse outcomes. The 4 'A's Test (4AT) is a short screening instrument for delirium. The aim of this study is to evaluate diagnostic accuracy of the Dutch version of the screening tool 4AT for delirium detection in different settings. METHODS: Prospective observational study conducted in two hospitals in patients aged ≥ 65 years in geriatric wards and the Emergency Department (ED). Each participant underwent two assessments; the index test 4AT, followed by the reference standard for delirium performed by a geriatric care specialist. The reference standard delirium is according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) criteria. RESULTS: A total of 71 geriatric inpatients and 49 older ED patients were included. The prevalence of delirium was 11.6% in the acute geriatric ward and 6.1% in the ED. The sensitivity and specificity of the 4AT in the acute geriatric ward were 0.88 and 0.69, respectively. In the ED, the sensitivity and specificity were 0.67 and 0.83, respectively. The area under the receiver operating characteristic curve was 0.80 for the acute geriatric ward setting and 0.74 for the ED setting. CONCLUSION: The Dutch version of the 4AT is a reliable screening tool for delirium detection in both acute geriatric wards and ED. Due to its brevity and practicality (i.e., no special training is required to administer the tool), it is useful in clinical practice.

Point-of-care ultrasound-guided versus standard reduction of displaced distal radius fractures in the emergency department: a randomised controlled clinical trial.

BACKGROUND: During closed reduction of displaced distal radius fractures, physical examination is used to determine the need for further manipulation before radiographic confirmation and cast application. Manipulation performed under ultrasound guidance has the potential to decrease the number of reduction attempts. METHODS: This multicentre randomised controlled trial was undertaken between December 2018 and July 2020 in the ED of four hospitals in the Netherlands. Patients aged ≥16 years presenting to the ED with a distal radius fracture requiring closed reduction were randomised to either point-of-care ultrasound (PoCUS)-guided or standard reduction. The primary outcome was the proportion of patients requiring more than one reduction attempt. The secondary outcomes were time to complete reduction and treatment plan at ED discharge (conservative or operative repair). RESULTS: A total of 214 patients were screened, of which 211 patients were included for primary endpoint analysis (87% female, median age 68 years, 94% dorsal angulation, 59% intra-articular and 73% multifragmentary). In total, 105 patients were randomised to standard treatment and 106 patients to PoCUS-guided fracture reduction. In the standard treatment group, 13 patients (12%) required more than one reduction attempt, compared with 6 patients (6%) in the PoCUS group (OR 2.35, 95% CI 0.86 to 6.45). The median reduction time was 5 min in the PoCUS group (IQR 3-6) vs 3 min (IQR 2-4) in the standard reduction group (p<0.001). At ED discharge, operative repair was indicated for 17 (16%) patients in the standard group and 21 (20%) patients in the PoCUS group (OR 0.78, 95% CI 0.39 to 1.58). CONCLUSION: This study could not demonstrate that PoCUS-guided reduction of distal radius fractures was associated with a statistically significant decrease in the number of reduction attempts. TRIAL REGISTRATION NUMBER: The Netherlands Trial Register (NTR7934).

Use of sepsis-related diagnostic criteria in primary care: a survey among general practitioners.

BACKGROUND: Use of sepsis-criteria in hospital settings is effective in realizing early recognition, adequate treatment and reduction of sepsis-associated morbidity and mortality. Whether general practitioners (GPs) use these diagnostic criteria is unknown. OBJECTIVE: To gauge the knowledge and use of various diagnostic criteria. To determine which parameters GPs associate with an increased likelihood of sepsis. METHODS: Two thousand five hundred and sixty GPs were invited and 229 agreed to participate in a survey, reached out to through e-mail and WhatsApp groups. The survey consisted of two parts: the first part aimed to obtain information about the GP, training and knowledge about sepsis recognition, and the second part tested specific knowledge using six realistic cases. RESULTS: Two hundred and six questionnaires, representing a response rate of 8.1%, were eligible for analysis. Gut feeling (98.1%) was the most used diagnostic method, while systemic inflammatory response syndrome (37.9%), quick Sequential Organ Failure Assessment (qSOFA) (7.8%) and UK Sepsis Trust criteria (UKSTc) (1.5%) were used by the minority of the GPs. Few of the responding GPs had heard of either the qSOFA (27.7%) or the UKSTc (11.7%). Recognition of sepsis varied greatly between GPs. GPs most strongly associated the individual signs of the qSOFA (mental status, systolic blood pressure, capillary refill time and respiratory rate) with diagnosing sepsis in the test cases. CONCLUSIONS: GPs mostly use gut feeling to diagnose sepsis and are frequently not familiar with the 'sepsis-criteria' used in hospital settings, although clinical reasoning was mostly in line with the qSOFA score. In order to improve sepsis recognition in primary care, GPs should be educated in the use of available screening tools.

