Frailty is associated with 30-day mortality: a multicentre study of Swedish emergency departments.

BACKGROUND: Older patients living with frailty have an increased risk for adverse events. The Clinical Frailty Scale (CFS) is a 9-point frailty assessment instrument that has shown promise to identify frail emergency department (ED) patients at increased risk of adverse outcomes. The aim of this study was to investigate the association between CFS scores and 30-day mortality in an ED setting when assessments are made by regular ED staff. METHOD: This was a prospective multicentre observational study carried out between May and November 2021 at three EDs in Sweden, where frailty via CFS is routinely assessed by ED staff. All patients ≥65 years of age were eligible for inclusion. Mortality at 7, 30 and 90 days, admission rate, ED and hospital length of stay (LOS) were compared between patients living with frailty (CFS≥5) and robust patients. Logistic regression was used to adjust for confounders. RESULTS: A total of 1840 ED visits of patients aged ≥65 years with CFS assessments done during the study period were analysed, of which 606 (32.9%) were patients living with frailty. Mortality after the index visit was higher in patients living with frailty at 7 days (2.6% vs 0.2%), 30 days (7.9% vs 0.9%) and 90 days (15.5% vs 2.4%). Adjusted ORs for mortality for those with frailty compared with more robust patients were 9.9 (95% CI 2.1 to 46.5) for 7-day, 6.0 (95% CI 3.0 to 12.2) for 30-day and 5.7 (95% CI 3.6 to 9.1) 90-day mortality. Patients living with frailty had higher admission rates, 58% versus 36%, a difference of 22% (95% CI 17% to 26%), longer ED LOS, 5 hours:08 min versus 4 hours:36 min, a difference of 31 min (95% CI 14 to 50), and longer in-hospital LOS, 4.8 days versus 2.7 days, a difference of 2.2 days (95% CI 1.2 to 3.0). CONCLUSION: Patients living with frailty, had significantly higher mortality and admission rates as well as longer ED and in-hospital LOS compared with robust patients. The results confirm the capability of the CFS to risk stratify short-term mortality in older ED patients. TRIAL REGISTRATION NUMBER: NCT04877028.

NK1 receptor mediates cerebral cellular and extracellular morphological changes during the LPS-induced febrile response.

Fever elicited by bacterial lypopolyssacharide (LPS) is mediated by pro-inflammatory cytokines, which activate central mediators and regulate the hypothalamic temperature setpoint. This response is often accompanied by morphological changes involving the extracellular matrix, neurons and glial cells, with significant health impacts. The NK1 receptor is involved in the febrile response induced by LPS but its effects over the extracellular matrix in the context of neuroinflammation remain unknown. The present work aims to clarify the extracellular changes associated with NK1 signaling in LPS-induced fever. Male Wistar rats were exposed to LPS intraperitoneally. Experimental groups were pre-treated intracerebroventricularly with the NK1 selective inhibitor SR140333B or saline. Histological changes involving the brain extracellular matrix were evaluated using hematoxylin and eosin, Mason's trichrome, picrosirius, alcian blue, periodic acid Schiff's stains. The expression of matrix metalloproteinase 9 (MMP9) was studied using confocal microscopy. Fever was accompanied by edema, perivascular lymphoplamacytic and neutrophylic infiltration, spongiosis and MMP9 overexpression. SR140333B significantly reduced LPS-induced fever (p < 0.0001), MMP9 overexpression (p < 0.01) and associated histological changes. These results contribute to characterize cerebral extracellular matrix changes associated with LPS-induced fever. Overall, the present work supports a role for NK1 receptor in these neuroinflammatory changes, involving MMP9 overexpression, edema and leukocytic infiltration.

Agreement of pCO2 in venous to arterial blood gas conversion models in undifferentiated emergency patients.

