Comparison of clinical outcomes of venous thromboembolic disease between outpatient and inpatient management.

Objectives: To compare the occurrence of death, bleeding, and recurrence according to inpatient or outpatient management of venous thromboembolic disease (VTE). Materials and methods: . Retrospective cohort that included a consecutive sampling of VTE consultations between 2016 and 2019 diagnosed in the Emergency Center of a private hospital in Argentina. Results: There were 1202 cases, 908 with isolated deep vein thrombosis (DVT), 205 with isolated pulmonary embolism (PE), and 89 cases of combined DVT - PE. 66% were women, with a median age of 77 years; 72% of cases were managed on an outpatient basis (n= 862). Comorbidities associated with hospitalization were obesity (p=0.03), chronic obstructive pulmonary disease (COPD) (p=0.01), heart failure (CHF) (p=0.01), chronic renal failure (CKD) (p=0.01), and cancer (p=0.01). At 90 days, the cumulative incidence of bleeding was 2.6% in inpatient compared to 2.9% in outpatient management (p=0.81); recurrence was 0% versus 0.9% (p=0.07), and mortality was 42.9% versus 18.9%, respectively (p=0.01). The HR for 90-day mortality in hospitalized patients adjusted for confounders (sex, age, type of VTE, obesity, CKD, CHF, COPD, and cancer) was 1.99 (95% CI 1.49-2.64; p=0.01). Conclusions: In this elderly, and predominantly female Argentine population, the 90-day mortality in patients hospitalized for VTE was higher than mortality in patients with outpatient management, without differences in recurrence or major bleeding.

Unscheduled Emergency Department Revisits Within 48 Hours of Discharge.

This study aimed to analyze early revisits (within 48 hours of discharge) in an Emergency Department. Among the 178,295 visits, 11,686 were revisits, resulting in a rate of 6.55% (95%CI 6.43-6.67). A total of 1,410 revisits required hospitalization, and 252 were due to preventable errors (17.87%). These errors were mainly related to an inadequate therapeutic plan at discharge (47.22%), an incomplete diagnostic process (29.37%), and misdiagnoses (13.10%). These findings represent a technology-enabled clinical audit tool. Electronic Healthcare Records have the potential to: provide quality metrics of hospital performance, help to keep revisit rates updated (assessment through a real-time dashboard), and improve clinical management (by transparency initiatives about errors, and a supportive learning environment regarding lessons learned).

Intervención educativa para mejorar la prescripción de ceftriaxona en un servicio de urgencias / Educational intervention to improve ceftriaxone prescription in an emergency department

Objetivo: Evaluar prevalencia y adecuación de ceftriaxona tras una intervención educativa en un servicio de urgencias.Métodos: Estudio cuasi experimental que incluyó un mues-treo consecutivo de consultas no programadas de pacien-tes adultos, durante dos meses preintervención y posin-tervención. Dicha intervención consistió en capacitación a médicos para limitar su indicación sólo a situaciones clínicas específicas (meningitis, enfermedad pélvica infla-matoria y abdomen agudo). Se utilizaron datos retrospecti-vos, con adicional revisión manual de historias, para validar adecuación de inicio antibiótico y apropiabilidad de droga. Se utilizó estadística descriptiva y analítica.Resultados: De un total de 28.570 consultas, 512 recibie-ron ceftriaxona (1,79%; IC95% 1,64-1,95), y sólo 60,54% se hospitalizaron. En cuanto a la comparación antes-después, se observó una reducción en la tasa de uso (de 3,66% a 0,63%; p<0,001), la adecuación en el inicio de un antimicro-biano se mantuvo (de 84,52% a 86,21%; p=0,778), aunque la adecuación de ceftriaxona aumentó en forma significativa (de 41,78% a 84,00% respectivamente; p<0,001). Adicional-mente, se redujo el tiempo de estadía hospitalaria (media-na de 6 a 5 días; p=0,014), sin diferencias en la mortalidad intrahospitalaria (19,44% vs 17,24%; p=0,691), ni en la mor-talidad a los 30 días (23,41% vs 18,96%; p=0,464).Conclusiones: Esta intervención resultó eficaz. Los hallaz-gos representan un paso fundamental en los programas de optimización del uso de antimicrobianos hospitalarios, que apuntan a reducir su sobreutilización y la consecuente resistencia.