Point-of-care ultrasound curriculum for internal medicine residents: what do you desire? A national survey.

BACKGROUND: Point-of-care Ultrasound is a relative new diagnostic tool for internists. Since 2019, it is a mandatory skill for internal medicine residents in the Netherlands but an ultrasound curriculum still has to be developed. In this study we explored the current ultrasound training program and educational wishes from internal medicine residents. METHODS: We have undertaken a national study in March 2019 using an online questionnaire. All internal medicine residents in the Netherlands were invited to respond. RESULTS: A total of 247 from 959 (26%) residents completed the questionnaire. The majority of residents (78.6%) received less than 10 h of ultrasound training and 40% has never made an ultrasound at all. Almost all residents (92%) indicate that ultrasound is a useful skill for the internist. They report that the most useful applications are ultrasound of the inferior vena cava, kidneys, abdominal free fluid, deep vein thrombosis, heart and lungs. The main perceived barrier to perform ultrasound is the lack of availability of experts for bedside supervision. CONCLUSION: This study confirms the need for a national ultrasound curriculum for internal medicine residents and may contribute to the development of an ultrasound curriculum in line with residents educational needs. We should begin the curriculum with the previously mentioned applications, perceived by internal residents as most useful. Additional applications can be appended in the future. Finally it is necessary to expand the number of experts to supervise the residents.

Diagnostic accuracy of evaluation of suspected syncope in the emergency department: usual practice vs. ESC guidelines.

BACKGROUND: Syncope is a frequent reason for referral to the emergency department. After excluding a potentially life-threatening condition, the second objective is to find the cause of syncope. The objective of this study was to assess the diagnostic accuracy of the treating physician in usual practice and to compare this to the diagnostic accuracy of a standardised evaluation, consisting of thorough history taking and physical examination by a research physician. METHODS: This prospective cohort study included suspected (pre) syncope patients without an identified serious underlying condition who were assessed in the emergency department. Patients were initially seen by the initial treating physician and the usual evaluation was performed. A research physician, blinded to the findings of the initial treating physician, then performed a standardised evaluation according to the ESC syncope guidelines. Diagnostic accuracy (proportion of correct diagnoses) was determined by expert consensus after long-term follow-up. RESULTS: One hundred and one suspected (pre) syncope patients were included (mean age 59 ± 20 years). The usual practice of the initial treating physicians did not in most cases follow ESC syncope guidelines, with orthostatic blood pressure measurements made in only 40% of the patients. Diagnostic accuracy by the initial treating physicians was 65% (95% CI 56-74%), while standardised evaluation resulted in a diagnostic accuracy of 80% (95% CI 71-87%; p = 0.009). No life-threatening causes were missed. CONCLUSIONS: Usual practice of the initial treating physician resulted in a diagnostic accuracy of 65%, while standardised practice, with an emphasis on thorough history taking, increased diagnostic accuracy to 80%. Results suggest that the availability of additional resources does not result in a higher diagnostic accuracy than standardised evaluation, and that history taking is the most important diagnostic test in suspected syncope patients. Netherlands Trial Registration: NTR5651. Registered 29 January 2016, https://www.trialregister.nl/trial/5532.

Orthostatic blood pressure recovery patterns in suspected syncope in the emergency department.

INTRODUCTION: Orthostasis is a frequent trigger for (pre)syncope but some forms of orthostatic (pre)syncope have a worse prognosis than others. Routine assessment of orthostatic BP in the ED can detect classic orthostatic hypotension, but often misses these other forms of orthostatic (pre)syncope. This study aimed to determine the frequency of abnormal orthostatic BP recovery patterns in patients with (pre)syncope by using continuous non-invasive BP monitoring. METHODS: We performed a prospective cohort study in suspected patients with (pre)syncope in the ED of a tertiary care teaching hospital between January and August 2014. Orthostatic BP was measured during the active lying-to-standing test with Nexfin, a continuous non-invasive finger arterial pressure measurement device. Orthostatic BP recovery patterns were defined as normal BP recovery, initial orthostatic hypotension, delayed BP recovery, classic orthostatic hypotension and reflex-mediated hypotension. RESULTS: Of 116 patients recruited, measurements in 111 patients (age 63 years, 51% male) were suitable for analysis. Classic orthostatic hypotension was the most prevalent abnormal BP pattern (19%), but only half of the patients received a final diagnosis of orthostatic hypotension. Initial orthostatic hypotension and delayed BP recovery were present in 20% of the patients with (pre)syncope of whom 45% were diagnosed as unexplained syncope. Reflex-mediated hypotension was present in 4% of the patients. CONCLUSION: Continuous non-invasive BP measurement can potentially identify more specific and concerning causes of orthostatic (pre)syncope. Correct classification is important because of different short-term and long-term clinical implications.

