A prospective registry of emergency department patients admitted with infection

Immediate Interventions After Surgery to Reduce Readmission for Upper Extremity Infections

ABSTRACT

Upper extremity infections (UEIs), commonly caused by intravenous drug use and direct trauma to the hand, can be devastating. Many studies support hand therapy postoperatively to improve outcomes. This population of patients often experience increased returns to the emergency department (ED) for treatment, repeat surgery, poor function, and increased hospital expenditure.This is a 2-phase study to investigate and intervene on the care pathway for patients undergoing surgery for UEI at a single urban university hospital. For the first 6-month phase, all patients with UEI requiring surgery received the standard of care, including written discharge instructions, a scheduled follow-up, and a determination for hand therapy based on evaluation. During the second phase, over the following 6 months, all patients with UEI requiring surgery received an intervention before discharge, in addition to standard of care, including a scripted educational session on the importance of hand therapy by a resident physician, home exercise program instructions, and a referral to hand therapy before discharge. Outcome measures were assessed for 6 months. Outcome measures included follow-up, hand therapy attendance, ED visits for the same complaint, readmissions, and reoperations.Forty-seven patients were in the first control group without intervention and 41 patients were in the second intervention group. Of the control group, 43% attended a follow-up appointment, 2% attended hand therapy, and 45% presented to the ED, resulting in a total of 167 visits. Eleven presented to the ED and were readmitted for complications from surgery, all 11 required a second operation. In the intervention group, 54% attended a follow-up appointment (P = 0.044), more patients attended hand therapy (22% P = 0.013), and 24% presented to the ED (P = 0.047), resulting in 40 ED visits.Seven were readmitted for complications from surgery and 4 required a second operation (P = 0.1). Early, simple intervention and education prove to be an effective method to decrease emergency department burden and healthcare expenditure for treatment of a challenging population. Although additional education and referral to hand therapy utilization do not change operation rates, it decreased returns to the ED, readmissions, and increased follow-up.

Characteristics, treatment and outcomes for all emergency department patients fulfilling criteria for septic shock: a prospective observational study

OBJECTIVE

Most published data on emergency department (ED) patients with septic shock have been generated from studies examining the effect of early protocolised resuscitation in selected cohorts. Consequently, these data do not generally represent patients falling outside trial inclusion criteria or judged unsuitable for aggressive treatment. Our aim was to determine the characteristics, treatment and outcomes for all ED patients fulfilling the criteria for septic shock.

METHODS

Septic shock patients were identified from a prospective database of consecutive ED patients admitted with infection. Descriptive data were compared with those from previous studies and associations between ED processes of care and mortality were determined.

RESULTS

A total of 399 septic shock patients were identified, with a 30-day mortality of 19.5%. The median ED length of stay was 9.2 h. Rates of vasopressor use (22.6%) and ICU admission (37.3%) were low. Subgroups fulfilling the lactate criteria alone, hypotension criteria alone and both criteria represented distinct shock phenotypes with increasing severity of illness and mortality. Mortality for patients with limitations to treatment determined in the ED was 65.6% and 6.1% for those without limitations. Greater volumes of intravenous fluid and early vasopressor therapy for appropriate patients were associated with survival.

CONCLUSION

Median length of stay over 9 hours may have enhanced identification of patients with limitations to treatment and fluid responders, reducing invasive therapies and ICU admissions. Distinct shock phenotypes were apparent, with implications for revision of septic shock definitions and future trial design. Liberal fluids and early vasopressor use in appropriate patients were associated with survival.

Utility of community-acquired pneumonia severity scores in guiding disposition from the emergency department: Intensive care or short-stay unit?

OBJECTIVE

To assess community-acquired pneumonia severity scores from two perspectives: (i) prediction of ICU admission or mortality; and (ii) utility of low scores for prediction of discharge within 48 h, potentially indicating suitability for short-stay unit admission.

METHODS

Patients with community-acquired pneumonia were identified from a prospective database of emergency patients admitted with infection. Pneumonia severity index (PSI), CURB-65, CORB, CURXO, SMARTCOP scores and the Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) minor criteria were calculated. Diagnostic accuracy statistics (sensitivity, specificity, predictive values, likelihood ratios and area under receiver operating characteristic curves [AUROC]) were determined for both end-points.

