Validation and comparison of triage-based screening strategies for sepsis.

OBJECTIVE: This study sought to externally validate and compare proposed methods for stratifying sepsis risk at emergency department (ED) triage. METHODS: This nested case/control study enrolled ED patients from four hospitals in Utah and evaluated the performance of previously-published sepsis risk scores amenable to use at ED triage based on their area under the precision-recall curve (AUPRC, which balances positive predictive value and sensitivity) and area under the receiver operator characteristic curve (AUROC, which balances sensitivity and specificity). Score performance for predicting whether patients met Sepsis-3 criteria in the ED was compared to patients' assigned ED triage score (Canadian Triage Acuity Score [CTAS]) with adjustment for multiple comparisons. RESULTS: Among 2000 case/control patients, 981 met Sepsis-3 criteria on final adjudication. The best performing sepsis risk scores were the Predict Sepsis version #3 (AUPRC 0.183, 95 % CI 0.148-0.256; AUROC 0.859, 95 % CI 0.843-0.875) and Borelli scores (AUPRC 0.127, 95 % CI 0.107-0.160, AUROC 0.845, 95 % CI 0.829-0.862), which significantly outperformed CTAS (AUPRC 0.038, 95 % CI 0.035-0.042, AUROC 0.650, 95 % CI 0.628-0.671, p < 0.001 for all AUPRC and AUROC comparisons). The Predict Sepsis and Borelli scores exhibited sensitivity of 0.670 and 0.678 and specificity of 0.902 and 0.834, respectively, at their recommended cutoff values and outperformed Systemic Inflammatory Response Syndrome (SIRS) criteria (AUPRC 0.083, 95 % CI 0.070-0.102, p = 0.052 and p = 0.078, respectively; AUROC 0.775, 95 % CI 0.756-0.795, p < 0.001 for both scores). CONCLUSIONS: The Predict Sepsis and Borelli scores exhibited improved performance including increased specificity and positive predictive values for sepsis identification at ED triage compared to CTAS and SIRS criteria.

Associations Between Ambient Extreme Heat Exposure and Emergency Department Visits Related to Kidney Disease.

RATIONALE & OBJECTIVE: Extreme heat exposure is associated with multiple diseases. However, our current understanding of the specific impact of extreme heat exposure on kidney disease is limited. STUDY DESIGN: Case-crossover study. SETTING & PARTICIPANTS: 1,114,322 emergency department (ED) visits with a principal diagnosis of kidney disease were identified in New York state, 2005-2013. EXPOSURE: Extreme heat exposure was defined as when the daily temperature exceeded the 90th percentile temperature of that month during the study period in the county. OUTCOME: ED visits with a principal diagnosis of kidney disease and its subtypes (ICD-9 [International Classification of Diseases, Ninth Revision] codes 580-599, 788). ANALYTICAL APPROACH: Extreme heat exposure on the ED visit days was compared with extreme heat exposure on control days using a conditional logistic regression model, controlling for humidity, air pollutants, and holidays. The excess risk of kidney disease was calculated for a week (lag days 0-6) after extreme heat exposure during the warm season (May through September). We also stratified our estimates by sociodemographic characteristics. RESULTS: Extreme heat exposure was associated with a 1.7% (lag day 0) to 3.1% (lag day 2) higher risk of ED visits related to kidney disease; this association was stronger with a greater number of extreme heat exposure days in the previous week. The association with extreme heat exposure lasted for an entire week and was stronger in the transitional months (ie, May and September; excess rates ranged from 1.8% to 5.1%) rather than the summer months (June through August; excess rates ranged from 1.5% to 2.7%). The strength of association was greater among those with ED visits related to acute kidney injury, kidney stones, and urinary tract infections. Age and sex may modify the association between extreme heat exposure and ED visits. LIMITATIONS: Individual exposure to heat-how long people were outside or whether they had access to air conditioning-was unknown. CONCLUSIONS: Extreme heat exposure was significantly associated with a dose-dependent greater risk of ED visits for kidney disease.

Racial and Ethnic Disparities in Acute Care Utilization Among Patients With Glomerular Disease.

