Can Triage Nurses Accurately Predict Patient Dispositions in the Emergency Department?

Contemporary emergency departments experience crowded conditions with poor patient outcomes. If triage nurses could accurately predict admission, one theoretical intervention to reduce crowding is to place patients in the admission cue on arrival to the emergency department. The purpose of this study was to determine if triage nurses could accurately predict patient dispositions.

METHODS

This prospective study was conducted in a tertiary academic hospital's emergency department using a data collection tool embedded in the ED electronic information system. Study variables included the predicted and actual disposition, as well as level of care, gender, age, and Emergency Severity Index level. Data were collected for 28 consecutive days from September 17 through October 9, 2013. Sensitivity and specificity, positive and negative predictive values, and accuracy of prediction, as well as the associations between patient characteristics and nurse prediction, were calculated.

RESULTS

A total of 5,135 cases were included in the analysis. The triage nurses predicted admissions with a sensitivity of 71.5% and discharges with a specificity of 88.0%. Accuracy was significantly higher for younger patients and for patients at very low or very high severity levels.

DISCUSSION

Although the ability to predict admissions at triage by nurses was not adequate to support a change in the bed procurement process, a specificity of 88.0% could have implications for rapid ED discharges or other low-acuity processes designed within the emergency department. Further studies in additional settings and on alternative interventions are needed.

Are Preexisting Retinal and Central Nervous System-Related Comorbidities Risk Factors for Complications Following Robotic-Assisted Laparoscopic Prostatectomy?

Purpose:

To assess whether retinal and central nervous system (CNS) comorbidities are risk factors for complications following robotic assisted laparoscopic prostatectomy (RALP).

Materials and Methods:

A retrospective review of our RALP database identified 1868 patients who underwent RALP by a single surgeon between December 10, 2003-March 14, 2014. We hypothesized that patients with preexisting retinal or CNS comorbidities were at a greater risk of suffering retinal and CNS complications following RALP. Perioperative complications and risk of recurrence were graded using the Clavien and D'Amico systems, respectively.

Results:

40 (2.1%) patients had retinal or CNS-related comorbidities, of which 15 had a history of retinal surgery and 24 had a history of cerebrovascular accident, aneurysm and/or neurosurgery. One additional patient had a history of both retinal and CNS events.

Patients with retinal or CNS comorbidities were significantly older, had elevated PSA levels and CCI (Charlson Comorbidity Index) scores than the control group. Blood loss, length of stay, surgical duration, BMI, diagnostic Gleason score and T-stage were not statistically different between groups.

No retinal or CNS complications occurred in either group. The distribution of patients between D'Amico risk categories was not statistically different between the groups. There was also no difference in the incidence of total complications between the groups.

Conclusions:

RALP-associated retinal and CNS complications are rare. While our RALP database is large, the cohort of patients with retinal or CNS-related comorbidities was relatively small. Our dataset suggests retinal and CNS pathology presents no greater risk of suffering from perioperative complications following RALP.

Abstract TP282: Eotaxin Shows a Sex-specific Association With Positive Ischemic Stroke Outcomes and Post-stroke Peripheral Leukocyte Activation

Background and Purpose: Eotaxin, a TH2 chemokine, has been shown to increase in mouse brain and plasma following experimental stroke. While eotaxin has been associated with age-related deficits in neurogenesis, little is known about its role in ischemic injury.

Hypothesis: We tested the hypothesis that serum eotaxin levels are associated with long-term stroke outcome, with follow up mechanistic studies in a mouse model of ischemic stroke.

Methods: Serum was taken from patients (n=158) 24 hours after ischemic stroke onset. Levels of serum eotaxin were quantified by ELISA, then analyzed for outcome association. For murine studies, animals (n=14) underwent 90-minute middle cerebral artery occlusion and were sacrificed at 24 hours, with sham surgery mice serving as controls. Blood was incubated with or without eotaxin (100 ng/ml) and stained for leukocyte markers and CD62L (L-selectin).

