Effect of Automated Real-Time Feedback on Early-Sepsis Care: A Pragmatic Clinical Trial.

OBJECTIVES: To determine if a real-time monitoring system with automated clinician alerts improves 3-hour sepsis bundle adherence. DESIGN: Prospective, pragmatic clinical trial. Allocation alternated every 7 days. SETTING: Quaternary hospital from December 1, 2020 to November 30, 2021. PATIENTS: Adult emergency department or inpatients meeting objective sepsis criteria triggered an electronic medical record (EMR)-embedded best practice advisory. Enrollment occurred when clinicians acknowledged the advisory indicating they felt sepsis was likely. INTERVENTION: Real-time automated EMR monitoring identified suspected sepsis patients with incomplete bundle measures within 1-hour of completion deadlines and generated reminder pages. Clinicians responsible for intervention group patients received reminder pages; no pages were sent for controls. The primary analysis cohort was the subset of enrolled patients at risk of bundle nonadherent care that had reminder pages generated. MEASUREMENTS AND MAIN RESULTS: The primary outcome was orders for all 3-hour bundle elements within guideline time limits. Secondary outcomes included guideline-adherent delivery of all 3-hour bundle elements, 28-day mortality, antibiotic discontinuation within 48-hours, and pathogen recovery from any culture within 7 days of time-zero. Among 3,269 enrolled patients, 1,377 had reminder pages generated and were included in the primary analysis. There were 670 (48.7%) at-risk patients randomized to paging alerts and 707 (51.3%) to control. Bundle-adherent orders were placed for 198 intervention patients (29.6%) versus 149 (21.1%) controls (difference: 8.5%; 95% CI, 3.9-13.1%; p = 0.0003). Bundle-adherent care was delivered for 152 (22.7%) intervention versus 121 (17.1%) control patients (difference: 5.6%; 95% CI, 1.4-9.8%; p = 0.0095). Mortality was similar between groups (8.4% vs 8.3%), as were early antibiotic discontinuation (35.1% vs 33.4%) and pan-culture negativity (69.0% vs 68.2%). CONCLUSIONS: Real-time monitoring and paging alerts significantly increased orders for and delivery of guideline-adherent care for suspected sepsis patients at risk of 3-hour bundle nonadherence. The trial was underpowered to determine whether adherence affected mortality. Despite enrolling patients with clinically suspected sepsis, early antibiotic discontinuation and pan-culture negativity were common, highlighting challenges in identifying appropriate patients for sepsis bundle application.

Fewer emergency department alarms is associated with reduced use of medications for acute agitation.

BACKGROUND AND OBJECTIVES: Patient monitoring systems provide critical information but often produce loud, frequent alarms that worsen patient agitation and stress. This may increase the use of physical and chemical restraints with implications for patient morbidity and autonomy. This study analyzes how augmenting alarm thresholds affects the proportion of alarm-free time and the frequency of medications administered to treat acute agitation. METHODS: Our emergency department's patient monitoring system was modified on June 28, 2022 to increase the tachycardia alarm threshold from 130 to 150 and to remove alarm sounds for several arrhythmias, including bigeminy and premature ventricular beats. A pre-post study was performed lasting 55 days before and 55 days after this intervention. The primary outcome was change in number of daily patient alarms. The secondary outcomes were alarm-free time per day and median number of antipsychotic and benzodiazepine medications administered per day. The safety outcome was the median number of patients transferred daily to the resuscitation area. We used quantile regression to compare outcomes between the pre- and post-intervention period and linear regression to correlate alarm-free time with the number of sedating medications administered. RESULTS: Between the pre- and post-intervention period, the median number of alarms per day decreased from 1332 to 845 (-37%). This was primarily driven by reduced low-priority arrhythmia alarms from 262 to 21 (-92%), while the median daily census was unchanged (33 vs 32). Median hours per day free from alarms increased from 1.0 to 2.4 (difference 1.4, 95% CI 0.8-2.1). The median number of sedating medications administered per day decreased from 14 to 10 (difference - 4, 95% CI -1 to -7) while the number of escalations in level of care to our resuscitation care area did not change significantly. Multivariable linear regression showed a 60-min increase of alarm-free time per day was associated with 0.8 (95% CI 0.1-1.4) fewer administrations of sedating medication while an additional patient on the behavioral health census was associated with 0.5 (95% CI 0.0-1.1) more administrations of sedating medication. CONCLUSION: A reasonable change in alarm parameter settings may increase the time patients and healthcare workers spend in the emergency department without alarm noise, which in this study was associated with fewer doses of sedating medications administered.

