Impact of the early phase of the COVID-19 pandemic on emergency department-to-intensive care unit admissions in Korea: an interrupted time-series analysis.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic resulted in significant disruptions to critical care systems globally. However, research on the impact of the COVID-19 pandemic on intensive care unit (ICU) admissions via the emergency department (ED) is limited. Therefore, this study evaluated the changes in the number of ED-to-ICU admissions and clinical outcomes in the periods before and during the pandemic. METHODS: We identified all adult patients admitted to the ICU through level 1 or 2 EDs in Korea between February 2018 and January 2021. February 2020 was considered the onset point of the COVID-19 pandemic. The monthly changes in the number of ED-to-ICU admissions and the in-hospital mortality rates before and during the COVID-19 pandemic were evaluated using interrupted time-series analysis. RESULTS: Among the 555,793 adult ED-to-ICU admissions, the number of ED-to-ICU admissions during the pandemic decreased compared to that before the pandemic (step change, 0.916; 95% confidence interval [CI] 0.869-0.966], although the trend did not attain statistical significance (slope change, 0.997; 95% CI 0.991-1.003). The proportion of patients who arrived by emergency medical services, those transferred from other hospitals, and those with injuries declined significantly among the number of ED-to-ICU admissions during the pandemic. The proportion of in-hospital deaths significantly increased during the pandemic (step change, 1.054; 95% CI 1.003-1.108); however, the trend did not attain statistical significance (slope change, 1.001; 95% CI 0.996-1.007). Mortality rates in patients with an ED length of stay of ≥ 6 h until admission to the ICU rose abruptly following the onset of the pandemic (step change, 1.169; 95% CI 1.021-1.339). CONCLUSIONS: The COVID-19 pandemic significantly affected ED-to-ICU admission and in-hospital mortality rates in Korea. This study's findings have important implications for healthcare providers and policymakers planning the management of future outbreaks of infectious diseases. Strategies are needed to address the challenges posed by pandemics and improve the outcomes in critically ill patients.

Journey of medication reconciliation compliance in a lower middle-income country: a retrospective chart review.

OBJECTIVE: There were three main objectives of the study: to determine the overall compliance of medication reconciliation over 4 years in a tertiary care hospital, to compare the medication reconciliation compliance between paper entry (initial assessment forms) and computerised physician order entry (CPOE), and to identify the discrepancies between the medication history taken by the physician at the time of admission and those collected by the pharmacist within 24 hours of admission. METHODS: This study was conducted at a tertiary care hospital in a lower middle-income country. Data were gathered from two different sources. The first source involved retrospective data obtained from the Quality and Patient Safety Department (QPSD) of the hospital, consisting of records from 8776 patients between 2018 and 2021. The second data source was also retrospective from a quality project initiated by pharmacists at the hospital. Pharmacists collected data from 1105 patients between 2020 and 2021, specifically focusing on medication history and identifying any discrepancies compared with the history documented by physicians. The collected data were then analysed using SPSS V.26. RESULTS: The QPSD noted an improvement in physician-led medication reconciliation, with a rise from 32.7% in 2018 to 69.4% in 2021 in CPOE. However, pharmacist-led medication reconciliation identified a 25.4% (n=281/1105) overall discrepancy in the medication history of patients admitted from 2020 to 2021, mainly due to incomplete medication records in the initial assessment forms and CPOE. Physicians missed critical drugs in 4.9% of records; pharmacists identified and updated them. CONCLUSION: In a lower middle-income nation where hiring pharmacists to conduct medication reconciliation would be an additional cost burden for hospitals, encouraging physicians to record medication history more precisely would be a more workable method. However, in situations where cost is not an issue, it is recommended to adopt evidence-based practices, such as integrating clinical pharmacists to lead medication reconciliation, which is the gold standard worldwide.

Association between holiday and weekend admissions and mortality outcomes among patients with acute myocardial infarction receiving percutaneous coronary intervention in Taiwan.

There is a lack of studies that concurrently differentiate the effect of the holiday season from the weekend effect on mortality risk in patients with acute myocardial infarction (AMI). We evaluated the mortality risk among patients admitted with AMI who underwent percutaneous coronary intervention, using data from the Taiwan National Health Insurance Research Database. Adult AMI patients admitted during January and February between 2013 and 2020 were enrolled and classified into the holiday season (using the Chinese New Year holiday seasons as an indicator) (n = 1729), weekend (n = 4725), and weekday (n = 14,583) groups according to the first day of admission. A multivariable logistic regression model was used to assess the risk. With the weekday group or the weekend group as the reference, the holiday season group did not have increased risks of in-hospital mortality (adjusted odds ratio [aOR] 1.15; 95% confidence intervals [CI] 0.93-1.42 or aOR 1.23; 95% CI 0.96-1.56) and 7-day mortality (aOR 1.20; 95% CI 0.90-1.58 or aOR 1.24; 95% CI 0.90-1.70). Stratified and subgroup analyses showed similar trends. We conclude that holiday season-initiated admissions were not associated with higher mortality risks in AMI admission cases than weekday or weekend admissions.

