Sex- and age-related patterns in the use of analgesics in older patients in the emergency department.

BACKGROUND: Treatment of acute pain in older patients is a common challenge faced in emergency departments (EDs). Despite many studies that have investigated chronic analgesic use in the elderly, data on patterns of acute use, especially in EDs, of analgesics according to patient characteristics is scarce. OBJECTIVE: To investigate sex- and age-related patterns of analgesic use in the Spanish EDs and determine differences in age-related patterns according to patient sex. DESIGN: A secondary analysis of the Emergency Department and Elderly Needs (EDEN) multipurpose cohort. SETTING: Fifty-two Spanish EDs (17% of Spanish EDs covering 25% of Spanish population). PARTICIPANTS: All patients' ≥65 years attending ED during 1 week (April 1-7, 2019). Patient characteristics recorded included age, sex, chronic treatment with non-steroidal anti-inflammatory drugs (NSAIDs) and opiates, comorbidity, dependence, dementia, depression, ability to walk and previous falls. Analgesics used in the ED were categorized in three groups: non-NSAID non-opioids (mainly paracetamol and metamizole, PM), NSAIDs, and opiates. OUTCOME MEASURES: Frequency of analgesic use was quantified, and the relationship between sex and age and analgesic use (in general and for each analgesic group) was assessed by unadjusted and adjusted logistic regression and restricted cubic spline models. Interaction between sex and age was explored. MAIN RESULTS: We included 24 573 patients, and 6678 (27.2%) received analgesics in the ED: 5551 (22.6%) PM, 1661 (6.8%) NSAIDs and 937 (3.8%) opiates (1312 received combinations). Analgesics were more frequently used in women (adjusted OR = 1.076, 95%CI = 1.014-1.142), as well as with NSAID (1.205, 1.083-1.341). Analgesic use increased with age, increasing PM and decreasing NSAIDs use. Opiate use remained quite constant across age and sex. Interaction of sex with age was present for the use of analgesics in general ( P  = 0.006), for PM ( P  < 0.001) and for opiates ( P  = 0.033), with higher use of all these analgesics in women. CONCLUSION: Use of analgesics in older individuals in EDs is mildly augmented in women and increases with age, with PM use increasing and NSAIDs decreasing with age. Conversely, opiate use is quite constant according to sex and age. Age-related patterns differ according to sex, with age-related curves of women showing higher probabilities than those of men to receive any analgesic, PM or opiates.

Hyperactive delirium during emergency department stay: analysis of risk factors and association with short-term outcomes.

To investigate factors related to the development of hyperactive delirium in patients during emergency department (ED) stay and the association with short-term outcomes. A secondary analysis of the EDEN (Emergency Department and Elderly Needs) multipurpose multicenter cohort was performed. Patients older than 65 years arriving to the ED in a calm state and who developed confusion and/or psychomotor agitation requiring intravenous/intramuscular treatment during their stay in ED were assigned to delirium group. Patients with psychiatric and epileptic disorders and intracranial hemorrhage were excluded. Thirty-four variables were compared in both groups and outcomes were adjusted for age, sex, Charlson Comorbidity Index, Barthel Index and polypharmacy. Hyperactive delirium that needed treatment were developed in 301 out of 18,730 patients (1.6%). Delirium was directly associated with previous episodes of delirium (OR: 2.44, 95% CI 1.24-4.82), transfer to the ED observation unit (1.62, 1.23-2.15), chronic treatment with opiates (1.51, 1.09-2.09) and length of ED stay longer than 12 h (1.41, 1.02-1.97) and was indirectly associated with chronic kidney disease (0.60, 0.37-0.97). The 30-day all-cause mortality was 4.0% in delirium group and 2.9% in non-delirium group (OR: 1.52, 95% CI 0.83-2.78), need for hospitalization 25.6% and 25% (1.09, 0.83-1.43), in-hospital mortality 16.4% and 7.3% (2.32, 1.24-4.35), prolonged hospitalization 54.5% and 48.6% (1.27, 0.80-2.00), respectively, and 90-day post-discharge combined adverse event 36.4% and 35.8%, respectively (1.06, 0.82-2.00). Patients with previous episodes of delirium, treatment with opioids and longer stay in ED more frequently develop delirium during ED stay and preventive measures should be taken to minimize the incidence. Delirium is associated with in-hospital mortality during the index event.