Results: Although eotaxin protein levels were not significantly different between sexes, a multivariate analysis controlling for age, stroke severity and cardiovascular risk factors revealed a male-specific association between higher eotaxin levels at 24 hours post-stroke and a positive functional outcome at three months (p=.010). Analysis of peripheral leukocytes isolated from both sham and stroke mice revealed that addition of eotaxin to whole blood significantly increased the activation of myeloid cells in both in male (p=.0031) and female (p=.0048) animals, as measured by shedding of L-selectin. Further experiments demonstrated that shedding of L-selectin on CD8+ T-cells after treatment of whole blood with eotaxin was significant only in female animals (p=.0008).

Conclusion: In conclusion, the results of this study suggest that eotaxin has a sex-specific association with improved stroke outcomes. Murine studies demonstrate that eotaxin causes activation of peripheral leukocytes (as measured by loss of L-selectin), with a sexually dimorphic effect on CD8+ T-cell activation that may alter the character of the post-stroke immune response and support a pro-recovery inflammatory phenotype in males. This research underscores the importance of studying both sexes in future ischemic inflammatory research.

Abstract TP343: Differential TNFα Expression in Patients of Acute Ischemic Stroke

Introduction: Inflammation plays a critical role in the pathophysiology of ischemia and atherosclerosis. TNFα plays a multifaceted role in stroke progression, having both protective and deleterious effects. Animal studies have shown that TNFα levels increase in cerebral tissue within the first 24 hours after experimental stroke.

Hypothesis: Expression of TNFα is related to outcomes after acute ischemic stroke. Differences in expression will be seen with respect to patient gender and other stroke characteristics.

Methods: Patients admitted to Hartford Hospital between January 2011 and March 2014 were considered for this study. Blood samples were collected within 24 hours of stroke presentation. Patients with a history of active cancer, primary or secondary neoplastic brain lesions, traumatic brain injury or intracranial hemorrhage were excluded from the study. Serum was analyzed using a multiplex human cytokine panel/Bio plex (Bio-Rad laboratories Inc.). Statistical analysis was performed using SPSS.

Results: A total of 163 ischemic stroke patients were included in the study. Outcome variables including NIH stroke scale, modified Rankin scale (mRS) at discharge, 3 months, 12 months and modified Barthel’s index (BI) were collected. Composite outcome scores were determined using the mRS and BI. A negative outcome was defined as death or BI ≤ 14 or mRS >2.There was a statistically significant difference (p=0.003) in the expression of TNFα between male - 21.74 pg/ml (15.11-30.21) and female 27.9 pg/ml (19.07-35.497) stroke patients. A significant difference (p=0.009) was observed in TNFα expression in patients with a good outcome - 22.96 pg/ml (15.69-30.85) as compared to those with a poor outcome (discharge to worse/hospice or death) - 30.78 pg/ml (22.03-35.38) post stroke.

Conclusions: Male- female sex differences are associated with changes in the post ischemic inflammatory cascade. Higher TNFα levels predict poorer outcomes post stroke. Cytokines like TNFα may serve as a potential therapeutic targets in patients with acute ischemic stroke.

Abstract TP375: Vitamin D Deficiency Correlates With Stroke Severity on Presentation in Intracerebral Hemorrhage

Introduction: Vitamin D, a neurosteroid present in cerebrospinal fluid and metabolized by brain tissue regulates calcium signaling and scavenging of reactive oxygen species, which play a role in acute cell injury after ischemic stroke and intracerebral hemorrhage (ICH). Low vitamin D (measured as 25(OH)D), has been found to increase the risk of ischemic stroke, predict severity and poor functional outcome. No studies investigating impact of vitamin D level on ICH stroke severity exist.

Hypothesis: We hypothesize that low 25(OH)D levels are associated with higher stroke severity of ICH on admission and poorer functional outcome.

Methods: A single-center retrospective chart review between February 2012 and September 2014 was performed. A total of 109 patients with primary ICH and 25(OH)D levels on admission were identified. Serum 25(OH)D levels were dichotomized at <30 ng/ml as Vitamin D deficient and <10 ng/ml as severely deficient. Dichotomized 25(OH)D groups were compared for continuous outcome variables using non-parametric Wilcoxon rank-sum test. Severity measures including dichotomized NIHSS (>20 or <20) and dichotomized Glasgow coma scale (GCS of 3-5, 6-15) were compared to vitamin D groups using Pearson Chi-square test of proportion.