RATIONALE & OBJECTIVE: The effects of race, ethnicity, socioeconomic status (SES), and disease severity on acute care utilization in patients with glomerular disease are unknown. STUDY DESIGN: Prospective cohort study. SETTING & PARTICIPANTS: 1,456 adults and 768 children with biopsy-proven glomerular disease enrolled in the Cure Glomerulonephropathy (CureGN) cohort. EXPOSURE: Race and ethnicity as a participant-reported social factor. OUTCOME: Acute care utilization defined as hospitalizations or emergency department visits. ANALYTICAL APPROACH: Multivariable recurrent event proportional rate models were used to estimate associations between race and ethnicity and acute care utilization. RESULTS: Black or Hispanic participants had lower SES and more severe glomerular disease than White or Asian participants. Acute care utilization rates were 45.6, 29.5, 25.8, and 19.2 per 100 person-years in Black, Hispanic, White, and Asian adults, respectively, and 55.8, 42.5, 40.8, and 13.0, respectively, for children. Compared with the White race (reference group), Black race was significantly associated with acute care utilization in adults (rate ratio [RR], 1.76 [95% CI, 1.37-2.27]), although this finding was attenuated after multivariable adjustment (RR, 1.31 [95% CI, 1.03-1.68]). Black race was not significantly associated with acute care utilization in children; Asian race was significantly associated with lower acute care utilization in children (RR, 0.32 [95% CI 0.14-0.70]); no significant associations between Hispanic ethnicity and acute care utilization were identified. LIMITATIONS: We used proxies for SES and lacked direct information on income, household unemployment, or disability. CONCLUSIONS: Significant differences in acute care utilization rates were observed across racial and ethnic groups in persons with prevalent glomerular disease, although many of these difference were explained by differences in SES and disease severity. Measures to combat socioeconomic disadvantage in Black patients and to more effectively prevent and treat glomerular disease are needed to reduce disparities in acute care utilization, improve patient wellbeing, and reduce health care costs.

Emergency department care experiences among people who use substances: a qualitative study.

BACKGROUND: People who use substances (PWUS) encounter significant barriers to accessing care for their complex health needs. As a result, emergency departments (EDs) often become the first point of healthcare access for many PWUS and are a crucial setting for the study of health inequities. This study aimed to understand the ED healthcare experiences of PWUS with the intent of informing ways of improving the delivery of equitable care. METHODS: This qualitative study was part of a larger cross-sectional, mixed-methods study that examined ED experiences among diverse underserved and equity-deserving groups (EDGs) within Kingston, Ontario, Canada. Participants shared and self-interpreted a story about a memorable ED or UCC visit within the preceding 24 months. Data from participants who self-identified as having substance use experiences was analyzed through inductive thematic analysis. RESULTS: Of the 1973 unique participants who completed the survey, 246 participants self-identified as PWUS and were included in the analysis. Most participants were < 45 years of age (61%), male (53%), and white/European (57%). 45% identified as a person with a disability and 39% frequently struggled to make ends meet. Themes were determined at the patient, provider, and system levels. PATIENT: history of substance use and experience of intersectionality negatively influenced participants' anticipation and perception of care. Provider: negative experiences were linked to assumption making, feelings of stigma and discrimination, and negative perceptions of provider care. Whereas positive experiences were linked to positive perceptions of provider care. System: timeliness of care and the perception of inadequate mental health resources negatively impacted participants' care experience. Overall, these themes shaped participants' trust of ED staff, their desire to seek care, and their perception of the care quality received. CONCLUSIONS: PWUS face significant challenges when seeking care in the ED. Given that EDs are a main site of healthcare utilization, there is an urgent need to better support staff in the ED to improve care experiences among PWUS. Based on the findings, three recommendations are proposed: (1) Integration of an equity-oriented approach into the ED, (2) Widespread training on substance use, and (3) Investment in expert resources and services to support PWUS.

Decline in emergency department visits during the COVID-19 quarantine.

