Patient Factors Associated With Prolonged Length of Stay After Traumatic Brain Injury.

Background For traumatic brain injury (TBI) survivors, recovery can lead to significant time spent in the inpatient/rehabilitation settings. Hospital length of stay (LOS) after TBI is a crucial metric of resource utilization and treatment costs. Risk factors for prolonged LOS (PLOS) after TBI require further characterization. Methodology We conducted a retrospective analysis of patients with diagnosed TBI at an urban trauma center. PLOS was defined as the 95th percentile of the LOS of the cohort. Patients with and without PLOS were compared using clinical/injury factors. Analyses included descriptive statistics, non-parametric analyses, and multivariable logistic regression for PLOS status. Results The threshold for PLOS was >24 days. In the cohort of 1,343 patients, 77 had PLOS. PLOS was significantly associated with longer mean intensive care unit (ICU) stays (16.4 vs. 1.5 days), higher mean injury severity scores (18.6 vs. 13.8), lower mean Glasgow coma scale scores (11.3 vs. 13.7) and greater mean complication burden (0.7 vs. 0.1). PLOS patients were more likely to have moderate/severe TBI, Medicaid insurance, and were less likely to be discharged home. In the regression model, PLOS was associated with ICU stay, inpatient disposition, ventilator use, unplanned intubation, and inpatient alcohol withdrawal. Conclusions TBI patients with PLOS were more likely to have severe injuries, in-hospital complications, and Medicaid insurance. PLOS was predicted by ICU stay, intubation, alcohol withdrawal, and disposition to inpatient/post-acute care facilities. Efforts to reduce in-hospital complications and expedite discharge may reduce LOS and accompanying costs. Further validation of these results is needed from larger multicenter studies.

Scaling the EQUIPPED medication safety program: Traditional and hub-and-spoke implementation models.

BACKGROUND: The EQUIPPED (Enhancing Quality of Prescribing Practices for Older Adults Discharged from the Emergency Department) medication safety program is an evidence-informed quality improvement initiative to reduce potentially inappropriate medications (PIMs) prescribed by Emergency Department (ED) providers to adults aged 65 and older at discharge. We aimed to scale-up this successful program using (1) a traditional implementation model at an ED with a novel electronic medical record and (2) a new hub-and-spoke implementation model at three new EDs within a health system that had previously implemented EQUIPPED (hub). We hypothesized that implementation speed would increase under the hub-and-spoke model without cost to PIM reduction or site engagement. METHODS: We evaluated the effect of the EQUIPPED program on PIMs for each ED, comparing their 12-month baseline to 12-month post-implementation period prescribing data, number of months to implement EQUIPPED, and facilitators and barriers to implementation. RESULTS: The proportion of PIMs at all four sites declined significantly from pre- to post-EQUIPPED: at traditional site 1 from 8.9% (8.1-9.6) to 3.6% (3.6-9.6) (p < 0.001); at spread site 1 from 12.2% (11.2-13.2) to 7.1% (6.1-8.1) (p < 0.001); at spread site 2 from 11.3% (10.1-12.6) to 7.9% (6.4-8.8) (p = 0.045); and at spread site 3 from 16.2% (14.9-17.4) to 11.7% (10.3-13.0) (p < 0.001). Time to implement was equivalent at all sites across both models. Interview data, reflecting a wide scope of responsibilities for the champion at the traditional site and a narrow scope at the spoke sites, indicated disproportionate barriers to engagement at the spoke sites. CONCLUSIONS: EQUIPPED was successfully implemented under both implementation models at four new sites during the COVID-19 pandemic, indicating the feasibility of adapting EQUIPPED to complex, real-world conditions. The hub-and-spoke model offers an effective way to scale-up EQUIPPED though a speed or quality advantage could not be shown.

Comparison of Frailty Indices and the Charlson Comorbidity Index in Traumatic Brain Injury.