BACKGROUND: Venous blood gas sampling has replaced arterial sampling in many critically ill patients, though interpretation of venous pCO2 still remains a challenge. Lemoël et al., Farkas and Zeserson et al. have proposed models to estimate arterial pCO2 based on venous pCO2. Our objective was to externally validate these models with a new dataset. This was a prospective cross-sectional study of consecutive adult patients with a clinical indication for blood gas analysis in an academic emergency department in Sweden. Agreement of pairs was reported as mean difference with limits of agreement (LoA). Vital signs and lead times were recorded. RESULTS: Two hundred and fifty blood gas pairs were collected consecutively between October 2021 and April 2022, 243 valid pairs were used in the final analysis [mean age 72.8 years (SD 17.8), 47% females]. Respiratory distress was the most common clinical indication (84% of all cases). The model of Farkas showed the best metrics with a mean difference between estimated and arterial pCO2 of - 0.11 mmHg (95% LoA - 6.86, + 6.63). For Lemoël the difference was 2.57 mmHg (95% LoA - 5.65, + 10.8), Zeserson 2.55 mmHg (95% LoA - 7.43, + 12.53). All three models showed a decrease in precision in patients with ongoing supplemental oxygen therapy. CONCLUSION: Arterial pCO2 may be accurately estimated in most patients based on venous blood gas samples. Additional consideration is required in patients with hypo- or hypercapnia or oxygen therapy. Thus, conversion of venous pCO2 may be considered as an alternative to arterial blood gas sampling with the model of Farkas being the most accurate.

Is the clinical frailty scale feasible to use in an emergency department setting? A mixed methods study.

BACKGROUND: The Clinical Frailty Scale (CFS) is a frailty assessment tool used to identify frailty in older patients visiting the emergency department (ED). However, the current understanding of how it is used and accepted in ED clinical practice is limited. This study aimed to assess the feasibility of CFS in an ED setting. METHODS: This was a prospective, mixed methods study conducted in three Swedish EDs where CFS had recently been introduced. We examined the completion rate of CFS assessments in relation to patient- and organisational factors. A survey on staff experience of using CFS was also conducted. All quantitative data were analysed descriptively, while free text comments underwent a qualitative content analysis. RESULTS: A total of 4235 visits were analysed, and CFS assessments were performed in 47%. The completion rate exceeded 50% for patients over the age of 80. Patients with low triage priority were assessed to a low degree (24%). There was a diurnal variation with the highest completion rates seen for arrivals between 6 and 12 a.m. (58%). The survey response rate was 48%. The respondents rated the perceived relevance and the ease of use of the CFS with a median of 5 (IQR 2) on a scale with 7 being the highest. High workload, forgetfulness and critical illness were ranked as the top three barriers to assessment. The qualitative analysis showed that CFS assessments benefit from a clear routine and a sense of apparent relevance to emergency care. CONCLUSION: Most emergency staff perceived CFS as relevant and easy to use, yet far from all older ED patients were assessed. The most common barrier to assessment was high workload. Measures to facilitate use may include clarifying the purpose of the assessment with explicit follow-up actions, as well as formulating a clear routine for the assessment. REGISTRATION: The study was registered on ClinicalTrials.gov 2021-06-18 (identifier: NCT04931472).

Emergency department crowding and mortality: an observational multicenter study in Sweden.