Improving Accuracy of Medication Reconciliation for Hospitalized Children: A Quality Project.

BACKGROUND AND OBJECTIVES: Medication reconciliation is a complex, but necessary, process to prevent patient harm from medication discrepancies. Locally, the steps of medication reconciliation are completed consistently; however, medication errors still occur, which suggest process inaccuracies. We focused on removal of unnecessary medications as a proxy for accuracy. The primary aim was to increase the percentage of patients admitted to the pediatric hospital medicine service with at least 1 medication removed from the home medication list by 10% during the hospital stay by June of 2022. METHODS: Using the Model for Improvement, a multidisciplinary team was formed at a children's hospital, a survey was completed, and multiple Plan-Do-Study-Act cycles were done focusing on: 1. simplifying electronic health record processes by making it easier to remove medications; 2. continuous resident education about the electronic health record processes to improve efficiency and address knowledge gaps; and 3. auditing charts and real-time feedback. Data were monitored with statistical process control charts. RESULTS: The project exceeded the goal, improving from 35% to 48% of patients having at least 1 medication removed from their home medication list. Improvement has sustained for 12 months. CONCLUSIONS: The combination of interventions including simplifying workflow, improving education, and enhancing accountability resulted in more patients with medications removed from their home medication list.

Gender-specific pathways in mental health crisis in adolescents, from consultation to (in)voluntary admission: a retrospective study.

BACKGROUND: A strong increase in mental health emergency consultations and admissions in youths has been reported in recent years. Although empirical evidence is lacking, gender differences in risk of admission may have contributed to this increase. A clearer understanding of the relationship, if any, between gender and various aspects of (in)voluntary care would help in more evidence-based service planning. METHODS: We analysed registry data for 2008-2017 on 3770 outpatient emergencies involving young people aged 12 to 18 years from one urban area in the Netherlands, served by outreaching psychiatric emergency services. These adolescents were seen in multiple locations and received a psychosocial assessment including a questionnaire on the severity of their problems and living conditions. Our aims were to (a) investigate the different locations, previous use of mental health service, DSM classifications, severity items, living conditions and family characteristics involved and (b) identify which of these characteristics in particular contribute to an increased risk of admission. RESULTS: In 3770 consultations (concerning 2670 individuals), more girls (58%) were seen than boys. Boys and girls presented mainly with relationship problems, followed by disruptive disorders and internalizing disorders. Diagnostic differences diminished in hospitalisation. More specifically, disruptive disorders were evenly distributed. Suicide risk was rated significantly higher in girls, danger to others significantly higher in boys. More girls than boys had recently been in mental health care prior to admission. Although boys and girls overall did not differ in the severity of their problems, female gender predicted admission more strongly. In both boys and girls severity of problems and lack of involvement of the family significantly predicted admission. Older age and danger to others significantly predicted admission among boys, whereas psychosis, suicidality and poor motivation for treatment predicted admission among girls. CONCLUSION: There are different pathways for youth admission, which can partly be explained by different psychiatric classifications as well as gender-specific differences with regard to age, suicide risk, danger to others and the influence of motivation for treatment. Finally, for both genders, family desire for hospitalisation is also an important predictor.

Applying Sydney Triage to Admission Risk Tool (START) to improve patient flow in emergency departments: a multicentre randomised, implementation study.

BACKGROUND: To determine the effectiveness of applying the Sydney Triage to Admission Risk Tool (START) in conjunction with senior early assessment in different Emergency Departments (EDs). METHODS: This multicentre implementation study, conducted in two metropolitan EDs, used a convenience sample of ED patients. Patients who were admitted, after presenting to both EDs, and were assessed using the existing senior ED clinician assessment, were included in the study. Patients in the intervention group were assessed with the assistance of START, while patients in the control group were assessed without the assistance of START. Outcomes measured were ED length of stay and proportion of patients correctly identified as an in-patient admission by START. RESULTS: A total of 773 patients were evaluated using the START tool at triage across both sites (Intervention group n = 355 and control group n = 418 patients). The proportion of patients meeting the 4-hour length of stay thresholds was similar between the intervention and control groups (30.1% vs. 28.2%; p = 0.62). The intervention group was associated with a reduced ED length of stay when compared to the control group (351 min, interquartile range (IQR) 221.0-565.0 min versus 383 min, IQR 229.25-580.0 min; p = 0.85). When stratified into admitted and discharged patients, similar results were seen. CONCLUSION: In this extension of the START model of care implementation study in two metropolitan EDs, START, when used in conjunction with senior early assessment was associated with some reduced ED length of stay.

