Acute Poisoning Readmissions to an Emergency Department of a Tertiary Hospital: Evaluation through an Active Toxicovigilance Program.

The aim of this study is to investigate hospital readmissions during 1 year after acute poisoning cases (APC), analyze the temporal behavior of early readmissions (ER) (in the month after the index episode) and predict possible ER. A descriptive analysis of the patients with APC assisted between 2011 and 2016 in the Emergency Department of Hospital La Paz is presented, and various methods of inferential statistics were applied and confirmed by Bayesian analysis in order to evaluate factors associated with total and early readmissions. Out of the 4693 cases of APC included, 968 (20.6%) presented, at least one readmission and 476 (10.1%) of them were ER. The mean age of APC with readmission was 41 years (12.7 SD), 78.9% had previous psychiatric pathology and 44.7% had a clinical history of alcohol addiction. Accidental poisoning has been a protective factor for readmission (OR 0.50; 0.26-0.96). Type of toxin ("drug of abuse" OR 8.88; 1.17-67.25), history of addiction (OR 1.93; 1.18-3.10) and psychiatric history (OR 3.30; 2.53-4.30) are risk factors for readmissions during the first year. Women showed three or more readmissions in a year. The results of the study allow for identification of the predictors for the different numbers of readmissions in the year after the index APC, as well as for ERs.

Eficacia de una vía de alta resolución en la evaluación del cólico renoureteral no complicado en un servicio de urgencias hospitalario: un ensayo clínico aleatorizado (Estudio STONE) / Efficacy of a fast-track pathway for managing uncomplicated renal orureteral colic in a hospital emergency department: the STONE randomized clinical trial of Sonography and Testing of a Nephrolithiasis Episode

OBJETIVO: Evaluar una vía de alta resolución (vía POC) que utiliza análisis en el punto de atención (point-of-care testing-POCT-) y ecografía en el punto de atención (point-of-care ultrasonography -POCUS-) en la sospecha del cólico renoureteral (CRU) no complicado y compararla con la vía estándar (vía STD). MÉTODO: Ensayo clínico aleatorizado, controlado, no ciego, realizado en un servicio de urgencias hospitalario (SUH). Incluyó pacientes con sospecha clínica de CRU agudo y se aleatorizaron 1:1 a seguir vía POC o vía STD. Se analizó el tiempo de estancia en el SUH, el tratamiento administrado, la proporción de diagnósticos alternativos a CRU y las complicaciones a 30 días. RESULTADOS: Entre noviembre de 2018 y octubre de 2019, se reclutaron 140 pacientes de los que se analizaron 124.El tiempo de estancia total en el SUH de la vía POC fue de 112 minutos (DE 45) y en la vía STD 244 minutos (DE102) (p < 0,001). No hubo diferencias en el tratamiento administrado en urgencias, en el número de diagnósticos alternativos, ni en las complicaciones a 30 días. CONCLUSIONES: La utilización de una vía de alta resolución del manejo del CRU en un SUH es eficaz, segura y reduce el tiempo de estancia en urgencias

OBJECTIVES: To evaluate a fast-track pathway utilizing point-of-care (POC) testing and sonography as soon as uncomplicated renal or ureteral colic is suspected and to compare the POC clinical pathway to a standard one. METHODS: Unblinded randomized controlled clinical trial in a hospital emergency department (ED). We enrolled patients with suspected uncomplicated renal or ureteral colic and randomized them to a POC or standard pathway(1:1 ratio). Duration of ED stay, treatments, the proportion of diagnoses other than uncomplicated colic, and 30-daycomplications were analyzed. RESULTS: One hundred forty patients were recruited between November 2018 and October 2019; data for 124 were analyzed. The mean (SD) total time in the ED was 112 (45) minutes in the POC arm and 244 (102) in the standard arm (P< .001). Treatments, alternative diagnoses, and complication rates did not differ. CONCLUSION: The use of a fast-track POC pathway to manage uncomplicated colic in the ED is effective and safe. It also reduces the amount of time spent in the ED

Efficacy of a fast-track pathway for managing uncomplicated renal or ureteral colic in a hospital emergency department: the STONE randomized clinical trial of Sonography and Testing of a Nephrolithiasis Episode. / Eficacia de una vía de alta resolución en la evaluación del cólico renoureteral no complicado en un servicio de urgencias hospitalario: un ensayo clínico aleatorizado (Estudio STONE).