BACKGROUND: Emergency department (ED) visits can be divided into urgent and non-urgent. A delay in seeking medical help, especially in urgent cases, can lead to fatal consequences, along with a higher rate of complications and morbidity. Coronavirus disease 2019 (COVID-19) pandemic spread led to restrictions and eventually quarantines. We investigated the impact of the COVID-19 spread and quarantine on ED visits rates comparing to parallel periods in preceding years (2013-2019). In addition, we compared this decrease to holidays and weekends, times in which a decrease in ED visits is seen. METHODS: This was a descriptive retrospective study. Causes of ED referrals were divided into urgent and non-urgent, then into different subcategories including infectious, cardiac, etc. RESULTS: For the spring COVID-192020 quarantine period, a 56.3% decrease of mean ED visits per day was seen, as compared to preceding years (55.7% and 98.9% respectively). This decrease was also statistically evident when comparing the urgent and non-urgent causes separately and for all sub-categories. This pattern of decrease also showed statistical evidence of fewer ED visits during holidays for most comparisons, in which lower ED visit rates are expected. Significantly lower rates of ED visits were demonstrated during the COVID-19 quarantine period, as compared to preceding years and main holidays and weekends, a decrease that was also demonstrated for urgent life-threatening causes. CONCLUSION: Our findings can be used to inform a wide range of stakeholders, including regional planners, historians, sociologists, and international healthcare organizations. Healthcare providers should understand the reasons for this ED visit decline pattern, attempt to address patients' concerns, and increase awareness regarding alarming symptoms in urgent medical situations.

Telehealth utilization barriers among Alabama parents of pediatric patients during COVID-19 outbreak.

BACKGROUND: Telehealth can improve access to evidence-based care at a lower cost for patients, especially those living in underserved and remote areas. The barriers to the widespread adoption of telehealth have been well documented in the literature. However, the barriers may not be the same for pediatric patients, who must rely on their parents or guardians to make healthcare decisions. This paper presents some of the leading barriers parents or guardians of pediatric patients report in using telehealth to meet their children's healthcare needs. METHODS: This cross-sectional survey was conducted in a tertiary care pediatric Emergency Department (ED) at a children's hospital in Alabama between September 2020 to December 2020. The parents or guardians of pediatric patients were asked about their reasons for not using telehealth despite having healthcare needs for their children, whether they canceled or rescheduled healthcare provider visits and facility visits, and whether the child's health conditions changed over the past three months. Descriptive analyses were conducted that explored the distribution of telehealth use across the variables listed above. RESULTS: Five hundred ninety-seven parents or guardians of pediatric patients participated in the survey, and 578 answered the question of whether they used telehealth or not over the past three months. Of them, 33.1% used telehealth, 54.3% did not, and 12.6% did not have healthcare needs for their child. The leading reason for not using telehealth was that the doctor or health provider did not give them a telehealth option, the second main reason was that they did not know what telehealth is, and the third leading reason was that the parents did not think telehealth would help meet healthcare needs for their child. CONCLUSIONS: This study highlights the telehealth utilization barriers among underserved pediatric populations, including the need for physicians to proactively offer telehealth options to parents or guardians of pediatric patients. Improving health literacy is of paramount importance, given that a substantial proportion of parents were not familiar with telehealth. Policymakers and healthcare organizations should raise awareness about the benefits of telehealth which can improve healthcare access for underserved pediatric patients.

Healthcare professionals' perspectives of the management of people with palliative care needs in the emergency department of a UK hospital.

BACKGROUND: The Emergency Department (ED) is not always the optimal place for people with palliative care needs but is the most common route for treatment when urgent care is sought. The aim of this study,''REasons for PalLIative Care Admissions (REPLICA)' was to explore the perspectives of ED healthcare professionals of hospital admission or discharge via ED for palliative care patients. METHODS: This is a sequential mixed methods study comprising (i) quantitative descriptive analysis of Hospital Episode Statistics (HES) of palliative care patients (code Z51.5) who were admitted through ED in a West Midlands Hospital and for the rest of England; (ii) in-depth semi-structured interviews with 17 ED staff which were analysed using thematic content analysis. RESULTS: Over the four years (2013-2017), 430,116 people admitted through ED were identified with a Z51.5 diagnosis code, 0.6% (n = 2736) of whom were from the West Midlands Hospital. The most common reasons for palliative care patients' admission to hospitals across England were for care of chronic kidney disease, cancers and urinary tract infections. Five themes were elicited from the qualitative analysis: (1) Providing palliative care in ED is challenging, due to factors including lack of training in palliative care and the unsuitable environment. (2) Patients go to ED due to challenges in community management such as inappropriate referrals and no care plan in place. (3) Health system influences admission and discharge decisions, including bed availability and being unable to set up community services out-of-hours. (4) Discussion with patient about treatment and end of life care needs to be outside of ED whilst the patient is still well enough to express their wishes. (5) Improving services for patients with palliative care needs. Recommendations include short training sessions for ED staff and accessing palliative care professionals 24/7. CONCLUSIONS: A large number of palliative care patients visit ED and are admitted to hospital for care; there is an urgent need to prevent patients attending the hospital through the establishment of a coordinated and dedicated service to support palliative care patients in the community.

