Evaluation and management of seasonal influenza in the emergency department

Clinical impact of rapid molecular diagnostic tests in patients presenting with viral respiratory symptoms: A systematic literature review

BACKGROUND

Molecular tests can detect lower concentrations of viral genetic material over a longer period of respiratory infection than antigen tests. Delays associated with central laboratory testing can result in hospital-acquired transmission, avoidable patient admission, and unnecessary use of antimicrobials, all which may lead to increased cost of patient management. The aim of this study was to summarize comparisons of clinical outcomes associated with rapid molecular diagnostic tests (RMDTs) versus other diagnostic tests for viral respiratory infections.

METHODS

A systematic literature review (SLR) conducted in April 2023 identified studies evaluating clinical outcomes of molecular and antigen diagnostic tests for patients suspected of having respiratory viral infections.

RESULTS

The SLR included 21 studies, of which seven and 14 compared RMDTs (conducted at points of care or at laboratories) to standard (non-rapid) molecular tests or antigen tests to detect SARS-CoV-2 and influenza, respectively. In studies testing for SARS-CoV-2, RMDTs led to reductions in time to test results versus standard molecular tests (range of the reported medians: 0.2-3.8 hours versus 4.3-35.9 hours), with similar length of emergency department stay (3.2-8 hours versus 3.7-28.8 hours). Similarly, in studies testing for influenza, RMDTs led to reductions in time to test results versus standard molecular tests (1-3.5 hours versus 18.2-29.2 hours), with similar length of emergency department stay (3.7-11 hours versus 3.8-11.9 hours). RMDTs were found to decrease exposure time of uninfected patients, rate of hospitalization, length of stay at the hospitals, and frequency of unnecessary antiviral and antibacterial therapy, while improving patient flow, compared to other tests.

CONCLUSIONS

Compared to other diagnostic tests, RMDTs improve clinical outcomes, test turnaround time, and stewardship by decreasing unnecessary use of antibiotics and antivirals. They also reduce hospital admission and length of stay, which may, in turn, reduce unnecessary exposure of patients to hospital-acquired infections and their associated costs.

Added value of rapid respiratory syndromic testing at point of care versus central laboratory testing: a controlled clinical trial

Background

Virus-associated respiratory infections are in the spotlight with the emergence of SARS-CoV-2 and the expanding use of multiplex PCR (mPCR). The impact of molecular testing as a point-of-care test (POCT) in the emergency department (ED) is still unclear.

Objectives

To compare the impact of a syndromic test performed in the ED as a POCT and in the central laboratory on length of stay (LOS), antibiotic use and single-room assignment.

Methods

From 19 November 2019 to 9 March 2020, adults with acute respiratory illness seeking care in the ED of a large hospital were enrolled, with mPCR performed with a weekly alternation in the ED as a POCT (week A) or in the central laboratory (week B).

Results

474 patients were analysed: 275 during A weeks and 199 during B weeks. Patient characteristics were similar. The hospital LOS (median 7 days during week A versus 7 days during week B, P = 0.29), the proportion of patients with ED-LOS <1 day (63% versus 60%, P = 0.57) and ED antibiotic prescription (59% versus 58%, P = 0.92) were not significantly different. Patients in the POCT arm were more frequently assigned a single room when having a positive PCR for influenza, respiratory syncytial virus and metapneumovirus [52/70 (74%) versus 19/38 (50%) in the central testing arm, P = 0.012].

Conclusions

Syndromic testing performed in the ED compared with the central laboratory failed to reduce the LOS or antibiotic consumption in patients with acute respiratory illness, but was associated with an increased single-room assignment among patients in whom a significant respiratory pathogen was detected.

Seasonal dengue surge: Providers⬨tm) perceptions about the impact of dengue on patient volume, staffing and use of point of care testing in Indian emergency departments

BACKGROUND

Global health emergencies, such as from diseases like dengue fever, can lead to rapid surges in visits to emergency departments. The objective of our study was to evaluate the impact of dengue on factors that could impact emergency department flow, including patient volume and staffing, on Indian emergency departments.

METHODS

This was a prospective cohort study of Indian emergency providers. Respondents were queried via online survey about a number of domains including practice environment, use of rapid testing, changes in ED volume and ED staffing adjustments occurring during dengue season. Data was analyzed using multivariate analysis.

RESULTS

We had a total of 210 respondents to our online survey. Less than half of respondents reported that their institutions used rapid point of care testing. When asked how dengue impacted ED flow, the most common response was that dengue increased the total number of ED visits (84%). Despite this increase, only about 32% of respondents reported that their institutions increased hospital staffing. In multivariate analysis, respondents at hospitals that experienced ED visit surges over 40% of baseline were more likely to also report that their institutions also increased staffing during this time (OR 3.28, 95% CI 1.44-7.46).

CONCLUSIONS

Our study shows that despite increases in visits during dengue season, ED providers noted that their EDs did not respond with staffing increases. More research is needed to better understand how emergency departments can adjust to dengue to provide optimal care for patients in India.

