Submersion Injuries and the Cost of Injury Associated with Drowning Events in the United States, 2006-2015

INTRODUCTION

The World Health Organization has reported submersion injuries as the third most common cause of death due to unintentional injury in the world. Greater detail in the rates, risk factors, and healthcare associated costs of submersion injuries could be instrumental in demonstrating the need for further funding and intervention.

METHODS

The study was a cross-sectional analysis of a nationally representative dataset of inpatient and emergency department (ED) encounters between 2006 and 2015 in the United States (US). Healthcare utilization costs were provided within the datasets and adjusted to reflect actual charges and provider fees. Lastly, the final cost values were adjusted to the 2020 US dollar (USD) and summarized using a log adjusted mean.

RESULTS

On average, there were 11,873 submersion injuries per year that presented to the ED in the US. Resulting in a rate where approximately 9 out of every 100,000 ED visits were associated with a submersion injury. Slightly more than 6% died in the ED, 24.2% were admitted, and 69.3% were discharged from the ED. In total, annual cost of submersion injuries in the US for ED care is approximately $12.5 million, inpatient care is approximately $27.5 million, and total annual healthcare cost exceeds $40 million.

DISCUSSION

While these results only represent a fraction of the total cost associated with submersion injuries, it remains substantial and unchanged over the 10-year study period. Certain demographic groups showed higher rates of injury and disease burden, thus bearing a greater amount of the cost.

Emergency Departments: Patient Screening, Prescribing, and Linkage to Care

In the pursuit of ending the HIV epidemic, U.S. emergency departments (EDs) have emerged as a valuable setting to increase HIV testing and linkage to care. There is limited data available, however, describing the incorporation of HIV prevention initiatives in U.S. EDs. Over the last decade, HIV pre-exposure prophylaxis (PrEP) has significantly changed the HIV prevention landscape globally and very little is known about the provision of PrEP in U.S. EDs. To address this gap in the literature, we conducted a systematic review of peer-reviewed quantitative studies and conference abstracts spanning July 2012 - October 2022. Of 433 citations, 11 articles and 13 abstracts meet our inclusion criteria, representing 18 unique studies addressing PrEP screening, prescribing, and/or linkage to PrEP care.Most studies describe screening processes to identify PrEP-eligible patients (n = 17); most studies leveraged a patient's STI history as initial PrEP eligibility screening criteria. Fewer studies describe PrEP prescribing (n = 2) and/or linkage to PrEP care (n = 8).Findings from this systematic review highlight the potential for U.S. EDs to increase PrEP uptake among individuals at risk for HIV infection. Despite a growing number of studies exploring processes for incorporating PrEP into the ED setting, such studies are small-scale and time limited. Models providing prescribing PrEP in the ED show higher initiation rates than post-discharge engagement models. Electronic health record (EHR)-based HIV screening is valuable, but post-ED linkage rates are low. Our findings emphasize the need to establish best practices for initiating and supporting prevention effective PrEP use in the ED setting.

Healthcare Providers' knowledge, attitudes and practice in relation to drug hypersensitivity reactions at King Abdulaziz Medical City in Riyadh

Background

Drug hypersensitivity reactions (DHRs) are immune-mediated responses triggered by exposure to a drug. DHRs are responsible for serious adverse drug reactions (ADRs) and are considered the fifth leading cause of death. This study aims to assess and evaluate the knowledge, practice, and attitudes of healthcare providers (HCPs) towards DHRs.

Methods

A cross-sectional survey was conducted at King Abdulaziz Medical City (KAMC) in Riyadh, Saudi Arabia. Healthcare providers, including pharmacists, physicians, and nurses, were recruited using a convenience sampling method to complete the survey. The survey comprised three domains: knowledge (14 items), attitudes (5 items), and practices (6 items), utilizing a standardized self-administered questionnaire.

Results

The survey was completed by 373 healthcare providers. The respondents were predominantly female (72.1 %) with a mean age of 33.8 ± 7.8 years. Of the respondents, 64 % were nurses, 25 % pharmacists, and 11.3 % physicians. Educational levels varied, with 53 % holding a bachelor's degree, 22 % an associate degree, and 25 % a master's degree or higher. The median knowledge score was 48. Female healthcare providers, those with advanced levels of education, and physicians had higher knowledge scores compared to male and nurse participants (p < 0.05). One-third of the respondents (33 %) were satisfied with their knowledge of DHRs, and 42 % believed HCPs should receive more advanced training in DHR management. Less than a quarter of HCPs reported inquiring about patients' histories of hypersensitivity reactions.