Importancia de la consulta ambulatoria previa a la visita a las urgencias hospitalarias en pacientes mayores: impacto sobre resultados de hospitalización / Importance of outpatient medical consultation prior to going to the hospital emergency department in patients over 65 years of age: Impact on hospitalization results

Objetivo: Investigar los factores asociados a una consulta ambulatoria previa (CAP), al acudir a un servicio de urgencias hospitalario (SUH), en los pacientes mayores de 65 años y su impacto sobre los resultados. Emplazamiento: Cincuenta y dos SUH españoles.ParticipantesPacientes mayores de 65 años que consultan a un SUH. Medidas principales y metodología: Se utilizó una cohorte (n=24.645) de pacientes mayores e 65 años atendidos en 52 SUH durante una semana. Se consignaron 5 variables sociodemográficas, 6 funcionales y 3 de gravedad y se analizó su asociación cruda y ajustada con la existencia o no de una CAP a la consulta al SUH. La variable de resultado primaria fue la necesidad de ingreso y secundarias la realización de exploraciones complementarias y tiempo de estancia en el SUH. Se analizó si la CAP influenció en los resultados. Resultados: El 28,5% de los pacientes tenía una CAP previa a su visita al SUH. Vivir en residencia, NEWS2≥5, edad ≥80 años, dependencia funcional, comorbilidad grave, vivir solo, deterioro cognitivo, sexo masculino y depresión se asociaron de forma independiente con la CAP. La CAP se asoció a mayor necesidad de hospitalización y menor tiempo de estancia en el SUH, pero no se observó un menor consumo de recursos diagnósticos. Conclusiones: Los pacientes que acuden al SUH tras una CAP tienen más necesidad de hospitalización, sugiriendo que son debidamente derivados, y las urgencias menores son solucionadas de forma efectiva en la CAP. Su estancia en el SUH previa a la hospitalización es menor, por lo que la CAP facilitaría su resolución clínica.(AU)

Objective: Investigate factors associated with a previous outpatient medical consultation (POMC), to the health center or another physician, before attending a hospital emergency department (ED), in patients aged >65 and its impact on the hospitalization rate and variables related to ED stay. Site: Fifty-two Spanish EDs. Participants: Patients over 65 years consulting an ED. Main measurements and design: A cohort (n=24645) of patients aged >65 attended for one week in 52 ED. We recorded five sociodemographic variables, six functional, three episode-related severity and analyzed their crude and adjusted association with the existence of a POMC at ED consultation. The primary outcome variable was the need for admission and the secondary variables were complementary examinations and ED stay length. We analyzed whether the POMC influenced these outcomes. Results: 28.5% of the patients had performed a POMC prior to their visit to the ED. Living in a residence, NEWS-2 score ≥5, aged ≥80, dependency functions, severe comorbidity, living alone, cognitive impairment, male gender and depression were independently associated with a POMC. Also was associated with a greater need for hospitalization and shorter length of stay in the ED. No minor consumption of diagnostic resources in patients with POMC. Conclusion:Patients presenting to the ED following POMC are admitted more frequently, suggesting that they are appropriately referred and that minor emergencies are probably effectively resolved in the POMC. Their stay in the ED prior to hospitalization is shorter, so the POMC would facilitate clinical resolution in the ED.(AU)

Influence of type of household on prognosis at one year in patients ≥65 years attending hospital emergency departments in Spain. The EDEN-6 study.

OBJECTIVE: To investigate whether the type of household is associated with prognosis at one year in patients ≥65 years of age discharged after medical consultation requiring emergency department care. METHODS: Data from the Emergency Department and Elder Needs (EDEN) cohort were used. This retrospective cohort included all patients ≥65 years of age seen in 52 Spanish emergency departments over one week (April 1-7, 2019) in whom the type of household was recorded and categorized as living at home alone, with relatives, with professional caregivers, or in a nursing home. Patient demographic and other baseline characteristics and management during the index emergency department episode were recorded and used to adjust the following 1-year outcomes: all-cause mortality, hospitalization and emergency department revisit. Associations between type of household and outcomes are expressed as adjusted hazard ratios with 95% confidence intervals using living alone as the reference category. RESULTS: 13,442 patients with a median age of 79 years (interquartile range 72-86) were included; 56% were women, 12.2% of patients lived alone, 74.9% with relatives, 3.9% with a professional caregiver, and 9.1% in a nursing home. During the year following discharge, the mortality rate was 14.0%, the hospitalization rate 29.7%, and the emergency department revisit rate 59.3%. In the fully adjusted model, the risk of death was associated only with living in a nursing home (hazard ratio 1.366 (1.101-1.695)). On the other hand, the risk of hospitalization was lower in individuals living in nursing homes (hazard ratio 0.783 [0.676-0.907]) and at home with relatives (hazard ratio 0.897 [0.810-0.992]), while the risk of emergency department revisit was lower in individuals living in nursing homes (hazard ratio 0.826 [0.742-0.920]) or at home with caregivers (hazard ratio 0.856 [0.750-0.976]). CONCLUSION: The type of household was modestly associated with the one-year prognosis of patients ≥65 years of age discharged after attendance at an emergency department. Living in a nursing home is associated with an increased risk of death but a decreased risk of rehospitalization or emergency department revisit, while living at home with relatives or professional caregivers is associated only with a decreased risk of hospitalization and emergency department revisit, respectively.