Effectiveness of the Weighted Blanket With Psychiatric Patients in the Emergency Department: A Pilot Study.

BACKGROUND: Restraint and seclusion continue to be used with patients demonstrating aggressive and violent behaviors while in the emergency department and as inpatients in behavioral health (BH) units. The use of sensory interventions such as the weighted blanket (WB) is garnering interest as alternatives to aid in managing anxiety, anger, and aggressive behaviors. Reports of the effectiveness of the WB have primarily been anecdotal, and results of research with children have been mixed. Only one study has been conducted with the WB with adults on an inpatient psychiatric unit. AIMS: The aim of this pilot study was to assess the effectiveness of the WB by determining whether it decreases anxiety and/or anger in adult emergency department patients with preexisting psychiatric diagnoses. METHODS: The study used a quasi-experimental, nonequivalent control group design with pre- and posttests for anxiety and anger. The intervention was a 15-pound WB. Participants (N = 15) were in one of three groups, which included no weighted blanket (NWB), WB for 15 minutes, or WB for 30 minutes. RESULTS: All three groups showed a decrease in anxiety and anger scores. However, participants in the WB groups had a greater decrease in anxiety and anger posttest scores. CONCLUSIONS: The small sample size in this study did not allow for the determination of any differences between groups on anxiety or anger scores that could be viewed as a significant finding.

Lung Ultrasound to Diagnose Pulmonary Congestion Among Patients on Hemodialysis: Comparison of Full Versus Abbreviated Scanning Protocols.

RATIONALE & OBJECTIVE: Pulmonary congestion contributes to morbidity and mortality in patients with kidney failure on hemodialysis, but physical assessment is an insensitive approach to its detection. Lung ultrasound is useful for assessing the presence and severity of pulmonary congestion, but the most widely validated 28-zone study is cumbersome. We sought to compare abbreviated 4-, 6-, and 8-zone studies to 28-zone studies. STUDY DESIGN: Diagnostic test study. SETTING & PARTICIPANTS: Convenience sample of 98 patients with kidney failure on hemodialysis presenting to an emergency department in the United States. TESTS COMPARED: 4-, 6-, and 8-zone lung ultrasound studies versus a 28-zone lung ultrasound. OUTCOME: Prediction of pulmonary congestion and 30-day mortality. RESULTS: All patients completed a 28-zone lung ultrasound. Correlation coefficients (nonparametric Spearman) between each of the studies were high (all values > 0.84). Bland-Altman analysis showed good agreement. Each of the short-form studies discriminated well with area under the receiver-operator characteristic curve > 0.83 for no-to-mild versus moderate-to-severe pulmonary congestion. During a median follow-up period of 778 days, 46 (47%) died. Patients with moderate-to-severe pulmonary congestion on lung ultrasound had a 30-day mortality rate similar to that observed among patients with no-to-mild pulmonary congestion (OR, 0.95 [95% CI, 0.70-1.29]). LIMITATIONS: Single-center study conducted in an emergency care setting, convenience sample of patients, and lack of long-term follow-up data. CONCLUSIONS: Among hemodialysis patients presenting to an emergency department, 4-, 6-, or 8-zone lung ultrasounds were comparable to 28-zone studies for the assessment of pulmonary congestion. The mortality rates did not differ between those with no-to-mild and moderate-to-severe pulmonary congestion.

Hepatitis C active viremia over time in an ED-based testing programme: Impact, disparities and surveillance tool.