Conclusions

The study revealed that healthcare workers had a relatively low level of knowledge about drug hypersensitivity reactions and lacked a consensus on DHR management. While displaying a positive attitude towards DHRs, they often did not translate this attitude into consistent clinical practice.

Waterpipe vs non-Waterpipe carbon monoxide poisoning: Comparison of patient characteristics, clinical presentation and outcomes

OBJECTIVE

The aim of this study is to describe the difference between carboxyhemoglobin (CO-Hb) acute poisoning caused by waterpipe vs non-waterpipe exposures as they relate to demographics, clinical presentations and outcome of patients.

DESIGN

Retrospective cohort study conducted in the Emergency Department (ED) at the Lebanon.

PATIENTS

All adult patients presenting with a CO-Hb level ≥ 10 between January 2019 and August 2023 with exposure types stratified as waterpipe or non-waterpipe.

MEASUREMENTS AND MAIN RESULTS

111 ED visits were identified. Among these, 73.9% were attributed to waterpipe exposure, while 26.1% were non-waterpipe sources. These included cigarette smoking (17.2%), burning coal (24.1%), fire incidents (3.6%), gas leaks (6.9%), heating device use (10.3%), and undocumented sources (37.9%). Patients with waterpipe-related carbon monoxide exposure were younger (41 vs 50 years, p = 0.015) women (63.4 vs 41.4%, p = 0.039) with less comorbidities compared to non-waterpipe exposures (22.2 vs 41.4%, p = 0.047). Waterpipe smokers were more likely to present during the summer (42.7 vs 13.8%, p = 0.002) and have shorter ED length of stays (3.9 vs 4.5 h, p = 0.03). A higher percentage of waterpipe smokers presented with syncope (52.4 vs 17.2%, p = 0.001) whereas cough/dyspnea were more common in non-waterpipe exposures (31 vs 9.8%, p = 0.006). The initial CO-Hb level was found to be significantly higher in waterpipe exposure as compared to non-waterpipe (19.7 vs 13.7, p = 0.004). Non-waterpipe exposures were more likely to be admitted to the hospital (24.1 vs 4.9%, p = 0.015). Waterpipe smokers had significantly higher odds of experiencing syncope, with a 5.74-fold increase in risk compared to those exposed to non-waterpipe sources (p = 0.004) irrespective of their CO-Hb level. Furthermore, males had significantly lower odds of syncope as compared to females, following carbon monoxide exposure (aOR 0.31, 95% CI 0.13-0.74).

CONCLUSION

CO-Hb poisoning related to waterpipe smoking has distinctive features. Syncope is a commonly associated presentation that should solicit a focused social history in communities where waterpipe smoking is common. Furthermore, CO-Hb poisoning should remain on the differential in patients presenting with headache, syncope, dizziness, vomiting or shortness of breath, even outside of the non-waterpipe exposure peaks of winter season.

Secular trends in the incidence and severity of injuries sustained by riders of electric bikes and powered scooters: The experience of a level 1 adult trauma center

BACKGROUND

The incidence of injuries caused by electric bicycles (E-bikes) and powered scooters (P-scooters) continues to increase. Data on the severity of those injuries is conflicting. The purpose of this study was to explore secular trends in the incidence and severity characteristics of patients following E-bike and P-scooter injuries and predictors for major trauma.

METHODS

A retrospective cohort study of patients aged ≥16 years following E-bike and P-scooter injuries was performed at a level 1-trauma center between 2017 and 2022. We explored secular trends in major trauma cases (primary outcome), emergency department (ED) visits, hospitalizations, and surgical interventions (secondary outcomes). Major trauma was defined by either an injury severity score (ISS) >15 or the patient's need for acute care, defined by any of the following: Intensive care unit admission, direct disposition to the operating room, acute interventions performed in the trauma room, and in-hospital death. Primary and secondary outcomes were compared between two time frames (2017-2018 vs.2019-2022).

RESULTS

In total, 9748 patients were presented following P-scooter and E-bike injuries. Of them, 1183 patients (12.1%) were hospitalized (854 males [72.2%],median age 33 years, median ISS 9).During the study period, the number of ED visits increased by 21-fold, with a parallel increase hospitalizations and surgical interventions numbers, which increased by 3.4-and 3.8-fold, respectively. Numbers of patients with ISSs >15 and patients who required acute care sharply increased during the study period, but no significant differences were found in the percentages of patients with ISSs >15 (p = 0.78) or patients' need for acute care (p = 0.32) between early and late periods. A severity analysis revealed that male sex (adjusted odds ratio [aOR] 1.7 [95% confidence interval (CI): 1.2-2.4], p = 0.001) and E-bike riders compared to P-scooter riders (aOR 1.5 [95% CI:1.1-2.0], p = 0.005) were independent predictors for severe trauma.

