Evaluating dynamic patterns in mortality before and after reconfiguration of the Danish emergency healthcare system.

BACKGROUND: This study explored changes in short-term mortality during a national reconfiguration of emergency care starting in 2007. METHODS: Unplanned hospital contacts at emergency departments across Denmark from 2007 to 2016. The reconfiguration was a natural experiment, resulting in individual timelines for each hospital. The outcome was in-hospital and 30-day mortality. RESULTS: Individual patient-level data included 9,745,603 unplanned hospital contacts from 2007 to 2016 at 20 hospitals with emergency departments. We observed a sharp downwards shift in in-hospital mortality and 30-day mortality in three hospitals in relation to the reconfiguration. CONCLUSION: This nationwide study identified three hospitals where the reconfiguration was closely associated with reduced in-hospital and 30-day mortality. In contrast, no major effects were identified for the remaining hospitals.

How do sepsis survivors experience life after sepsis? A Danish qualitative study exploring factors of importance.

OBJECTIVE: Sepsis is a condition associated with high mortality and morbidity, and survivors often experience physical and psychological decline. Previous research has primarily focused on sepsis survivors discharged from the intensive care unit (ICU). We aimed to explore and understand the consequences of sepsis experienced by sepsis survivors in general. DESIGN: A qualitative study inspired by a phenomenological hermeneutical approach was conducted. Data were analysed using systematic text condensation. SETTING: Patients with sepsis were identified on admission to the emergency department and invited to an interview 3 months after discharge. PARTICIPANTS: Sixteen sepsis survivors were purposively sampled and interviewed. Among these survivors, one patient was admitted to the ICU. RESULTS: Three main themes were derived from the analysis: new roles in life, cognitive impairment and anxiety. Although many survivors described a physical decline, they experienced psychological and cognitive impairments after sepsis as the most influential factors in daily life. The survivors frequently experienced fatigue, withdrawals from social activities and anxiety. CONCLUSION: Sepsis survivors' experiences appeared to overlap regardless of ICU admission or treatment at the general ward. Identifying patients with sepsis-related decline is important to understand and support overall patient processes and necessary in meeting specific needs of these patients after hospital discharge.

Predictive value and interrater reliability of mental status and mobility assessment in the emergency department.

AIM: To investigate the predictive value of both mental status, assessed with the AVPUC (Alert, responds to Voice, responds to Pain, Unresponsive, and new Confusion) scale, and mobility assessments, and their interrater reliability (IRR) between triage clinicians and a research team. METHOD: Prospective study of consecutive patients who presented to an ED. Mental status and mobility were assessed by triage clinicians and by a dedicated research team. RESULTS: 4,191 patients were included. After adjustment for age and sex, patients with altered mental status have an odds ratio of 6.55 [4.09-10.24] to be admitted in the ICU and an odds ratio of 21.16 [12.06-37.01] to die within 30 days; patients with impaired mobility have an odds ratio of 7.08 [4.60-11.12] to be admitted in the ICU and an odds ratio of 12.87 [5.93-32.30] to die within 30 days. The kappa coefficient between triage clinicians and the research team for mental status assessment was 0.75, and 0.80 for mobility. CONCLUSION: Assessment of mental status by the AVPUC scale, and mobility by a simple dichotomous scale are suitable for ED triage. Both altered mental status and impaired mobility are associated with adverse outcomes. Mental status and mobility assessment have good interrater reliability.

Clinical Frailty Scale at presentation to the emergency department: interrater reliability and use of algorithm-assisted assessment.

