Effect of a Point-of-Care Ultrasound-Driven vs Standard Diagnostic Pathway on 24-Hour Hospital Stay in Emergency Department Patients with Dyspnea-Protocol for A Randomized Controlled Trial.

Purpose: Point-of-care ultrasound (POCUS) helps emergency department (ED) physicians make prompt and appropriate decisions, but the optimal diagnostic integration and potential clinical benefits remain unclear. We describe the protocol and statistical analysis plan for a randomized controlled trial. The objective is to determine the effect of a POCUS-driven diagnostic pathway in adult dyspneic ED patients on the proportion of patients having a hospital stay of less than 24 hours when compared to the standard diagnostic pathway. Patients and Methods: This is a multicenter, randomized, investigator-initiated, open-labeled, pragmatic, controlled trial. Adult ED patients with chief complaint dyspnea are eligible. Patients are randomized (1:1) to the POCUS-driven diagnostic pathway or standard diagnostic pathway, with 337 patients in each group. The primary outcome is the proportion of patients having a hospital stay (from ED arrival to hospital discharge) of less than 24 hours. Key secondary outcomes include hospital length-of-stay, 72-hour revisits, and 30-day hospital-free days. Conclusion: Sparse evidence exists for any clinical benefit from a POCUS-integrated diagnostic pathway. The results from this trial will help clarify the promising signals for POCUS to influence patient care among ED patients with dyspnea.

Point-of-Care Lung Ultrasound in Emergency Medicine: A Scoping Review With an Interactive Database.

BACKGROUND: This scoping review was conducted to provide an overview of the evidence of point-of-care lung ultrasound (LUS) in emergency medicine. By emphasizing clinical topics, time trends, study designs, and the scope of the primary outcomes, a map is provided for physicians and researchers to guide their future initiatives. RESEARCH QUESTION: Which study designs and primary outcomes are reported in published studies of LUS in emergency medicine? STUDY DESIGN AND METHODS: We performed a systematic search in the PubMed/MEDLINE, Embase, Web of Science, Scopus, and Cochrane Library databases for LUS studies published prior to May 13, 2023. Study characteristics were synthesized quantitatively. The primary outcomes in all papers were categorized into the hierarchical Fryback and Thornbury levels. RESULTS: A total of 4,076 papers were screened and, following selection and handsearching, 406 papers were included. The number of publications doubled from January 2020 to May 2023 (204 to 406 papers). The study designs were primarily observational (n = 375 [92%]), followed by randomized (n = 18 [4%]) and case series (n = 13 [3%]). The primary outcome measure concerned diagnostic accuracy in 319 papers (79%), diagnostic thinking in 32 (8%), therapeutic changes in 4 (1%), and patient outcomes in 14 (3%). No increase in the proportions of randomized controlled trials or the scope of primary outcome measures was observed with time. A freely available interactive database was created to enable readers to search for any given interest (https://public.tableau.com/app/profile/blinded/viz/LUSinEM_240216/INFO). INTERPRETATION: Observational diagnostic studies have been produced in abundance, leaving a paucity of research exploring clinical utility. Notably, research exploring whether LUS causes changes to clinical decisions is imperative prior to any further research being made into patient benefits.

Focused lung ultrasound to predict respiratory failure in patients with symptoms of COVID-19: a multicentre prospective cohort study.

Background: In this study we aimed to assess if a focused lung ultrasound examination predicts the need for mechanical ventilation, admission to an intensive care unit, high-flow oxygen treatment, death from COVID-19 within 30 days and 30-day all-cause mortality in patients with clinical suspicion of COVID-19 or PCR-verified SARS-CoV-2 infection. Methods: A multicentre prospective cohort trial was performed. Film clips from focused lung ultrasound examinations were recorded and rated by blinded observers using different scoring systems. A prediction model was built and used to test relationship between lung ultrasound scores and clinical outcomes. Diagnostic performance of scoring systems was analysed. Results: A total of 3889 film clips of 398 patients were analysed. Patients who had any of the outcomes of interest had a significantly higher ultrasound score than those who did not. Multivariable logistic regression analyses showed that lung ultrasound predicts mechanical ventilation (relative risk 2.44, 95% CI 1.32-5.52), admission to intensive care (relative risk 2.55, 95% CI 1.41-54.59) and high-flow oxygen treatment (relative risk 1.95, 95% CI 1.5-2.53) but not survival when adjusting for sex, age and relevant comorbidity. There was no diagnostic difference in area under the receiver operating characteristic curve between a scoring system using only anterolateral thorax zones and a scoring system that also included dorsal zones. Conclusion: Focused lung ultrasound in patients with clinical suspicion of COVID-19 predicts respiratory failure requiring mechanical ventilation, admission to intensive care units and the need for high-flow oxygen treatment. Thus, focused lung ultrasound may be used to risk stratify patients with COVID-19 symptoms.

Change in diagnosis from the emergency department to hospital discharge in dyspnoeic patients.

