Impact of Triage Systems on Time to Diagnosis and Treatment of Traumatic Brain Injuries

BACKGROUND

Intracerebral hemorrhage (ICH) is a potential complication from traumatic brain injury, with a 30-day mortality rate of 35-52%. Rapid diagnosis allows for earlier treatment, which impacts patient outcomes. A trauma activation (TA) is called when injury severity meets institutional criteria. The patient is immediately roomed, and a multispecialty team is present. A trauma evaluation (TE) occurs when injuries are identified after standard triage processes.

OBJECTIVES

Our aim was to determine whether TA patients with ICH were diagnosed and treated more rapidly than TE patients.

METHODS

This was a retrospective study of patients presenting to trauma centers within a large hospital system diagnosed with traumatic ICH between January 2018 and December 2018. Patients were categorized as TA or TE patients. The time to diagnosis was compared between groups, and additional times were evaluated, including time to imaging, computed tomography interpretation, and treatment.

RESULTS

A total of 294 patients were included. Groups had similar demographic characteristics and medical history; there was no difference in head Abbreviated Injury Score, Injury Severity Score, or anticoagulant use. Time to diagnosis was decreased for TA patients compared with TE patients (p < 0.0001). In addition, TA patients received treatment sooner (median 107 min) than TE patients (184.5 min) (p < 0.0001).

CONCLUSIONS

Diagnosis and treatment times were significantly faster in TA patients than in TE patients. Given the similarities in injury severity between groups, the increased time to treatment may be detrimental for patients. Trauma activations are a resource-heavy process, but TE delays care. These data suggest that an intermediary process may be beneficial.

Computed Tomography Utilization for Patients Presenting with Chest Pain

INTRODUCTION

Computed tomography (CT) is routinely used in the emergency department (ED) due to its ease of access and its ability to rapidly rule in or out many serious conditions. Freestanding emergency departments (FSEDs) have become increasingly used as an alternative to hospital-based emergency departments (HBEDs). The objective of this study was to investigate if the utilization rate of CT differs between FSEDs and HBEDs for chest pain.

METHODS

A retrospective evaluation of patients presenting to 17 EDs within a large integrated healthcare system between May 1, 2019 - April 30, 2021 with a chief complaint chest pain. Categorical variables are presented as frequencies and percentages. Continuous variables are presented as mean and standard deviation. Multiple logistic regression was used to assess the effect of facility on CT utilization for chest pain.

RESULTS

There were 67,084 patient encounters included in the study. Patients were predominately female (55%), white (61%), and insured through Medicare/Medicaid (59%). After controlling for predictive variables which included Charlson Comorbidity Index, ESI, age, sex, and race, patients who presented to FSEDs with chest pain were less likely to have a CT than those who presented to a HBED (AOR = 0.85, CI (0.81-0.90).

CONCLUSION

CT scans of the chest are utilized less frequently at FSEDs compared to HBEDs for patient presenting with chest pain.

Performance of different body weights in the Cockcroft-Gault equation in critically ill patients with and without augmented renal clearance: A multicenter cohort

STUDY OBJECTIVE

The primary objective was to evaluate the performance of the Cockcroft-Gault (CG) equation with different body weights (BWs) compared to a measured creatinine clearance (mCrCl) in an intensive care unit (ICU) population with and without augmented renal clearance (ARC).

DESIGN

Multicenter, retrospective cohort.

SETTING

Two ICUs in the United States and four ICUs from a previous international observational analysis.

PATIENTS

Adult ICU patients admitted from January 1, 2010 to July 30, 2020 with at least one mCrCl collected within the initial 10 days of hospitalization were eligible for inclusion.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was the performance of the CG equation in ARC (mCrCl≥130 ml/min/1.73 m2 ) and non-ARC (mCrCl<130 ml/min/1.73 m2 ) patients. Correlation was analyzed by Pearson's correlation coefficient, bias by mean difference, and accuracy by the percentage of patients within 30% of the mCrCl. A total of 383 patients were included, which provided 1708 mCrCl values. The majority were male (n = 239, 62%), median age of 55 years [IQR 40-65] with a surgical diagnosis (n = 239, 77%). ARC was identified in 229 (60%) patients. The ARC group had lower Scr values (0.6 [0.5-0.7] vs. 0.7 [0.6-0.9] mg/dl, p < 0.001) and higher mCrCl (172.8 (SD 39.1) vs. 89.9 mL/min/1.73 m2 (SD 25.4), p < 0.001) compared with the non-ARC group, respectively. Among non-ARC patients there was a moderate correlation (r = 0.33-0.39), moderate accuracy (range 48-58%), and low bias (range of -12.9 to 17.1) among the different BW estimations with the adjusted BW having the better performance. Among ARC patients there was low correlation (r = 0.24-0.28), low to moderate accuracy (range 38-70%), and high bias (range of -58.5 to -21.6).