PURPOSE: The Clinical Frailty Scale (CFS) allows health care providers to quickly stratify older patients, to support clinical decision-making. However, few studies have evaluated the CFS interrater reliability (IRR) in Emergency Departments (EDs), and the freely available smartphone application for CFS assessment was never tested for reliability. This study aimed to evaluate the interrater reliability of the Clinical Frailty Scale (CFS) ratings between experienced and unexperienced staff (ED clinicians and a study team (ST) of medical students supported by a smartphone application to assess the CFS), and to determine the feasibility of CFS assignment in patients aged 65 or older at triage. METHODS: Cross-sectional study using consecutive sampling of ED patients aged 65 or older. We compared assessments by ED clinicians (Triage Clinicians (TC) and geriatric ED trained nurses (geriED-TN)) and a study team (ST) of medical students using a smartphone application for CFS scoring. The study is registered on Clinicaltrials.gov (NCT05400707). RESULTS: We included 1349 patients aged 65 and older. Quadratic-weighted kappa values for ordinal CFS levels showed a good IRR between TC and ST (Ï° = 0.73, 95% CI 0.69-0.76), similarly to that between TC and geriED-TN (Ï° = 0.75, 95% CI 0.66-0.82) and between the ST and geriED-TN (Ï° = 0.74, 95% CI 0.63-0.81). A CFS rating was assigned to 972 (70.2%) patients at triage. CONCLUSION: We found good IRR in the assessment of frailty with the CFS in different ED providers and a team using a smartphone application to support rating. A CFS assessment occurred in more than two-thirds (70.2%) of patients at triage.

Prevalence and prognostic value of electrocardiographic abnormalities in hypokalemia: A multicenter cohort study.

BACKGROUND: Hypokalemia is common in hospitalized patients and associated with ECG abnormalities. The prevalence and prognostic value of ECG abnormalities in hypokalemic patients are, however, not well established. METHODS: The study was a multicentered cohort study, including all ault patients with an ECG and potassium level <4.4 mmol/L recorded at arrival to four emergency departments in Denmark and Sweden. Using computerized measurements from ECGs, we investigated the relationship between potassium levels and heart rate, QRS duration, corrected QT (QTc) interval, ST-segment depressions, T-wave flattening, and T-wave inversion using cubic splines. Within strata of potassium levels, we further estimated the hazard ratio (HR) for 7-day mortality, admission to the intensive care unit (ICU), and diagnosis of ventricular arrhythmia or cardiac arrest, comparing patients with and without specific ECG abnormalities matched 1:2 on propensity scores. RESULTS: Among 79,599 included patients, decreasing potassium levels were associated with a concentration-dependent increase in all investigated ECG variables. ECG abnormalities were present in 40% of hypokalemic patients ([K+ ] <3.5 mmol/L), with T-wave flattening, ST-segment depression, and QTc prolongation occurring in 27%, 16%, and 14%. In patients with mild hypokalemia ([K+ ] 3.0-3.4 mmol/L), a heart rate >100 bpm, ST-depressions, and T-wave inversion were associated with increased HRs for 7-day mortality and ICU admission, whereas only a heart rate >100 bpm predicted both mortality and ICU admission among patients with [K+ ] <3.0 mmol/L. HR estimates were, however, similar to those in eukalemic patients. The low number of events with ventricular arrhythmia limited evaluation for this outcome. CONCLUSIONS: ECG abnormalities were common in hypokalemic patients, but they are poor prognostic markers for short-term adverse events under the current standard of care.

Comparison of international guideline recommendations for the diagnosis of pulmonary embolism.

Pulmonary embolism is one of the leading causes of death due to cardiovascular disease. Timely diagnosis is crucial, but challenging, as the clinical presentation of pulmonary embolism is unspecific and easily mistaken for other common medical emergencies. Clinical prediction rules and D-dimer measurement allow stratification of patients into groups of expected prevalence and are key elements in adequate selection of patients for diagnostic imaging; however, the strengths and weaknesses of the multiple proposed prediction rules, when to measure D-dimer, and which cutoff to apply might be elusive to a significant proportion of physicians. 13 international guidelines authored by medical societies or expert author groups provide recommendations on facets of the diagnostic investigations in suspected pulmonary embolism, some of which are hallmarked by pronounced heterogeneity. This Review summarises key recommendations of each guideline, considers the most recent evidence on the topic, compares guideline recommendations on each facet of the diagnosis of pulmonary embolism, and provides a synthesis on the most common recommendations.

THE ASSOCIATION BETWEEN SYSTOLIC BLOOD PRESSURE AND HEART RATE IN EMERGENCY DEPARTMENT PATIENTS: A MULTICENTER COHORT STUDY.

