The CCEDRRN COVID-19 Mortality Score to predict death among nonpalliative patients with COVID-19 presenting to emergency departments: a derivation and validation study.

BACKGROUND: Predicting mortality from COVID-19 using information available when patients present to the emergency department can inform goals-of-care decisions and assist with ethical allocation of critical care resources. The study objective was to develop and validate a clinical score to predict emergency department and in-hospital mortality among consecutive nonpalliative patients with COVID-19; in this study, we define palliative patients as those who do not want resuscitative measures, such as intubation, intensive care unit care or cardiopulmonary resuscitation. METHODS: This derivation and validation study used observational cohort data recruited from 46 hospitals in 8 Canadian provinces participating in the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN). We included adult (age ≥ 18 yr) nonpalliative patients with confirmed COVID-19 who presented to the emergency department of a participating site between Mar. 1, 2020, and Jan. 31, 2021. We randomly assigned hospitals to derivation or validation, and prespecified clinical variables as candidate predictors. We used logistic regression to develop the score in a derivation cohort and examined its performance in predicting emergency department and in-hospital mortality in a validation cohort. RESULTS: Of 8761 eligible patients, 618 (7.0%) died. The CCEDRRN COVID-19 Mortality Score included age, sex, type of residence, arrival mode, chest pain, severe liver disease, respiratory rate and level of respiratory support. The area under the curve was 0.92 (95% confidence interval [CI] 0.90-0.93) in derivation and 0.92 (95% CI 0.90-0.93) in validation. The score had excellent calibration. These results suggest that scores of 6 or less would categorize patients as being at low risk for in-hospital death, with a negative predictive value of 99.9%. Patients in the low-risk group had an in-hospital mortality rate of 0.1%. Patients with a score of 15 or higher had an observed mortality rate of 81.0%. INTERPRETATION: The CCEDRRN COVID-19 Mortality Score is a simple score that can be used for level-of-care discussions with patients and in situations of critical care resource constraints to accurately predict death using variables available on emergency department arrival. The score was derived and validated mostly in unvaccinated patients, and before variants of concern were circulating widely and newer treatment regimens implemented in Canada. STUDY REGISTRATION: ClinicalTrials.gov, no. NCT04702945.

Comparison of rates of opioid withdrawal symptoms and reversal of opioid toxicity in patients treated with two naloxone dosing regimens: a retrospective cohort study.

INTRODUCTION: When managing opioid overdose (OD) patients, the optimal naloxone regimen should rapidly reverse respiratory depression while avoiding opioid withdrawal. Published naloxone administration guidelines have not been empirically validated and most were developed before fentanyl OD was common. In this study, rates of opioid withdrawal symptoms (OW) and reversal of opioid toxicity in patients treated with two naloxone dosing regimens were evaluated. METHODS: In this retrospective matched cohort study, health records of patients who experienced an opioid OD treated in two urban emergency departments (ED) during an ongoing fentanyl OD epidemic were reviewed. Definitions for OW and opioid reversal were developed a priori. Low dose naloxone (LDN; ≤0.15 mg) and high dose naloxone (HDN; >0.15 mg) patients were matched in a 1:4 ratio based upon initial respiratory rate (RR). The proportion of patients who developed OW and who met reversal criteria were compared between those treated initially with LDN or HDN. Odds ratios (OR) for OW and opioid reversal were obtained via logistic regression stratified by matched sets and adjusted for age, sex, pre-naloxone GCS, and presence of non-opioid drugs or alcohol. RESULTS: Eighty LDN patients were matched with 299 HDN patients. After adjustment, HDN patients were more likely than LDN patients to have OW after initial dose (OR = 8.43; 95%CI: 1.96, 36.3; p = 0.004) and after any dose (OR = 2.56; 95%CI: 1.17, 5.60; p = 0.019). HDN patients were more likely to meet reversal criteria after initial dose (OR = 2.73; 95%CI: 1.19, 6.26; p = 0.018) and after any dose (OR = 6.07; 95%CI: 1.81, 20.3; p = 0.003). CONCLUSIONS: HDN patients were more likely to have OW but also more likely to meet reversal criteria versus LDN patients.

Incidence of clinically relevant medication errors in the era of electronically prepopulated medication reconciliation forms: a retrospective chart review.

BACKGROUND: To reduce medication discrepancies (unintended differences between a patient's outpatient and inpatient medication regimens), Canadian institutions have implemented medication reconciliation forms that are prepopulated with outpatient medication dispensing data. These may prompt prescribers to reorder discontinued medications or continue newly contraindicated medications. Our objective was to evaluate the incidence of medication discrepancies and errors of commission after the implementation of such forms. METHODS: This retrospective chart review included patients previously enrolled in an observational study in which a research pharmacist prospectively collected best-possible medication histories in the emergency department. Research assistants uninvolved with the parent study compared medication orders written in the first 48 hours after admission with the research pharmacist's best-possible medication history to identify medication discrepancies and errors of commission, defined as inappropriate medication continuations and reordering of previously stopped medications. An independent panel adjudicated the clinical significance of the errors. RESULTS: Of 151 patients, 71 (47.0% [95% confidence interval (CI) 39.2-54.9]) were exposed to 112 medication errors on admission. Of the 112 errors, 24 (21.4% [95% CI 14.9-29.9]) were clinically significant. Errors of commission accounted for 24.1% (27/112 [95% CI 17.3-32.8]) of all errors; 10 (37.0% [95% CI 18.8-55.2]) of the errors of commission were clinically significant. INTERPRETATION: Medication errors were common after the implementation of electronically prepopulated medication reconciliation forms. Prospective research is required to examine the impact of prepopulated medication reconciliation forms and ensure they do not facilitate errors of commission.