CT utilization in evaluation of skin and soft tissue extremity infections in the ED: Retrospective cohort study.

OBJECTIVE: Skin and soft tissue infections (SSTI) are commonly diagnosed in the emergency department (ED). While most SSTI are diagnosed with patient history and physical exam alone, ED clinicians may order CT imaging when they suspect more serious or complicated infections. Patients who inject drugs are thought to be at higher risk for complications from SSTI and may undergo CT imaging more frequently. The objective of this study is to characterize CT utilization when evaluating for SSTI in ED patients particularly in patients with intravenous drug use (IVDU), the frequency of significant and actionable findings from CT imaging, and its impact on subsequent management and ED operations. METHODS: We performed a retrospective analysis of encounters involving a diagnosis of SSTI in seven EDs across an integrated health system between October 2019 and October 2021. Descriptive statistics were used to assess overall trends, compare CT utilization frequencies, actionable imaging findings, and surgical intervention between patients who inject drugs and those who do not. Multivariable logistic regression was used to analyze patient factors associated with higher likelihood of CT imaging. RESULTS: There were 4833 ED encounters with an ICD-10 diagnosis of SSTI during the study period, of which 6% involved a documented history of IVDU and 30% resulted in admission. 7% (315/4833) of patients received CT imaging, and 22% (70/315) of CTs demonstrated evidence of possible deep space or necrotizing infections. Patients with history of IVDU were more likely than patients without IVDU to receive a CT scan (18% vs 6%), have a CT scan with findings suspicious for deep-space or necrotizing infection (4% vs 1%), and undergo surgical drainage in the operating room within 48 h of arrival (5% vs 2%). Male sex, abnormal vital signs, and history of IVDU were each associated with higher likelihood of CT utilization. Encounters involving CT scans had longer median times to ED disposition than those without CT scans, regardless of whether these encounters resulted in admission (9.0 vs 5.5 h), ED observation (5.5 vs 4.1 h), or discharge (6.8 vs 2.9 h). DISCUSSION: ED clinicians ordered CT scans in 7% of encounters when evaluating for SSTI, most frequently in patients with abnormal vital signs or a history of IV drug use. Patients with a history of IVDU had higher rates of CT findings suspicious for deep space infections or necrotizing infections and higher rates of incision and drainage procedures in the OR. While CT scans significantly extended time spent in the ED for patients, this appeared justified by the high rate of actionable findings found on imaging, particularly for patients with a history of IVDU.

Design and Implementation of a Real-time Monitoring Platform for Optimal Sepsis Care in an Emergency Department: Observational Cohort Study.

BACKGROUND: Sepsis is the leading cause of death in US hospitals. Compliance with bundled care, specifically serial lactates, blood cultures, and antibiotics, improves outcomes but is often delayed or missed altogether in a busy practice environment. OBJECTIVE: This study aims to design, implement, and validate a novel monitoring and alerting platform that provides real-time feedback to frontline emergency department (ED) providers regarding adherence to bundled care. METHODS: This single-center, prospective, observational study was conducted in three phases: the design and technical development phase to build an initial version of the platform; the pilot phase to test and refine the platform in the clinical setting; and the postpilot rollout phase to fully implement the study intervention. RESULTS: During the design and technical development, study team members and stakeholders identified the criteria for patient inclusion, selected bundle measures from the Center for Medicare and Medicaid Sepsis Core Measure for alerting, and defined alert thresholds, message content, delivery mechanisms, and recipients. Additional refinements were made based on 70 provider survey results during the pilot phase, including removing alerts for vasopressor initiation and modifying text in the pages to facilitate patient identification. During the 48 days of the postpilot rollout phase, 15,770 ED encounters were tracked and 711 patient encounters were included in the active monitoring cohort. In total, 634 pages were sent at a rate of 0.98 per attending physician shift. Overall, 38.3% (272/711) patients had at least one page. The missing bundle elements that triggered alerts included: antibiotics 41.6% (136/327), repeat lactate 32.4% (106/327), blood cultures 20.8% (68/327), and initial lactate 5.2% (17/327). Of the missing Sepsis Core Measures elements for which a page was sent, 38.2% (125/327) were successfully completed on time. CONCLUSIONS: A real-time sepsis care monitoring and alerting platform was created for the ED environment. The high proportion of patients with at least one alert suggested the significant potential for such a platform to improve care, whereas the overall number of alerts per clinician suggested a low risk of alarm fatigue. The study intervention warrants a more rigorous evaluation to ensure that the added alerts lead to better outcomes for patients with sepsis.