Results: NIHSS on admission was higher in patients with severe vitamin D deficiency (p=0.016) with the odds ratio of having an NIHSS of >20 on admission 5.9 (95% CI --1.4-25.5). Patients with severe deficiency were far more likely to have very low GCS (3-5) (p=0.022; OR=8.8; 95% CI 1.7 - 45.5). Vitamin D deficiency was associated with lower pre-albumin level and older age (p=0.021 and 0.018, respectively). No statistical significance between 25(OH)D level and ICH score, ICH volume, location, presence of intraventricular hemorrhage, length of stay, mortality, disposition or pre-stroke and discharge modified Rankin Scale was found.

Conclusions: ICH patients with severe vitamin D deficiency had significantly worse stroke severity. Patients with older age and malnutrition are at higher risk for severe clinical presentation of ICH. Larger scale studies identifying increased risk of morbidity and mortality from ICH in vitamin D deficient patients are needed.

Polyuria and cerebral vasospasm after aneurysmal subarachnoid hemorrhage

Background

Natriuresis with polyuria is common after aneurysmal subarachnoid hemorrhage (aSAH). Previous studies have shown an increased risk of symptomatic cerebral vasospasm or delayed cerebral ischemia (DCI) in patients with hyponatremia and/or the cerebral salt wasting syndrome (CSW). However, natriuresis may occur in the absence of hyponatremia or hypovolemia and it is not known whether the increase in DCI in patients with CSW is secondary to a concomitant hypovolemia or because the physiology that predisposes to natriuretic peptide release also predisposes to cerebral vasospasm. Therefore, we investigated whether polyuria per se was associated with vasospasm and whether a temporal relationship existed.

Methods

A retrospective review of patients with aSAH was performed. Exclusion criteria were admission more than 48 h after aneurysmal rupture, death within 5 days, and the development of diabetes insipidus or acute renal failure. Polyuria was defined as >6 liters of urine in a 24 h period. Vasospasm was defined as a mean velocity > 120 m/s on Transcranial Doppler Ultrasonography (TCDs) or by evidence of vasospasm on computerized tomography (CT) or catheter angiography. Multivariable logistic regression was performed to assess the relationship between polyuria and vasospasm.

Results

95 patients were included in the study. 51 had cerebral vasospasm and 63 met the definition of polyuria. Patients with polyuria were significantly more likely to have vasospasm (OR 4.301, 95 % CI 1.378–13.419) in multivariate analysis. Polyuria was more common in younger patients (52 vs 68, p <.001) but did not impact mortality after controlling for age and disease severity. The timing of the development of polyuria was clustered around the diagnosis of vasospasm and patients with polyuria developed vasospasm faster than those without polyuria.

Conclusions

Polyuria is common after aSAH and is significantly associated with cerebral vasospasm. The development of polyuria may be temporally related to the development of vasospasm. An increase in urine volume may be a useful clinical predictor of patients at risk for vasospasm.

Sex differences and the role of IL-10 in ischemic stroke recovery

Females experience poorer recovery after ischemic stroke compared to males, even after controlling for age and stroke severity. IL-10 is an anti-inflammatory cytokine produced by T regulatory cells and Th2 CD4⁺ helper T cells. In ischemic stroke, an excessive IL-10 response contributes to post-stroke immunosuppression, which worsens outcomes. However, it is unknown if sex differences exist in IL-10 levels after ischemic stroke. In this study, we found that higher levels of IL-10 were associated with poor acute and long-term outcomes after ischemic stroke in female patients but not in males. After controlling for confounders, IL-10 was not an independent predictor of functional outcomes. This suggests that higher serum IL-10 levels may reflect factors that interact with sex such as age and stroke severity.

Effect of β-Adrenergic Antagonists on In-Hospital Mortality after Ischemic Stroke

BACKGROUND

Ischemic stroke accounts for 85%-90% of all strokes and currently has very limited therapeutic options. Recent studies of β-adrenergic antagonists suggest they may have neuroprotective effects that lead to improved functional outcomes in rodent models of ischemic stroke; however, there are limited data in patients. We aimed to determine whether there was an improvement in mortality rates among patients who were taking β-blockers during the acute phase of their ischemic stroke.