BACKGROUND: Comorbidity scales for outcome prediction in traumatic brain injury (TBI) include the 5-component modified Frailty Index (mFI-5), the 11-component modified Frailty Index (mFI-11), and the Charlson Comorbidity Index (CCI). OBJECTIVE: To compare the accuracy in predicting clinical outcomes in TBI of mFI-5, mFI-11, and CCI. METHODS: The National Trauma Data Bank (NTDB) of the American College of Surgeons (ACS) was utilized to study patients with isolated TBI for the years of 2017 and 2018. After controlling for age and injury severity, individual multivariable logistic regressions were conducted with each of the 3 scales (mFI-5, mFI-11, and CCI) against predefined outcomes, including any complication, home discharge, facility discharge, and mortality. RESULTS: All 3 scales demonstrated adequate internal consistency throughout their individual components (0.63 for mFI-5, 0.60 for CCI, and 0.56 for mFI-11). Almost all studied complications were significantly more likely in frail patients. mFI-5 and mFI-11 had similar areas under the curve (AUC) for all outcomes, while CCI had lower AUCs (0.62-0.61-0.53 for any complication, 0.72-0.72-0.52 for home discharge, 0.78-0.78-0.53 for facility discharge, and 0.71-0.70-0.52 for mortality, respectively). CONCLUSION: mFI-5 and mFI-11 demonstrated similar accuracy in predicting any complication, home discharge, facility discharge, and mortality in TBI patients across the NTDB. In addition, CCI's performance was poor for the aforementioned metrics. Since mFI-5 is simpler, yet as accurate as the 2 other scales, it may be the most practical both for clinical practice and for future studies with the NTDB.

A New Teaching Tool for Peer Review of Charting and Care in the Emergency Department.

Poor documentation, incomplete medical decision-making, missing progress notes, and inappropriate care play a major role in medical malpractice cases. We introduced a new quality improvement (QI) process focused on evaluating and improving documentation and clinical care. We hypothesized that a modified, simplified QI scoring rubric would demonstrate inter-rater reliability among attending physicians and provide a useful new standardized tool for both QI departmental review and peer review. We modified a previously developed rubric template that demonstrated high inter-rater reliability for a more streamlined, simpler, and more generalized application. We developed a new system using three discrete templated sections with choices limited to five options. Eight experienced attending physicians evaluated the same 10 charts using our scoring rubrics. Consistency among raters was assessed using the Shrout-Fleiss relative: fixed set mean kappa scores. Our statistical analysis found excellent consistency among our experienced raters for both the documentation (κ = 0.91) and clinical care (κ = 0.84) scoring tools. We conclude that a modified, simplified QI scoring rubric demonstrates inter-rater reliability among experienced attending physicians. We believe this tool can be used as a standardized tool for a departmental review process by experienced quality leaders as well as by faculty to provide peer review while improving their own charting prowess. We further used this tool for peer review by having the attending staff participate in reviewing a specified number of charts using our modified template with explicit criteria so they could provide feedback as well, while gaining a better understanding of the elements of a "good" chart and of opportunities for improved care and resource utilization. By using this tool, we were able to provide more than 50 attendings summative feedback on their charting by a group of their peers that was both numerical and descriptive.

Delayed Cranial Decompression Rates After Initiation of Unfractionated Heparin versus Low-Molecular-Weight Heparin in Traumatic Brain Injury.

BACKGROUND: Both unfractionated heparin (UH) and low-molecular-weight heparin (LMWH) are routinely used prophylactically after traumatic brain injury (TBI) to prevent deep vein thrombosis (DVT). Their comparative risk for development or worsening of intracranial hemorrhage necessitating cranial decompression is unclear. Furthermore, the absence of a specific antidote for LMWH may lead to UH being used more often for high-risk patients. This study aims to compare the incidence of delayed cranial decompression occurring after initiation of prophylactic UH versus LMWH using the National Trauma Data Bank. METHODS: Cranial decompression procedures included craniotomy and craniectomy. Multiple imputation was used for missing data. Propensity score matching was used to account for selection bias between UH and LMWH. The 1:1 matched groups were compared using logistic regression for the primary outcome of postprophylaxis cranial decompression. RESULTS: A total of 218,594 patients with TBI were included, with 61,998 (28.3%) receiving UH and 156,596 (71.7%) receiving LMWH as DVT prophylaxis. The UH group had higher patient age, body mass index, comorbidity rates, Injury Severity Score, and worse motor Glasgow Coma Scale score. After the UH and LMWH groups were matched for these factors, logistic regression showed lower rates of postprophylaxis cranial decompression for the LMWH group (odds ratio, 0.13; 95% confidence interval, 0.11-0.16; P < 0.001). CONCLUSIONS: Despite the absence of a specific antidote, LMWH was associated with lower rates of need for post-DVT-prophylaxis in craniotomy/craniectomy. This finding questions the notion of UH being safer for patients with TBI because it can be readily reversed. Randomized studies are needed to elucidate causality.