OBJECTIVES: To evaluate a fast-track pathway utilizing point-of-care (POC) testing and sonography as soon as uncomplicated renal or ureteral colic is suspected and to compare the POC clinical pathway to a standard one. MATERIAL AND METHODS: Unblinded randomized controlled clinical trial in a hospital emergency department (ED). We enrolled patients with suspected uncomplicated renal or ureteral colic and randomized them to a POC or standard pathway (1:1 ratio). Duration of ED stay, treatments, the proportion of diagnoses other than uncomplicated colic, and 30-day complications were analyzed. RESULTS: One hundred forty patients were recruited between November 2018 and October 2019; data for 124 were analyzed. The mean (SD) total time in the ED was 112 (45) minutes in the POC arm and 244 (102) in the standard arm (P .001). Treatments, alternative diagnoses, and complication rates did not differ. CONCLUSION: The use of a fast-track POC pathway to manage uncomplicated colic in the ED is effective and safe. It also reduces the amount of time spent in the ED.

OBJETIVO: Evaluar una vía de alta resolución (vía POC) que utiliza análisis en el punto de atención (point-of-care testing ­POCT­) y ecografía en el punto de atención (point-of-care ultrasonography ­POCUS­) en la sospecha del cólico renoureteral (CRU) no complicado y compararla con la vía estándar (vía STD). METODO: Ensayo clínico aleatorizado, controlado, no ciego, realizado en un servicio de urgencias hospitalario (SUH). Incluyó pacientes con sospecha clínica de CRU agudo y se aleatorizaron 1:1 a seguir vía POC o vía STD. Se analizó el tiempo de estancia en el SUH, el tratamiento administrado, la proporción de diagnósticos alternativos a CRU y las complicaciones a 30 días. RESULTADOS: Entre noviembre de 2018 y octubre de 2019, se reclutaron 140 pacientes de los que se analizaron 124. El tiempo de estancia total en el SUH de la vía POC fue de 112 minutos (DE 45) y en la vía STD 244 minutos (DE 102) (p 0,001). No hubo diferencias en el tratamiento administrado en urgencias, en el número de diagnósticos alternativos, ni en las complicaciones a 30 días. CONCLUSIONES: La utilización de una vía de alta resolución del manejo del CRU en un SUH es eficaz, segura y reduce el tiempo de estancia en urgencias.

Results of a Prospective Study to Evaluate the Impact of Point-of-Care Ultrasound in the Enhancement of Gastrointestinal Bleeding Risk Scores.

OBJECTIVES: Gastrointestinal (GI) bleeding is a common illness seen in the emergency department. The prognosis varies from self-limited to potentially life threatening. Currently available GI bleeding risk scores have only a modest predictive value, limiting their wide implementation. The aim of this study was to assess the association and capability of point-of-care ultrasound (POCUS) used by emergency physicians to improve common GI bleeding scores for predicting complications and long-term outcomes of patients with GI bleeding, which to our knowledge have never been studied. METHODS: Between August 2015 and April 2017, 203 hemodynamically stable patients with acute GI bleeding admitted to the emergency department were prospectively investigated. Using ultrasound, we measured the inferior vena cava diameter, cardiac output with surrogate markers such as the velocity time integral before and after the passive leg-raising test, and the presence of systolic obliteration of the left ventricle. The Rockall and Glasgow-Blatchford scores were calculated for patients with upper GI bleeding and the Velayos score for lower GI bleeding. The patients had follow-up during hospitalization and 30 days later to assess for early and late adverse events (AEs). Then we integrated the ultrasound findings of hypovolemia into the GI bleeding scores, assessing the capability to detect AEs. RESULTS: In our cohort, patients with upper GI bleeding who showed left ventricle kissing walls had a worse evolution, with a greater presence of late AEs (odds ratio [OR], 3.8; 95% confidence interval [CI], 1.32-10.96; P = .01). Patients with lower GI bleeding who showed a collapse of the inferior vena cava (>50%) after passive leg raising had a greater presence of early AEs (OR, 3.6; 95% CI, 1.46-9.00; P = .004). The predictive performance of the Rockall score (receiver operating characteristic analysis: area under the curve [AUC], 77.6%; 95% CI, 66.3%-88.8%) increased with POCUS (AUC, 80.3%; 95% CI, 69.5%-91.1%); that of the Glasgow-Blatchford score (AUC, 72.5%; 95% CI, 59.9%-85.2%) increased with POCUS (AUC, 73.2%; 95% CI, 61.1%-85.4%); and that of Velayos score (AUC, 55.7%; 95% CI, 42.5%-69.0%) also increased with POCUS (AUC, 72.2%; 95% CI, 61.1%-83.3%). CONCLUSIONS: The use of POCUS in GI bleeding is feasible and enhances common GI bleeding risk scores, showing better predictive performance in detecting AEs.