Background: Emergency department (ED) crowding is a serious problem worldwide causing decreased quality of care. It is reasonable to assume that the negative effects of crowding are at least partially due to high staff workload, but previous crowding metrics based on high workload have not been generalisable to Swedish EDs and have not been associated with increased mortality, in contrast to, e.g., occupancy rate. We recently derived and validated the modified Skåne Emergency Department Assessment of Patient Load model (mSEAL) that measures crowding based on staff workload in Swedish EDs, but its ability to identify situations with increased mortality is unclear. In this study, we aimed to investigate the association between ED crowding measured by mSEAL model, or occupancy rate, and mortality. Methods: All ED patients from 2017-01-01 to 2017-06-30 from two regional healthcare systems (Skåne and Östergötland Counties with a combined population of approximately 1.8 million) in Sweden were included. Exposure was ED- and hour-adjusted mSEAL or occupancy rate. Primary outcome was mortality within 7 days of ED arrival, with one-day and 30-day mortality as secondary outcomes. We used Cox regression hazard ratio (HR) adjusted for age, sex, arrival by ambulance, hospital admission and chief complaint. Results: We included a total of 122,893 patients with 168,900 visits to the six participating EDs. Arriving at an hour with a mSEAL score above the 95th percentile for that ED and hour of day was associated with an non-significant HR for death at 7 days of 1.04 (95% CI 0.96-1.13). For one- and 30-day mortality the HR was non-significant at 1.03 (95% CI 0.9-1.18) and 1.03 (95% CI 0.97-1.09). Similarly, occupancy rate above the 95th percentile with a HR of 1.04 (95% CI 0.9-1.19), 1.03 (95%CI 0.95-1.13) and 1.04 (95% CI 0.98-1.11) for one-, 7- and 30-day mortality, respectively. Conclusion: In this multicenter study in Sweden, ED crowding measured by mSEAL or occupancy rate was not associated with a significant increase in short-term mortality.

Risk of venous thromboembolism in patients with COVID-19 during 2020; a retrospective cross-sectional study in a Swedish health care system.

To establish the impact of COVID-19 on the pre-test probability for VTE in patients with suspected VTE. This was a retrospective, observational, cross-sectional study of patients 18 years and older undergoing diagnostic tests for VTE in an integrated healthcare system covering a population of 465,000 during the calendar year of 2020. We adjusted for risk factors such as age, sex, previous VTE, ongoing anticoagulant treatment, malignancy, Charlson score, ward care, ICU care and wave of COVID-19. In total, 303 of 5041 patients had a positive diagnosis of COVID-19 around the time of investigation. The prevalence of VTE in COVID-positive patients was 10.2% (36/354), 14.7% (473/3219) in COVID-19 negative patients, and 15.6% (399/2589) in patients without a COVID-19 test. A COVID-positive status was not associated with an increased risk for VTE (crude odds ratio 0.64, 95% CI 0.45-0.91, adjusted odds ratio 0.46, 95%CI 0.19-1.16). We found no increased VTE risk in COVID-positive patients. This indicates that COVID-19 status should not influence VTE workup.The study was pre-registered on May 26, 2020 at ClinicalTrials.gov with identifier NCT04400877.

Emergency unit capacity in Northern Tanzania: a cross-sectional survey.

INTRODUCTION: Emergency medicine (EM) is a growing field in Sub-Saharan Africa. Characterising the current capacity of hospitals to provide emergency care is important in identifying gaps and future directions of growth. This study aimed to characterise the ability of emergency units (EU) to provide emergency care in the Kilimanjaro region in Northern Tanzania. METHODS: This was a cross-sectional study conducted at 11 hospitals with emergency care capacity in three districts in the Kilimanjaro region of Northern Tanzania assessed in May 2021. An exhaustive sampling approach was used, whereby all hospitals within the three-district area were surveyed. Hospital representatives were surveyed by two EM physicians using the Hospital Emergency Assessment tool developed by the WHO; data were analysed in Excel and STATA. RESULTS: All hospitals provided emergency services 24 hours a day. Nine had a designated area for emergency care, four had a core of fixed providers assigned to the EU, two lacked a protocol for systematic triage. For Airway and Breathing interventions, oxygen administration was adequate in 10 hospitals, yet manual airway manoeuvres were only adequate in six and needle decompression in two. For Circulation interventions, fluid administration was adequate in all facilities, yet intraosseous access and external defibrillation were each only available in two. Only one facility had an ECG readily available in the EU and none was able to administer thrombolytic therapy. For trauma interventions, all facilities could immobilise fractures, yet lacked interventions such as cervical spinal immobilisation and pelvic binding. These deficiencies were primarily due to lack of training and resources. CONCLUSION: Most facilities perform systematic triage of emergency patients, though major gaps were found in the diagnosis and treatment of acute coronary syndrome and initial stabilisation manoeuvres of patients with trauma. Resource limitations were primarily due to equipment and training deficiencies. We recommend the development of future interventions in all levels of facilities to improve the level of training.