Prognostic Factors for Stage 3 Acute Kidney Injury in Isolated Serious Traumatic Brain Injury.

BACKGROUND: Stage 3 acute kidney injury (AKI) has been observed to develop after serious traumatic brain injury (TBI) and is associated with worse outcomes, though its incidence is not consistently established. This study aims to report the incidence of stage 3 AKI in serious isolated TBI in a large, national trauma database and explore associated predictive factors. METHODS: This was a retrospective cohort study using 2015-2018 data from the American College of Surgeons Trauma Quality Improvement Program, a national database of trauma patients. Adult trauma patients admitted to the hospital with isolated serious TBI were included. Variables relating to demographics, comorbidities, vitals, hospital presentation, and course of stay were assessed. Imputed multivariable logistic regression assessed factors predictive of stage 3 AKI development. RESULTS: A total of 342,675 patients with isolated serious TBI were included, 1585 (0.5%) of whom developed stage 3 AKI. Variables associated with stage 3 AKI in multivariable analysis were older age, male sex, Black race, higher body mass index, history of hypertension, diabetes, peripheral artery disease, chronic kidney disease, higher injury severity score, higher heart rate on arrival, lower oxygen saturation and motor Glasgow Coma Scale, admission to the intensive care unit or operating room, development of catheter-associated urinary tract infections or acute respiratory distress syndrome, longer intensive care unit stay, and ventilation duration. CONCLUSIONS: Stage 3 AKI occurred in 0.5% of serious TBI cases. Complications of acute respiratory distress syndrome and catheter-associated urinary tract infections are more likely to co-occur with stage 3 AKI in patients with serious TBI.

Utility Of An Emergency Department Clinical Protocol For Early Identification of Coronavirus Infection.

INTRODUCTION: We assessed the utility of an emergency department (ED) protocol using clinical parameters to rapidly distinguish likelihood of novel coronavirus 2019 (COVID-19) infection; the applicability aimed to stratify infectious-risk pre-polymerase chain reaction (PCR) test results and accurately guide early patient cohorting decisions. METHODS: We performed this prospective study over a two-month period during the initial surge of the 2020 COVID-19 pandemic in a busy urban ED of patients presenting with respiratory symptoms who were admitted for in-patient care. Per protocol, each patient received assessment consisting of five clinical parameters: presence of fever; hypoxia; cough; shortness of breath/dyspnea; and performance of a chest radiograph to assess for bilateral pulmonary infiltrates. All patients received nasopharyngeal COVID-19 PCR testing. RESULTS: Of 283 patients studied, 221 (78%) were PCR+ and 62 (22%) PCR-. Chest radiograph revealed bilateral pulmonary infiltrates in 85%, which was significantly more common in PCR+ (94%) vs PCR- (52%) patients (P < 0.0001). The rate of manifesting all five positive clinical parameters was significantly greater in PCR+ (63%) vs PCR- (6.5%) patients (P < 0.0001). For PCR+ outcome, the presence of all five positive clinical parameters had a specificity of 94%, positive predictive value of 98%, and positive likelihood ratio of 10. CONCLUSIONS: Using an ED protocol to rapidly assess five clinical parameters accurately distinguishes likelihood of COVID-19 infection prior to PCR test results, and can be used to augment early patient cohorting decisions.

Utility of measuring serum creatinine to detect renal compromise in ED patients receiving IV contrast-enhanced CT scan.