Utilization of a multidisciplinary emergency department sepsis huddle to reduce time to antibiotics and improve SEP-1 compliance.

Sepsis is a significant public health crisis in the United States, contributing to 50% of inpatient hospital deaths. Given its dramatic health effects and implications in the setting of new CMS care guidelines, ED leaders have renewed focus on appropriate and timely sepsis care, including timely administration of antibiotics in patients at risk for sepsis. Modeling the success of multidisciplinary bedside huddles in improving compliance with appropriate care in other healthcare settings, a Sepsis Huddle was implemented in a large, academic ED, with the goal of driving compliance with standardized sepsis care as described in the CMS SEP-1 measure. A retrospective cohort analysis was performed, with the primary finding that utilization of the Sepsis Huddle resulted in antibiotics being administered on average 41 min sooner than when the Sepsis Huddle was not performed. Given that literature suggests that early administration of appropriate antibiotic therapy is a major driver of mortality reduction in patients with sepsis, this study represents a proof of concept that utilization of a Sepsis Huddle may serve to improve outcomes among ED patients at risk for sepsis.

Allergic-like contrast reactions in the ED: Incidence, management, and impact on patient disposition.

PURPOSE: Determine the incidence, management, and impact on patient disposition of allergic-like contrast reactions (ALCR) to intravenous iodinated contrast in the emergency department (ED). METHODS: All ED patients who developed an ALCR following contrast-enhanced CT (CECT) from June 2011-December 2016 were retrospectively identified. Medical records were reviewed and reaction severity, management, and disposition were quantified using descriptive statistics. The total number of consecutive CECTs performed in the ED were available from June 2011-March 2016 and were used to derive ALCR incidence over that time period. RESULTS: A total of 90 patients developed an ALCR during the study period. An ALCR incidence of 0.2% was derived based on 74 ALCRs occurring out of 47,059 consecutive contrast injections in ED patients from June 2011-April 2016. Reaction severity was mild in 63/90 (70%) and moderate in 27/90 (30%) cases; no patient developed a severe reaction by American College of Radiology criteria. The most commonly administered treatments were diphenhydramine in 67/90 (74%), corticosteroid in 24/90 (27%), and epinephrine in 13/90 (14%); symptoms subsequently resolved in all cases. No patient required inpatient admission for contrast reaction alone, and 5 patients were sent to the ED observation unit for post-epinephrine monitoring and subsequently discharged. CONCLUSION: ALCR among ED patients undergoing CECT are rare, generally of mild severity, respond well to pharmacologic management, and do not alter patient disposition in most cases. Familiarity with symptoms, management, and prevention strategies is increasingly relevant to the emergency physician given the ubiquity of CECT.

Implications of iodinated contrast media extravasation in the emergency department.

PURPOSE: To characterize the management, outcomes, and emergency department (ED) length of stay (LOS) following iodinated contrast media extravasation events in the ED. METHODS: All ED patients who developed iodinated contrast media extravasation following contrast-enhanced CT (CECT) from October 2007-December 2016 were retrospectively identified. Medical records were reviewed and management, complications, frequency of surgical consultation, and ED LOS were quantified using descriptive statistics. The Wilcoxon rank sum test was used to compare ED LOS in patients who did and did not receive surgical consultation. RESULTS: A total of 199 contrast extravasation episodes occurred in ED patients during the 9-year study period. Of these, 42 patients underwent surgical consultation to evaluate the contrast extravasation event. No patient developed progressive symptoms, compartment syndrome, or tissue necrosis, and none received treatment beyond supportive care (warm/cold packs, elevation, compression). Median ED LOS for patients who did and did not receive surgical consultation was 11.3h versus 9.0h, respectively (p<0.01). CONCLUSION: Close observation and supportive care are sufficient for contrast extravasation events in the ED without concerning symptoms (progressive pain/swelling, altered tissue perfusion, sensory changes, or blistering/ulceration). Routine surgical consultation is likely unnecessary in the absence of these symptoms - concordant with the current American College of Radiology guidelines - and may be associated with longer ED LOS without impacting management.

MR angiography can guide ED management of suspected acute aortic dissection.