Fluid balance, biomarkers of renal function and mortality in critically ill patients with AKI diagnosed before, or within 24 h of intensive care unit admission: a prospective study.

BACKGROUND: To evaluate fluid balance, biomarkers of renal function and its relation to mortality in patients with acute kidney injury (AKI) diagnosed before, or within 24 h of intensive care unit admission. METHODS: A prospective cohort study considered 773 critically ill patients observed over six years. Pre-intensive care unit-onset AKI was defined as AKI diagnosed before, or within 24 h of intensive care unit admission. Body weight-adjusted fluid balance and fluid balance-adjusted biomarkers of renal function were measured daily for the first three days of intensive care unit admission. Primary outcome was mortality in the intensive care unit. RESULTS: Prevalence of pre-intensive care unit-onset AKI was 55.1%, of which 55.6% of cases were hospital-acquired and 44.4% were community-acquired. Fluid balance was higher in AKI patients than in non-AKI patients (p < 0.001) and had a negative correlation with urine output (p < 0.01). Positive fluid balance and biomarkers of renal function were independently related to mortality. Multivariate analysis identified the following AKI-related variables associated with increased mortality: (1) In AKI patients: type 1 cardiorenal syndrome (OR 2.00), intra-abdominal hypertension (OR 1.71), AKI stage 3 (OR 2.15) and increase in AKI stage (OR 4.99); 2) In patients with community-acquired AKI: type 1 cardiorenal syndrome (OR 5.16), AKI stage 2 (OR 2.72), AKI stage 3 (OR 4.95) and renal replacement therapy (OR 3.05); and 3) In patients with hospital-acquired AKI: intra-abdominal hypertension (OR 2.31) and increase in AKI stage (OR 4.51). CONCLUSIONS: In patients with pre-intensive care unit-onset AKI, positive fluid balance is associated with worse renal outcomes. Positive fluid balance and decline in biomarkers of renal function are related to increased mortality, thus in this subpopulation of critically ill patients, positive fluid balance is not recommended and renal function must be closely monitored.

Variations in Hospital Admissions of Non-Communicable Disease Patients Before and During The COVID-19 Pandemic (A Tertiary Care Setting, January 2018-June 2021).

BACKGROUND: This study aimed to analyze the variations (if any) in hospital admissions of patients with any of the five common non-communicable diseases (NCDs), based on secondary analysis of electronic health records of patients admitted to Hacettepe University Hospitals at least once, from January 1, 2018 through June 15, 2021. DESIGN: Data were recruited from hospital's electronic health records on patients with diagnoses of ischemic heart disease, hypertension, diabetes, cancer, and chronic obstructive pulmonary disease, using relevant ICD-10 codes. RESULTS: Compared to the corresponding time span in the pre-pandemic period, the number of hospital admissions of patients with selected five NCDs significantly decreased during the pandemic, with an official start in Turkey on March 11, 2020. Number of total-, out-patient-, and in-patient admissions of NCD patients were significantly lower in the pandemic period compared to the expected values in time series analysis, controlling for patient characteristics, and seasonality. CONCLUSIONS: Study findings suggest that there has been a prominent impediment in NCD patients' access to, and/or use of health care services over the pandemic, which might evolve to higher admission rates, severity and fatality of such patients in the upcoming years. Further studies are warranted for confirmation of our findings in other care settings, with individual-based data on care compensation through settings other than regular admission sites (if any), and/or the reasons for under-use of services.

Dynamic changes in patient admission and their disabilities in multiple sclerosis and neuromyelitis optica: A Japanese nationwide administrative data study.