Objective: To evaluate the prevalence and appropriateness of ceftriaxone after an educational intervention in an emergency department.Methods: Quasi-experimental study, which included a consecutive sampling of unscheduled consultations of adult patients, during 2 months pre-intervention and post-intervention. The intervention consisted of training physicians to limit its indication only to specific clinical situations (meningitis, pelvic inflammatory disease, and acute abdomen). Retrospective data were used, with additional manual chart review, to validate appropriateness of antibiotic initiation and drug appropriateness. Descriptive and analytical statistics were used.Results: Among 28570 visits, 512 received ceftriaxone (1.79%; 95%CI 1.64-1.95), and only 60.54% were hospitalized. Regarding the before-after comparison, we observed a reduction in the rate of use (from 3.66% to 0.63%; p<0.001), the appropriateness in starting an antimicrobial was maintained (from 84.52% to 86.21%; p=0.778), and the appropriateness of ceftriaxone increased significantly (from 41.78% to 84.00% respectively; p<0.001). Additionally, hospital length of stay was reduced (median 6 to 5 days; p=0.014), with no difference in in-hospital mortality (19.44% vs 17.24%; p=0.691), nor in 30-day mortality (23.41% vs 18.96%; p=0.464)

Efecto de la inactivación de las órdenes múltiples para solicitud de estudios complementarios en una central de emergencias.

Introducción. La plantilla de órdenes múltiples es una herramienta informática que podría producir consecuencias inadvertidas pese a sus innumerables beneficios. Nos propusimos explorar el efecto de su inactivación sobre las solicitudes de estudios complementarios y los costos asociados. Métodos. Corte transversal en la Central de Emergencias de Adultos del Hospital Italiano de Buenos Aires, que incluyó muestra consecutiva de consultas pre-intervención (Enero-Febrero 2020) y post-intervención (2021). Mediante el uso de bases secundarias, las variables incluidas fueron los débitos administrativos y sus respectivos precios de facturación. Resultados. Hubo 27.671 consultas en 2020 con una mediana de valor total de 474$, y 20.819 con 1.639$ en 2021. Tras el análisis restringido al área de consultorios de moderada complejidad (excluyendo consultas por COVID-19), se encontró: una disminución en la mediana del número de prácticas por consulta (mediana de 11 vs 10, p=0,001), una disminución en la solicitud de al menos una práctica de laboratorio (45% versus 39%, p=0,001), sin encontrar cambios significativos en costos globales (mediana 1.419$ vs 1.081$; p=0,122) ni en costos específicos de laboratorio (mediana 1.071$ vs 1.089$, p=0,710). Conclusión. Pese a la inflación interanual, se logró una reducción significativa en el número de prácticas y se mantuvieron los costos globales por consulta. Estos hallazgos demuestran la efectividad de la intervención, pero serán necesarias medidas educativas que apunten al recordatorio de los potenciales daños en la sobreutilización, y los costos sanitarios de los estudios innecesarios.

[Chemotherapy at the end of life is compatible with dignified death and palliative care] / Quimioterapia al final de la vida es compatible con muerte digna y cuidados paliativos.