BACKGROUND: Guidelines and textbooks assert that tachycardia is an early and reliable sign of hypotension, and an increased heart rate (HR) is believed to be an early warning sign for the development of shock, although this response may change by aging, pain, and stress. OBJECTIVE: To assess the unadjusted and adjusted associations between systolic blood pressure (SBP) and HR in emergency department (ED) patients of different age categories (18-50 years; 50-80 years; > 80 years). METHODS: A multicenter cohort study using the Netherlands Emergency department Evaluation Database (NEED) including all ED patients ≥ 18 years from three hospitals in whom HR and SBP were registered at arrival to the ED. Findings were validated in a Danish cohort including ED patients. In addition, a separate cohort was used including ED patients with a suspected infection who were hospitalized from whom measurement of SBP and HR were available prior to, during, and after ED treatment. Associations between SBP and HR were visualized and quantified with scatterplots and regression coefficients (95% confidence interval [CI]). RESULTS: A total of 81,750 ED patients were included from the NEED, and a total of 2358 patients with a suspected infection. No associations were found between SBP and HR in any age category (18-50 years: -0.03 beats/min/10 mm Hg, 95% CI -0.13-0.07, 51-80 years: -0.43 beats/min/10 mm Hg, 95% CI -0.38 to -0.50, > 80 years: -0.61 beats/min/10 mm Hg, 95% CI -0.53 to -0.71), nor in different subgroups of ED patient. No increase in HR existed with a decreasing SBP during ED treatment in ED patients with a suspected infection. CONCLUSION: No association between SBP and HR existed in ED patients of any age category, nor in ED patients who were hospitalized with a suspected infection, even during and after ED treatment. Emergency physicians may be misled by traditional concepts about HR disturbances because tachycardia may be absent in hypotension.

Utilisation and time to performance of diagnostic imaging in patients admitted to Danish emergency departments: a nationwide register-based study from 2007 to 2017.

OBJECTIVES: To describe the development of diagnostic imaging utilisation in Denmark from 2007 to 2017, coinciding with a major national reform of the emergency healthcare system. DESIGN: Nationwide descriptive register-based study. SETTING: All public hospitals in Denmark. PARTICIPANTS: All unplanned hospital contacts ≥18 years old at somatic hospitals in Denmark from 1 January 2007 to 31 December 2017. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome measure was the probability of having CT, X-ray, MRI or ultrasound performed during hospitalisation in 2017 compared with 2007. The secondary outcome measure was receiving diagnostic imaging within 4 hours of hospitalisation. RESULTS: The probability of having a radiological examination during unplanned hospital admission increased from 2007 to 2017 (CT: 3.5%-10.3%; MRI: 0.2%-0.8%; ultrasound: 2.3%-4.5%; X-ray: 23.8%-26.8%). For CT scan, the adjusted OR was 3.09 (95% CI: 2.73, 3.51); for MRI, the adjusted OR was 3.39 (95% CI: 1.87, 6.12) and for ultrasound, the adjusted OR was 1.93 (95% CI: 1.56, 2.38). The likelihood of having the examination within the first 4 hours in the hospital increased from 2007 to 2017. For X-ray, the adjusted OR was 1.39 (95% CI: 1.07, 1.56); for CT scan, the adjusted OR was 1.35 (95% CI: 1.16, 1.59); for MRI, the adjusted OR was 1.34 (95% CI: 1.09, 1.66) and for ultrasound, the adjusted OR was 1.38 (95% CI: 1.16, 1.64). CONCLUSION: This nationwide study describes the development of diagnostic imaging utilisation in Denmark from 2007 to 2017. The probability of receiving radiological examinations during unplanned hospitalisation increased over this period, and the time from hospital contact to performance decreased. This supports the notion that enhancement in radiological equipment will also lead to more frequent and faster utilisation.

Resuscitation preferences of older acutely admitted medical and mentally competent patients with one and six months follow-up.