OBJECTIVE: The objectives of this study are to determine the efficacy of a roster of clinical factors in identifying risk for renal insufficiency in emergency department (ED) patients requiring intravenous contrast-enhanced CT scan (IVCE-CT) and to help mitigate potential for developing contrast-induced nephropathy (CIN). METHODS: A review was conducted of consecutive ED patients who received IVCE-CT during a 4-month period in our urban ED. The values of ED serum creatinine (SCr) performed were tabulated. The medical records of all patients with an elevated SCr (> 1.4 mg/dL) were reviewed to determine and correlate the presence of clinical risk factors for underlying renal insufficiency. RESULTS: During the 4-month study period, there were 2260 consecutive cases who received IVCE-CT; of these, 2250 (99.6%) had concomitant measurement of SCr. Elevated SCr occurred in 141 patients (6.2%); of these, 75 had a SCr > 2 mg/dL. In all, 139/141 (98.6%) with an elevated SCr had an underlying chronic or acute medical condition identified by medical record review which potentially compromised renal function, including chronic renal disease, diabetes mellitus, HIV infection, cancer, hypertension, congestive heart failure, sepsis/septic shock, chronic alcoholism, and sickle cell disease. Two patients with no identified risk factor each had (mildly) elevated SCr; both had a normal SCr measured post-CT scan. The total cost of performing serum basic metabolic panel to measure SCr in all patients during the 4-month study period was $94,500. CONCLUSIONS: Elevated SCr is rarely present in ED patients without recognized risk factors who receive IVCE-CT scan. The vast majority with underlying renal insufficiency are readily identified by a review of the patient's medical history and/or clinical findings. Routine SCr measurement on all ED patients regardless of risk stratification prior to IVCE imaging is neither time nor cost-effective.

Practical protocols for managing patients with SARS-CoV-2 infection (COVID-19) in the emergency department.

Coronavirus disease (COVID-19), caused by the SARS-CoV-2 virus, originated in Wuhan, Hubei Province, China in late 2019 and grew rapidly into a pandemic. As of the writing of this monograph, there are over 100 million confirmed cases worldwide and 2.3 million deaths.1 New York City, with over 630,000 COVID-19-positive patients and over 27,000 deaths, became the infection epicenter in the United States. The Mount Sinai Health System, with 8 hospitals spread across New York City and Long Island, has been on the forefront of the pandemic. This compendium summarizes the lessons learned through interdisciplinary collaborations to meet the varied challenges created by the explosive appearance of the infection in our community, and will be updated continuously as new research and best practices emerge. It is our hope is that the collaborations and lessons learned that went into creating these guidelines and protocols can serve as a useful template for other systems to adapt to their fight against COVID-19.

Emergency department COVID management policies: one institution's experience and lessons learned.

Coronavirus disease (COVID-19), caused by the SARS-CoV-2 virus, originated in Wuhan, Hubei Province, China in late 2019 and grew rapidly into a pandemic. As of the writing of this monograph, there are over 2 million confirmed cases worldwide and 147,000 deaths. New York City, with over 120,000 COVID-19-positive patients and over 11,000 deaths, has become the infection epicenter in the United States. The Mount Sinai Health System, with 8 hospitals spread across New York City and Long Island, has been on the forefront of the pandemic. This compendium summarizes the lessons learned through interdisciplinary collaborations to meet the varied challenges created by the explosive appearance of the infection in our community, and will be updated continuously as new research and best practices emerge. It is our hope is that the collaborations and lessons learned that went into creating these guidelines and protocols can serve as a useful template for other systems to adapt to their fight against COVID-19.

Ongoing and Focused Provider Performance Evaluations in Emergency Medicine: Current Practices and Modified Delphi to Guide Future Practice.

The Joint Commission requires ongoing and focused provider performance evaluations (OPPEs/FPPEs). The authors aim to describe current approaches in emergency medicine (EM) and identify consensus-based best practice recommendations. An online survey was distributed to leaders in EM to gain insight into current practices. A modified Delphi approach was then used to develop consensus to recommend best practice. A variety of strategies are currently in use for OPPE/FPPE. "Peer reviewed cases with opportunity for improvement" was identified as a preferred metric for OPPE. Although the preference was for use of peer review in OPPE, a consistent and standard adoption of robust internal care review processes is needed to establish expected norms. National benchmarking is not available currently. This was a limited survey of self-identified leaders, and there is an opportunity for additional engagement of leaders in EM to identify a unified approach that appropriately relates to patient outcomes.

Correlation of Venous Lactate and Time of Death in Emergency Department Patients with Noncritical Lactate Levels and Mortality from Trauma.