Hepatitis C virus (HCV) surveillance is a critical component of a comprehensive strategy to prevent and control HCV infection and HCV-related chronic liver disease. The emergency department (ED) has been increasingly recognized as a vital partner in HCV testing and linkage. We sought to consider active RNA HCV viremia over time in patients participating in an ED-based testing programme as a measure of local HCV surveillance and as a barometer of ED-testing programme impact. We performed a retrospective analysis of individuals participating in our ED-based HCV testing programme between 2015 and 2021. Chi-square tests were used to compare the demographic characteristics of HCV antibody positive tests with active viremia to those without active viremia. Cox proportional hazard models were used to estimate the trend in active viremia risk over time in the overall study population as well as in key subpopulations of interest. Of 5456 HCV antibody positive individuals, 3102 (56.8%) had active viremia. In the overall study population, we found that the risk of active viremia decreased by 4.8% per year during the study period (RR: 0.95, 95% CI: 0.93-0.97|p < .0001). Baby boomers experienced a 9% decrease in active viremia risk per year over the study period while non-baby boomers only had a 2% decrease in risk per year (p = .0009). Compared with insured patients, uninsured patients had a smaller decrease in risk of active HCV viremia per year (p = .003). No significant differences in the risk of active viremia over time were observed for gender (p = .4694) or by primary care provider status (p = .2208). In conclusion, this ED-based testing and linkage programme demonstrates significantly decreased active HCV viremia over time. It also highlights subpopulations, specifically non-baby boomers and uninsured patients, who may benefit from focused interventions to improve access to and adoption of definitive HCV care.

Predictors of Delayed Recognition of Critical Illness in Emergency Department Patients and Its Effect on Morbidity and Mortality.

PURPOSE: Timely recognition of critical illness is associated with improved outcomes, but is dependent on accurate triage, which is affected by system factors such as workload and staffing. We sought to first study the effect of delayed recognition on patient outcomes after controlling for system factors and then to identify potential predictors of delayed recognition. METHODS: We conducted a retrospective cohort study of Emergency Department (ED) patients admitted to the Intensive Care Unit (ICU) directly from the ED or within 48 hours of ED departure. Cohort characteristics were obtained through electronic and standardized chart abstraction. Operational metrics to estimate ED workload and volume using census data were matched to patients' ED stays. Delayed recognition of critical illness was defined as an absence of an ICU consult in the ED or declination of ICU admission by the ICU team. We employed entropy-balanced multivariate models to examine the association between delayed recognition and development of persistent organ dysfunction and/or death by hospitalization day 28 (POD+D), and multivariable regression modeling to identify factors associated with delayed recognition. RESULTS: Increased POD+D was seen for those with delayed recognition (OR 1.82, 95% CI 1.13-2.92). When the delayed recognition was by the ICU team, the patient was 2.61 times more likely to experience POD+D compared to those for whom an ICU consult was requested and were accepted for admission. Lower initial severity of illness score (OR 0.26, 95% CI 0.12-0.53) was predictive of delayed recognition. The odds for delayed recognition decreased when ED workload is higher (OR 0.45, 95% CI 0.23-0.89) compared to times with lower ED workload. CONCLUSIONS: Increased POD+D is associated with delayed recognition. Patient and system factors such as severity of illness and ED workload influence the odds of delayed recognition of critical illness and need further exploration.

Positive scores on the 4AT delirium assessment tool at hospital admission are linked to mortality, length of stay and home time: two-centre study of 82,770 emergency admissions.

BACKGROUND: Studies investigating outcomes of delirium using large-scale routine data are rare. We performed a two-centre study using the 4 'A's Test (4AT) delirium detection tool to analyse relationships between delirium and 30-day mortality, length of stay and home time (days at home in the year following admission). METHODS: The 4AT was performed as part of usual care. Data from emergency admissions in patients ≥65 years in Lothian, UK (n = 43,946) and Salford, UK (n = 38,824) over a period of $\sim$3 years were analysed using logistic regression models adjusted for age and sex. RESULTS: 4AT completion rates were 77% in Lothian and 49% in Salford. 4AT scores indicating delirium (≥4/12) were present in 18% of patients in Lothian, and 25% of patients in Salford. Thirty-day mortality with 4AT ≥4 was 5.5-fold greater than the 4AT 0/12 group in Lothian (adjusted odds ratio (aOR) 5.53, 95% confidence interval [CI] 4.99-6.13) and 3.4-fold greater in Salford (aOR 3.39, 95% CI 2.98-3.87). Length of stay was more than double in patients with 4AT scores of 1-3/12 (indicating cognitive impairment) or ≥ 4/12 compared with 4AT 0/12. Median home time at 1 year was reduced by 112 days (Lothian) and 61 days (Salford) in the 4AT ≥4 group (P < 0.001). CONCLUSIONS: Scores on the 4AT used at scale in practice are strongly linked with 30-day mortality, length of hospital stay and home time. The findings highlight the need for better understanding of why delirium is linked with poor outcomes and also the need to improve delirium detection and treatment.