AIM: Determining patients' cardiopulmonary resuscitation (CPR) preferences in the emergency department (ED) is common practice but the stability of these preferences and their recollection by patients has been questioned. Therefore, this study assessed the stability and recall of CPR preferences of older patients at and following ED discharge. METHODS: This survey-based cohort study was conducted between February and September 2020 at three EDs in Denmark. It consecutively asked mentally competent patients aged 65 years or older who were admitted to hospital through the ED and then one and six months later "In your current state of health, do you wish that physicians should try to intervene if your heart stops beating?" Possible responses were confined to "definitely yes", "definitely no", "uncertain", and "prefer not to answer". RESULTS: In total, 3688 patients admitted to hospital via the ED patients were screened, 1766 were eligible and 491 (27.8%) were included: median age was 76 (IQR 71-82) years, and 257 (52.3%) were men. One third of patients who expressed definite yes or no preferences in ED had changed their preference at one month follow-up. Only 90 (27.4%) and 94 (35.7%) patients recalled their preferences at one and six months follow-up, respectively. CONCLUSION AND RELEVANCE: In this study, one-in-three older ED patients who initially expressed definite resuscitation preferences had changed their minds at one month follow-up. Preferences were more stable at six months but only a minority were able to recall their preferences.

Centralization of emergency hospital care is not associated with increased in-hospital mortality; a population-based cohort study.

BACKGROUND: We describe changes in the distance travelled, the utilization of emergency services, and the inhospital mortality before and after the centralization of hospital emergency services in Denmark. METHODS: All unplanned non-psychiatric hospital contacts from adults (aged ≥18 years) in 2008 and 2016 are included. Analyses are age-standardized and conducted at a municipality level. The municipalities are divided into groups according to the presence of emergency hospital services. RESULTS: Municipalities where hospitals with emergency services have been closed differed by having the most significant increase in distance travelled from 2008 to 2016. All groups experienced a reduction in overall in-hospital mortality. The reduction in mortality was not present for acute myocardial infarct contacts from municipalities where hospitals with emergency services have been closed. CONCLUSION: Our data do not suggest that hospital closures, and thereby increased travel distance, have contributed significantly as a barrier to emergency-care access and changes to in-hospital mortality.

The COVID-19 pandemic has not affected the mortality for patients admitted with pneumonia in Denmark.

During the COVID-19 pandemic, several hospital systems observed a reduction in patients with respiratory complaints. Using the Danish national registers, we conducted an observational study on disease severity and 30-day all-cause mortality for acutely admitted pneumonia patients before (3/19-3/20) and during (3/20-2/21) the pandemic. We calculated mortality rate ratios and Cox regression analyses. We identified 54,405 patients and during the pandemic, patients were older, more likely to be male, had more co-morbidity and a lower albumin on admission. Crude mortality was higher during the pandemic (8.4 vs. 6.9%). Adjusted hazard ratio for 30-day all-cause mortality was 1.07 (95%CI 1.01-1.14). We showed a small but significant, increase in mortality risk for patients admitted to hospital during the COVID-19 pandemic in Denmark.

Readmission is experienced as inevitable among older adults receiving homecare: A qualitative interview study.

BACKGROUND: Older adults receiving homecare have an increased risk of readmission. The transition from hospital to home can be experienced as unsafe, and older adults describe themselves as vulnerable during the post-discharge period. Thus, the objective was to explore the experiences of unplanned readmissions among older adults who receive homecare. METHODS: We conducted qualitative individual semi-structured interviews with older adults, 65 years or above, receiving homecare and being readmitted to an emergency department (ED) between August and October 2020. Data were analysed by systematic text condensation as described by Malterud. FINDINGS: We included 12 adults aged 67-95 years, seven were male, and eight lived alone. The analysis derived three themes: (1) Responsibility and security at home, (2) the role of family, friends and homecare and (3) the importance of trust. The older adults felt that the hospital strived for too-early discharge, as they still did not feel well. They worried about how to manage their daily life. Active involvement of their family increased their sense of security, but those living alone described feeling anxious being at home by themselves after discharge. Although older adults did not wish to go to the hospital, inadequate treatment at home and the feeling of responsibility for their illness made them feel insecure. They expressed that earlier negative experiences affected their trust in the system and their inclination to ask for help. CONCLUSIONS: The older adults were discharged from the hospital despite feeling ill. They described inadequate competencies from healthcare professionals in the home as a contributing factor to their readmission. The readmission increased a sense of security. Support from the family in the process was essential and provided a sense of security, whereas older adults living alone experienced feelings of insecurity in the home environment.

Mobile emergency department care to nursing home residents: a novel outreach service.