Research priority setting in emergency care: A scoping review.

Objective: Priority areas for emergency care research are emerging and becoming ever more important. The objectives of this scoping review were to (1) provide a comprehensive overview of published emergency care priority-setting studies by collating and comparing priority-setting methodology and (2) describe the resulting research priorities identified. Methods: The Joanna Briggs Institute methodological framework was used. Inclusion criteria were peer-review articles available in English, published between January 1, 2008 and March 31, 2019 and used 2 or more search terms. Five databases (Scopus, AustHealth, EMBASE, CINAHL, and Ovid MEDLINE) were searched. REporting guideline for PRIority SEtting of health research (REPRISE) criteria were used to assess the quality of evidence of included articles. Results: Forty-five studies were included. Fourteen themes for emergency care research were considered within 3 overarching research domains: emergency populations (pediatrics, geriatrics), emergency care workforce and processes (nursing, shared decision making, general workforce, and process), and emergency care clinical areas (imaging, falls, pain management, trauma care, substance misuse, infectious diseases, mental health, cardiology, general clinical care). Variation in the reporting of research priority areas was evident. Priority areas to drive the global agenda for emergency care research are limited given the country and professional group-specific context of existing studies. Conclusion: This comprehensive summary of generated research priorities across emergency care provides insight into current and future research agendas. With the nature of emergency care being inherently broad, future priorities may warrant population (eg, children, geriatrics) or subspecialty (eg, trauma, toxicology, mental health) focus and be derived using a rigorous framework and patient engagement.

Inter-rater reliability of the Clinical Frailty Scale by staff members in a Swedish emergency department setting.

INTRODUCTION: As frailty among the elderly is receiving increasing attention in emergency departments (EDs) around the world, the use of frailty assessment tools is growing. An often used such tool is the Clinical Frailty Scale (CFS), whose inter-rater reliability has been sparingly investigated in ED settings. No inter-rater reliability study regarding CFS has previously been performed within the Scandinavian ED context. The primary aim of this study was to evaluate the inter-rater reliability of the CFS in a Swedish ED setting. METHODS: This was a prospective observational study conducted at three Swedish EDs. Patients ≥65 years were independently assessed with CFS by their responsible physician, registered nurse, and assistant nurse. Demographic information for each assessor was collected, along with frailty status (frail/not frail) on the basis of clinical judgment. Inter-rater reliability was calculated using intraclass correlation coefficient (ICC), whereas agreement of frailty assessed by CFS (dichotomized between frail/not frail, cutoff at ≥5 points) versus solely by clinical judgment was calculated by using cross-tabulation. RESULTS: One-hundred patients were included. We found inter-rater reliability to be moderate to good (ICC 0.78, 95% confidence interval [CI] 0.72-0.84), regardless of whether the care team included an emergency physician (ICC 0.74, 95% CI 0.62-0.83) or an intern/resident from another specialty (ICC 0.83, 95% CI 0.74-0.89). The agreement of clinically judged frailty compared to frailty according to CFS was 84%. In the opposing cases, staff tended to assess patients as frail to a higher extent using clinical judgment than by applying CFS on the same patient. CONCLUSIONS: The CFS appears to have a moderate to good inter-rater reliability when used in a clinical ED setting. When guiding clinical decisions, we advise that the CFS score should be discussed within the team. Further research needs to be performed on the accuracy of clinical judgment to identify frailty in ED patients.

Airway management procedures in Swedish emergency department patients - a national retrospective study.