Skin Cancer Associated With Chronic Leg Ulcers in the Population of Olmsted County, Minnesota.

Malignant skin tumors in the setting of chronic leg ulcers (CLUs) are often underdiagnosed which may contribute to treatment delay and poor outcomes. The aims of our study were to determine the incidence and clinical characteristics of skin cancers in leg ulcers in the Olmsted County population from 1995 to 2020. We used the Rochester Epidemiology Project (a collaboration between health care providers) infrastructure to describe this epidemiology, allowing "population-based" research. Electronic medical records of adult patients with International Classification of Diseases diagnosis codes for leg ulcers and skin cancers on the legs were queried. Thirty-seven individuals with skin cancers in nonhealing ulcers were identified. The cumulative incidence of skin cancer over the 25-year period was 37:7864 (0.47%). The overall incidence rate was 470 per 100,000 patients. Eleven (29.7%) men and 26 (70.3%) women were identified with mean age of 77 years. History of venous insufficiency was present in 30 (81.1%) patients and diabetes in 13 (35.1%) patients. Clinical characteristics of CLU with skin cancer included abnormal granulation tissue in 36 (94.7%) and irregular borders in 35 (94.6%) cases. Skin cancers among CLUs included 17 (41.5%) basal cell carcinomas, 17 (41.5%) squamous cell carcinomas, 2 (4.9%) melanomas, 2 (4.9%) porocarcinomas, 1 (2.4%) basosquamous cell carcinoma, and 1 (2.4%) eccrine adenocarcinoma. The apparent association between chronic wounds and subsequent biopsy-proven skin cancer of the same site was primarily observed in elderly patients; malignant transformation of wounds favored basal cell carcinoma and squamous cell carcinoma. This retrospective cohort study further characterizes the association between skin cancers and chronic leg wounds.

[Importance of outpatient medical consultation prior to going to the hospital emergency department in patients over 65 years of age: Impact on hospitalization results]. / Importancia de la consulta ambulatoria previa a la visita a las urgencias hospitalarias en pacientes mayores: impacto sobre resultados de hospitalización.

OBJECTIVE: Investigate factors associated with a previous outpatient medical consultation (POMC), to the health center or another physician, before attending a hospital emergency department (ED), in patients aged >65 and its impact on the hospitalization rate and variables related to ED stay. SITE: Fifty-two Spanish EDs. PARTICIPANTS: Patients over 65 years consulting an ED. MAIN MEASUREMENTS AND DESIGN: A cohort (n=24645) of patients aged >65 attended for one week in 52 ED. We recorded five sociodemographic variables, six functional, three episode-related severity and analyzed their crude and adjusted association with the existence of a POMC at ED consultation. The primary outcome variable was the need for admission and the secondary variables were complementary examinations and ED stay length. We analyzed whether the POMC influenced these outcomes. RESULTS: 28.5% of the patients had performed a POMC prior to their visit to the ED. Living in a residence, NEWS-2 score ≥5, aged ≥80, dependency functions, severe comorbidity, living alone, cognitive impairment, male gender and depression were independently associated with a POMC. Also was associated with a greater need for hospitalization and shorter length of stay in the ED. No minor consumption of diagnostic resources in patients with POMC. CONCLUSION: Patients presenting to the ED following POMC are admitted more frequently, suggesting that they are appropriately referred and that minor emergencies are probably effectively resolved in the POMC. Their stay in the ED prior to hospitalization is shorter, so the POMC would facilitate clinical resolution in the ED.

Mortality risk model validation in a prospective cohort of patients from the sixth wave of the COVID-19 pandemic in a hospital emergency department. / Validación del modelo de riesgo de mortalidad en una cohorte prospectiva de pacientes de la sexta ola epidémica de la COVID-19 en un servicio de urgencias hospitalario.

OBJECTIVES: To validate risk factors for mortality in patients treated for COVID-19 in a hospital emergency department during the sixth wave of the pandemic. MATERIAL AND METHODS: Prospective observational noninterventional study. We included patients over the age of 18 years with a confirmed diagnosis of COVID-19 between December 1, 2021, and February 28, 2022. For each patient we calculated a risk score based on age 50 years or older (2 points) plus 1 point each for the presence of the following predictors: Barthel index less than 90 points, altered level of consciousness, ratio of arterial oxygen saturation to fraction of inspired oxygen less than 400, abnormal breath sounds, platelet concentration less than 100 × 109/L, C-reactive protein level of 5 mg/dL or more, and glomerular filtration rate less than 45 mL/min. The model was assessed with the area under the receiver operating characteristic curve (AUC). RESULTS: Of the 1156 patients included, 790 (68%) had received at least 2 vaccine doses. The probability of 30-day survival was 96%. A risk score was calculated for 609 patients. Four hundred seventeen patients were at low risk of death, 180 were at intermediate risk, and 10 were at high risk. The probability of death within 30 days was 1%, 13%, and 50% for patients in the 3 risk groups, respectively. The sensitivity, specificity, and positive and negative predictive values of a risk score of 3 points or less were 88%, 72%, 19%, 99%, respectively.The AUC for the model was 0.87. CONCLUSION: The risk model identified low risk of mortality and allowed us to safely discharge patients treated for COVID-19 in our tertiary-care hospital emergency department.