CONCLUSIONS

The CG-adjusted BW had the best performance in the non-ARC patients, while CG performed poorly with any BW in ARC patients. Although the CG equation remains the standard equation for estimating CrCl in the ICU setting, a new, validated equation is needed for patients with ARC.

The impact of COVID-19 on emergency department boarding and in-hospital mortality

INTRODUCTION

The COVID-19 pandemic has been challenging for healthcare systems in the United States and globally. Understanding how the COVID-19 pandemic has impacted emergency departments (EDs) and patient outcomes in a large integrated healthcare system may help prepare for future pandemics. Our primary objective was to evaluate if there were changes to ED boarding and in-hospital mortality before and during the COVID-19 pandemic.

METHODS

This was a retrospective cohort study of all patients ages 18 and over who presented to one of 17 EDs (11 hospital-based; 6 freestanding) within our healthcare system. The study timeframe was March 1, 2019- February 29, 2020 (pre-pandemic) vs. March 1, 2020-August 31, 2021 (during the pandemic). Categorical variables are described using frequencies and percentages, and p-values were obtained from Pearson chi-squared or Fisher's exact tests where appropriate. In addition, multiple regression analysis was used to compare ED boarding and in-hospital mortality pre-pandemic vs. during the pandemic.

RESULTS

A total of 1,374,790 patient encounters were included in this study. In-hospital mortality increased by 16% during the COVID-19 Pandemic AOR 1.16(1.09-1.23, p < 0.0001). Boarding increased by 22% during the COVID-19 pandemic AOR 1.22(1.20-1.23), p < 0.0001). More patients were admitted during the COVID-19 pandemic than prior to the pandemic (26.02% v 24.97%, p < 0.0001). Initial acuity level for patients presenting to the ED increased for both high acuity (13.95% v 13.18%, p < 0.0001) and moderate acuity (60.98% v 59.95%, p < 0.0001) during the COVID-19 pandemic.

CONCLUSION

The COVID-19 pandemic led to increased ED boarding and in-hospital mortality.

Evaluation of an Elective Induction Protocol at a Regional Tertiary Obstetric Care Center

OBJECTIVE

To evaluate the safety of elective induction at or beyond 39 weeks gestation in the setting of a regional tertiary obstetric care center.

METHODS

We conducted a prospective cohort feasibility study of low-risk pregnant women who delivered at a regional tertiary obstetric care center. We compared maternal and neonatal outcomes of low risk pregnant women who opted for elective induction at or beyond 39 weeks gestation (n = 112) to a comparison group who opted for expectant management (n = 116). All deliveries occurred between May 1, 2019 and November 30, 2019 and February 15, 2020 and August 15, 2020.

RESULTS

There were no significant differences in the rates of cesarean deliveries or hypertensive disorders between women who underwent elective induction and those who chose expectant management. There were also no differences in neonatal outcomes. Women in the elective induction group received significantly more cervical ripening agents (p < 0.0001) and had significantly longer stays on the antepartum (p < 0.0001) and labor and delivery units (p = 0.0015) but experienced significantly shorter stays on the postpartum unit (p = 0.0368). There was no difference in total length of hospital stay between groups.

CONCLUSION

Elective induction protocols can be safely implemented in our regional tertiary obstetric care center without increased risk of maternal complications or neonatal morbidity. Women considering elective induction should be adequately counseled on use of cervical ripening agents and length of stay on antepartum and labor and delivery units.