BACKGROUND: With the on-going debate about which specialty should be responsible for intubations in the emergency department in mind, the aim of this study was to describe the prevalence of endotracheal intubation and other airway management procedures in emergency department patients in Sweden. METHODS: All patients registered in the Swedish Intensive Care Registry with admission date from January 1 2013 until June 7 2018 and reported admission type "from the emergency department" or "emergency department" reported in the SAPS3 scoring were included. All patients missing codes for procedures were excluded. RESULTS: A total of 110,072 admissions from an emergency department to an ICU were registered during the study period. Of these, 41,619 admissions (37.8%) were excluded due to lack of codes for medical procedures. The remaining 68,453 admissions (62.2%) were included, and 31,888 emergency airway procedures (within 3 h from admission time to the intensive care unit) were registered. Invasive emergency airway procedures were the most common type of airway procedure (n = 23,446), followed by non-invasive airway procedures (n = 8377) and high-flow nasal cannula (n = 880). In 2017 a total of 4720 invasive emergency airway management procedures were registered. CONCLUSIONS: The frequency of invasive airway management procedures in Swedish EDs is low. With approximately 1.9 million adult ED visits per year, this gives an estimated incidence of 2.4 invasive airway management procedures per thousand ED visits in 2017. TRIAL REGISTRATION: Not applicable.

In vivo dose-response analysis to acetylcholine: pharmacodynamic assessment by polarized reflectance spectroscopy.

Transdermal iontophoresis offers an in vivo alternative to the strain-gauge model for measurement of vascular function but is limited due to lack of technical solutions for outcome assessment. The aims of this study were to, after measurement by polarized reflectance spectroscopy (PRS), use pharmacodynamic dose-response analysis on responses to different concentrations of acetylcholine (ACh); and to examine the effect of three consecutively administered iontophoretic current pulses. The vascular responses in 15 healthy volunteers to iontophorised ACh (5 concentrations, range 0.0001% to 1%, three consecutive pulses of 0.02 mA for 10 min each) were recorded using PRS. Data were fitted to a four-parameter logistic dose response model and compared. Vascular responses were quantifiable by PRS. Similar pharmacodynamic dose response curves could be generated irrespectively of the ACh concentration. Linearly increasing maximum vasodilatory responses were registered with increasing concentration of ACh. A limited linear dose effect of the concentration of ACh was seen between pulses. Polarized reflectance spectroscopy is well suited for measuring vascular responses to iontophoretically administrated ACh. The results of this study support further development of iontophoresis as a method to study vascular function and pharmacological responses in vivo.

Pathways to the emergency department - a national, cross-sectional study in Sweden.

BACKGROUND: Swedish Emergency Departments (EDs) see 2.6 million visits annually. Sweden has a strong tradition of health care databases, but information on patients' pathways to the ED is not documented in any registry. The aim of this study was to provide a national overview of pathways, degree of medical acuteness according to triage, chief complaints, and hospital admission rates for adult patients (≥18 years) visiting Swedish EDs during 24 h. METHODS: A national cross-sectional study including all patients at 43 of Sweden's 72 EDs during 24 h on April 25th, 2018. Pathway to the ED, medical acuteness at triage, admission and basic demographics were registered by dedicated assessors present at every ED for the duration of the study. Descriptive data are reported. RESULTS: A total of 3875 adult patients (median age 59; range 18 to 107; 50% men) were included in the study. Complete data for pathway to the ED was reported for 3693 patients (98%). The most common pathway was self-referred walk-in (n = 1310; 34%), followed by ambulance (n = 920; 24%), referral from a general practitioner (n = 497; 1 3%), and telephone referral by the national medical helpline "1177" (n = 409; 10%). In patients 18 to 64 years, self-referred walk-in was most common, whereas transport by ambulance dominated in patients > 64 years. Of the 3365 patients who received a medical acuteness level at triage, 4% were classified as Red (Immediate), 18% as Orange (very urgent), 47% as Yellow (Urgent), 26% as Green (Standard), and 5% as Blue (Non-Urgent). Abdominal or chest pain were the most common chief complaints representing approximately 1/3 of all presentations. Overall, the admission rate was 27%. Arrival by ambulance was associated with the highest rate of admission (53%), whereas walk-in patients and telephone referrals were less often admitted. CONCLUSION: Self-referred walk-in was the overall most common pathway followed by ambulance. Patients arriving by ambulance were often elderly, critically ill and often admitted to in-patient care, whereas arrival by self-referred walk-in was more common in younger patients.