BACKGROUND: Serum venous lactate (LAC) levels help guide emergency department (ED) resuscitation of patients with major trauma. Critical LAC level (CLAC, ≥4.0 mmol/L) is associated with increased disease severity and higher mortality in injured patients. The characteristics of injured patients with non-CLAC (NCLAC) (<4.0 mmol/L) and death have not been previously described. OBJECTIVES: (1) To describe the characteristics of patients with venous NCLAC and death from trauma. (2) To assess the correlation of venous NCLAC with time of death. METHODS: A retrospective cohort study at an urban teaching hospital between 9/2011 and 8/2014. Inclusion: All trauma patients (all ages) who presented to the ED with any injury and met all criteria: (1) Venous LAC drawn at the time of arrival that resulted in an NCLAC level; (2) were admitted to the hospital; (3) died during their hospitalization. Exclusion: CLAC. Outcome: Correlation of NCLAC and time of death. Data were extracted from an electronic medical record by trained data abstractors using a standardized protocol. Cross-checks were performed on 10% of data entries and inter-observer agreement was calculated. Data were explored using descriptive statistics and Kaplan-Meier curves were created to define survival estimates. Data are presented as percentages with 95% confidence interval (CI) for proportions and medians with quartiles for continuous variables. Kaplan-Meier curves with differences in time to events based on LAC are used to analyze the data. RESULTS: A total of 60 patients met the inclusion criteria. The median age was 52 years (quartiles: 30, 75) and 73% were male (age range 2-92). The median LAC in the overall cohort was 1.9 mmol/L (quartiles: 1.5, 2.1). Sixteen patients (27%) died during the first 24 h with 5 (31%) due to intracranial hemorrhage. The median survival time was 5.6 days (134.4 h) (95% CI: 2.3-12.6). CONCLUSIONS: In trauma patients with NCLAC who died during the index hospitalization, the median survival time was 5.6 days, approximately one-third of patients died within the first 24 h. These findings indicate that relying on a triage NCLAC level alone may result in underestimating injury severity and subsequent morbidity and mortality.

A Hanging and Its Complications.

Hanging has become the second most common form of successful suicide in the United States. Along with a high mortality rate, the long-term morbidity is consequential for both the individual patient and society. A thorough knowledge of the clinical approach will assist the emergency physician in providing optimal care and helping to minimize delayed respiratory complications. Using a case-based scenario, the initial management strategies along with rational evidence-based treatments are reviewed.

The prognostic role of non-critical lactate levels for in-hospital survival time among ED patients with sepsis.

OBJECTIVE: This study describes emergency department (ED) sepsis patients with non-critical serum venous lactate (LAC) levels (LAC <4.0 mmol/L) who suffered in-hospital mortality and examines LAC in relation to survival times. METHODS: An ED based retrospective cohort study accrued September 2010 to August 2014. Inclusion criteria were ED admission, LAC sampling, >2 systemic inflammatory response syndrome criteria with an infectious source (sepsis), and in-hospital mortality. Kaplan-Meier curves were used for survival estimates. An a priori sub-group analysis for patients with repeat LAC within 6 hours of initial sampling was undertaken. The primary outcome was time to in-hospital death evaluated using rank-sum tests and regression models. RESULTS: One hundred ninety-seven patients met inclusion criteria. Pulmonary infections were the most common (44%) and median LAC was 1.9 mmol/L (1.5, 2.5). Thirteen patients (7%) died within 24 hours and 79% by ≤28 days. Median survival was 11 days (95% CI, 8.0-13). Sixty-two patients had repeat LAC sampling with 14 (23%) and 48 (77%) having decreasing increasing levels, respectively. No significant differences were observed in treatment requirements between the LAC subgroups. Among patients with decreasing LAC, median survival was 24 days (95% CI, 5-32). For patients with increasing LAC median survival was significantly shorter (7 days; 95% CI, 4-11, P = .04). Patients with increasing LAC had a non-significant trend toward reduced survival (HR = 1.6 95% CI, 0.90-3.0, P = .10). CONCLUSIONS: In septic ED patients experiencing in-hospital death, non-critical serum venous lactate may be utilized as a risk-stratifying tool for early mortality, while increasing LAC levels may identify those in danger of more rapid deterioration.