CONCLUSIONS

The incidence of E-bike and P-scooter injuries sharply increased over time, with a parallel elevation in numbers of hospitalizations, surgical interventions, and major trauma cases. Major trauma percentages did not increase during the study period. Male sex and E-bikes emerged as independent predictors for major trauma.

Differentiating hidradenitis suppurativa flare from infection in the emergency department and recommendations for transitioning care to the outpatient setting

Hidradenitis suppurativa is a painful and often progressive inflammatory skin condition that presents with papules, nodules, abscesses, and tunnels in the axillary, inframammary and anogenital regions. HS can be difficult to differentiate from a skin infection, such as a bacterial abscess. However, differentiation between the two is important as management of hidradenitis suppurativa often requires long-term follow-up and specialist care. Emergency physicians should be aware of how to differentiate acute hidradenitis suppurativa flares from similarly presenting conditions, particularly skin and soft tissue infection, when encountered in the emergency department and what steps should be taken to adequately bridge care to the outpatient setting.

Partial pressure of carbon dioxide/pH interaction and its association with mortality among patients mechanically ventilated in the emergency department

OBJECTIVES

There is currently conflicting data as to the effects of hypercapnia on clinical outcomes among mechanically ventilated patients in the emergency department (ED). These conflicting results may be explained by the degree of acidosis. We sought to test the hypothesis that hypercapnia is associated with increased in-hospital mortality and decreased ventilator-free days at lower pH, but associated with decreased in-hospital mortality and increased ventilator-free days at higher pH, among patients requiring mechanical ventilation in the emergency department (ED).

METHODS

Secondary analysis of patient level data from prior clinical trials and cohort studies that enrolled adult patients who required mechanical ventilation in the ED. Patients who had a documented blood gas while on mechanical ventilation in the ED were included in these analyses. The primary outcome was in-hospital mortality, and secondary outcome was ventilator-free days. Mixed-effects logistic, linear, and survival-time regression models were used to test if pH modified the association between partial pressure of carbon dioxide (pCO2) and outcome measures.

RESULTS

Of the 2348 subjects included, the median [interquartile range (IQR)] pCO2 was 43 (35-54) and pH was 7.31 (7.22-7.39). Overall, in-hospital mortality was 27%. We found pH modified the association between pCO2 and outcomes, with higher pCO2 associated with increased probability of in-hospital mortality when pH is below 7.00, and decreased probability of in-hospital mortality when pH is above 7.10. These results remained consistent across multiple sensitivity and subgroup analyses. A similar relationship was found with ventilator-free days.

CONCLUSIONS

Higher pCO2 is associated with decreased mortality and greater ventilator-free days when pH is >7.10; however, it is associated with increased mortality and fewer ventilator-free days when the pH is below 7.00. Targeting pCO2 based on pH in the ED may be a potential intervention target for future clinical trials to improve clinical outcomes.

Telephone follow-up by nurse practitioners of geriatric patients discharged from the emergency department after traumatic injury

INTRODUCTION

Geriatric patients discharged from the emergency department (ED) after an injury are at risk for adverse outcomes. Older patients are at a higher risk for sensory impairments and cognitive problems which can make comprehension of discharge instructions more difficult. Moreover, geriatric patients often have limited skills with or access to alternative sources of information, such as hospital web pages or phone applications, which could put them at a higher risk of undertreatment. Implementing telephone follow-up after discharge presents a potential solution to enhance information transfer and address problems related to the injury.

METHODS

An exploratory cohort study was conducted in the ED of an inner-city hospital in the Netherlands between 2019-2020. Patients ≥70 years were included if they presented with an injury and were discharged home from the ED. Telephone follow-up was performed by an ED nurse practitioner within 48 hours after discharge to address any problems or questions relating to the injury. Feasibility was assessed by determining whether the intervention could be performed within the allotted time period during normal work hours (1 h per day). The frequency and type of additional advice given, as well as patient satisfaction with the intervention, were documented.

RESULTS

635 patients were eligible for inclusion, and 266 completed the intervention (median age 77 years; 32 % male). Nurse practitioners were able to complete the intervention on over 90 % of days. A total of 64 % of patients received additional advice during the telephone call, mostly related to pain medication adjustments and instructions to contact their GP. Patient satisfaction with the intervention was high (median score 8/10).