METHODS

A retrospective analysis of a prospectively collected database of ischemic stroke patients was performed. Patients who were on β-adrenergic antagonists both at home and during the first 3 days of hospitalization were compared with patients who were not on β-adrenergic antagonists to determine the association with patient mortality rates.

RESULTS

The study included a patient population of 2804 patients. In univariate analysis, use of β-adrenergic antagonists was associated with older age, atrial fibrillation, hypertension, and more-severe initial stroke presentation. Despite this, multivariable analysis revealed a reduction in in-hospital mortality among patients who were treated with β-adrenergic antagonists (odds ratio, .657; 95% confidence interval, .655-.658).

CONCLUSIONS

The continuation of home β-adrenergic antagonist medication during the first 3 days of hospitalization after an ischemic stroke is associated with a decrease in patient mortality. This supports the work done in rodent models suggesting neuroprotective effects of β-blockers after ischemic stroke.

Thyroid hormones and functional outcomes after ischemic stroke

Background

Stroke is the fifth leading cause of death and the primary cause of long-term adult disability in the United States. Increasing evidence suggests that low T3 levels immediately following acute ischemic stroke are associated with greater stroke severity, higher mortality rates, and poorer functional outcomes. Prognosis is also poor in critically ill hospitalized patients who have non-thyroidal illness syndrome (NTIS), where T3 levels are low, but TSH is normal. However, data regarding the association between TSH levels and functional outcomes are contradictory. Thus, this study investigated the role of TSH on stroke outcomes, concomitantly with T3 and T4.

Findings

In this work, blood was collected from patients with radiologically confirmed acute ischemic stroke at 24±6 hours post-symptom onset and serum levels of TSH, free T3, and free T4 were measured. Stroke outcomes were measured at discharge, 3 and 12 months using the modified Rankin scale and modified Barthel Index as markers of disability. Though we found that lower levels of free T3 were associated with worse prognosis at hospital discharge, and at 3 and 12 months post-stroke, none of these outcomes held after multivariate analysis. Thus, it is likely that thyroid hormones are associated with other factors that impact stroke outcomes, such as sex, age and stroke etiology.

Conclusions

This study found that lower levels of free T3 were associated with poorer outcomes at hospital discharge, and at 3 and 12 months post stroke, however, these associations diminished after correction for other known predictors of stroke outcome. Thyroid hormones have a complex relationship with ischemic stroke and stroke recovery, which merits further larger investigations.

Clinical Characteristics and Outcomes of Patients with Intracerebral Hemorrhage after Interhospital Transfer to a Designated Stroke Center

Patients with acute ischemic stroke have improved outcomes when cared for in designated stroke centers (SC), in part due to enhanced thrombolytic use. Whether patients with intracerebral hemorrhage (ICH) also benefit from SC care is unknown. In this study, we compared the clinical characteristics and outcomes of ICH patients who underwent interhospital transfer (IHT) to a Joint Commission (JC) designated SC, to ICH patients who presented directly to the SC's emergency department (ED).

METHODS

Patients with ICH admitted between 2006 and 2013 were evaluated. The primary outcome measure was in-hospital death or hospice.

RESULTS

Among 760 consecutive admissions for ICH, 321 (42.2%) were IHTs. There has been a 30% annual increase in IHT of ICH patients since 2006. The IHT group was younger (70.26 vs 72.28; P =.055), had lower ICH scores (P = .007), a higher Glasgow Coma Scale (GCS) (P = .037), and lower systolic blood pressure (SBP) (P = .003) than those arriving directly to the ED. Female sex was a predictor of in-hospital mortality (OR = 2.26).

CONCLUSION

IHT is increasingly common for patients with ICH. The benefit of transfer remains unclear, as younger, healthier patients were the most likely to be transferred. Comprehensive stroke registries are needed to determine if outcomes differ for ICH patients based on transfer or SC care.

Weighted Gleason scores do not outperform standard clinical Gleason scores

INTRODUCTION

Predicting patient survival rates following radical prostatectomy remains an area of clinical interest. We compared the ability of standard clinical Gleason scores and alternative 'weighted' Gleason scores to predict pathology, margin status and recurrence in prostate cancer.