BACKGROUND: Every month, 6% of Danish nursing home residents are admitted to hospital. However, these admissions might have limited benefits and are associated with an increased risk of complications. We initiated a new mobile service comprising consultants performing emergency care in nursing homes. OBJECTIVE: Describe the new service, the recipients of this service, hospital admission patterns and 90-day mortality. DESIGN: A descriptive observational study. MODEL: When an ambulance is requested to a nursing home, the emergency medical dispatch centre simultaneously dispatches a consultant from the emergency department who will provide an emergency evaluation and decisions regarding treatment at the scene in collaboration with municipal acute care nurses. METHOD: We describe the characteristics of all nursing home contacts from 1st November 2020 to 31st December 2021. The outcome measures were hospital admissions and 90-day mortality. Data were extracted from the patients' electronic hospital records and prospectively registered data. RESULTS: We identified 638 contacts (495 individuals). The new service had a median of two (interquartile range: 2-3) new contacts per day. The most frequent diagnoses were related to infections, unspecific symptoms, falls, trauma and neurologic disease. Seven out of eight residents remained at home following treatment, 20% had an unplanned hospital admission within 30 days and 90-day mortality was 36.4%. CONCLUSION: Transitioning emergency care from hospitals to nursing homes could present an opportunity for providing optimised care to a vulnerable population and limiting unnecessary transfers and admissions to hospitals.

Development and External Validation of the International Early Warning Score for Improved Age- and Sex-Adjusted In-Hospital Mortality Prediction in the Emergency Department.

OBJECTIVES: Early Warning Scores (EWSs) have a great potential to assist clinical decision-making in the emergency department (ED). However, many EWS contain methodological weaknesses in development and validation and have poor predictive performance in older patients. The aim of this study was to develop and externally validate an International Early Warning Score (IEWS) based on a recalibrated National Early warning Score (NEWS) model including age and sex and evaluate its performance independently at arrival to the ED in three age categories (18-65, 66-80, > 80 yr). DESIGN: International multicenter cohort study. SETTING: Data was used from three Dutch EDs. External validation was performed in two EDs in Denmark. PATIENTS: All consecutive ED patients greater than or equal to 18 years in the Netherlands Emergency department Evaluation Database (NEED) with at least two registered vital signs were included, resulting in 95,553 patients. For external validation, 14,809 patients were included from a Danish Multicenter Cohort (DMC). MEASUREMENTS AND MAIN RESULTS: Model performance to predict in-hospital mortality was evaluated by discrimination, calibration curves and summary statistics, reclassification, and clinical usefulness by decision curve analysis. In-hospital mortality rate was 2.4% ( n = 2,314) in the NEED and 2.5% ( n = 365) in the DMC. Overall, the IEWS performed significantly better than NEWS with an area under the receiving operating characteristic of 0.89 (95% CIs, 0.89-0.90) versus 0.82 (0.82-0.83) in the NEED and 0.87 (0.85-0.88) versus 0.82 (0.80-0.84) at external validation. Calibration for NEWS predictions underestimated risk in older patients and overestimated risk in the youngest, while calibration improved for IEWS with a substantial reclassification of patients from low to high risk and a standardized net benefit of 5-15% in the relevant risk range for all age categories. CONCLUSIONS: The IEWS substantially improves in-hospital mortality prediction for all ED patients greater than or equal to18 years.

Prognosis for older people at presentation to emergency department based on frailty and aggregated vital signs.