Introduction: Cancer treatment is increasingly aggressive. The aim was to estimate who died due to cancer, to report use of chemotherapy (CT) in the last 3 months of life, and to describe clinical-epidemiological characteristics of these patients. Methods: We included a consecutive sample of deceased during 2017, affiliated to Hospital Italiano de Buenos Aires. Through manual review of medical helath records, they were classified according to the cause of death (cancer or other cause), validating diagnosis and baseline stage, performance status (PS). Prevalences with 95% CI are reported and descriptive statistics were used. Results: A total of 2293 adults died, 59% women with a median age of 84 years old. There were a total of 736 deaths from cancer, representing 32% (95%CI 30-34). This last subgroup were 54% women, with a median age of 75 years, and only one patient had advance directives. Regarding the place of death, 80% were hospitalized (65% general ward and 15% intensive care units). The most frequent tumors were: lung, colorectal-gastric, hematological, and breast. A total of 390 patients received CT at the end of life (53%; 95%CI 49-57), 53% being women and with a mean age of 68 years. Regarding the underlying oncological disease: 81% had a solid tumor, 75% advanced stage, and mostly with poor/regular ability to perform daily activities (25% PS3 and 32% PS4, respectively). Conclusion: There is a high frequency of CT at the end of life and deaths continue to be mainly in-hospital.

Introducción: El tratamiento oncológico es cada vez más agresivo. El objetivo de este trabajo fue estimar las personas fallecidas por causa oncológica, reportar la frecuencia de uso de quimioterapia (QT) en los últimos 3 meses de vida, y describir las características clínicas-epidemiológicas de estos pacientes. Métodos: Se incluyó una muestra consecutiva de fallecidos durante el 2017, afiliados a prepaga del Hospital Italiano de Buenos Aires. Mediante revisión de historias clínicas, se los clasificó según la causa de muerte (oncológico u otra causa), validando diagnóstico y estadio de base, performance status (PS). Se reportan prevalencias con IC95% y se utilizó estadística descriptiva. Resultados: Fallecieron 2293 personas, 59% mujeres con mediana de 84 años. Hubo un total de 736 fallecidos por cáncer, representando el 32% (IC95% 30-34). Este último subgrupo presentó una mediana de 75 años, 54% eran mujeres y sólo una paciente tenía directivas anticipadas. En cuanto al lugar de fallecimiento, 80% ocurrió hospitalizado (65% sala general y 15% unidad cerrada). Los tumores más frecuentes fueron: pulmón, colorrectal-gástrico, hematológico, y mama. Un total de 390 pacientes recibieron QT al final de la vida (53%; IC95% 49-57), siendo 53% mujeres y con promedio de 68 años. En cuanto a la enfermedad oncológica de base: 81% tenían tumor sólido, 75% estadío avanzado, y mayoritariamente con mala/regular capacidad para realizar actividades cotidianas (25% PS3 y 32% PS4 respectivamente). Conclusión: Existe una frecuencia preocupante del uso de QT en el fin de vida y los fallecimientos siguen siendo principalmente intrahospitalarios.

Effect of computerized physician order entry inactivation to order complementary studies in an emergency department / [Efecto de la inactivación de las órdenes múltiples para solicitud de estudios complementarios en una central de emergencias.]

Introduction: The computerized provider order entry (CPOE) is a computing tool that could lead to unintended consequences despite its myriad benefits. We aimed to explore the effect of its inactivation on requests for complementary studies and the associated costs. Methods: Cross sectional study at the Emergency Department of Hospital Italiano de Buenos Aires, which included a consecutive sample of pre-intervention (January-February 2020) and post-intervention (2021) consultations. Using secondary bases, the variables included were administrative debits and their respective billing prices. Results: There were 27,671 consultations in 2020 with a total median value of $474, and 20,819 with $1,639 in 2021. After the analysis restricted to the area of ​​moderately complex clinics (excluding COVID-19 consultations), the following was found: a decrease in the median number of practices per consultation (median of 11 vs. 10, p=0.001), a decrease in the request for at least one laboratory practice (45% vs. 39%, p=0.001), without finding significant changes in global costs (median $1,419 vs. $1,081; p=0.122) or in specific laboratory costs (median $1,071 vs. $1,089, p=0.710). Conclusion: Despite inflation, a significant reduction in the number of practices was achieved and overall costs per consultation were maintained. These findings demonstrate the effectiveness of the intervention, but an educational intervention aimed at reminding the potential harm of overuse and the health costs of unnecessary studies will be necessary.