MATERIALS AND METHODS

Patients who underwent robotic radical prostatectomy performed by a single surgeon between Jan 2007 - Dec 2008 were included. Tumor at the inked margin in pathologic samples was considered a positive margin. Recurrence was defined as PSA ≥ 0.2 or the institution of salvage therapy. Standard pathologic Gleason scores were recorded. The proportion of tumor in each core was used to calculate 'weighted' and 'rounded weighted ' Gleason scores. The ability of each Gleason score to predict pathology, margin status and recurrence were statistically compared.

RESULTS

Of 433 cases, 281 with uniform Gleason 6 cores were excluded. One hundred and fifty-two cases had Gleason scores ≥ 7, of which complete data were unavailable for three patients. In the final cohort of 149 cases, 72 (48.3%) patients had uniformly scored biopsies, while 77 (51.7%) had biopsies with non-uniform Gleason scores. The positive margin rate and recurrence free rates were 30.2% and 77.2%, respectively. Analyses of the entire patient cohort, and patients with non-uniform cores, found no significant difference between the predictive capacities of each scoring system. The alternative algorithms were not shown to be better predictors of pathologic Gleason score, margin status or recurrence.

CONCLUSIONS

Using the highest standard Gleason score of all cores to define a preoperative Gleason score remains an appropriate clinical practice.

Surgical complications associated with robotic urologic procedures in elderly patients

INTRODUCTION

Urologic malignancies are often diagnosed at an older age, and are increasingly managed utilizing robotic-assisted surgical techniques. As such, we assessed and compared peri-postoperative complication rates following robotic urologic surgery in elderly and younger patients.

MATERIALS AND METHODS

A retrospective analysis of IRB-approved databases and electronic medical records identified patients who underwent robotic-assisted urologic surgery between December 2003-September 2013. Patients were grouped according to surgical procedure (partial nephrectomy, radical cystectomy, radical prostatectomy) and age at surgery (≤ 74 or ≥ 75 years old). Associations between age, comorbidities, Charlson comorbidity index (CCI), and patient outcomes were evaluated within each surgery type.

RESULTS

97.5% and 2.5% of patients were ≤ 74 or ≥ 75 years old, respectively. Cystectomies, partial nephrectomies and prostatectomies accounted for 3.5%, 9.5% and 87.1% of surgeries, respectively. Within cystectomy, nephrectomy and prostatectomy groups, 24.4%, 12.5% and 0.6% patients were ≥ 75 years old. Within each surgical type, elderly patients had significantly elevated CCI scores. Length of stay was significantly prolonged in elderly patients undergoing partial nephrectomy or prostatectomy. In elderly cystectomy, partial nephrectomy and prostatectomy patients, 36.7%, 14.3% and 5.9% suffered ≥ 1 Clavien grade 3-5 complication, respectively. Major complications were not significantly different between age groups. A qualitatively similar pattern was observed regarding Clavien grade 1-2 complications.

CONCLUSIONS

The risks of robotic-assisted urologic surgery in elderly patients are not significantly elevated compared to younger patients.

Abstract W MP59: Thyroid Hormones And Functional Outcomes After Ischemic Stroke

Background: Hypothyroidism can lead to hypertension, hypercholesterolemia, and cardiac dysfunction, which are risk factors for stroke. Activity of the hypothalamic-pituitary-thyroid axis may contribute to functional stroke outcomes. Low levels of thyroid stimulating hormone (TSH) correlate with an increased risk of ischemic stroke. However, once a stroke occurs, hypothyroidism is associated with more favorable outcomes. It is well known that thyroid hormone levels drop rapidly in critically ill patients (“sick-euthryoid” syndrome), which may be prevented by the exogenous thyroid replacement provided to hypothyroid patients. We directly assessed thyroid function with measurements of TSH, free T3 (fT3) and free T4 (fT4) in patients with ischemic stroke and evaluated acute and long-term outcomes.

Methods: Blood was collected prospectively from patients with radiologically confirmed ischemic stroke (AIS) (n=136) 24 hours after symptom onset. Serum levels of TSH, fT4, and fT3 were quantified by ELISA. Primary outcomes were in-hospital mortality and admission NIH Stroke Scale (NIHSS). Secondary outcomes were admission to discharge change in NIHSS, modified Barthel Index (mBI) and modified Rankin score (mRs) at 3 and 12 months (mo), and mortality at 3 and 12 mo.