Hypertension in cancer patients seeking acute care: an opportunity to intervene.

BACKGROUND: The objectives were to describe clinical factors associated with hypertension or increased blood pressure in cancer patients seeking acute care, to describe the outcomes of these patients related to hypertension or increased blood pressure, and to determine whether these patients receive appropriate treatment and follow-up instructions. METHODS: We retrospectively reviewed the records of patients admitted to the emergency center at The University of Texas M. D. Anderson Cancer Center from May 1, 2001 through August 5, 2001. Patients were included in our analysis if their emergency center triage blood pressure was 140 mm Hg or greater, systolic, or 90 mm Hg or greater, diastolic and remained in this range at emergency center discharge or if they were treated with an antihypertensive medication in the emergency center. Descriptive statistics, chi and Student t tests were utilized in the analysis. RESULTS: Records of 143 patients were analyzed. The mean baseline, emergency center triage, and emergency center discharge blood pressure were 140/78 mm Hg, 159/84 mm Hg, and 153/81 mm Hg, respectively. Of 77 patients (54%) with controlled neoplastic disease, 54 (38%) were not receiving cancer treatment. Forty-one (30%) were admitted to the hospital and 27 (19%) returned to the emergency center with hypertension or possible hypertension-related events within 6 months. Discharge instructions regarding hypertension follow-up were documented in 9% of records. CONCLUSIONS: Most patients (54%) had controlled cancer; more than one third were not receiving cancer treatment and had good performance status. Such patients would be likely to benefit from management of hypertension. In addition, only 9% of hypertensive patients were given hypertensive specific discharge instructions. The emergency center may provide another opportunity to alert patients of abnormal blood pressures and assist in arranging follow-up.

Predictors of breast and cervical screening in Vietnamese women in Harris County, Houston, Texas.

The Vietnamese are a quickly growing, important part of the Texas population. Breast cancer is known to have different biologic characteristics in Vietnamese women. In order to develop appropriate intervention and screening strategies, we conducted a study of barriers to cervical and breast screening in Vietnamese women in Harris County, Tex. Our objective was to characterize the demographic factors, beliefs, and barriers to cervical and breast cancer screening in our study population and test the effect of these on Papanicolaou test, breast self-examination (BSE), medical breast examination (MBE), and mammography use. The Health Belief Model Scales for Measuring Beliefs Related to Breast Cancer (Champion VL, Nursing Research 1993;42:139-143) was the framework used to assess attitudes regarding risk of breast cancer and to design a component assessing risk of cervical cancer. The questionnaire addressed susceptibility, seriousness, benefits, barriers, and health about screening for breast and cervical cancer. It was translated into Vietnamese and back-translated into English prior to use. The questionnaire was mailed to Harris County residents. Those returned were entered into a database. The data were analyzed for validity using Chronbach's alpha. Simple descriptive analyses and nominal logistic regression identified predictors of Papanicolaou test, BSE, MBE, and mammography use. Twelve hundred surveys were mailed out to Vietnamese women using the telephone directory and the church directories in Harris County; 209 were returned and entered into the database. Of the respondents, 67% had ever received a Papanicolaou test; of these, 89% had received a Papanicolaou test within the past year; 55% of respondents had performed a BSE, 45% of patients received an MBE, and 45% of respondents had ever received a mammogram (15% of respondents had a mammogram during the previous year). The most significant predictors of Papanicolaou test, BSE, MBE, and mammography use were marital status (being married), high educational level, lack of barriers, a family history of the cancer, older age, and increased perception of seriousness. Compared to other studies of Vietnamese women, the women in Texas are among the highest users of the Papanicolaou test, BSE, MBE, and mammography. Barriers and incentives to breast and cervical screening were similar to those in other studies.

Outcomes of treatment pathways in outpatient treatment of low risk febrile neutropenic cancer patients.

BACKGROUND: We treated low-risk febrile neutropenic cancer patients utilizing two standard outpatient antibiotic pathways: oral ampicillin/clavulanate (500 mg) and ciprofloxacin (500 mg) or intravenous ceftazidime (2 g) and clindamycin (600 mg) every 8 h. The objectives were to determine the success of outpatient treatment of low-risk febrile neutropenia, to identify factors predicting outpatient failure, and to determine mortality related to the febrile episode. METHODS: Eligibility criteria included solid tumor diagnosis, stable vital signs, temperature > or =38.0 degrees C, absolute neutrophil count (ANC) of <1000/ml, patient compliance, no significant organ dysfunction, ability to tolerate oral medication and fluids for oral pathway, residence within 30 miles of the institution, 24-h caregiver, and telephone and transportation access. RESULTS: There were 257 febrile episodes in 191 patients meeting the criteria. Patients were treated during March 1998 through February 2000. Median age was 48 (range, 17-77) years, and 60% (n = 153) had an entry ANC of <100/ml; 205 (80%) febrile episodes successfully responded to outpatient treatment, and 52 (20%) were hospitalized. Logistic regression analysis showed the following were related to hospitalization: mucositis >grade 2 (p < 0.002); Zubrod performance status > or =2 (p = 0.029); ANC <100/ml (p = 0.039), and age > or =70 years (p = 0.048). CONCLUSIONS: Outpatient treatment of low-risk febrile neutropenic cancer patients utilizing standard treatment pathways is associated with minimal morbidity and mortality and should be considered an acceptable standard of care with appropriate infrastructure available to provide strict and careful follow-up while on treatment. Certain factors are associated with higher risk of hospitalization and should be further examined in eligible patients with low-risk febrile neutropenia.