Differentiating properties of occupancy rate and workload to estimate crowding: A Swedish national cross-sectional study.

BACKGROUND: Emergency department (ED) crowding causes increased patient morbidity and mortality. ED occupancy rate (OR; patients by treatment beds) is a common measure of crowding, but the comparability of ORs between EDs is unknown. The objective of this investigation was to investigate differences in ORs between EDs using staff-perceived workload as reference. METHODS: This was a national cross-sectional study in Sweden. EDs provided data on census, treatment beds, staffing, and workload (1-6) at 5 time points. A baseline patient turnover was calculated as the average daily census by treatment beds, denoted turnover per treatment bed (TTB), for each ED. A census ratio (CR), current by daily census, was calculated to adjust for differences in the number of treatment beds. RESULTS: Data were returned from 37 (51%) EDs. TTB varied considerably (mean = 4, standard deviation = 1.6; range, 2.1-9.2), and the OR was higher in EDs with TTB >4 compared with ≤4, 0.86 versus 0.43 (0.43; 95% confidence interval [CI], 0.27-0.59), but not workload, 2.75 versus 2.52 (0.23; 95% CI, -0.19 to 0.64). After adjusting for confounders, both TTB (k = -0.3; 95% CI, -0.49 to -0.14) and OR (k = 3.4; 95% CI, 1.76-5.03) affected workload. Correlation with workload was better for CR than for OR (r = 0.75 vs 0.60, respectively). CONCLUSION: OR is affected by patient-to-treatment bed ratios that differ significantly between EDs and should be accounted for when measuring crowding. CR is not affected by baseline treatment beds and is a better comparable measure of crowding compared with OR in this national comparator study.

Admission of patients with chest pain and/or breathlessness from the emergency department in relation to risk assessment and copeptin levels - an observational study.

Background: One of the most critical decisions that emergency department (ED) physicians make is the discharge versus admission of patients. We aimed to study the association of the decision in the ED to admit patients with chest pain and/or breathlessness to a ward with risk assessment using the Rapid Emergency Triage and Treatment System (RETTS), the National Early Warning Score (NEWS), and plasma levels of the biomarkers copeptin, midregional proadrenomedulin (MR-proADM), and midregional proatrial natriuretic peptide (MR-proANP). Methods: Patients presenting at the ED with chest pain and/or breathlessness with less than one week onset were enrolled. Patients were triaged according to RETTS. NEWS was calculated from the vital signs retrospectively. Results: Three hundred and thirty-four patients (167 males), mean age 63.8 ± 16.8 years, were included. Of which, 210 (62.8%) patients complained of chest pain, 65 (19.5%) of breathlessness, and 59 (17.7%) of both. Of these, 176 (52.7%) patients were admitted to a ward, and 158 (47.3%) patients were discharged from the ED. In binary logistic models, age, gender, vital signs (O2 saturation and heart rate), NEWS class, and copeptin were associated with admission to a ward from the ED. In receiver-operating-characteristics (ROC) analysis, copeptin had an incremental predictive value compared to NEWS alone (P = 0.002). Conclusions: Emergency physicians' decisions to admit patients with chest pain and/or breathlessness from the ED to a ward are related to age, O2 saturation, heart rate, NEWS category, and copeptin. As an independent predictive marker for admission, early analysis of copeptin might be beneficial when improving patient pathways at the ED.

Respiratory rate monitoring in healthy volunteers by central photoplethysmography compared to capnography.

Monitoring of respiration is a central task in clinical medicine, crucial to patient safety. Despite the uncontroversial role of altered respiratory frequency as an important sign of impending or manifest deterioration, reliable measurement methods are mostly lacking outside of intensive care units and operating theaters. Photoplethysmography targeting the central blood circulation in the sternum could offer accurate and inexpensive monitoring of respiration. Changes in blood flow related to the different parts of the respiratory cycle are used to identify the respiratory pattern. The aim of this observational study was to compare photoplethysmography at the sternum to standard capnography in healthy volunteers. Bland Altman analysis showed good agreement (bias -0.21, SD 1.6, 95% limits of agreement -3.4 to 2.9) in respiratory rate values. Photoplethysmography provided high-quality measurements of respiratory rate comparable to capnographic measurements. This suggests that photoplethysmography may become a precise, cost-effective alternative for respiratory monitoring.