BACKGROUND: Risk stratification for older people based on aggregated vital signs lack the accuracy to predict mortality at presentation to the Emergency Department (ED). We aimed to develop and internally validate the Frailty adjusted Prognosis in ED tool (FaP-ED) for 30-day mortality combining frailty and aggregated vital signs. METHODS: Single-center prospective cohort of undifferentiated ED patients aged 65 or older, consecutively sampled upon ED presentation from a tertiary Emergency Center. Vital signs were aggregated using the National Early Warning Score (NEWS) as a measure of illness or injury severity and frailty was assessed with the Clinical Frailty Scale (CFS). The FaP-ED was constructed by combining NEWS and CFS in multivariable logistic regression. The primary outcome was 30-day mortality. Measures of discrimination and calibration were assessed to evaluate predictive performance and internally validated using bootstrapping. RESULTS: 2250 patients were included, 67 (1.8%) were omitted from analyses due to missing CFS, loss to follow-up, or terminal illness. Thirty-day mortality rate was 5.4% (N = 122, 95% CI = 4.5%-6.4%). Median NEWS was 1 (Inter-Quartile Range (IQR): 0-3) and median CFS was 4 (IQR: 3-5). The Area Under Receiver Operating Characteristic (AUROC) for FaP-ED was 0.86 (95% CI = 0.83-0.90). This was significantly higher than NEWS (0.81, 95% CI = 0.77-0.85, DeLong: Z = 3.5, p < 0.001) or CFS alone (0.82, 95% CI = 0.78-0.86, DeLong: Z = 4.4, p < 0.001). Bootstrapped estimates of FaP-ED AUROC, calibration slope, and intercept were 0.86, 0.95, and -0.09, respectively, suggesting internal validity. A decision-threshold of CFS 5 and NEWS 3 was proposed based on qualitative comparison of positive Likelihood Ratio at all relevant FaP-ED cutoffs. CONCLUSION: Combining aggregated vital signs and frailty accurately predicted 30-day mortality at ED presentation and illustrated an important clinical interaction between frailty and illness severity. Pending external validation, the Fap-ED operationalizes the concept of such "geriatric urgency" for the ED setting.

Mortality before and after reconfiguration of the Danish hospital-based emergency healthcare system: a nationwide interrupted time series analysis.

OBJECTIVES: The study aimed to investigate how the 'natural experiment' of reconfiguring the emergency healthcare system in Denmark affected in-hospital and 30-day mortality on a national level. The reconfiguration included the centralisation of hospitals and the establishment of emergency departments with specialists present around the clock. DESIGN: Hospital-based cohort study. SETTING: All public hospitals in Denmark. PARTICIPANTS: Patients with an unplanned contact from 1 January 2007 until 31 December 2016. INTERVENTIONS: Stepped-wedge reconfiguration of the Danish emergency healthcare system. MAIN OUTCOME MEASURES: We determined the adjusted ORs for in-hospital mortality and HRs for 30-day mortality using logistic and Cox regression analysis adjusted for sex, age, Charlson Comorbidity Index, income, education, mandatory referral and the changes in the out of hours system in the Capital Region. The main outcomes were stratified by the time of arrival. We performed subgroup analyses on selected diagnoses: myocardial infarction, stroke, pneumonia, aortic aneurysm, bowel perforation, hip fracture and major trauma. RESULTS: We included 11 367 655 unplanned hospital contacts. The adjusted OR for overall in-hospital mortality after reconfiguration of the emergency healthcare system was 0.998 (95% CI 0.968 to 1.010; p=0.285), and the adjusted OR for 30-day mortality was 1.004 (95% CI 1.000 to 1.008; p=0.045)). Subgroup analyses showed some possible benefits of the reconfiguration such as a reduction in-hospital and 30-day mortality for myocardial infarction, stroke, aortic aneurysm and major trauma. CONCLUSIONS: The Danish emergency care reconfiguration programme was not associated with an improvement in overall in-hospital mortality trends and was associated with a slight slowing of prior improvements in 30-day mortality trends.

Readmission trends before and after a national reconfiguration of emergency departments in Denmark.

OBJECTIVE: In order to achieve better and more efficient emergency health care, the Danish public hospital system has been reconfigured, with hospital emergency care being centralised into extensive and specialised emergency departments. This article examines how this reconfiguration has affected patient readmission rates. METHODS: We included all unplanned hospital admissions (aged ≥18 years) at public, non-psychiatric hospitals in four geographical regions in Denmark between 1 January 2007 and 24 December 2017. Using an interrupted time-series design, we examined trend changes in the readmission rates. In addition to analysing the overall effect, analyses stratified according to admission time of day and weekdays/weekends were conducted. The analyses were adjusted for patient characteristics and other system changes. RESULTS: The seven-day readmission rate increased from 2.6% in 2007 to 3.8% in 2017, and the 30-day rate increased from 8.1% to 11.5%. However, the rates were less than what they would have been had the reconfiguration not been introduced. The reconfiguration reduced the seven-day readmission rate by 1.4% annually (hazard ratio [CI 95%] 0.986 [0.981-0.991]) and the 30-day rate by 1% annually (hazard ratio [CI 95%] 0.99 [0.987-0.993]). CONCLUSIONS: Reconfiguration reduced the rate of increase in readmissions, but nevertheless readmissions still increased across the study period. It seems hospitals and policymakers will need to identify further ways to reduce patient loads.