Development and validation of a delirium risk prediction model using a modified version of the Delirium Elderly at Risk (mDEAR) screen in hospitalized patients aged 65 and older: A medical record review

Most delirium risk prediction models are cumbersome to use, time consuming to complete, and require education ensure accuracy. The purpose of this study was to develop and validate a risk prediction model using routinely assessed risk factors predictive of delirium including: cognitive impairment, ≥80-years old, functional dependence, sensory impairment, and chronic substance use. This retrospective study included 7999 encounters of hospitalized patients aged 65-years or older admitted from 1/1/2019 to 12/31/2019. Various models were compared, with the best tested for validation. A model, where cognitive impairment was worth 2-points and a threshold of 3-points to predict delirium, was determined to be the best model and was validated with an area-under Receiver-Operating-Characteristic curve=0.7126. Management of delirium could be enhanced by integrating a nursing admission delirium risk screening process into the workflow, triggering initiation of prevention interventions and prompt assessment for signs and symptoms of delirium for those at high risk.

DO HIGHER DOSES OF NALOXONE INCREASE THE RISK OF PULMONARY COMPLICATIONS?

BACKGROUND

Although naloxone has proven to be an effective opioid reversal agent, concern that high doses of naloxone can cause pulmonary edema may prevent health care providers from administering it in initial high doses.

OBJECTIVE

Our aim was to determine whether increased doses of naloxone are correlated with an increase in pulmonary complications in patients presenting to the emergency department (ED) after an opioid overdose.

METHODS

This was a retrospective study of patients treated with naloxone by emergency medical services (EMS) or in the ED at an urban level I trauma center and three associated freestanding EDs. Data were queried from EMS run reports and the medical record and included demographic characteristics, naloxone dosing, administration route, and pulmonary complications. Patients were grouped by naloxone dose received, defined as low (≤ 2 mg), moderate (> 2 mg to ≤ 4 mg), and high (> 4 mg).

RESULTS

Of the 639 patients included, 13 (2.0%) were diagnosed with a pulmonary complication. There was no difference in the development of pulmonary complications across groups (p = 0.676). There was no difference in pulmonary complications based on the route of administration (p = 0.342). The administration of higher doses of naloxone was not associated with longer hospital stays (p = 0.0327).

CONCLUSIONS

Study results suggest that the reluctance of many health care providers to administer larger doses of naloxone on initial treatment may not be warranted. In this investigation, there were no poor outcomes associated with an increase in naloxone administration. Further investigation in a more diverse population is warranted.

Patients utilizing emergency medical services - Does facility type matter?

BACKGROUND

Emergency departments (EDs) play a critical role in the US healthcare system. As freestanding EDs (FSEDs) are integrated into the acute care landscape, local EMS providers are transporting to these facilities, which may be closer in proximity and provide faster turnaround times. We hypothesized that patients transported via EMS to a freestanding ED required fewer tests and are admitted less frequently than those transported to a HBED. Our objective was to compare testing frequency and admission rates between patients transported via EMS to a FSED vs. HBED.

METHODS

This was a retrospective cohort study of all patients who presented within a large integrated hospital system via EMS to one of 10 HBEDs or one of 6 FSEDs between April 1, 2020 - May 1, 2021. Categorical variables are presented as frequencies and percentages and comparisons between groups were obtained using chi squared tests. Continuous variables are presented as mean and standard deviation and p-values comparing groups were obtained using t-tests. Multiple logistic regression was used to assess the effect of ED type on admission status, labs ordered, and testing performed.

RESULTS

A total of 123,120 encounters were included in our study. Mean age at the FSEDs was 59.9 vs. 61.3 at the HBEDs. At the FSEDs 55.6% (n = 4675) were female vs. 53.0% (n = 60,809) at the HBEDs. At the FSEDs 82.0% (n = 6805) were White vs. 60.7% (n = 68,430) at the HBEDs. We found 50.0% (n = 3974) had Medicare at the FSEDs vs 50.9% (n = 55,372) at the FSEDs. At the FSEDs, 69.5% (n = 5846) had bloodwork vs. 82.4% (n = 94,512) at the HBEDs; 68.3% (n = 5745) had an x-ray at the FSEDs vs. 70.7% (n = 81,089) at the HBEDs; 40.1% (n = 3370) had a CT scan at the FSEDs vs. 44.9% (n = 51,503) at the HBEDs; and 40.6% (n = 3412) were admitted at the FSEDs vs. 56.1% (n = 64,355) at the HBEDs. After controlling for Charlson Comorbidity Index, acuity, age, gender, sex, insurance and race, patients in FSEDs were 35% less likely to be admitted as compared to HBEDs.