Economic and operational impact of an improved pathway using rapid molecular diagnostic testing for patients with influenza-like illness in a German emergency department

To evaluate the economic and operational effects of implementing a shorted diagnostic pathway during influenza epidemics. This retrospective study used emergency department (ED) data from the 2014/2015 influenza season. Alere i influenza A & B rapid molecular diagnostic test (RDT) was compared with the polymerase chain reaction (PCR) pathway. Differences in room occupancy time in the ED and inpatient ward and cost differences were calculated for the 14-week influenza season. The process flow was more streamlined with the RDT pathway, and the necessary isolation time in the ED was 9 h lower than for PCR. The difference in the ED examination room occupancy time was 2.9 h per patient on a weekday and 4 h per patient on a weekend day, and the difference in the inpatient room occupancy time was 2 h per patient on a weekday and 3 h per patient on a weekend day. Extrapolated time differences across the influenza season were projected to be 2733 h in the ED examination room occupancy and 1440 h in inpatient room occupancy. In patients with a negative diagnosis, the RDT was also estimated to reduce the total diagnostic costs by 41.52 € per patient compared with PCR. The total cost difference was projected to be 31,892 € across a 14-week influenza season. The improved process and earlier diagnosis with the RDT pathway compared with conventional PCR resulted in considerable savings in ED, inpatient room occupancy time and cost across the influenza season.

National Institutes of Health Support for Clinical Emergency Care Research, 2011 to 2014

STUDY OBJECTIVE

I report on the results of a portfolio analysis of National Institutes of Health (NIH) support for clinical emergency care research.

METHODS

A targeted query was created with data-mining techniques that accessed the NIH database for 2011 to 2014. The search was constructed to have a clinical focus; animal and bench research projects, as well as career development grants, were excluded. The search results were manually reviewed for appropriateness and then analyzed.

RESULTS

Six-hundred eighty-eight applications were analyzed. During the study period, the number of new emergency care projects submitted to NIH increased from 62 in 2011 to 153 in 2014. A total of 112 new applications were funded for $100 million, with an overall success rate of 23%. The total amount of support for both new and existing projects during the 4-year study period was $263 million. One third of the funded principal investigators were emergency medicine faculty, and their success rate for R01 funding was twice the NIH average.

CONCLUSION

Emergency care research makes up 0.7% of NIH spending on new research project grants. The success rate is high for emergency medicine principal investigators conducting clinical work. The overall success rate for emergency medicine R01s is similar to that of other clinical specialties.

Gradient band gap engineered alloyed quaternary/ternary CdZnSeS/ZnSeS quantum dots: an ultrasensitive fluorescence reporter in a conjugated molecular beacon system for the biosensing of influenza virus RNA

Composition-dependent alloyed CdZnSeS/ZnSeS QDs were synthesized and used as a fluorescent reporter in a molecular beacon assay to detect influenza virus RNA.

Emergency department and 'Google flu trends' data as syndromic surveillance indicators for seasonal influenza

We evaluated syndromic indicators of influenza disease activity developed using emergency department (ED) data - total ED visits attributed to influenza-like illness (ILI) ('ED ILI volume') and percentage of visits attributed to ILI ('ED ILI percent') - and Google flu trends (GFT) data (ILI cases/100 000 physician visits). Congruity and correlation among these indicators and between these indicators and weekly count of laboratory-confirmed influenza in Manitoba was assessed graphically using linear regression models. Both ED and GFT data performed well as syndromic indicators of influenza activity, and were highly correlated with each other in real time. The strongest correlations between virological data and ED ILI volume and ED ILI percent, respectively, were 0·77 and 0·71. The strongest correlation of GFT was 0·74. Seasonal influenza activity may be effectively monitored using ED and GFT data.

Clinical characteristics of children and adults hospitalized for influenza virus infection

BACKGROUND/PURPOSE

Influenza infection has different clinical presentations and outcomes in children and adults, and bacterial coinfection is associated with significantly higher morbidity and mortality. This study compared the clinical features in children and adults hospitalized for influenza virus infection and the role of concomitant bacteremia.

METHODS

A retrospective observational cohort study was conducted by a review of medical records of all consecutive patients admitted for influenza infection between April 1, 2009 and February 28, 2011.

RESULTS

Of the 1203 patients, 76.2% were children, and ranged in age from 1 month to 99 years, with a mortality of 3.1% for adults; no children died. Pneumonia, acute respiratory distress syndrome, acute respiratory failure, septic shock, and cardiovascular complications were more common in adults. Bacteremia was more common in adults than in children (3.5% vs. 0.4%). C-reactive protein (CRP) > 4 mg/dL and a longer hospital stay occurred more often in children with bacteremia than in the group without bacteremia. In adults with bacteremia, acute respiratory failure, septic shock, and cardiovascular complications were more common, with a mortality of 50% versus 1.4% compared with those without bacteremia, and thrombocytopenia and increased CRP were independent risk factors. Using receiver operating characteristic analysis, CRP ≥ 14 mg/dL had a sensitivity of 90.0% and a specificity of 80.0%.

CONCLUSION

Influenza infection in adults is associated with increased risk of complications, bacteremia, and mortality compared with that in children. Bacteremia in adults with influenza is associated with increased complications and mortality; thrombocytopenia and elevated CRP levels could identify those at risk.