Introducción: La plantilla de órdenes múltiples es una herramienta informática que podría producir consecuencias inadvertidas pese a sus innumerables beneficios. Nos propusimos explorar el efecto de su inactivación sobre las solicitudes de estudios complementarios y los costos asociados. Métodos: Corte transversal en la Central de Emergencias de Adultos del Hospital Italiano de Buenos Aires, que incluyó muestra consecutiva de consultas pre-intervención (Enero-Febrero 2020) y post-intervención (2021). Mediante el uso de bases secundarias, las variables incluidas fueron los débitos administrativos y sus respectivos precios de facturación. Resultados: Hubo 27.671 consultas en 2020 con una mediana de valor total de 474$, y 20.819 con 1.639$ en 2021. Tras el análisis restringido al área de consultorios de moderada complejidad (excluyendo consultas por COVID-19), se encontró: una disminución en la mediana del número de prácticas por consulta (mediana de 11 vs 10, p=0,001), una disminución en la solicitud de al menos una práctica de laboratorio (45% versus 39%, p=0,001), sin encontrar cambios significativos en costos globales (mediana 1.419$ vs 1.081$; p=0,122) ni en costos específicos de laboratorio (mediana 1.071$ vs 1.089$, p=0,710). Conclusión: Pese a la inflación interanual, se logró una reducción significativa en el número de prácticas y se mantuvieron los costos globales por consulta. Estos hallazgos demuestran la efectividad de la intervención, pero serán necesarias medidas educativas que apunten al recordatorio de los potenciales daños en la sobreutilización, y los costos sanitarios de los estudios innecesarios.

Intoxicación por monóxido de carbono: estudio observacional de pacientes que acudieron a Urgencias durante 2020 / Carbon monoxide poisoning: an observational study of patients admitted to Emergency Department during 2020

El objetivo fue describir las intoxicaciones monóxido de carbono. Se diseñó un corte transversal que incluyó una muestra consecutiva de mediciones de carboxihemoglobina (COHb), realizadas Enero y Diciembre 2020 en la Central de Emergencias del Hospital Italiano de Buenos Aires. Se utilizaron bases secundarias y revisión manual de historias clínicas para recolección de varia-bles de interés. Durante el período de estudio hubo 20 pacientes confirmados, con media de 50 años (DE 20), 55% sexo masculino, 20% tabaquistas, y una única embarazada. El 70% correspondieron al trimestre Junio-Julio-Agosto. La fuente de intoxicación más frecuente se debió a accidentes domésticos (calefón, estufa, brasero, hornalla, salamandra) que representaron el 50% de los casos, 30% por incendios, y el 20% restante explicado por tabaco o factor desconocido. Los estudios de laboratorio más solicitados fueron: 95% recuento de glóbulos blancos, 85% glucemia, 70% CPK, y 55% troponina. Los hallazgos relevantes fueron COHb con mediana de 7.15%, CPK con mediana de 89 U/mL, y troponina con mediana de 8.5 pg/mL. La totalidad se realizó electrocardiograma: 15% presentaron arritmia como hallazgo patológico, y ninguno isquemia. En cuanto la presentación clínica: 30% presentó cefalea, 15% síncope, 15% coma, 10% mareos y 10% convulsiones. Sólo 25% tuvieron tomografía y 15% resonancia de cerebro, sin hallazgos críticos. Sin embargo, 15% fueron derivados para trata-miento con cámara hiperbárica. La mayoría ocurrieron en invierno y explicados por accidentes domésticos. Será necesario un fortalecimiento del rol preventivo que apunte al control de la instalación y el buen funcionamiento de artefactos, como mantener los ambientes bien ventilados (AU)