CONCLUSION

Patients brought in via EMS to a FSED were less likely to have blood work, x-ray, or CT scan, and were less likely to be admitted to the hospital than those transported to a HBED.

Race and Sex Are Associated With Variations in Pain Management in Patients Presenting to the Emergency Department With Undifferentiated Abdominal Pain

BACKGROUND

Pain management is critical to the management of patients in the emergency department (ED). The clinical decision-making process for prescribing medications is complicated by its subjective nature. Historically, racial and ethnic minority groups and women have not had their pain managed as aggressively as White and male patients.

OBJECTIVE

The objective of this study was to determine whether race and biological sex affect the pain management process by means of evaluating data from a large hospital system with diverse patient demographic characteristics.

METHODS

This was a retrospective study of adult patients who presented an ED within the hospital system and were discharged from the ED with a diagnosis of undifferentiated abdominal pain during a single year. Patient pain was classified as mild, moderate, or severe, and patients were further stratified by race, ethnicity, sex, and insurance status. Pain management was assessed by narcotic vs non-narcotic administration.

RESULTS

A total of 32,676 patients were included in the study. Narcotic administration was more likely in White patients with undifferentiated abdominal pain (22%) compared with Black patients (12%; adjusted odds ratio 0.50; 95% CI 0.46-0.54). This persists across patient-reported pain scores. In addition, women (16.99%) were prescribed narcotics less often than men (19.41%; p < 0.0001).

CONCLUSIONS

Although differences in pain management practices have been explored previously, this study provided a large, updated, multifacility assessment that confirmed that race- and sex-based differences in pain management persist, specifically in the decision to treat with narcotics. Further investigation is warranted to determine the root causes of these differences.

Incidence of Atrioventricular Blocks and its Association with In-Hospital Mortality and Morbidity in Patients with Coronavirus Disease 2019

Background

Cardiovascular sequelae of coronavirus disease 2019 (COVID-19) infection have been explored by clinicians and researchers all over the world.

Objective

The purpose of this study was to evaluate the incidence of atrioventricular block (AV) in patients hospitalized for COVID-19 and its association between in-hospital morbidity and mortality.

Methods

In-hospital electrocardiograms (ECGs) of 438 patients were compared with their prior or baseline ECGs to ascertain the development of new onset AV block. Patients who developed new AV blocks were then followed at 30 and 90 days post-discharge to check for resolution of AV block. Demographic characteristics, clinical characteristics, and complications during their hospital stay were evaluated. Major complications including respiratory failure requiring oxygen supplementation and mechanical ventilation, sepsis, deep vein thrombosis, elevated troponins, hospital and intensive care unit (ICU) length of stay, as well as death were compared between those who developed new onset AV blocks and those who did not.

Results

Based on our single center study, the incidence of new onset AV blocks among patients admitted for COVID-19 during the study period was 5.5 cases per 100 patients. New onset AV blocks were not associated with longer hospital and ICU length of stay, increased intubation rates, or increased mortality.

Conclusion

Although the development of a new onset AV block is most likely multifactorial and not solely due to COVID-19, it is still important for clinicians to be mindful about the possibility of developing symptomatic bradycardia and life-threatening arrhythmias in patients admitted for COVID-19. This can be achieved by appropriate rhythm monitoring in-patient but the need for a cardiac event monitor upon discharge is unlikely to be necessary. Careful history taking, including family and drug use history is also of great importance as emerging drug therapies for COVID-19 have potential arrhythmogenic effects.

Estimates of throughput and utilization at freestanding compared to low-volume hospital-based emergency departments

OBJECTIVE

Our investigation compared throughput metrics and utilization measures for freestanding emergency departments (FSEDs) versus hospital-based emergency departments (HBEDs) of similar volumes in the United States.