INTRODUCTION: To improve the outcomes of dyspnoeic patients, it is potentially important to determine the influence of uncertain diagnostic aetiology and to characterise this patient group. A change in diagnosis from emergency department (ED) contact to hospital discharge (i.e., a discordant diagnosis) served as a surrogate measure for an uncertain diagnostic aetiology. This study investigated the association between a change in diagnosis from ED contact to hospital discharge and length of stay (LOS), readmission and mortality in patients whose chief complaint was dyspnoea. The study also characterises the group of patients found to have a discordant diagnosis. METHODS: This cohort study was based on data from all ED contacts at Aarhus University Hospital from 1 July 2016 to 30 June 2017. Patients triaged with dyspnoea and subsequently admitted to an inpatient unit were included. RESULTS: Concordant contacts had an average LOS of 3.63 days, whereas discordant contacts had an average LOS of 4.65 days; the adjusted relative difference was 1.28 (95% CI: 1.10-1.48). Readmission, whether at seven or 30 days, was not significantly different between the groups. The 30-day mortality was 5% in the concordant and 10% in the discordant group, with an adjusted OR of 2.32 (95% CI: 1.08-4.96). CONCLUSIONS: We found an association between a change in diagnosis and longer LOS, and between a change in diagnosis and 30-day mortality. The effort made to achieve diagnostic certainty in the ED may have an impact lasting throughout the entire hospital stay. FUNDING: none. TRIAL REGISTRATION: not relevant.

Predicting mortality and readmission based on chief complaint in emergency department patients: a cohort study.

BACKGROUND: Emergency department (ED) patients present with complaints and not diagnoses. Characterization and risk stratification based on chief complaint can therefore help clinicians improve ED workflow and clinical outcome. In this study we investigated the 30-day mortality and readmission among ED patients based on chief complaint. METHODS: In this cohort study we retrieved routinely collected data from electronic medical records and the Danish Civil Registration System of all ED contacts from July 1, 2016 through June 30, 2017. All patients triaged with one chief complaint using the Danish Emergency Process Triage system were included. Patients with minor injuries were excluded. The chief complaint assigned by the triaging nurse was used as exposure, and 30-day mortality and 30-day readmission were the primary outcomes. Logistic regression was used to determine crude and adjusted ORs with reference to the remaining study population. RESULTS: A total of 41 470 patients were eligible. After exclusion of minor injuries and patients not triaged, 19 325 patients were included. The 30-day mortality and 30-day readmission differed significantly among the chief complaints. The highest 30-day mortality was observed among patients presenting with altered level of conscousness (ALOC) (8.4%, OR=2.0, 95% CI 1.3 to 3.1) and dyspnea (8.0%, OR=2.1, 95% CI 1.6 to 2.6). 30-day readmission was highest among patients presenting with fever/infection (11.7%, OR=1.9, 95% CI 1.4 to 2.4) and dyspnea (11.2%, OR=1.7, 95% CI 1.4 to 2.0). DISCUSSION: Chief complaint is associated with 30-day mortality and readmission in a mixed ED population. ALOC and dyspnea had the highest mortality; fever/infection and dyspnea had the highest readmission rate. This knowledge may assist in improving and optimizing symptom-based initial diagnostic workup and treatment, and ultimately improve workflow and clinical outcome. LEVEL OF EVIDENCE: Level III.

Simulation-based team training in time-critical clinical presentations in emergency medicine and critical care: a review of the literature.

BACKGROUND: The use of simulation-based team training has increased over the past decades. Simulation-based team training within emergency medicine and critical care contexts is best known for its use by trauma teams and teams involved in cardiac arrest. In the domain of emergency medicine, simulation-based team training is also used for other typical time-critical clinical presentations. We aimed to review the existing literature and current state of evidence pertaining to non-technical skills obtained via simulation-based team training in emergency medicine and critical care contexts, excluding trauma and cardiac arrest contexts. METHODS: This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Before the initiation of the study, the protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) database. We conducted a systematic literature search of 10 years of publications, up to December 17, 2019, in the following databases: PubMed/MEDLINE, EMBASE, Cochrane Library, and CINAHL. Two authors independently reviewed all the studies and extracted data. RESULTS: Of the 456 studies screened, 29 trials were subjected to full-text review, and 13 studies were included in the final review. None of the studies was randomized controlled trials, and no studies compared simulation training to different modalities of training. Studies were heterogeneous; they applied simulation-training concepts of different durations and intensities and used different outcome measures for non-technical skills. Two studies reached Kirkpatrick level 3. Out of the remaining 11 studies, nine reached Kirkpatrick level 2, and two reached Kirkpatrick level 1. CONCLUSIONS: The literature on simulation-based team training in emergency medicine is heterogeneous and sparse, but somewhat supports the hypothesis that simulation-based team training is beneficial to teams' knowledge and attitudes toward non-technical skills (Kirkpatrick level 2). Randomized trials are called for to clarify the effect of simulation compared to other modalities of team training. Future research should focus on the transfer of skills and investigate improvements in patient outcomes (Kirkpatrick level 4).