The effect of the COVID-19 pandemic on non-COVID respiratory ED visits in Israel.

BACKGROUND: The COVID 19 pandemic has had a crucial effect on the patterns of disease and treatment in the healthcare system. This study examines the effect of the COVID-19 pandemic on respiratory ED visits and admissions broken down by age group and respiratory diagnostic category. METHODS: Data on non-COVID related ED visits and hospitalizations from the ED were obtained in a retrospective analysis for 29 acute care hospitals, covering 98% of ED beds in Israel, and analyzed by 5 age groups: under one-year-old, 1-17, 18-44, 45-74 and 75 and over. Diagnoses were classified into three categories: Upper respiratory tract infections (URTI), pneumonia, and COPD or asthma. Data were collected for the whole of 2020, and compared for each month to the average number of cases in the three pre-COVID years (2017-2019). RESULTS: In 2020 compared to 2017-2019, there was a decrease of 34% in non-COVID ED visits due to URTI, 40% for pneumonia and a 35% decrease for COPD and asthma. Reductions occurred in most age groups, but were most marked among infants under a year, during and following lockdowns, with an 80% reduction. Patients over 75 years old displayed a marked drop in URTI visits. Pediatric asthma visits fell during lockdowns, but spiked when restrictions were lifted, accompanied by a higher proportion admitted. The percent of admissions from the ED visits remained mostly stable for pneumonia; the percent of young adults admitted with URTI decreased significantly from March to October. CONCLUSIONS: Changing patterns of ED use were probably due to a combination of a reduced rate of viral diseases, availability of additional virtual services, and avoidance of exposure to the ED environment. Improved hygiene measures during peaks of respiratory infections could be implemented in future to reduce respiratory morbidity; and continued provision of remote health services may reduce overuse of ED services for mild cases.

A case study to investigate the impact of overcrowding indices in emergency departments.

BACKGROUND: Emergency department (ED) overcrowding is widespread in hospitals in many countries, causing severe consequences to patient outcomes, staff work and the system, with an overall increase in costs. Therefore, health managers are constantly looking for new preventive and corrective measures to counter this phenomenon. To do this, however, it is necessary to be able to characterize the problem objectively. For this reason, various indices are used in the literature to assess ED crowding. In this work, we explore the use of two of the most widespread crowding indices in an ED of an Italian national hospital, investigate their relationships and discuss their effectiveness. METHODS: In this study, two of the most widely used indices in the literature, the National Emergency Department Overcrowding Scale (NEDOCS) and the Emergency Department Working Index (EDWIN), were analysed to characterize overcrowding in the ED of A.O.R.N. "A. Cardarelli" of Naples, which included 1678 clinical cases. The measurement was taken every 15 minutes for a period of 7 days. RESULTS: The results showed consistency in the use of EDWIN and NEDOCS indices as measures of overcrowding, especially in severe overcrowding conditions. Indeed, in the examined case study, both EDWIN and NEDOCS showed very low rates of occurrence of severe overcrowding (2-3%). In contrast, regarding differences in the estimation of busy to overcrowded ED rates, the EDWIN index proved to be less sensitive in distinguishing these variations in the occupancy of the ED. Furthermore, within the target week considered in the study, the results show that, according to both EDWIN and NEDOCS, higher overcrowding rates occurred during the middle week rather than during the weekend. Finally, a low degree of correlation between the two indices was found. CONCLUSIONS: The effectiveness of both EDWIN and NEDOCS in measuring ED crowding and overcrowding was investigated, and the main differences and relationships in the use of the indices are highlighted. While both indices are useful ED performance metrics, they are not always interchangeable, and their combined use could provide more details in understanding ED dynamics and possibly predicting future critical conditions, thus enhancing ED management.

Improving urinary tract infection treatment through a multifaceted antimicrobial stewardship intervention in the emergency department.

