Patients with pulmonary hypertension presenting to the emergency department.

OBJECTIVES: Pulmonary hypertension (PH) patients represent a complex subset of patients in the emergency department (ED), yet little is known about their presentations and outcomes. The objective of this study is to analyze the demographics, dispositions and the rates of return visits for PH patients visiting the ED, focusing on PH patients identified as having high frequency visits. METHODS: We performed a retrospective cohort analysis of all patients with ICD-9-CM and ICD-10-CM codes corresponding to PH presenting to an academic medical center emergency department during a 21-month period. The primary outcome was patients with high frequency ED visits, defined as 4 or more visits in a 12-month period. Secondary outcomes included ED dispositions, return ED visits, hospital length of stay, and in-hospital mortality. RESULTS: Six hundred and eighty four unique patients with a coded diagnosis of PH visited the emergency department a total of 1447 times. Eighty-four patients (12.28%) were identified as having high frequency visits. Factors associated with high frequency ED visits included male sex, liver disease, rheumatologic disease, and having Group 1 PH. PH patients' admission rate was substantial at 56.60%, and their inpatient mortality was increased (6.7% vs 3.7% for all admissions from ED, P < 0.0001). CONCLUSION: PH patients in this study had frequent return ED visits, as well as elevated admission and readmission rates. Factors associated with high frequency ED visits included male sex, liver disease, rheumatologic disease, and Group 1 PH. PH patients also had increased mortality rates compared to the general ED population.

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.

Lack of racial and ethnic-based differences in acute care delivery in intracerebral hemorrhage.

BACKGROUND AND AIM: Early diagnosis and treatment of intracerebral hemorrhage (ICH) is thought to be critical for improving outcomes. We examined whether racial or ethnic disparities exist in acute care processes in the first hours after ICH. METHODS: We performed a retrospective review of a prospectively collected cohort of consecutive patients with spontaneous primary ICH presenting to a single urban tertiary care center. Acute care processes studied included time to computerized tomography (CT) scan, time from CT to inpatient bed request, and time from bed request to hospital admission. Clinical outcomes included mortality, Glasgow Outcome Scale, and modified Rankin Scale. RESULTS: Four hundred fifty-nine patients presented with ICH between 2006 and 2018 and met inclusion criteria (55% male; 75% non-Hispanic White [NHW]; mean age of 73). In minutes, median time to CT was 43 (interquartile range [IQR] 28, 83), time to bed request was 62 (IQR 33, 114), and time to admission was 142 (IQR 95, 232). In a multivariable analysis controlling for demographic factors, clinical factors, and disease severity, race/ethnicity had no effect on acute care processes. English language, however, was independently associated with slower times to CT (ß = 30.7 min, 95% CI 9.9 to 51.4, p = 0.004) and to bed request (ß = 32.8 min, 95% CI 5.5 to 60.0, p = 0.02). Race/ethnicity and English language were not independently associated with worse outcome. CONCLUSIONS: We found no evidence of racial/ethnic disparities in acute care processes or outcomes in ICH. English as first language, however, was associated with slower care processes.

Intervention to decrease leaving without treatment among intoxicated emergency department patients.

OBJECTIVE: Approximately 15% of the >4000 patients presenting each year to our emergency department (ED) with a chief complaint or discharge diagnosis related to alcohol were leaving without treatment (LWT). If they are not clinically sober at the time of departure, these patients are at risk for falls or other injury. Our goal was to create an intervention to decrease this rate of early departure. METHODS: A stakeholder group identified the reasons why intoxicated patients were leaving without treatment, concluding that the primary reason patients left was there was no process in place for evaluating and caring for these patients who potentially had impaired decision-making capacity. The group created a worksheet for the triage nurse to identify and manage patients presenting with intoxication and impaired decision-making or ambulation, with protocols to keep the patient in a supervised area. We performed a before and after analysis, evaluating 12 months before and 12 months after the protocol was initiated, with the primary outcome being the rate of intoxicated patients who left without treatment. We also measured the recidivism rate (the rate of return to the ED within 24 h after departure) and the ED length of stay (LOS). RESULTS: After the intervention was initiated, the percentage of intoxicated patients who left without treatment decreased from 15.0% to 7.4% LWT (p < 0.001). Among patients who stayed until discharge during the intervention period, the 24-hour recidivism was 9.4%, compared to 22.6% for those who left without treatment (p < 0.001). This difference in recidivism rates for each group was the same before and after the intervention, but fewer patients left without treatment after. For those patients with alcohol-related visits, the ED LOS was statistically significantly longer in the intervention phase, by a mean of 42 min for all patients (p < 0.001), as well as by a mean of 24 min for those who stayed to be dispositioned (p = 0.031). CONCLUSION: Providing a standardized process for caring for acutely intoxicated patients leads to fewer patients leaving the ED before discharge. Patients who stay to the completion of treatment have a lower recidivism rate within 24 h after leaving than those in the leaving without treatment category.