The objective was to describe carbon monoxide poisoning. A cross sectional was designed, which included a consecutive sample of carboxyhemoglobin (COHb) measurements, carried from January to December 2020 at the Emergency Department of tHospital Italiano de Buenos Aires. Secondary databases and manual review of medical records were used to collect variables of interest. During the study period there were 20 confirmed patients, with a mean age of 50 (SD 20), mostly male (55%), 20% smokers, and only one pregnant woman, 70% corresponded to June-July-August. The most frequent source of poisoning was explained to domestic accidents (water heater, stove, brazier, stove, salamander) which represented 50% of cases, 30% due to fires, and the remaining 20% by tobacco or unknown factor. The most laboratory studies were: 95% white blood cell count, 85% glycemia, 70% CPK, and 55% troponin. Meanwhile, relevant findings were carboxyhemoglobin with a median of 7.15%, CPK with a median of 89 U/mL, and troponin with a median of 8.5 pg/mL. All underwent an electrocardiogram: 15% presented arrhythmia as a pathological finding, and none ischemia. Regarding the clinical presentation: 30% presented headache, 15% syncope, 15% coma, 10% dizziness and 10% seizures. Only 25% had brain tomography and 15% MRI, without pathological findings. However, 15% were referred for treatment with a hyperbaric chamber. Most of the cases occurred in winter and explained by domestic accidents. It will be necessary to strengthen the preventive role that aims to control the installation and the proper functioning of devices, such as keeping rooms well ventilated (AU)

Can CPOE Based on Electronic Order Sets Cause Unintended Consequences (Expensive and Unnecessary Tests) at the Emergency Department?

Computerized Provider Order Entry (CPOE) systems may cause unintended consequences. This study aimed to describe the on-going system for CPOE order sets, and to explore an economic evaluation at the Emergency Department. First, we developed a costs dashboard which showed us the significant and excessive use of medical tests per consultation. We identified the top 10 most widely used and most expensive tests. Additionally we noticed that the labs seemed to continually increase. Then, we found that 27% of the consultations have at least one item of laboratory practice between January and February 2020, and this represents more than 80% of the consultation costs. Health care spending has reached epic proportions globally. We think that it is time to rethink effective strategies. Maybe it is time to deactivate/remove electronic order sets (EOSs) and the functionality to develop and create their own "private" order sets, in order to eliminate waste and inefficiencies.

Evaluation of Telehealth Service for COVID-19 Outpatients: A Dashboard to Measure Healthcare Quality and Safety.

Due to the COVID-19 pandemic, changes and improvements regarding the organization have been made to adapt quickly at the Emergency Department (ED) of the Hospital Italiano de Buenos Aires, Argentina. This article describes the design, implementation, and use of an electronic dashboard which provided monitoring of patients discharged home, during follow-up with telehealth. It was useful to access essential information to organize and coordinate professional work and patients' surveillance, providing highly relevant data in real-time as proxy variables for quality and safety during home isolation. The implemented tool innovated in the integration of technologies within a real context. The information management was crucial to optimize services and decision-making, as well to guarantee safety for healthcare workers and patients.

Impact of COVID-19 Pandemic on Telehealth and In-Person Visits: Implications from an Emergency Department in Argentina.

Since Argentina's government declared a national emergency to combat the COVID-19 pandemic with a lockdown status, it has produced consequences on the healthcare system. We aimed to quantify the effect on the Emergency Department (ED) visits at Hospital Italiano de Buenos Aires. Our electronic health data showed that ED in-person visits declined 46% during the COVID-19 pandemic, from an overall of 176,370 visits during 2019 to 95,421 visits during 2020. Simultaneously, there was a telehealth visits boom when mandatory quarantine began (March 20, 2020): from a median of 12 daily in February 2020 to a median of 338 daily in April 2020; reaching a maximum daily peak of 1,132 on March 26 2020. For a while, teleconsultations replaced ED visits. Then, when face-to-face visits began to increase, teleconsultations began to decrease slowly, as the phenomenon reversed.

Using Informatics Framework in Immunosuppressed or Transplanted Patients for a Preferential Care Route at the Emergency Department.