Prehospital delay is an important risk factor for mortality in community-acquired bloodstream infection (CA-BSI): a matched case-control study.

OBJECTIVES: The aim of this study was to identify prehospital and early hospital risk factors associated with 30-day mortality in patients with blood culture-confirmed community-acquired bloodstream infection (CA-BSI) in Sweden. METHODS: A retrospective case-control study of 1624 patients with CA-BSI (2015-2016), 195 non-survivors satisfying the inclusion criteria were matched 1:1 with 195 survivors for age, gender and microorganism. All forms of contact with a healthcare provider for symptoms of infection within 7 days prior CA-BSI episode were registered. Logistic regression was used to analyse risk factors for 30-day all-cause mortality. RESULTS: Of the 390 patients, 61% (115 non-survivors and 121 survivors) sought prehospital contact. The median time from first prehospital contact till hospital admission was 13 hours (6-52) for non-survivors and 7 hours (3-24) for survivors (p<0.01). Several risk factors for 30-day all-cause mortality were identified: prehospital delay OR=1.26 (95% CI: 1.07 to 1.47), p<0.01; severity of illness (Sequential Organ Failure Assessment score) OR=1.60 (95% CI: 1.40 to 1.83), p<0.01; comorbidity score (updated Charlson Index) OR=1.13 (95% CI: 1.05 to 1.22), p<0.01 and inadequate empirical antimicrobial therapy OR=3.92 (95% CI: 1.64 to 9.33), p<0.01. In a multivariable model, prehospital delay >24 hours from first contact remained an important risk factor for 30-day all-cause mortality due to CA-BSI OR=6.17 (95% CI: 2.19 to 17.38), p<0.01. CONCLUSION: Prehospital delay and inappropriate empirical antibiotic therapy were found to be important risk factors for 30-day all-cause mortality associated with CA-BSI. Increased awareness and earlier detection of BSI in prehospital and early hospital care is critical for rapid initiation of adequate management and antibiotic treatment.

Emergency department admissions to the intensive care unit - a national retrospective study.

BACKGROUND: Emergency departments (EDs) see a rising number of patients, but only a small fraction of ED patients need immediate intensive care. The characteristics of these patients are mostly unknown and there is reason to believe that there are large inter-hospital differences in thresholds for intensive care admissions from the ED. The purpose of this study was to give a nationwide overview of ED admissions directly to intensive care units. METHODS: We used the Swedish Intensive care Registry to identify all patients admitted to intensive care from the ED (January 1, 2013 until June 7, 2018). The primary outcome was discharge diagnosis after intensive care (primary ICU diagnosis code). ICU mortality and" ICU admission due to only observation" were analyzed as secondary outcomes. RESULTS: 110,072 ICU admissions were included, representing 94,546 unique patients. Intoxication, trauma and neurological conditions were the most common causes for intensive care, but large variations according to age, sex and hospital type were seen. Intoxication was the most prevalent diagnosis in young adults (46.8% of admissions in 18-29 years old), whereas infectious diseases predominated in the elderly (17.0% in 65-79 years old). Overall, ICU mortality was 7.2%, but varied substantially with age, sex, type of hospital and medical condition. Cardiac conditions had the highest mortality rates, reaching 32.9%. The mortality was higher in academic centers compared to rural hospitals (9.3% vs 5.0%). It was more common to be admitted to ICU for only observation in rural hospitals than in academic centers (20.1% vs 7.8%). Being admitted to ICU only for observation was most common in patients with intoxication (30.6%). CONCLUSIONS: Overall, intoxication was the most common cause for ICU admission from the ED. However, causes of ED ICU admissions differ substantially according to age, sex and hospital type. Being admitted to the ICU only for observation was most common in intoxicated patients. TRIAL REGISTRATION: Not applicable (no interventions).