Results: AIS patients show a negative correlation in fT3 with age (r=-.332, p<0.01 ). AIS patients with a higher pre-stroke mRS had higher levels of fT3, and fT4 , p=0.01, p=0.03 ). Patients that died or went to hospice had significantly lower levels of fT3 and TSH (1.99pg/ml (1.75-2.48), 0.52 pg/ml (0.30-0.76)).TSH levels were lower in AIS patients with worsened NIHSS (0.72 pg/ml (0.36-1.12)). Higher fT3 levels were significantly associated with better mRS and mBI at 3 and 12 mo ( p=0.01, p=0.01, p=0.03, p=0.02 ), whereas lower levels of TSH were significant for worse mRS at 3mo (0.87pg/ml (0.59-1.48)).

Conclusion: While higher levels of fT3 correlate with stroke risk factors, high fT3 is seen in patients with better functional outcome at 3 and 12mo post-stroke. Ischemic stroke patients with low TSH levels at 24 hrs have higher mortality. Thus, monitoring the hypothalamus-pituitary-thyroid axis during acute stroke may improve long-term stroke outcomes.

Prestroke living situation and depression contribute to initial stroke severity and stroke recovery

Substantial evidence from both experimental and clinical studies has demonstrated that social isolation can increase stroke incidence and impair recovery. Social isolation leads to higher rates of recurrent stroke but is often not reported as a risk factor. We examined prospectively collected stroke center database variables, which included prestroke living situation, to determine if social isolation could be determined from existing data using living arrangement as a proxy. Patients were categorized into 4 groups hypothesized to represent increasing levels of social isolation: living with spouse, living with family, living alone with visiting services, and living alone. Initial stroke severity and recovery were measured using the National Institutes of Health Stroke Scale and Barthel Index, respectively. A multivariate model was used to determine the relationship among prestroke living situation, stroke severity, and functional outcome. Patients living alone had less severe strokes on admission and better recovery at 3 months compared with the other cohorts. Patients living alone or those who lived with a spouse had less severe strokes on presentation and better recovery at both 3 and 12 months after stroke compared with the other cohorts. However, on detailed examination, it was found that these patients also had significantly higher prestroke function. Pre-existing depression was significantly higher in women, and depressed patients had poorer outcomes 3 months after stroke. Information regarding isolation is notably absent from most large stroke databases. A more comprehensive evaluation of social interaction should be obtained to more accurately measure social isolation.

Clinical and radiographic characteristics governing the selection of therapy of small renal masses

INTRODUCTION

Renal masses are commonly managed by partial nephrectomy (PN) or active surveillance (AS). We assessed the impact of patient demographics and clinical indices in determining treatment decisions of renal masses between these two options.

MATERIALS AND METHODS

We retrospectively reviewed our renal mass database to retrieve demographic and clinical records of patients who underwent immediate PN or entered a >= 12 month period of AS during February 1999 to May 2014. Age, gender, body mass index (BMI), Charlson Comorbidity Index (CCI) score, follow up time, tumor size, tumor location, renal invasion, creatinine, and estimated glomerular filtration rate (eGFR) were assessed as predictors of the selected treatment option.

RESULTS

Seven hundred thirty-five patients with 744 renal masses underwent immediate PN, while 123 patients with 140 renal masses entered active surveillance. PN patients were predominantly male, younger, had elevated BMI, lower CCI scores, elevated eGFR and had larger tumors that invaded further into the renal collecting system. Renal masses in men were more likely to be treated by PN, while patients categorized as overweight or obese were 2-3 fold more likely to have their renal mass being manage by PN (versus patients with BMI in the normal range). Higher CCI scores were associated with a renal mass being more likely to be treated by AS, while increased renal mass size was associated with decisions to treat with PN. Compared to cortical location, renal masses abutting the renal collecting system were more likely to be treated by PN.

CONCLUSIONS

Gender, BMI, CCI, tumor size, and tumor invasion into the renal system are useful predictors of renal mass treatment.