Eficiencia en el diagnóstico y tratamiento de la intoxicación aguda por paracetamol: análisis de costeefectividad a través de un programa de toxicovigilancia activa hospitalario / Efficient diagnosis and treatment of acute paracetamol poisoning: cost-effectiveness analysis of approaches based on a hospital toxicovigilance program

OBJETIVO: Evaluar la eficiencia de cinco estrategias diagnóstico-terapéuticas posibles ante la sospecha de intoxicación aguda (IA) por paracetamol (PCT) a través de un análisis coste-efectividad, según la perspectiva del financiador en un hospital universitario terciario dotado de un programa de toxicovigilancia activa validado (SAT-HULP). MÉTODO: Estudio de análisis de coste-efectividad (ACE) de cinco alternativas diagnóstico-terapéuticas consideradas en el abordaje de los pacientes atendidos en el servicio de urgencias hospitalario (SUH) con intoxicación por PCT mediante un modelo de árbol de decisión. La población estudiada fueron los pacientes atendidos en un SUH detectados por el SAT-HULP, entre el 1/04/2011 y el 31/01/2015. Las alternativas diagnóstico-terapéuticas consideradas fueron: 1) administración sistemática de Nacetilcisteína; 2) administración del tratamiento según la dosis confirmada; 3) tratamiento según el nomograma de Rümack Matthew; 4) tratamiento según test de orina confirmado con posterior test en sangre; y 5) tratamiento según el cálculo de la semivida. Los datos correspondientes a probabilidades fueron obtenidos del programa SAT-HULP y publicaciones sobre la validación de las pruebas diagnósticas. Se realizaron análisis de sensibilidad determinístico y probabilístico. RESULTADOS: Las opciones "Tratar según dosis comunicada" y "Tratar según el nomograma" son las que muestran mejor coste-efectividad. Al compararlas, la razón coste-efectividad incremental es de 5.985,37 Euros para la primera. El análisis de sensibilidad mostró una importante dependencia del modelo a la variación de las variables principales. En el análisis de sensibilidad probabilístico la estrategia "Tratar a todos los casos" respecto a "Cálculo de semivida" obtuvo una razón coste-efectividad incremental de unos 25.111,06 Euros (DE: 1.534.420,16; intervalo: -42.136,03 a 92.358,75), resultando esta última la más eficiente. CONCLUSIONES: La estrategia "Tratar según el nomograma" es la alternativa más eficiente en el diagnóstico y tratamiento de la intoxicacióna aguda por Paracetamol en nuestro medio, no así para un escenario de mayor prevalencia e incertidumbre, donde la opción "Cálculo de semivida" se muestra como la más eficiente

OBJECTIVE: To evaluate 5 diagnostic-therapeutic strategies for suspected acute paracetamol poisoning in terms of cost-effectiveness in a tertiary university hospital with an active, validated poisoning surveillance program (SAT-HULP). METHODS: Cost-effectiveness analysis of the 5 diagnostic-therapeutic alternatives considered when attending patients with suspected paracetamol poisoning. The alternatives were chosen by means of a decision tree. We studied patients detected by the SAT-HULP program between April 1, 2011, and January 31, 2015. The diagnostic-therapeutic alternatives were as follows: 1) systematic treatment of all patients with N-acetylcysteine (NAC), 2) NAC treatment according to the reported dose; 3) NAC treatment according to a Rümack-Matthew nomogram; 4) NAC treatment according to urine test results confirmed by a blood test, and 5) treatment according to elimination half-life calculation. Probability data were obtained from the SAT-HULP program and validation studies corresponding to the diagnostic tests. Deterministic and probabilistic sensitivity analyses were performed. RESULTS: The approaches that were most cost-effective were those guided by reported doses and nomograms. The incremental cost-effectiveness of treatment according to reported dose was Euros 5985.37. The sensitivity analysis showed that the model was highly dependent on variations in the main variables; the probabilistic sensitivity analysis indicated an incremental cost-effectiveness of Euros 25 111.06 (SD, Euros 1 534 420.16; range, Euros 42 136.03-Euros 92 358.75) between the first approach (treat all cases) and last (calculate elimination half-life); half-life calculation was the more efficient. CONCLUSIONS: Treating according to nomogram was the most efficient diagnostic-therapeutic approach to treating paracetamol poisoning in our hospital. However, when the prevalence of paracetamol poisoning is higher and uncertainty is greater, it would be more efficient to treat based on calculating the half-life

Efficient diagnosis and treatment of acute paracetamol poisoning: cost-effectiveness analysis of approaches based on a hospital toxicovigilance program. / Eficiencia en el diagnóstico y tratamiento de la intoxicación aguda por paracetamol: análisis de costeefectividad a través de un programa de toxicovigilancia activa hospitalario.