Risk of venous thromboembolism in a Swedish healthcare system during the COVID-19 pandemic: A retrospective cross-sectional study.

OBJECTIVE: The objective of this study was to investigate the risk and prevalence of venous thromboembolism (VTE) for patients undergoing a diagnostic test for VTE with confirmed COVID-19 infection compared with patients with no COVID-19 infection. METHODS: This was a retrospective cross-sectional study of patients in an integrated healthcare system in Sweden, covering a population of 465,000, with a diagnostic test for VTE between March 1 and May 31 in the years 2015 to 2020. Risk for VTE with COVID-19 was assessed by logistic regression, adjusting for baseline risk factors. RESULTS: A total of 8702 patients were included, and 88 of those patients tested positive on the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction test. A positive SARS-CoV-2 test did not increase the odds for VTE (odds ratio, 0.97; 95% confidence interval [CI], 0.55-1.74) and did not change when adjusting for sex, previous VTE, previous malignancy, Charlson score, hospital admission, intensive care, or ongoing treatment with anticoagulation (odds ratio, 0.72; 95% CI, 0.16-3.3). The prevalence of VTE was unchanged in 2020 compared with 2015 to 2019 (16.5% vs 16.1%, respectively), and there was no difference in VTE between the SARS-CoV-2 positive, negative, or untested groups in 2020 (15.9%, 17.6%, and 15.7%, respectively; P = 0.85). CONCLUSIONS: We found no increased prevalence of VTE in the general population compared with previous years and no increased risk of VTE in patients who were SARS-CoV-2 positive, suggesting that SARS-CoV-2 status should not influence VTE workup in the emergency department. The prevalence of VTE was high in patients with SARS-CoV-2 treated in the intensive care unit (ICU), where the suspicion for VTE should remain high.

Validation of the modified Skåne emergency department assessment of patient load (mSEAL) model for emergency department crowding and comparison with international models; an observational study.

BACKGROUND: Emergency Department crowding is associated with increased morbidity and mortality but no measure of crowding has been validated in Sweden. We have previously derived and internally validated the Skåne Emergency Department Assessment of Patient Load (SEAL) score as a measure of crowding in Emergency Departments (ED) in a large regional healthcare system in Sweden. Due to differences in electronic health records (EHRs) between health care systems in Sweden, all variables in the original SEAL-score could not be measured reliably nationally. We aimed to derive and validate a modified SEAL (mSEAL) model and to compare it with established international measures of crowding. METHODS: This was an observational cross sectional study at four EDs in Sweden. All clinical staff assessed their workload (1-6 where 6 is the highest workload) at 5 timepoints each day. We used linear regression with stepwise backward elimination on the original SEAL dataset to derive and internally validate the mSEAL score against staff workload assessments. We externally validated the mSEAL at four hospitals and compared it with the National Emergency Department Overcrowding Score (NEDOCS), the simplified International Crowding Measure in Emergency Department (sICMED), and Occupancy Rate. Area under the receiver operating curve (AuROC) and coefficient of determination was used to compare crowding models. Crowding was defined as an average workload of 4.5 or higher. RESULTS: The mSEAL score contains the variables Patient Hours and Time to physician and showed strong correlation with crowding in the derivation (r2 = 0.47), internal validation (r2 = 0.64 and 0.69) and in the external validation (r2 = 0.48 to 0.60). AuROC scores for crowding in the external validation were 0.91, 0.90, 0.97 and 0.80 for mSEAL, Occupancy Rate, NEDOCS and sICMED respectively. CONCLUSIONS: The mSEAL model can measure crowding based on workload in Swedish EDs with good discriminatory capacity and has the potential to systematically evaluate crowding and help policymakers and researchers target its causes and effects. In Swedish EDs, Occupancy Rate and NEDOCS are good alternatives to measure crowding based on workload.