Multiorgan ultrasonographic findings in patients with pulmonary embolism at diagnosis and clinical follow-up: a proof of concept study.

PURPOSE: The purpose of this descriptive feasibility study was to assess the clinical impact and feasibility of conducting a multiorgan ultrasound examination of patients with pulmonary embolism at both time of diagnosis and at clinical follow-up. METHODS: Hemodynamically stable patients with pulmonary embolism verified by CT pulmonary angiography or ventilation perfusion scintigraphy were eligible for inclusion. Enrolled patients underwent multiorgan ultrasound investigation encompassing echocardiography supplemented with focused lung and deep venous ultrasound emphasizing right ventricular strain, subpleural consolidations and presence of deep venous thrombi. Identical investigations were conducted at 3 months follow-up. The presence of ultrasonographic findings at diagnosis and follow-up was compared and the clinical impact of any remaining pathology or strain was described. RESULTS: Twenty-one patients were enrolled in the study of whom 20 survived to attend follow-up. Mean age was 62 ± 15 years and 48% were female. At diagnosis, the most prevalent ultrasonographic findings were subpleural consolidations in 11 patients and right ventricular dilation in eight. At follow-up, signs of right ventricular strain had resolved in all patients. However, in one patient, no resolution was seen in a subpleural consolidation observed at the time of pulmonary embolism diagnosis, resulting in referral to a chest CT. Additionally, one patient exhibited residual deep venous thrombotic material, leading to prolongation of anticoagulative treatment. CONCLUSION: In patients with pulmonary embolism, multiorgan ultrasound is feasible in follow-up and adequately powered studies should determine the clinical utility of such an approach.

What matters and influence resuscitation preference? Development, field testing, and structural validation of items among older patients in the emergency department.

BACKGROUND: Decisions about resuscitation preference is an essential part of patient-centered care but a prerequisite is having an idea about which questions to ask and understand how such questions may be clustered in dimensions. The European Resuscitation Council Guidelines 2021 encourages resuscitation shared decision making in emergency care treatment plans and needs and experiences of people approaching end-of-life have been characterized within the physical, psychological, social, and spiritual dimensions. We aimed to develop, test, and validate the dimensionality of items that may influence resuscitation preference in older Emergency Department (ED) patients. METHODS: A 36-item questionnaire was designed based on qualitative interviews exploring what matters and what may influence resuscitation preference and existing literature. Items were organized in physical, psychological, social, and spiritual dimensions. Initial pilot-testing to assess content validity included ten older community-dwelling persons. Field-testing, confirmatory factor analysis and post-hoc bifactor analysis was performed on 269 older ED patients. Several model fit indexes and reliability coefficients (explained common variance (ECV) and omega values) were computed to evaluate structural validity, dimensionality, and model-based reliability. RESULTS: Items were reduced from 36 to 26 in field testing. Items concerning religious beliefs from the spiritual dimension were misunderstood and deemed unimportant by older ED patients. Remaining items concerned physical functioning in daily living, coping, self-control in life, optimism, overall mood, quality of life and social participation in life. Confirmatory factor analysis displayed poor fit, whereas post-hoc bifactor analysis displayed satisfactory goodness of fit (χ2 =562.335 (p<0.001); root mean square error of approximation=0.063 (90% CI [0.055;0.070])). The self-assessed independence may be the bifactor explaining what matters to older ED patients' resuscitation preference. CONCLUSIONS: We developed a questionnaire and investigated the dimensionality of what matters and may influence resuscitation preference among older ED patients. We could not confirm a spiritual dimension. Also, in bifactor analysis the expected dimensions were overruled by an overall explanatory general factor suggesting independence to be of particular importance for clinicians practicing resuscitation discussions in EDs. Studies to investigate how independence may relate to patients' choice of resuscitation preference are needed.