OBJECTIVES: To evaluate 5 diagnostic-therapeutic strategies for suspected acute paracetamol poisoning in terms of cost-effectiveness in a tertiary university hospital with an active, validated poisoning surveillance program (SAT-HULP). MATERIAL AND METHODS: Cost-effectiveness analysis of the 5 diagnostic-therapeutic alternatives considered when attending patients with suspected paracetamol poisoning. The alternatives were chosen by means of a decision tree. We studied patients detected by the SAT-HULP program between April 1, 2011, and January 31, 2015. The diagnostic-therapeutic alternatives were as follows: 1) systematic treatment of all patients with N-acetylcysteine (NAC), 2) NAC treatment according to the reported dose; 3) NAC treatment according to a Rümack-Matthew nomogram; 4) NAC treatment according to urine test results confirmed by a blood test, and 5) treatment according to elimination half-life calculation. Probability data were obtained from the SAT-HULP program and validation studies corresponding to the diagnostic tests. Deterministic and probabilistic sensitivity analyses were performed. RESULTS: The approaches that were most cost-effective were those guided by reported doses and nomograms. The incremental cost-effectiveness of treatment according to reported dose was €5985.37. The sensitivity analysis showed that the model was highly dependent on variations in the main variables; the probabilistic sensitivity analysis indicated an incremental cost-effectiveness of €25 111.06 (SD, €1 534 420.16; range, €42 136.03-€92 358.75) between the first approach (treat all cases) and last (calculate elimination half-life); half-life calculation was the more efficient. CONCLUSION: Treating according to nomogram was the most efficient diagnostic-therapeutic approach to treating paracetamol poisoning in our hospital. However, when the prevalence of paracetamol poisoning is higher and uncertainty is greater, it would be more efficient to treat based on calculating the half-life.

OBJETIVO: Evaluar la eficiencia de cinco estrategias diagnóstico-terapéuticas posibles ante la sospecha de intoxicación aguda (IA) por paracetamol (PCT) a través de un análisis coste-efectividad, según la perspectiva del financiador en un hospital universitario terciario dotado de un programa de toxicovigilancia activa validado (SAT-HULP). METODO: Estudio de análisis de coste-efectividad (ACE) de cinco alternativas diagnóstico-terapéuticas consideradas en el abordaje de los pacientes atendidos en el servicio de urgencias hospitalario (SUH) con intoxicación por PCT mediante un modelo de árbol de decisión. La población estudiada fueron los pacientes atendidos en un SUH detectados por el SAT-HULP, entre el 1/04/2011 y el 31/01/2015. Las alternativas diagnóstico-terapéuticas consideradas fueron: 1) administración sistemática de Nacetilcisteína; 2) administración del tratamiento según la dosis confirmada; 3) tratamiento según el nomograma de Rümack- Matthew; 4) tratamiento según test de orina confirmado con posterior test en sangre; y 5) tratamiento según el cálculo de la semivida. Los datos correspondientes a probabilidades fueron obtenidos del programa SAT-HULP y publicaciones sobre la validación de las pruebas diagnósticas. Se realizaron análisis de sensibilidad determinístico y probabilístico. RESULTADOS: Las opciones "Tratar según dosis comunicada" y "Tratar según el nomograma" son las que muestran mejor coste-efectividad. Al compararlas, la razón coste-efectividad incremental es de 5.985,37 € para la primera. El análisis de sensibilidad mostró una importante dependencia del modelo a la variación de las variables principales. En el análisis de sensibilidad probabilístico la estrategia "Tratar a todos los casos" respecto a "Cálculo de semivida" obtuvo una razón coste-efectividad incremental de unos 25.111,06 € (DE: 1.534.420,16; intervalo: ­42.136,03 a 92.358,75), resultando esta última la más eficiente. CONCLUSIONES: La estrategia "Tratar según el nomograma" es la alternativa más eficiente en el diagnóstico y tratamiento de la intoxicacióna aguda por Paracetamol en nuestro medio, no así para un escenario de mayor prevalencia e incertidumbre, donde la opción "Cálculo de semivida" se muestra como la más eficiente.