BACKGROUND: Aortic dissection is typically evaluated with computed tomography angiography (CTA). However, the feasibility of using magnetic resonance angiography (MRA) in the ED is unclear. This study examined the indications and outcomes of MRA in suspected aortic dissection evaluation in the ED. METHODS: An IRB approved review identified patients who underwent MRA in the ED for acute thoracic aortic dissection from January 2010 to June 2016. Demographics, clinical assessment, CTA contraindications, outcomes, and ED disposition were analyzed. RESULTS: 50 MRAs were ordered for suspected thoracic aortic dissection. 21 (42%) for iodinated contrast allergy, 21 (42%) for renal insufficiency, 2 (4%) due to both, 2 (4%) to spare ionizing radiation, 2 (4%) for further work-up after CTA, and 2 (4%) due to prior contrast enhanced CT within 24h. Median ED arrival to MRA completion time was 311min. 42 studies were fully diagnostic; 7 were limited. One patient could not tolerate the examination. 49 MRAs were completed: 2 (4%) patients had acute dissection on MRA and 47 (96%) had negative exams. 17 (35%) received gadolinium. 18 (37%) patients were discharged home from the ED with a median length of stay of 643min. 2 (4%) were admitted for acute dissection seen on MRA and 29 (59%) for further evaluation. CONCLUSION: MRA has a clear role in the evaluation for acute thoracic aortic dissection in the ED in patients with contraindications to CTA, and can guide management and facilitate safe discharge to home.

Opportunity to reduce transfer of patients with mild traumatic brain injury and intracranial hemorrhage to a Level 1 trauma center.

OBJECTIVE: Current guidelines do not address the disposition of patients with mild traumatic brain injury (TBI) and resultant intracranial hemorrhage (ICH). Emergency medicine clinicians working in hospitals without neurosurgery coverage typically transfer patients with both to a trauma center with neurosurgery capability. Evidence is accruing which demonstrates that the risk of neurologic decompensation depends on the type of ICH and as a result, not every patient may need to be transferred. The purpose of this study was to identify risk factors for admission among patients with mild TBI and ICH who were transferred from a community hospital to the emergency department (ED) of a Level 1 trauma center. METHODS: Study subjects were patients ≥18years of age who were transferred from a community hospital to the ED of an urban, academic Level 1 trauma center between April 1, 2015 and March 31, 2016, and with an isolated traumatic ICH. Patients who had an epidural hematoma, were deemed to require a trauma center's level of service, were found to have non-traumatic ICHs, or had a Glasgow Coma Scale of <13 were excluded. Using a multivariable logistic regression model, we sought to determine patient factors and Computed Tomography (CT) findings which were associated with admission (to the floor, intensive care unit, or operating room with neurosurgery) of the Level 1 trauma center. RESULTS: 644 transferred patients were identified; 205 remained eligible after exclusion criteria. Presence of warfarin (odds ratio [OR] 4.09, 95% Confidence Interval [CI] 1.64, 10.25, p=0.0026) and a subdural hematoma (SDH) ≥1 cm (OR 6.28, 95% CI 1.24, 31.71, p=0.0263) were independently statistically significant factors predicting admission. Age, sex, GCS, presence of neurologic deficit, aspirin use, clopidogrel use, SDH <1 cm, IPH, and SAH were each independently not significant predictive factors of an admission. CONCLUSIONS: After controlling for factors, transferred patients with mild TBI with a SDH ≥1 cm or on warfarin have a higher odds ratio of requiring inpatient admission to a Level 1 trauma center. While these patients may require admission, there may be opportunities to develop and study a low risk traumatic intracranial hemorrhage protocol, which keeps a subgroup of patients with a mild TBI and resultant ICH at community hospitals with access to a nearby Level 1 trauma center.

Death or revascularization among nonadmitted ED patients with low-positive vs negative troponin T results.