BACKGROUND: The real-world data evidences how establishment of neuromyelitis optica (NMO) disease concept and development disease modifying therapy affect the patients with multiple sclerosis (MS) and NMO are lacking. The aim of this study is to clarify the diachronic trend of the severity and admissions of patients with MS and NMO. METHODS: We retrospectively investigated the trends in admissions, treatments, and disabilities in the patients with MS and NMO using the Japanese administrative data between 2012 and 2017. RESULTS: We analyzed acute stage 9545 and 2035 admissions in each 6100 MS and 1555 NMO patients. The annual number of admission in MS significantly decreased in 6 years; however, those in NMO consistently increased. The patient proportion with lower disability was significantly increased in MS and NMO. These trends were especially observed in patients admitted to centralized hospitals with more active treatments, such as second-line disease modifying therapy for MS and plasmapheresis for NMO. Patients with NMO using DMT for MS diminished in 6 years. CONCLUSION: A gradual improvement of disability in patients with MS and NMO was observed, probably due to advanced treatments, increased NMO awareness, and decreased misdiagnosis, which seems to be the key for better prognosis in MS and NMO.

Does the opening of an emergency department influence hospital admissions? Evidence from French private hospitals.

Although operating an emergency department (ED) can influence general admission activity of hospitals, most articles that analyze hospital care ignore the potential spillover of emergency activity. In this paper, we examine the consequences of a French reform that encouraged the creation of EDs within private-for-profit (PFP) hospitals in order to decrease congestion in EDs. We use administrative panel data on 365 French PFP hospitals observed between 2002 and 2012. Specifications including hospital fixed-effects are estimated to examine the impact of an ED opening on private hospitals' admission activity, namely inpatient and day-care admissions (ED visits are excluded, but patients admitted following an ED visit are included). We control for shocks that can impact demand for care in hospitals, and we estimate yearly changes before and after the opening. We find that an ED opening is followed by an increase in the number and proportion of inpatient admissions, and by an increase in the length of inpatient stays. A transitory increase in the bed occupancy rate is also observed. In many countries, public and private hospitals compete to some extent. The former provide a public service, while the latter are profit-maximizers that are allowed to specialize in profitable activities. They generally focus on day-care admissions. We provide empirical evidence that private hospitals experience a significant change in the composition of their admissions when they start providing emergency care. Opening an ED creates a new non-selective entryway to private hospitals, resulting in admissions of inpatients with health problems that are more severe. Hence, involving PFP hospitals in the provision of emergency care is likely to make the structure of admissions of private hospitals closer to that of public hospitals.

Examining Disparities in Alcohol Use Testing on Burn Patient Admissions: A Call for Association Guidance.

Burn injuries are associated with as well as complicated by alcohol misuse. To date, there are no stated guidelines for alcohol testing upon burn patient admissions. This study investigated if there were associations between race and testing for alcohol upon burn admissions, controlling for demographics, burn severity (degree), and other circumstances associated with burn injuries. This study was a secondary analysis of 32 258 cases from the National Burn Data Repository. The dependent variable was whether a burn case was screened for alcohol use, and independent variables were age, gender, whether physical abuse was reported, mental health comorbidities, marital status, the severity of burns, whether the injury was work-related, injury circumstances, and etiology of injury. Controlling for independent variables, race was associated with an increased probability of having been screened for alcohol use on admission to a burn center. Data reflecting alcohol screening/testing results reported in the NBR were not included in the analysis. Study results were consistent with the possibility of bias and may have influenced decisions to screen/test for alcohol misuse/abuse in reported burn cases. It is argued these findings support the recommendation that guidelines for alcohol testing of burn patients are warranted and would benefit from specific guidance from the American Burn Association.

The SingHealth Perioperative and Anesthesia Subject Area Registry (PASAR), a large-scale perioperative data mart and registry.

BACKGROUND: To enhance perioperative outcomes, a perioperative registry that integrates high-quality real-world data throughout the perioperative period is essential. Singapore General Hospital established the Perioperative and Anesthesia Subject Area Registry (PASAR) to unify data from the preoperative, intraoperative, and postoperative stages. This study presents the methodology employed to create this database. METHODS: Since 2016, data from surgical patients have been collected from the hospital electronic medical record systems, de-identified, and stored securely in compliance with privacy and data protection laws. As a representative sample, data from initiation in 2016 to December 2022 were collected. RESULTS: As of December 2022, PASAR data comprise 26 tables, encompassing 153,312 patient admissions and 168,977 operation sessions. For this period, the median age of the patients was 60.0 years, sex distribution was balanced, and the majority were Chinese. Hypertension and cardiovascular comorbidities were also prevalent. Information including operation type and time, intensive care unit (ICU) length of stay, and 30-day and 1-year mortality rates were collected. Emergency surgeries resulted in longer ICU stays, but shorter operation times than elective surgeries. CONCLUSIONS: The PASAR provides a comprehensive and automated approach to gathering high-quality perioperative patient data.