CONCLUSION

Telephone follow-up is a feasible intervention that may be able to enhance older patients' comprehension of discharge instructions and help identify new problems after discharge. During the follow-up call, the majority of patients received additional advice, indicating a potential demand for this intervention. The main limitation was that not all eligible patients were approached or did not want to participate in the intervention. Future studies should investigate whether telephone follow-up can effectively reduce adverse events and improve the quality of life for these patients.

Pilot intervention to increase uptake of lung cancer screening through the emergency department

INTRODUCTION

The goal of this study is to demonstrate the feasibility of referring patients for lung cancer screening (LCS) from the emergency department (ED) as a method to increase the uptake of LCS.

METHODS

This is a single-arm pilot study at a large safety-net ED. ED LCS-eligible patients were offered a referral to our LCS clinic upon ED discharge. The primary outcome was the frequency at which patients connected with the LCS clinic.

RESULTS

During the study period, 105 patients were approached; 26 (24.8%) participated. Reasons for non-enrollment include 29 (27.6%) who were not interested in research, 10 (9.5%) who did not speak English, and 40 (38.1%) who did not meet the pack-years criteria. Seventeen patients (65.4%, 17/26) connected with the LCS clinic, with 10 (38.5%) having been seen in the clinic and received a low dose computed tomography (LDCT) scan. Of the 17 that were connected with the clinic, 7 (26.9%) had a non-LDCT chest CT scan in the past year. Of those that were not seen in the clinic (n = 9), 4 (44.4%) were unreachable via 3 phone calls and a post-marked letter, and 3 (33.3%) did not attend the scheduled appointment, and 2 (22.2%) were delayed due to COVID-19. Of those that had CT scans over the study period (n = 17), 0 scans were normal, one patient (5.9%) had asymptomatic lung cancer, 7 (41.2%) had pulmonary nodules, 11 (64.7%) had emphysema, and 9 (52.9%) had coronary artery disease.

CONCLUSION

This pilot study suggests the feasibility and suggests initial indications of the efficacy of referring ED patients for LCS.

Clinical Characteristics and Appropriateness of Investigations in Children With Headaches at the Emergency Department

BACKGROUND

Identifying the cause of headaches in pediatric emergency departments (PEDs) can be challenging due to the lack of comprehensive research. This study aims to identify the frequency, characteristics, and unnecessary diagnostic procedures of patients with headaches in the PED setting.

METHODS

A six-month cross-sectional study was conducted at the PED of Alexandria University Children's Hospital, including all children with headaches. Children were classified as having primary headache (PH), secondary benign headache (SBH), and secondary serious headache (SSH) according to predetermined criteria. Logistic regression was employed to analyze the risk factors associated with SSH.

RESULTS

A total of 164 visits to the PED were recorded, out of a total of 22,662 visits, accounting for approximately 0.72% of all visits and 1.17% of the total number of children admitted. PH was the most common cause, accounting for 61.0% of cases, followed by SSH with 24.4%, whereas SBH was the least common with 13.4%. Abnormal neurological examination (odds ratio, 53.752 [1.628 to 1774.442], P = 0.026∗) was found to have a strong and statistically significant association with SSH in the multivariate analysis. Regarding the appropriateness of the investigations conducted, it was found that over half (66.5%) of the cases had unnecessary neuroimaging, with 52% of these cases being children with PH.

CONCLUSIONS

Headaches in children are commonly reported during visits to the PED. PH was the most prevalent, followed by SSH, whereas SBH was the least common. Many of the children received inaccurate first diagnoses and performed unnecessary laboratory tests, neuroimaging, and other tests, mostly electroencephalography.

Utility of non-invasive monitoring of exhaled carbon dioxide and perfusion index in adult patients in the emergency department

BACKGROUND

Several noninvasive solutions are available for the assessment of patients at risk of deterioration. Capnography, in the form of end-tidal exhaled CO2 (ETCO2) and perfusion index (PI), could provide relevant information about patient prognosis. The aim of the present project was to determine the association of ETCO2 and PI with mortality of patients admitted to the emergency department (ED).

METHODS

Multicenter, prospective, cohort study of adult patients with acute disease who needed continuous monitoring in the ED. The study included two tertiary hospitals in Spain between October 2022 and June 2023. The primary outcome of the study was in-hospital mortality (all-cause). Demographics, vital signs, ETCO2 and PI were collected.