OBJETIVO: Validación de un indicador de mortalidad derivado durante los primeros meses de la pandemia de la COVID-19 en pacientes con COVID-19 atendidos durante la sexta ola epidémica en un servicio de urgencias hospitalario (SUH). METODO: Estudio observacional prospectivo no intervencionista. Se incluyeron pacientes > 18 años diagnosticados de casos confirmados de COVID-19 (1 diciembre 2021-28 febrero 2022). Se calculó el indicador para cada paciente: edad $ 50 años (2 puntos), índice de Barthel 90 puntos (1 punto), alteración de consciencia (1 punto), índice de SaO2/FIO2 400 (1 punto), auscultación respiratoria patológica (1 punto), plaquetas 100 x 109/L (1 punto), proteína C reactiva $ 5 mg/dL (1 punto) y filtrado glomerular 45 mL/min (1 punto). El rendimiento del indicador se valoró con el análisis del área bajo la curva de la característica operativa del receptor (ABC-COR). RESULTADOS: De los 1.156 pacientes incluidos en el estudio, 790 (68%) habían recibido como mínimo una dosis de vacuna. La probabilidad de supervivencia a los 30 días de la serie fue del 96%. El indicador de riesgo se pudo calcular en 609 pacientes. Cuatrocientos diecisiete pacientes se clasificaron como de riesgo bajo, 182 de riesgo intermedio y 10 de riesgo alto. La probabilidad de mortalidad a los 30 días fue de 1%, 13% y 50%, respectivamente. La sensibilidad, especificidad y valores predictivos positivo y negativo para un punto de corte menor o igual a 3 puntos fue 88%, 72%, 19%, 99%, respectivamente. El ABC-COR para el indicador fue de 0,87. CONCLUSIONES: Un valor del indicador de bajo riesgo permite dar de alta con seguridad a los pacientes con COVID-19 que se atienden en un SUH de un centro de tercer nivel.

Validación del modelo de riesgo de mortalidad en una cohorte prospectiva de pacientes de la sexta ola epidémica de la COVID-19 en un servicio de urgencias hospitalario / Mortality risk model validation in a prospective cohort of patients from the sixth wave of the COVID-19 pandemic in a hospital emergency department

Objetivo. Validación de un indicador de mortalidad derivado durante los primeros meses de la pandemia de la COVID-19 en pacientes con COVID-19 atendidos durante la sexta ola epidémica en un servicio de urgencias hospitalario (SUH). Método. Estudio observacional prospectivo no intervencionista. Se incluyeron pacientes > 18 años diagnosticados de casos confirmados de COVID-19 (1 diciembre 2021-28 febrero 2022). Se calculó el indicador para cada paciente: edad $ 50 años (2 puntos), índice de Barthel < 90 puntos (1 punto), alteración de consciencia (1 punto), índice de SaO2/FIO2 < 400 (1 punto), auscultación respiratoria patológica (1 punto), plaquetas < 100 x 109/L (1 punto), proteína C reactiva $ 5 mg/dL (1 punto) y filtrado glomerular < 45 mL/min (1 punto). El rendimiento del indicador se valoró con el análisis del área bajo la curva de la característica operativa del receptor (ABC-COR). Resultados. De los 1.156 pacientes incluidos en el estudio, 790 (68%) habían recibido como mínimo una dosis de vacuna. La probabilidad de supervivencia a los 30 días de la serie fue del 96%. El indicador de riesgo se pudo calcular en 609 pacientes. Cuatrocientos diecisiete pacientes se clasificaron como de riesgo bajo, 182 de riesgo intermedio y 10 de riesgo alto. La probabilidad de mortalidad a los 30 días fue de 1%, 13% y 50%, respectivamente. La sensibilidad, especificidad y valores predictivos positivo y negativo para un punto de corte menor o igual a 3 puntos fue 88%, 72%, 19%, 99%, respectivamente. El ABC-COR para el indicador fue de 0,87. Conclusión. Un valor del indicador de bajo riesgo permite dar de alta con seguridad a los pacientes con COVID-19 que se atienden en un SUH de un centro de tercer nivel. (AU)