BACKGROUND: Urinary tract infection (UTI) is frequently encountered in the emergency department (ED). We assessed an antibiotic stewardship intervention tailored for the ED. The primary objective was improving overall adherence to agent choice and treatment duration. The secondary objective was a decrease in fluoroquinolone prescription. METHODS: This pre-post study included patients discharged from the ED with a UTI diagnosis. The intensive intervention period lasted three months and involved dissemination of guidelines, short lectures, incorporation of order sets into electronic ED charts and weekly personal audit and feedback. The following 11-month phase was a booster period consisting of monthly text messages of the treatment protocol. Assessment of adherence to the protocol was compared between the three-month pre-intervention period and the last two months of the intensive intervention period, as well as with the last two months of the booster period. RESULTS: A total of 177 patients were included in the pre-intervention period, 156 in the intervention period, and 94 in the late follow-up assessing the booster period. Median age was 49 (18-94) years, 78.2% were female, 84.8% had cystitis. During the intervention period, protocol adherence with antibiotic selection and duration increased from 41% to 84% (p < 0.001). Adherence remained high in the late follow-up period (73.4% vs. 41%, p < 0.001). Fluoroquinolone use decreased from 19.1% pre-intervention, to 5% in the intervention and 7.4% in the late follow-up periods (p < 0.001). CONCLUSIONS: An antibiotic stewardship intervention in a busy ED resulted in adherence to treatment protocols, including a decrease in fluoroquinolone use. A monthly reminder preserved most of the effect for a year.

Ecological factors associated with Emergency Department use by older people in Italy.

BACKGROUND: Many studies investigated factors associated with overuse of Emergency Department (ED) by older people. However, there is little evidence of how a better access to long-term care services can affect ED visit rates. Therefore, we estimated the association between ED use and contextual (distance to closest ED), need (priority level at admission and care deprivation), predisposing (socio-economic conditions) and enabling factors (availability of health services) at the municipal level. METHODS: We investigated ED visit rates by comparing the older population (aged 75 and more) to those aged less than 75 years among 233 municipalities and 13 health districts in the Marche Region, Central Italy. Administrative data were enriched by spatial dimensions. The outcomes were analysed using t-tests and ANOVA, while OLS and multilevel regressions have been used to identify independent correlates of ED visit rates. RESULTS: Mean ED visit rate was 56.3% and 25.3% among older people and the rest of the population (< 75 years), respectively. The multivariate analysis for older people showed that the presence of an ED within the municipality and living alone were positively associated with ED use, whereas greater availability of nursing homes was negatively associated. For general population (< 75 years), distance to closest ED, economic deprivation and bigger hospitals were negatively associated with ED visits. CONCLUSIONS: Our study shows that interventions to reduce frequent ED use by older people should include the availability of long-term care facilities in the area. As population ageing is progressing, our results suggest that investing in alternative care options for older people with long-term care needs might have the beneficial impact of reducing the overall ED rates and improving quality and appropriateness of care.

Evaluation of emergency department utilization for dermatologic conditions in the pediatric population within the United States from 2009-2015.

BACKGROUND: Dermatologic conditions comprise a significant number of emergency department visits in the pediatric population in the United States. Understanding key predictors of emergency department utilization for dermatologic conditions is important to reduce inappropriate use. METHODS: A total of 44 554 sampled patient emergency department visits, consisting of patients less than 18 years of age, were collected from the National Hospital Ambulatory Medical Care Survey between 2009 to 2015. ICD-9 codes were used to define dermatologic conditions versus non-dermatologic conditions with univariate and multivariate analyses used to identify factors significantly correlated with dermatologic emergency department utilization. RESULTS: A total of 13 681 691 pediatric dermatologic emergency department visits (weighted) were evaluated over the seven-year period, representing 6.4% of total pediatric emergency department visits. The most common dermatologic diagnosis was cellulitis (25.6% of visits). The majority of patients were five years old or younger (54.4%). Patients with primary dermatologic conditions were more likely to be triaged as non-urgent (16.7%) or semi-urgent (45.8%) than patients without dermatologic conditions. Only 2.1% of patients with dermatologic conditions required further observation or admission. On further regression modeling, age ≤ 5, semi-urgent or non-urgent acuity, Medicaid insurance, and residence in the Northeastern or Midwestern United States were significantly associated with presentation to the emergency department with a dermatologic condition when compared to non-dermatologic condition. CONCLUSIONS: Dermatologic conditions continue to comprise a significant number of ED visits in the pediatric population. Increased ED utilization by vulnerable pediatric populations highlights the need to better direct or provide access to outpatient dermatologic care.