Titration of oxygen therapy in critically ill emergency department patients: a feasibility study.

BACKGROUND: Liberal use of oxygen in an emergency situation is common. Today, most health care professionals do not adjust the amount of oxygen given when a saturation of 100% or a PaO2 which exceeds the normal range is reached- which may result in hyperoxia. There is increasing evidence for the toxic effects of hyperoxia. Therefore, it seems justified to aim for normoxia when giving oxygen. This study evaluates whether it is feasible to aim for normoxia when giving oxygen therapy to patients at the emergency department (ED). METHODS: A prospective cohort study was performed at the ED of the University Medical Center Groningen (UMCG). A protocol was developed, aiming for normoxia. During a 14 week period all patients > 18 years arriving at the ED between 8 a.m. and 23 p.m. requiring oxygen therapy registered for cardiology, internal medicine, emergency medicine and pulmonology were included. Statistical analysis was performed using student independent t-test, Mann-Whitney U-test, Fisher's exact test or a Pearson's chi-squared test. RESULTS: During the study period the study protocol was followed and normoxia was obtained after 1 h at the ED in 86,4% of the patients. Patients with COPD were more at risk for not being titrated to normal oxygen levels. CONCLUSIONS: We showed that it is feasible to titrate oxygen therapy to normoxia at the ED. The study results will be used for further research assessing the potential beneficial effects of normoxia compared to hyper- or hypoxia in ED patients and for the development of guidelines.

Pain score, desire for pain treatment and effect on pain satisfaction in the emergency department: a prospective, observational study.

BACKGROUND: Pain management in the Emergency Department has often been described as inadequate, despite proven benefits of pain treatment protocols. The aim of this study was to investigate the effectiveness of our current pain protocol on pain score and patient satisfaction whilst taking the patients' wishes for analgesia into account. METHODS: We conducted a 10-day prospective observational study in the Emergency Department. Demographics, pain characteristics, Numeric Rating Scale pain scores and the desire for analgesics were noted upon arrival at the Emergency Department. A second Numeric Rating Scale pain score and the level of patient satisfaction were noted 75-90 min after receiving analgesics. Student T-tests, Mann-Whitney U tests and Kruskall-Wallis tests were used to compare outcomes between patients desiring vs. not desiring analgesics or patients receiving vs. not receiving analgesics. Univariate and multivariate logistic regression models were used to investigate associations between potential predictors and outcomes. RESULTS: In this study 334 patients in pain were enrolled, of which 43.7% desired analgesics. Initial pain score was the only significant predictive factor for desiring analgesia, and differed between patients desiring (7.01) and not desiring analgesics (5.14). Patients receiving analgesics (52.1%) had a greater decrease in pain score than patients who did not receive analgesics (2.41 vs. 0.94). Within the group that did not receive analgesics there was no difference in satisfaction score between patients desiring and not desiring analgesics (7.48 vs. 7.54). Patients receiving analgesics expressed a higher satisfaction score than patients not receiving analgesics (8.10 vs. 7.53). CONCLUSIONS: This study pointed out that more than half of the patients in pain entering the Emergency Department did not desire analgesics. In patients receiving analgesics, our pain protocol has shown to adequately treat pain, leading to a higher satisfaction for emergency health-care at discharge. This study emphasizes the importance of questioning pain score and desire for analgesics to prevent incorrect conclusions of inadequate pain management, as described in previous studies.

An acute oral intoxication with haloperidol decanoate.

Haloperidol decanoate is a typical antipsychotic drug used as maintenance therapy for schizophrenia and mood disorders formulated as an ester for intramuscular injection. Cases of oral haloperidol decanoate intoxications have not been described in literature. In this report, we present for the first time a case of an oral ingestion of haloperidol decanoate of a young woman who presented to the emergency department following an intentional oral ingestion of 1 ampoule of haloperidol decanoate 100mg. At presentation, she had a bilateral rest tremor of both hands and mild hypothermia. No other obvious signs of an intoxication were observed. She was treated with a single dose of activated charcoal and laxative and was admitted to the intensive care for rhythm monitoring and observation. During the night the QTc interval increased to 453ms, but stayed within the normal range. Haloperidol plasma levels increased as well, but also stayed within therapeutic ranges. These findings indicate that treatment with oral activated charcoal was sufficient to prevent any serious events.

Exploiting the Features of Clinical Judgment to Improve Assessment of Disease Severity in the Emergency Department: An Acutelines Study.