Objective. To validate risk factors for mortality in patients treated for COVID-19 in a hospital emergency department during the sixth wave of the pandemic. Method. Prospective observational noninterventional study. We included patients over the age of 18 years with a confirmed diagnosis of COVID-19 between December 1, 2021, and February 28, 2022. For each patient we calculated a risk score based on age 50 years or older (2 points) plus 1 point each for the presence of the following predictors: Barthel index less than 90 points, altered level of consciousness, ratio of arterial oxygen saturation to fraction of inspired oxygen less than 400, abnormal breath sounds, platelet concentration less than 100 × 109 /L, C-reactive protein level of 5 mg/dL or more, and glomerular filtration rate less than 45 mL/min. The model was assessed with the area under the receiver operating characteristic curve (AUC). Results. Of the 1156 patients included, 790 (68%) had received at least 2 vaccine doses. The probability of 30-day survival was 96%. A risk score was calculated for 609 patients. Four hundred seventeen patients were at low risk of death, 180 were at intermediate risk, and 10 were at high risk. The probability of death within 30 days was 1%, 13%, and 50% for patients in the 3 risk groups, respectively. The sensitivity, specificity, and positive and negative predictive values of a risk score of 3 points or less were 88%, 72%, 19%, 99%, respectively.The AUC for the model was 0.87. Conclusion. The risk model identified low risk of mortality and allowed us to safely discharge patients treated for COVID-19 in our tertiary-care hospital emergency department. (AU)

Risk score for mortality due to COVID-19: a prospective temporal validation cohort study in the emergency department of a tertiary care hospital. / Validación temporal de un modelo de riesgo de mortalidad por COVID-19 en una cohorte prospectiva en un servicio de urgencias de un hospital de tercer nivel.

OBJECTIVES: To validate a previously described hospital emergency department risk model to predict mortality in patients with COVID-19. MATERIAL AND METHODS: Prospective observational noninterventional study. Patients aged over 18 years diagnosed with COVID-19 were included between December 1, 2020, and February 28, 2021. We calculated a risk score for each patient based on age 50 years (2 points) plus 1 point each for the presence of the following predictors: Barthel index 90 points, altered level of consciousness, ratio of arterial oxygen saturation to fraction of inspired oxygen 400, abnormal breath sounds, platelet concentration 100 × 109/L, C reactive protein level 5 mg/dL, and glomerular filtration rate 45 mL/min. The dependent variable was 30-day mortality. We assessed the score's performance with the area under the receiver operating characteristic curve (AUC). RESULTS: The validation cohort included 1223 patients. After a median follow-up of 80 days, 143 patients had died; 901 patients were classified as having low risk (score, 4 points), 270 as intermediate risk (5-6 points), and 52 as high risk ( 7 points). Thirty-day mortality rates at each risk level were 2.8%, 22.5%, and 65.4%, respectively. The AUC for the score was 0.883; for risk categorization, the AUC was 0.818. CONCLUSION: The risk score described is useful for stratifying risk for mortality in patients with COVID-19 who come to a tertiary-care hospital emergency department.

OBJETIVO: Validación de un indicador de mortalidad previamente descrito en pacientes con COVID-19 en un servicio de urgencias hospitalario (SUH). METODO: Estudio observacional prospectivo no intervencionista. Se incluyeron pacientes 18 años diagnosticados de COVID-19 (1 de diciembre de 2020 hasta 28 de febrero de 2021). Se calculó el indicador para cada paciente: edad 50 años (2 puntos), índice de Barthel 90 puntos (1 punto), alteración de consciencia (1 punto), índice de SaO2/ FIO2 400 (1 punto), auscultación respiratoria patológica (1 punto), plaquetas 100 x 109/L (1 punto), proteína C reactiva 5 mg/dL (1 punto) y filtrado glomerular 45 mL/min (1 punto). La variable dependiente fue la mortalidad observada a 30 días. El rendimiento del indicador se valoró con el análisis del área bajo la curva de la característica operativa del receptor (ABC-COR). RESULTADOS: La validación del indicador se realizó sobre una cohorte de 1.223 pacientes. Tras una mediana de seguimiento de 80 días, 143 pacientes habían fallecido. Un total de 901 pacientes fueron catalogados como riesgo bajo (indicador 4 puntos), 270 lo fueron como riesgo intermedio (5-6 puntos) y 52 como riesgo alto ( 7 puntos). La mortalidad a 30 días observada en cada categoría fue de 2,8%, 22,5% y 65,4%, respectivamente. El ABC-COR fue de 0,883 para el indicador utilizado cuantitativamente y de 0,818 cuando se usó cualitativamente en forma de categorías de riesgo. CONCLUSIONES: El indicador descrito es una herramienta útil para estratificar el riesgo de mortalidad de los pacientes con COVID-19 que consultan a un SUH de un centro de tercer nivel.