METHODS

This study is a cross sectional survey of 183 FSEDs and 317 HBEDs located across the United States using the Emergency Department Benchmarking Alliance (EDBA) Database. We measured common emergency department (ED) throughput metrics. Primary outcomes included overall length of stay, length of stay for admitted, and length of stay for treated and released patients. Outcomes were weighted based on the proportion of ED volume per facility as per a prior pilot study. Multiple linear regression analysis was used to adjust for measured differences between FSEDs and HBEDs. The variables that were controlled for in regression analysis included geographic location of the ED (urban, suburban, and rural), percent of high acuity capacity, ED volume, percentage of patients arriving via emergency medical services (EMS), and percentage of pediatric patients.

RESULTS

Nationally, the median length of stay in minutes (104.2 vs 140.0), length of stay for treated and released patients (98.6 vs 122.9), door-to-bed (4.0 vs 8.0), door-to-doctor (11.0 vs 16.0), percentage of patients admitted through the ED (4.0 vs 11.0), and percentage of patients leaving the ED without being seen (LWBS) (0.9 vs 1.5), were significantly lower at FSEDs compared to HBEDs (P < 0.0001 for all comparisons). Length of stay for admitted patients (265.9 vs 241.8) and median boarding time (96.8 vs. 71.3) were significantly lower in HBEDs compared to FSEDs. X-ray, computed tomography, and ECG utilization per 100 patients was significantly lower at the FSEDs compared to HBEDs. Multiple linear regression analysis demonstrated that the length of stay for treated and released patients was 8.67 minutes shorter for FSEDs as compared to HBEDs (95% confidence interval [CI] = -1.4 to -16.0). The length of stay for admitted patients was 44 minutes longer for FSEDs as compared to HBEDs (95% CI = 25.5 to 63.0).

CONCLUSIONS

In this study of similarly sized EDs in the United States, throughput metrics for FSEDs tended to be significantly shorter from the arrival of the patient until their departure, except for patients requiring hospital admission. For measures favoring FSEDs, throughput times range from 20%-50% shorter than HBEDs.

MON-618 National In-Hospital Trends in Acquired Hypothyroidism

Background - Factors contributing to acquired hypothyroidism have increased in the United States during recent years. Known factors include advanced age, thyroidectomy, anti-thyroid and thyroid-affecting medications, susceptibility to autoimmune thyroiditis, iodine intake, radioactive ablation, and external beam neck irradiation. However, it is not understood how this increase in contributing factors impacts inpatient trends related to acquired hypothyroidism. Research aim - The objective of this epidemiological study is to describe the national inpatient trends in acquired hypothyroidism including prevalence, in-hospital mortality, length of stay (LOS), and healthcare expenditure. Methods - The National Inpatient Sample database was used to identify individuals 18 years or older, hospitalized between January 2000 and December 2014, with ICD 9 Code 244 acquired hypothyroidism as the principal discharge diagnosis. Longitudinal differences related to acquired hypothyroidism in the total number of hospital discharges, mean LOS, in-hospital mortality percentage, and inflation-adjusted cost were assessed. Linear regression analysis was used to assess the relationship between these variables and time. Relationships with a p-value of less than or equal to 0.05 were deemed significant. Analyses were performed using SAS® Software (version 9.4; Cary, NC). Results - During the 15-year period, the total number of discharges with the principal diagnosis of acquired hypothyroidism increased by 95 cases/year (p<0.0001), and the mean charges per acquired hypothyroidism hospitalization increased by $1218/year (p<0.0001). Conversely, the mean LOS per hospitalization decreased by 0.06 days/year (p= 0.0423) and the mean age of hospitalization decreased by 0.32 years/year (p<0.0001). Acquired hypothyroidism-related in-hospital mortality rate did not change over time (p=0.2048). Discussion - This is the first study to describe the trends in acquired hypothyroidism in the United States over a 15-year period utilizing the largest publicly available inpatient database. The considerable rise in the incidence of acquired hypothyroidism along with a significant growth in associated health care costs in this condition may be attributable to the rise in risk factors for acquired hypothyroidism and the general rise in health care cost, respectively. Hospitalization LOS has decreased possibly indicating better utilization of outpatient follow up for these patients. While the decrease in mean age may be secondary to a younger population exposed to more risk factors. In-hospital mortality in patients with acquired hypothyroidism did not change, which should be further evaluated in future studies focusing on better outcomes and treatment strategies.