For immunosuppressed or transplanted patients, appropriate triage is a timely topic, especially in the Emergency Department (ED) of a high-volume referral center. We implemented a new Program called Rapid Clinical Care by Internal Medicine Specialists, as a preferential care route for these patients, which combines the proposed informatics framework in the field of total quality management in the healthcare units, as an example of digital technologies that can improve processes in the clinical routine. Our study aimed to describe waiting-time and attention-time in ED and to explore the effect on patients' clinical outcomes after discharge. Findings were: shortened waiting time (median of 8 minutes versus 21, p<0.001), improved ED on-call time (median of 2 hours compared to 4, p<0.001), and greater follow-up after discharge, measured as 1-week scheduled-visits rate (69% with 95%CI 63-75; compared to 43% with 95%CI 35-51; p<0.001).

Medición del subtriaje como indicador de calidad y seguridad en un servicio de urgencias / Undertriage as quality of care parameter in an emergency department

Background: Undertriage or the underestimation of the urgency of the condition of a person arriving in an emergency department (ED) represents a measure of quality care. Aim: To estimate the prevalence of undertriage in a high complexity hospital of Argentina; to describe characteristics and mortality of these patients. Material and Methods: All consultations admitted to the ED during 2014 were analyzed. Those assigned to a lower level of admission risk (classified as Emergency Severity Index -ESI- 3 to 5) but required hospitalization in intensive care units (ICU) as the first hospitalization place were considered as an undertriage. A random sample of correctly categorized admissions (ESI 1 or 2), who were subsequently hospitalized in the ICU, was selected as a comparison group. Results: The global undertriage prevalence was 0.30% (316/104,832). Among patients admitted to the ICU, the prevalence was 21% (316/1,461; 95% confidence intervals (CI) 19-24). The 316 patients whose severity was underestimated had a median age of 73 years, and admitted between 7 a.m. and 9 p.m. in a greater proportion. Overall hospital mortality was 8.9% (95% CI 6.78-11.38), and all deaths occurred after the patient was transferred from the emergency room. There were no differences in mortality between patients with correct triage or undertriage (11 and 7% respectively, p = 0.09). No differences were observed either in the total number of critical interventions during care in the first 24 hours. Significant differences were observed in requirements for mechanical ventilation (11 and 4% respectively, p = 0.01), orotracheal intubation (10 and 5% respectively p = 0.01) and non-invasive ventilation (8 and 4% respectively, p = 0.05). Conclusions: Undertriage rate in this series was low, but it can be improved.

[Undertriage as quality of care parameter in an emergency department]. / Medición del subtriaje como indicador de calidad y seguridad en un servicio de urgencias.

BACKGROUND: Undertriage or the underestimation of the urgency of the condition of a person arriving in an emergency department (ED) represents a measure of quality care. AIM: To estimate the prevalence of undertriage in a high complexity hospital of Argentina; to describe characteristics and mortality of these patients. MATERIAL AND METHODS: All consultations admitted to the ED during 2014 were analyzed. Those assigned to a lower level of admission risk (classified as Emergency Severity Index -ESI- 3 to 5) but required hospitalization in intensive care units (ICU) as the first hospitalization place were considered as an undertriage. A random sample of correctly categorized admissions (ESI 1 or 2), who were subsequently hospitalized in the ICU, was selected as a comparison group. RESULTS: The global undertriage prevalence was 0.30% (316/104,832). Among patients admitted to the ICU, the prevalence was 21% (316/1,461; 95% confidence intervals (CI) 19-24). The 316 patients whose severity was underestimated had a median age of 73 years, and admitted between 7 a.m. and 9 p.m. in a greater proportion. Overall hospital mortality was 8.9% (95% CI 6.78-11.38), and all deaths occurred after the patient was transferred from the emergency room. There were no differences in mortality between patients with correct triage or undertriage (11 and 7% respectively, p = 0.09). No differences were observed either in the total number of critical interventions during care in the first 24 hours. Significant differences were observed in requirements for mechanical ventilation (11 and 4% respectively, p = 0.01), orotracheal intubation (10 and 5% respectively p = 0.01) and non-invasive ventilation (8 and 4% respectively, p = 0.05). CONCLUSIONS: Undertriage rate in this series was low, but it can be improved.