Validación temporal de un modelo de riesgo de mortalidad por COVID-19 en una cohorte prospectiva en un servicio de urgencias de un hospital de tercer nivel / Risk score for mortality due to COVID-19: a prospective temporal validation cohort study in the emergency department of a tertiary care hospital

Objetivo. Validación de un indicador de mortalidad previamente descrito en pacientes con COVID-19 en un servicio de urgencias hospitalario (SUH). Método. Estudio observacional prospectivo no intervencionista. Se incluyeron pacientes $ 18 años diagnosticados de COVID-19 (1 de diciembre de 2020 hasta 28 de febrero de 2021). Se calculó el indicador para cada paciente: edad $ 50 años (2 puntos), índice de Barthel < 90 puntos (1 punto), alteración de consciencia (1 punto), índice de SaO2/ FIO2 < 400 (1 punto), auscultación respiratoria patológica (1 punto), plaquetas < 100 x 109/L (1 punto), proteína C reactiva $ 5 mg/dL (1 punto) y filtrado glomerular < 45 mL/min (1 punto). La variable dependiente fue la mortalidad observada a 30 días. El rendimiento del indicador se valoró con el análisis del área bajo la curva de la característica operativa del receptor (ABC-COR). Resultados. La validación del indicador se realizó sobre una cohorte de 1.223 pacientes. Tras una mediana de seguimiento de 80 días, 143 pacientes habían fallecido. Un total de 901 pacientes fueron catalogados como riesgo bajo (indicador # 4 puntos), 270 lo fueron como riesgo intermedio (5-6 puntos) y 52 como riesgo alto ($ 7 puntos). La mortalidad a 30 días observada en cada categoría fue de 2,8%, 22,5% y 65,4%, respectivamente. El ABC-COR fue de 0,883 para el indicador utilizado cuantitativamente y de 0,818 cuando se usó cualitativamente en forma de categorías de riesgo. Conclusión. El indicador descrito es una herramienta útil para estratificar el riesgo de mortalidad de los pacientes con COVID-19 que consultan a un SUH de un centro de tercer nivel.

Objective. To validate a previously described hospital emergency department risk model to predict mortality in patients with COVID-19. Methods. Prospective observational noninterventional study. Patients aged over 18 years diagnosed with COVID-19 were included between December 1, 2020, and February 28, 2021. We calculated a risk score for each patient based on age $50 years (2 points) plus 1 point each for the presence of the following predictors: Barthel index <90 points, altered level of consciousness, ratio of arterial oxygen saturation to fraction of inspired oxygen <400, abnormal breath sounds, platelet concentration <100 × 109/L, C reactive protein level $5 mg/dL, and glomerular filtration rate <45 mL/min. The dependent variable was 30-day mortality. We assessed the score’s performance with the area under the receiver operating characteristic curve (AUC). Results. The validation cohort included 1223 patients. After a median follow-up of 80 days, 143 patients had died; 901 patients were classified as having low risk (score, #4 points), 270 as intermediate risk (5-6 points), and 52 as high risk ($7 points). Thirty-day mortality rates at each risk level were 2.8%, 22.5%, and 65.4%, respectively. The AUC for the score was 0.883; for risk categorization, the AUC was 0.818. Conclusion. The risk score described is useful for stratifying risk for mortality in patients with COVID-19 who come to a tertiary-care hospital emergency department.

Factores predictivos de mortalidad en los pacientes con sepsis y un valor del indicador 'Quick Sequential Organ Failure Assessment' (qSOFA) de 2 o 3 puntos atendidos en un servicio de urgencias / Predictors of mortality in emergency department patients with sepsisscored 2 or 3 on the Quick Sequential Organ Failure Assessment scale

OBJETIVO. Determinar los factores predictivos de mortalidad de los pacientes que acuden a urgencias con sepsis y tiene un qSOFA de 2 o 3 puntos tras la implementación de un paquete de medidas a cumplimentar en las primeras 3 horas. MÉTODO: De septiembre de 2018 a marzo de 2019 el equipo investigador identificó a los pacientes adultos que se encontraban en urgencias en el inicio del turno de mañana con el diagnóstico de sepsis. De estos pacientes se seleccionaron los que en el momento de su llegada tenían un qSOFA de 2 o 3 puntos. Se realizó análisis estadístico para establecer los factores relacionados con mortalidad. RESULTADOS: Se incluyeron 90 pacientes con una edad media de 72 (DE 16) años. La mortalidad global fue de 33 pacientes (37%). En el análisis univariado de mortalidad, el único indicador del qSOFA con significación estadística fue el nivel de consciencia (79% vs 54%, p = 0,02). Otras variables relacionadas con mayor mortalidad fueron: edad igual o mayor de 70 años, orden de limitación del esfuerzo terapéutico en urgencias y valor de la primera y de la segunda determinación de lactato. El cumplimiento del paquete de medidas fue del 42% y se asoció a una menor mortalidad (21% vs 54%, p = 0,003). En el análisis multivariado mediante regresión de Cox, los pacientes en los que no se cumplimentó el paquete de medidas en las primeras 3 horas tuvieron mayor riesgo de mortalidad al final del episodio (HR = 2,67; IC95% = 1,15-6,21; p = 0,02). CONCLUSIÓN: En los pacientes con sepsis y un qSOFA de 2-3 puntos a su llegada a urgencias el cumplimiento del paquete de medidas en las primeras 3 horas mejora la supervivencia. Es recomendable hacer los esfuerzos organizativos y docentes necesarios para mejorar el cumplimiento