DISC: Describing Infections of the Spine treated with Ceftaroline

OBJECTIVES

Infections of the spine lead to considerable morbidity and a high cost to the global healthcare system. Currently, evidence for using ceftaroline, an advanced-generation cephalosporin active against methicillin-resistant Staphylococcus aureus (MRSA), in spine infections is limited.

METHODS

Describing Infections of the Spine treated with Ceftaroline (DISC) is a multicentre, retrospective, cohort study that evaluated ceftaroline for treating spine infections. Patients were included if they were aged ≥18 years, diagnosed with a spine infection and treated with ceftaroline for ≥28 days. A control group was identified with the same inclusion criteria as the study population except they were treated with a comparator antibiotic for ≥28 days.

RESULTS

Thirty-seven patients were included each in the ceftaroline and control groups. MRSA was the most commonly identified pathogen. With no differences between groups in age, sex, race or co-morbidities (with the exception of chronic kidney disease), treatment with ceftaroline led to similar clinical success compared with the control group. Multivariate regression analysis did not show a significant difference between the two groups in terms of clinical success after controlling for other covariates (adjusted odds ratio=1.49; P=0.711). More patients who received ceftaroline were discharged to an extended-care or rehabilitation facility than home compared with controls (81% vs. 54%, respectively; P=0.024). Side effects and toxicities were rare, including one case of eosinophilic pneumonia in the ceftaroline group.

CONCLUSIONS

Ceftaroline appears to be a safe and effective therapy for infections of the spine, including from MRSA.

Clostridium difficile Infection in Trauma, Surgery, and Medical Patients Admitted to the Intensive Care Unit

BACKGROUND

Clostridium difficile infection (CDI) causes significant morbidity and mortality rates, especially for patients in the intensive care unit (ICU). Data comparing trauma and surgery patients with CDI in the ICU with medical patients with CDI in the ICU are limited.

METHODS

In a single-center study, we analyzed retrospective data from 25 trauma patients and 13 surgery patients aged 18 years or older who had CDI and had been admitted to the ICU. A comparison group of 156 medical patients aged 18 years or greater who had CDI and were admitted to the ICU also was identified.

RESULTS

The trauma/surgery patients had a significantly higher mean number of ventilator days (13.5 ± 9.3 vs. 7.3 ± 7.2; p < 0.0004), Foley catheter days (11.9 ± 6.8 vs. 8.0 ± 7.9; p = 0.005), mean ICU length of stay (LOS) (12.34 ± 9.7 vs. 5.9 ± 5.9 days; p < 0.0003), and mean total LOS (16 ± 9.3 vs. 10.7 ± 8.4 days; p = 0.0008). However, the medical group had a significantly higher mean number of vasopressor days (2.07 ± 3.51) than the trauma/surgery group (0.58 ± 1.55; p < 0.0001). The overall survival rate was significantly higher in the trauma/surgery group than in the medical group (100% vs. 81%, respectively; p = 0.003). A higher percentage of patients in the trauma/surgery group received piperacillin/tazobactam before the diagnosis of CDI than the medical patients (58% vs. 37%, respectively; p = 0.02). The number of days that antibiotics were given prior to the development of CDI was greater in the trauma/surgery group than in the medical group (10.3 ± 6.7 vs. 7.6 ± 7.3 days; p = 0.04). Multiple logistic regression models determined ICU LOS (adjusted odds ratio [aOR] 1.27 days; 95% confidence interval [CI] 1.13-1.41), the presence of chronic obstructive pulmonary disease (COPD) (aOR 3.44; 95% CI 1.19-9.95), and piperacillin/tazobactam use (aOR 3.27; 95% CI 1.24-8.65) to be positively associated with CDI in the trauma/surgery group compared with the medical patients.

CONCLUSIONS

Longer ICU stay, receipt of piperacillin/tazobactam, and having COPD were positively associated with CDI in trauma/surgery patients compared with medical patients. These findings suggest further consideration of the possibility of CDI should be given to patients admitted the surgical ICU for an extended period of time, receiving piperacillin/tazobactam, or having COPD. Additional evaluation of these factors in a larger patient sample is warranted.