BACKGROUND: Clinical judgment, also known as gestalt or gut feeling, can predict deterioration and can be easily and rapidly obtained. To date, it is unknown what clinical judgement precisely entails. The aim of this study was to elucidate which features define the clinical impression of health care professionals in the ED. METHOD: A nominal group technique (NGT) was used to develop a consensus-based instrument to measure the clinical impression score (CIS, scale 1-10) and to identify features associated with either a more severe or less severe estimated disease severity. This single-center observational cohort study included 517 medical patients visiting the ED. The instrument was prospectively validated.. The predictive value of each feature for the clinical impression was assessed using multivariate linear regression analyses to adjust for potential confounders and validated in the infection group. RESULTS: The CIS at the ED was associated with ICU admission (OR 1.67 [1.37-2.03], p < 0.001), in-hospital mortality (OR 2.25 [1.33-3.81], p < 0.001), and 28-day mortality (OR 1.33 [1.07-1.65], <0.001). Dry mucous membranes, eye glance, red flags during physical examination, results of arterial blood gas analysis, heart and respiratory rate, oxygen modality, triage urgency, and increased age were associated with a higher estimated disease severity (CIS). On the other hand, behavior of family, self-estimation of the patient, systolic blood pressure, and Glascow Coma Scale were associated with a lower estimated disease severity (CIS). CONCLUSION: We identified several features that were associated with the clinical impression of health care professionals in the ED. Translating the subjective features and objective measurements into quantifiable parameters may aid the development of a novel triage tool to identify patients at risk of deterioration in the ED.

Plasma procalcitonin and urine interleukin-8, neutrophil gelatinase-associated lipocalin, and calprotectin in the diagnostic process of a urinary tract infection at the emergency department.

OBJECTIVES: This study aimed to assess the usefulness of plasma procalcitonin and urine IL-8 (interleukin-8), NGAL (neutrophil gelatinase-associated lipocalin), and calprotectin for diagnosis of urinary tract infections (UTIs) at the emergency department (ED). METHODS: In adults presenting at the ED with UTI suspicion, biomarker performance was compared with that of routine diagnostics (urine dipstick, automated urinalysis). Patients with a urine catheter, leukopenia, or neither (standard) were analyzed separately. RESULTS: A UTI was clinically diagnosed in 91 of 196 episodes (46.4%) (standard: 29/67 [43.2%]; catheter: 46/73 [63.0%]; leukopenia: 17/60 [28.3%]; four patients had both). Procalcitonin did not discriminate between UTI and no UTI. Urinary biomarker levels were elevated in UTI episodes (median, µg/mmol creatinine: NGAL, 7.8 vs 46.3; IL-8, 6.1 vs 76.6; calprotectin, 23.9 vs 265.4); the three subgroups also had higher levels. Biomarker cut-off values (90% sensitivity) showed low specificity (range 20.8-64.9%) and moderate accuracy (58.6-75.4%). The biomarkers performed similarly to routine diagnostics, except for patients with leukopenia, who exhibited nonsignificantly higher area under the curve values. All urinary biomarkers correlated positively with urine leukocyte count. CONCLUSION: Plasma procalcitonin could not accurately diagnose UTI. Urine IL-8, NGAL, and calprotectin showed no additional value relative to routine diagnostics, except a minor improvement in patients with leukopenia. These urine biomarkers seem to predominantly reflect leukocyturia.

Clinical usefulness of urine Gram stain for diagnosing urinary tract infections at the emergency department.

BACKGROUND: Diagnosis of urinary tract infections (UTIs) is a frequent challenge at the emergency department (ED). The clinical usefulness of the urine Gram stain (GS) is uncertain. OBJECTIVE: We studied the GS performance to clarify its clinical utility at the ED. METHODS: Urine dipstick (UD), automated urinalysis (UF-1000i), GS and urine culture (UC) were performed in a cohort of consecutive adults presenting at the ED suspected of a UTI. GS performance was assessed and compared to UD and UF-1000i. RESULTS: A UTI diagnosis was established in 487/1358 (35.9%) episodes. Sensitivity and specificity for 'many' GS leucocytes was 33.7% and 95.4%; for 'many' GS bacteria 51.3% and 91.0%. GS diagnostic performance by ROC analysis was 0.796 for leucocytes and 0.823 for bacteria. GS bacteria performed better than UD nitrite comparable to UF-1000i bacteria. GS leucocytes underperformed compared to UD leucocyte esterase and UF-1000i leucocytes. UC was positive in 455 episodes. GS correctly predicted urine culture of gram-negative rods (PPV 84.6%). Prediction was poor for gram-positive bacteria (PPV 38.4% (cocci), 1.0% (rods)). CONCLUSION: With the exception of a moderate prediction of gram-negative bacteria in the UC, urine GS does not improve UTI diagnosis at the ED compared to other urine parameters.