STUDY OBJECTIVE: Compare outcomes among emergency department (ED) patients with low-positive (0.01-0.02 ng/mL) vs negative troponin T. METHODS: Retrospective cohort study of nonadmitted ED patients with troponin testing at a tertiary-care hospital. Trained research assistants used a structured tool to review charts from all nonadmitted ED patients with troponin testing, 12/1/2009 to 11/30/2010. Outcomes of death and coronary revascularization were assessed at 30 days and 6 months via medical record review, Social Security Death Index searches, and patient contact. RESULTS: There were 57596 ED visits; with 33388 (58%) discharged immediately, 6410 (11%) assigned to the observation unit, and 17798 (31%) admitted or other. Troponin was measured in 2684 (6.7%) of the nonadmitted cases. Troponin was negative in 2523 (94.0%), low positive in 78 (2.9%), and positive (≥0.03 ng/mL) in 83 (3.1%). Of troponin-negative cases, 0.8% (95% CI, 0.4-1.1%) died or were revascularized by 30 days, vs 2.8% (95% CI, 0.0-6.7%) of low-positive cases (risk difference [RD], 2.0%; 95% CI, -1.8 to 5.9%). At 6 months, the rates were 1.7% (95% CI, 1.1-2.2%) and 12.9% (95% CI, 5.0-20.7%) (RD, 11%; 95% CI, 3.3-19.1%). Death alone at 30 days occurred in 0.4% (95% CI, 0.1-0.6%) vs 1.3% (95% CI, 0.0-3.8%) (RD, 0.9%; 95% CI, -1.6 to 3.4%). Death at 6 months occurred in 1.2% (95% CI, 0.8-1.6%) vs 11.7% (95% CI, 4.5-18.9%) (RD, 10%; 95% CI, 3.3-17.7%). CONCLUSION: Among patients not initially admitted, rates of death and coronary revascularization differed insignificantly at 30 days but significantly at 6 months. Detailed inspection of our results reveals that the bulk of the added risk at 6 months was due to non-cardiac mortality.

Patient Experience With an In-Home COVID Virtual Observation Unit: An Analysis.

We performed a retrospective cohort study of patients admitted to a novel, home-based COVID Virtual Observation Unit (CVOU) from an urban, university-affiliated emergency department with ∼112,000 annual visits. Telephone-based survey questions were administered by nursing staff working with the program. Of 402 patients enrolled in the CVOU, 221 (55%) were able to be contacted during the study period; 180 (45%) agreed to participate in the telephone interview. Overall, 95% (169 out of 177) of the surveyed patients reported 8 to 10 on the likelihood to recommend CVOU and 82% (100 out of 122) rated the quality of care as 10 out of 10. Over 90% of respondents reported that all role groups (nurses, paramedics, and physicians) treated them with courtesy and respect, explained things in an understandable way, and listened to them carefully. Over 80% of respondents reported that the program kept them at home. In summary, patient experiences with this novel home-based care program were highly positive. These data help underscore the importance of patient-centeredness in home-based care, and further support the concept of these innovative care models.

Impact of Emergency Department Crowding on Discharged Patient Experience.

INTRODUCTION: While emergency department (ED) crowding has deleterious effects on patient care outcomes and operational efficiency, impacts on the experience for patients discharged from the ED are unknown. We aimed to study how patient-reported experience is affected by ED crowding to characterize which factors most impact discharged patient experience. METHODS: This institutional review board-exempt, retrospective, cohort study included all discharged adult ED patients July 1, 2020-June 30, 2021 with at least some response data to the the National Research Corporation Health survey, sent to most patients discharged from our large, academic medical center ED. Our query yielded 9,401 unique encounters for 9,221 patients. Based on responses to the summary question of whether the patient was likely to recommend our ED, patients were categorized as "detractors" (scores 0-6) or "non-detractors" (scores 7-10). We assessed the relationship between census and patient experience by 1) computing percentage of detractors within each care area and assessing for differences in census and boarder burden between detractors and non-detractors, and 2) multivariable logistic regression assessing the relationship between likelihood of being a detractor in terms of the ED census and the patient's last ED care area. A second logistic regression controlled for additional patient- and encounter-specific covariates. RESULTS: Survey response rate was 24.8%. Overall, 13.9% of responders were detractors. There was a significant difference in the average overall ED census for detractors (average 3.70 more patients physically present at the time of arrival, 95% CI 2.33-5.07). In unadjusted multivariable analyses, three lower acuity ED care areas showed statistically significant differences of detractor likelihood with changes in patient census. The overall area under the curve (AUC) for the unadjusted model was 0.594 (CI 0.577-0.610). The adjusted model had higher AUC (0.673, CI 0.657-.690]; P<0.001), with the same three care areas having significant differences in detractor likelihood based on patient census changes. Length of stay (OR 1.71, CI 1.50-1.95), leaving against medical advice/without being seen (OR 5.15, CI 3.84-6.89), and the number of ED care areas a patient visited (OR 1.16, CI 1.01-1.33) was associated with an increase in detractor likelihood. CONCLUSION: Patients arriving to a crowded ED and ultimately discharged are more likely to have negative patient experience. Future studies should characterize which variables most impact patient experience of discharged ED patients.