RESULTS

Of 618 patients admitted with community-acquired pneumonia judged eligible for invasive therapies, 75 (12.1%) were admitted to ICU or deceased at 30 days, and 87 (14.1%) were discharged within 48 h. All scores effectively stratified patients into categories of risk. For prediction of severe pneumonia, SMARTCOP, CURXO and IDSA/ATS discriminated well (AUROC 0.84-0.87). SMARTCOP and CURXO showed optimal sensitivity (85% [95% confidence interval (CI) 75-92]), while specificity was highest for CORB and CURB-65 (93% and 94%, respectively). Using lowest risk categories for prediction of discharge within 48 h, only SMARTCOP and CURXO showed specificity >80%. PSI demonstrated highest positive predictive value (31% [95% CI 24-39]) and AUROC (0.74 [95% CI 0.69-0.79]).

CONCLUSIONS

Community-acquired pneumonia severity scores had different strengths; SMARTCOP and CURXO were sensitive with potential to rule out severe disease, while the high specificity of CORB and CURB-65 facilitated identification of patients at high risk of requirement for ICU. Low severity scores were not useful to identify patients suitable for admission to short-stay units.

Severity Scores in Emergency Department Patients With Presumed Infection: A Prospective Validation Study

OBJECTIVES

The objectives of this study were to 1) validate a number of severity of illness scores in a large cohort of emergency department patients admitted with presumed infection and 2) compare the performance of scores in patient subgroups with increasing mortality: infection without systemic inflammatory response syndrome, sepsis, severe sepsis, and septic shock.

DESIGN

Prospective, observational study.

SETTING

Adult emergency department in a metropolitan tertiary, university-affiliated hospital.

PATIENTS

Emergency department patients admitted with presumed infection.

INTERVENTIONS

None.

METHODS

Consecutive emergency department patients admitted with presumed infection were identified over 160 weeks in two periods between 2007 and 2011. Clinical and laboratory data sufficient to calculate Mortality in Emergency Department Sepsis score, Acute Physiology and Chronic Health Evaluation II, Simplified Acute Physiology Score II, Sequential Organ Failure Assessment, and the Severe Sepsis Score were entered into a database. Model discrimination was quantified using area under the receiver operating curve. Calibration was assessed using visual plots, Hosmer-Lemeshow statistics, and linear regressions of observed and predicted values.

MEASUREMENTS AND MAIN RESULTS

A total of 8,871 patients were enrolled with 30-day mortality of 3.7%. Area under the receiver operating curve values for the entire cohort were: Mortality in Emergency Department Sepsis score of 0.92, Simplified Acute Physiology Score II and Acute Physiology and Chronic Health Evaluation II scores of 0.90, Sequential Organ Failure Assessment score of 0.86, and Severe Sepsis Score of 0.82. Discrimination decreased in subgroups with greater mortality for each score. All scores overestimated mortality, but closest concordance between predicted and observed mortality was seen with Mortality in Emergency Department Sepsis score.

CONCLUSIONS

The decrease in area under the receiver operating curve seen in subgroups with increasing mortality may explain some variation in results seen in previous validation studies. Scores developed in intensive care settings overestimated mortality in the emergency department. Our results underscore the importance of employing predictive models developed in similar patient populations. The Mortality in Emergency Department Sepsis score outperformed more complex predictive models and would be the most appropriate scoring system for use in similar emergency department populations with a wide spectrum of mortality risk.

[Profile and initial management of infection in elderly patients in an Emergency Department]

OBJECTIVE

To determine the clinical profile and the initial management of elderly patients with acute infections attending Spanish Emergency Departments (EDs), and to analyse whether there are any differences compared to younger adults.

MATERIAL AND METHODS

A descriptive, cross-sectional, multicentre study using the data recorded in the INFURG-SEMES register. It included a total of 79,654 of 15 years or over treated for an acute infection in 49 Spanish EDs between 10 October 2010 and 20 September 2011. Demographic variables, clinical profile, and care in the ED, were collected. The classifying variable was to be 65 years or over.

RESULTS

Of the total of 11,399 cases, 4,255 (37.3%) were 65 years or over. Statistically significant differences were found on comparing the elderly with the younger adults as regards the presence of a high comorbidity (P<.001), of at least one risk factor for multidrug resistance (P<.001), or septic syndrome (P<.001), type of infection (P<.001), taking of the specimen for blood culture (P<.001), determination of antigens in urine (P<.001), the antibiotic prescribed in the ED (P<.001), and final destination (P<.001).

CONCLUSIONS

There are significant age-dependent differences in the profile and management of patients with infections that attend Spanish EDs, which must be taken into account when developing strategies for improving quality, as well as for future lines of research.