OBJECTIVE: To identify predictors of mortality after implementation of a treatment protocol in the first 3 hours for patients who come to our emergency department with sepsis scored 2 or 3 on the Quick Sequential Organ Failure Assessment (qSOFA) scale. METHODS: Our team identified adult emergency department patients with a diagnosis of sepsis on starting the morning shift between September 2018 and March 2019. We selected patients whose qSOFA score on arrival was 2 or 3. Variables were explored statistically to identify factors associated with mortality. RESULTS: A total of 90 patients with a mean (SD) age of 72 (16) years were included. Thirty-three (37%) died. Univariate analysis detected that the only qSOFA indicator that was significantly associated with mortality was altered mentation (level of consciousness), which was noted in 79% of patients who died versus 54% of survivors (P=.02). Other variables associated with higher mortality were age 70 years or older, an order to limit therapeutic interventions in emergencies, and lactic acid levels on first and second extractions. The treatment protocol was completed in 42% of the cases and compliance was associated with a lower mortality rate of 21% versus 54% when the protocol was not fully implemented (P=.003). Multivariate Cox regression analysis showed that risk for death was higher when the full protocol was not implemented within 3 hours of arrival (hazard ratio, 2.67; 95% CI, 1.15-6.21; P=.02). CONCLUSIONS: Full implementation of the protocol within 3 hours of hospital arrival favors survival in patients with sepsis and qSOFA scores of 2 or 3 on arrival. We recommend that emergency departments organize ways to train staff in the use of a sepsis treatment protocol and improve compliance

Predictors of mortality in emergency department patients with sepsis scored 2 or 3 on the Quick Sequential Organ Failure Assessment scale. / Factores predictivos de mortalidad en los pacientes con sepsis y un valor del indicador 'Quick Sequential Organ Failure Assessment' (qSOFA) de 2 o 3 puntos atendidos en un servicio de urgencias.

OBJECTIVES: To identify predictors of mortality after implementation of a treatment protocol in the first 3 hours for patients who come to our emergency department with sepsis scored 2 or 3 on the Quick Sequential Organ Failure Assessment (qSOFA) scale. MATERIAL AND METHODS: Our team identified adult emergency department patients with a diagnosis of sepsis on starting the morning shift between September 2018 and March 2019. We selected patients whose qSOFA score on arrival was 2 or 3. Variables were explored statistically to identify factors associated with mortality. RESULTS: A total of 90 patients with a mean (SD) age of 72 (16) years were included. Thirty-three (37%) died. Univariate analysis detected that the only qSOFA indicator that was significantly associated with mortality was altered mentation (level of consciousness), which was noted in 79% of patients who died versus 54% of survivors (P=.02). Other variables associated with higher mortality were age 70 years or older, an order to limit therapeutic interventions in emergencies, and lactic acid levels on first and second extractions. The treatment protocol was completed in 42% of the cases and compliance was associated with a lower mortality rate of 21% versus 54% when the protocol was not fully implemented (P=.003). Multivariate Cox regression analysis showed that risk for death was higher when the full protocol was not implemented within 3 hours of arrival (hazard ratio, 2.67; 95% CI, 1.15-6.21; P=.02). CONCLUSION: Full implementation of the protocol within 3 hours of hospital arrival favors survival in patients with sepsis and qSOFA scores of 2 or 3 on arrival. We recommend that emergency departments organize ways to train staff in the use of a sepsis treatment protocol and improve compliance.