BRASH Syndrome: A Case Report.

BACKGROUND: BRASH syndrome, a relatively new entity, has been described in the recent literature. It is defined as a combination of bradycardia, renal failure, atrioventricular nodal blockade, shock, and hyperkalemia. Although it is apparent that clinical symptomatology includes shock, it is still unclear whether all patients will initially present with all five components mentioned in the BRASH acronym. CASE REPORT: An elderly woman presented to our Emergency Department (ED) with hyperkalemia, acute renal failure, and metabolic acidosis with bradycardia, which was refractory to antikalemic measures and atropine. The montage of clinical features put together showed a clear picture of BRASH syndrome, which helped us to streamline the management and achieve a better patient outcome. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Renal failure with various metabolic derangements is commonly seen in the ED. We should be aware of this new clinical entity, as its incidence will certainly increase, and the management is a bit different. Prognosis is excellent with timely recognition and management of this rare clinical entity.

Outpatient Interventions for Managing Acute Complications of Chronic Diseases: A Scoping Review and Implications for Patients With CKD.

RATIONALE & OBJECTIVE: Patients with chronic kidney disease (CKD) have high rates of emergency department (ED) use and hospitalization. Outpatient care may provide an alternative to ED and inpatient care in this population. We aimed to explore the scope of outpatient interventions used to manage acute complications of chronic diseases and highlight opportunities to adapt and test interventions in the CKD population. STUDY DESIGN: Scoping review of quantitative and qualitative studies. SETTING & POPULATION: Outpatient interventions for adults experiencing acute complications related to 1 of 5 eligible chronic diseases (ie, CKD, chronic respiratory disease, cardiovascular disease, cancer, and diabetes). SELECTION CRITERIA FOR STUDIES: MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, grey literature, and conference abstracts were searched to December 2019. DATA EXTRACTION: Intervention and study characteristics were extracted using standardized tools. ANALYTICAL APPROACH: Quantitative data were summarized descriptively; qualitative data were summarized thematically. Our approach observed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) extension for scoping reviews. RESULTS: 77 studies (25 randomized controlled trials, 29 observational, 12 uncontrolled before-after, 5 quasi-experimental, 4 qualitative, and 2 mixed method) describing 57 unique interventions were included. Of identified intervention types (hospital at home [n = 16], observation unit [n = 9], ED-based specialist service [n = 4], ambulatory program [n = 18], and telemonitoring [n = 10]), most were studied in chronic respiratory and cardiovascular disease populations. None targeted the CKD population. Interventions were delivered in the home, ED, hospital, and ambulatory setting by a variety of health care providers. Cost savings were demonstrated for most interventions, although improvements in other outcome domains were not consistently observed. LIMITATIONS: Heterogeneity of included studies; lack of data for outpatient interventions for acute complications related to CKD. CONCLUSIONS: Several interventions for outpatient management of acute complications of chronic disease were identified. Although none was specific to the CKD population, features could be adapted and tested to address the complex acute-care needs of patients with CKD.

Monocyte distribution width (MDW) as a screening tool for sepsis in the Emergency Department.

Objectives The diagnosis of sepsis in the Emergency Department (ED) is challenging and a reliable biomarker is needed. The current study aimed to evaluate the diagnostic accuracy of monocyte distribution width (MDW) for the early identification of sepsis in the ED. Methods We performed a large observational study including consecutive adult patients (≥18 years of age) presenting to the ED between September and November 2019, with an order for complete blood count (CBC) evaluation. A total of 2,215 patients were enrolled and classified based on Sepsis-2 criteria as the control group (1,855), infection group (172), Systemic Inflammatory Response Syndrome (SIRS) group (100), and sepsis group (88). Results MDW levels were higher in patients with sepsis than in all other groups (p<0.001). ROC curve analysis showed an optimal diagnostic accuracy of MDW for sepsis prediction at a cut-off point of 23.5, with an AUC of 0.964, sensitivity and specificity of 0.920 and 0.929, respectively. Conclusions Our findings encourage further investigation to validate the use of MDW as a screening tool for the early identification of patients at risk of sepsis in the ED.