Pacientes con Influenza A subtipo H3N2 y soporte ventilatorio durante el brote estacional en una central de emergencias en Argentina / Patients with Influenza A Subtype H3N2 and Ventilatory Support During A Seasonal Outbreak in an Emergency Department in Argentina

Objetivo: Describir las características de los pacientes con Influenza A subtipo H3N2 y requerimiento de soporte ventilatorio durante el brote del 2017, así como la evolución y los resultados clínicos. Materiales y métodos: Cohorte retrospectiva. Se incluyeron todos los pacientes con diagnóstico confirmado de H3N2 durante el mes de junio 2017 con requerimientos de asistencia respiratoria mecánica invasivo, no invasivo, terapia de alto flujo por cánula nasal y/o presión continua en la vía aérea que consultaron a la central de emergencias. Resultados: Se incluyeron 34 pacientes, 52.9% hombres, media de edad 81 (DE 10) años. Las principales comorbilidades de los pacientes al ingreso fueron: 73.5% hipertensión arterial, 44.1% enfermedad pulmonar obstructiva crónica y 76.5% insuficiencia cardíaca congestiva. La media del score de Charlson fue de 6 (DE 2), la mediana de APACHE II fue de 17 (IIC 14-20) y la de SOFA al día 1 de 5 (IIC 3-7). Al ingreso, 23 pacientes requirieron ventilación no invasiva, 5 presión continua en la vía aérea, 4 asistencia respiratoria mecánica invasiva y 2 terapia de alto flujo. Se registró un 47.8% (IC95% 26.8-69.4) de falla de la ventilación no invasiva y finalmente el 38.2% fueron intubados y ventilados mecánicamente. La mortalidad hospitalaria fue de 52.9% (IC95% 35.1-70.2). Conclusiones: se observó una alta mortalidad en una población añosa y comórbida durante el brote de H3N2. La mayoría realizó una prueba de ventilación no invasiva al ingreso, un alto porcentaje falló. El cuadro inicial pudo ser interpretado como enfermedad pulmonar obstructiva crónica reagudizada y/o insuficiencia cardíaca congestiva.

Patients with Influenza A Subtype H3N2 and Ventilatory Support During A Seasonal Outbreak in an Emergency Department in Argentina / Pacientes con Influenza A subtipo H3N2 y soporte ventilatorio durante el brote estacional en una central de emergencias en Argentina

Objective: To describe the characteristics of patients with influenza A subtype H3N2 requiring ventilatory support during the 2017 outbreak, as well as the evolution of the disease and clinical results. Materials and Methods: Retrospective cohort. We included all patients admitted to the Emergency Department with confirmed diagnosis of H3N2 during June 2017, requiring invasive or noninvasive mechanical respiratory assistance, high-flow nasal cannula treatment or continuous airway pressure. Results: 34 patients were included; 52.9% men, mean age 81 years (Standard Deviation [SD] 10). Main comorbidities of patients on admission were: 73.5% hypertension, 44.1% chronic obstructive pulmonary disease and 76.5% congestive heart failure. The mean Charlson Index score was 6 (SD 2), the APACHE II median (Acute Physiology and Chronic Health Evaluation II) was 17 (IQR 14-20) and the SOFA median (Sequential Organ Failure Assessment) on day 1 was 5 (IQR 3-7). On admission, 23 patients required noninvasive ventilation, 5 continuous positive airway pressure, 4 invasive mechanical ventilation and 2 high-flow nasal cannula therapy. The rate of noninvasive ventilation failure was 47.8% (95% CI [confidence interval] 26.8-69.4) and finally 38.2% of patients were intubated and mechanically ventilated. Hospital mortality was 52.9% (95% CI 35.1-70.2). Conclusions: A high mortality rate was observed among elderly patients with comorbidities during the H3N2 outbreak. Most patients underwent a noninvasive ventilation trial on admission, however a high percentage failed. The initial condition could have been interpreted as acute chronic obstructive pulmonary disease or congestive heart failure.