OBJETIVO: Determinar los factores predictivos de mortalidad de los pacientes que acuden a urgencias con sepsis y tiene un qSOFA de 2 o 3 puntos tras la implementación de un paquete de medidas a cumplimentar en las primeras 3 horas. METODO: De septiembre de 2018 a marzo de 2019 el equipo investigador identificó a los pacientes adultos que se encontraban en urgencias en el inicio del turno de mañana con el diagnóstico de sepsis. De estos pacientes se seleccionaron los que en el momento de su llegada tenían un qSOFA de 2 o 3 puntos. Se realizó análisis estadístico para establecer los factores relacionados con mortalidad. RESULTADOS: Se incluyeron 90 pacientes con una edad media de 72 (DE 16) años. La mortalidad global fue de 33 pacientes (37%). En el análisis univariado de mortalidad, el único indicador del qSOFA con significación estadística fue el nivel de consciencia (79% vs 54%, p = 0,02). Otras variables relacionadas con mayor mortalidad fueron: edad igual o mayor de 70 años, orden de limitación del esfuerzo terapéutico en urgencias y valor de la primera y de la segunda determinación de lactato. El cumplimiento del paquete de medidas fue del 42% y se asoció a una menor mortalidad (21% vs 54%, p = 0,003). En el análisis multivariado mediante regresión de Cox, los pacientes en los que no se cumplimentó el paquete de medidas en las primeras 3 horas tuvieron mayor riesgo de mortalidad al final del episodio (HR = 2,67; IC95% = 1,15-6,21; p = 0,02). CONCLUSIONES: En los pacientes con sepsis y un qSOFA de 2-3 puntos a su llegada a urgencias el cumplimiento del paquete de medidas en las primeras 3 horas mejora la supervivencia. Es recomendable hacer los esfuerzos organizativos y docentes necesarios para mejorar el cumplimiento.

Adecuación del uso de antibióticos de "Categoría Especial" en el Servicio de Urgencias de un hospital de tercer nivel / Adequacy of the special category antibiotics prescriptions in the Emergency Department of a third level urban Hospital

OBJETIVO: Analizar la adecuación de las prescripciones de antibióticos de categoría especial (ATB de CE) en el Servicio de Urgencias Hospitalario (SUH) de un centro urbano de tercer nivel. MATERIAL Y MÉTODOS: Se seleccionó una muestra aleatoria de 100 pacientes diferentes a los que se les inició un ATB de CE en Urgencias durante el año 2018. El equipo investigador revisó la historia clínica del episodio de urgencias y de ingreso. Se determinó mediante regresión logística los factores independientes asociados con el grado de adecuación del tratamiento. RESULTADOS: Se analizaron 97 prescripciones de las cuales 66 (68%) cumplían los criterios de prescripción adecuada. El grado de adecuación fue del 70% si la infección estaba relacionada con la asistencia sanitaria y del 75% si el paciente tenía factores de riesgo de infección por microorganismos multirresistentes (MMR). El porcentaje de adecuación fue mayor en los casos en los que se especificó el foco de la infección (72%) y la gravedad del episodio (73%). Las variables independientes que se asociaron a una prescripción adecuada fueron: la presencia de factores de riesgo de infección por MMR (OR: 2,35 IC 95%: 1,65 - 3,17 p: 0,01), el especificar el foco de la infección (OR: 3,79 IC 95%: 1,72 - 4,22 p: 0,02) y señalar la gravedad del episodio (OR: 3,09 IC 95%: 1,12 - 3,09 p: 0,03). CONCLUSIONES: La prescripción de los ATB de CE en el SUH es adecuada en la medida que se tenga en cuenta el ámbito de adquisición de la infección, los factores de riesgo de MMR, el foco de infección y la gravedad del cuadro clínico

OBJECTIVE: The aim of the study was to analyze the adequacy of the special category antibiotics prescriptions in the Emergency Department (ED) of a third level urban Hospital. MATERIAL AND METHODS: A random sample of 100 different patients who were started with a special category antibiotic along 2018 in the ED was selected. The research team reviewed the medical history of the emergency and admission episode. The independent factors associated with the degree of adequacy of the treatment were determined by logistic regression. RESULTS: A total of 97 prescriptions were analyzed of which 66 (68%) met the criteria of adequate prescription, 23 (24%) adequate prescription, but with equally recommended alternatives and 8 (8%) were inappropriate prescriptions. The degree of adequacy was 70% if the infection was related to healthcare and 75% if the patient had risk factors for multiresistant (MR) microorganisms' infection. The percentage of adequacy was higher in the cases in which the focus of the infection (72%) and the severity of the episode (73%) were specified. The independent variables that were associated with an adequate prescription were: the presence of risk factors for MR microorganisms' infection (OR: 2.35 95% CI: 1.65 - 3.17 p: 0.01), if the focus of the infection (OR: 3.79 95% CI: 1.72 - 4.22 p: 0.02) and the severity of the episode (OR: 3.09 95% CI: 1.12 - 3.09 p: 0.03) were specified. CONCLUSIONS: The prescription of special category antibiotics in ED is appropriate if the clinical guidelines are followed and if the setting of infection acquisition, the risk factors of MR microorganisms, the focus and the severity of infection are taken into account in clinical picture