RESULTS

A total of 687 patients were included in the study. The in-hospital mortality rate was 6.8%. The median age was 79 years (IQR: 69-86), and 63.3% were males. The median ETCO2 value was 30 mmHg (26-35) in survivors and 23 mmHg (16-30) in nonsurvivors (p = 0.001). For the PI, the medians were 4.7% (2.8-8.1) for survivors and 2.5% (0.98-4-4) for nonsurvivors (p < 0.001). The model that presented the best AUC was age (odds ratio (OR): 1.02 (1.00-1.05)), the respiratory rate (OR: 1.06 (1.02-1.11)), and the PI (OR: 0.83 (0.75-0.91)), with a result of 0.840 (95% CI: 0.795-0.886); the model with the respiratory rate (OR: 1.05 (1.01-1.10)), the PI (OR: 0.84 (0.76-0.93)), and the ETCO2 (no statistically significant OR), with an AUC of 0.838 (95% CI: 0.787-0.889).

CONCLUSIONS

The present study showed that the PI and respiratory rate are independently associated with in-hospital mortality. Both the PI and ETCO2 are predictive parameters with improved prognostic performance compared with that of standard vital signs.

Acute Heart Failure: From The Emergency Department to the Intensive Care Unit

Acute heart failure (AHF) is a frequent cause of hospitalization around the world and is associated with high in-hospital and post-discharge morbidity and mortality. This review summarizes data on diagnosis and management of AHF from the emergency department to the intensive care unit. While more evidence is needed to guide risk stratification and care of patients with AHF, hospitalization is a key opportunity to optimize evidence-based medical therapy for heart failure. Close linkage to outpatient care is essential to improve post-hospitalization outcomes.

Predictive factors of basic palliative and hospice care among patients with cancer visiting the emergency department in a Hungarian tertiary care center

Introduction

Patients with advanced cancer tend to utilize the services of the health care system, particularly emergency departments (EDs), more often, however EDs aren't necessarily the most ideal environments for providing care to these patients. The objective of our study was to analyze the clinical and demographic characteristics of advanced patients with cancer receiving basic palliative care (BPC) or hospice care (HC), and to identify predictive factors of BPC and HC prior to their visit to the ED, in a large tertiary care center in Hungary.

Methods

A retrospective, detailed analysis of patients receiving only BPC or HC, out of 1512 patients with cancer visiting the ED in 2018, was carried out. Sociodemographic and clinical data were collected via automated and manual chart review. Patients were followed up to determine length of survival. Descriptive and exploratory statistical analyses were performed.

Results

Hospital admission, multiple (≥4x) ED visits, and respiratory cancer were independent risk factors for receiving only BPC (OR: 3.10, CI: 1.90-5.04; OR: 2.97, CI: 1.50-5.84; OR: 1.82, CI: 1.03-3.22, respectively), or HC (OR: 2.15, CI: 1.26-3.67; OR: 4.94, CI: 2.51-9.71; OR: 2.07, CI: 1.10-3.91). Visiting the ED only once was found to be a negative predictive factor for BPC (OR: 0.28, CI: 0.18-0.45) and HC (OR: 0.18, 0.10-0.31) among patients with cancer visiting the ED.

Conclusions

Our study is the first from this European region to provide information regarding the characteristics of patients with cancer receiving BPC and HC who visited the ED, as well as to identify possible predictive factors of receiving BPC and HC. Our study may have relevant implications for health care planning strategies in practice.

Predictors of 30-day recurrent emergency department visits for hyperglycemia in patients with types 1 and 2 diabetes: a population-based cohort study

OBJECTIVES

This study's aims were to describe the outcomes of patients with diabetes presenting with their first ED visit for hyperglycemia, and to identify predictors of recurrent ED visits for hyperglycemia.

METHODS

Using linked databases, we conducted a population-based cohort study of adult and pediatric patients with types 1 and 2 diabetes presenting with a first ED visit for hyperglycemia from April 2010 to March 2020 in Ontario, Canada. We determined the proportion of patients with a recurrent ED visit for hyperglycemia within 30 days of the index visit. Using multivariable regression analysis, we examined clinical and socioeconomic predictors for recurrent visits.

RESULTS

There were 779,632 patients with a first ED visit for hyperglycemia. Mean (SD) age was 64.3 (15.2) years; 47.7% were female. 11.0% had a recurrent visit for hyperglycemia within 30 days. Statistically significant predictors of a recurrent visit included: male sex, type 1 diabetes, regions with fewer visible minority groups and with less education or employment, higher hemoglobin A1C, more family physician or internist visits within the past year, being rostered to a family physician, previous ED visits in the past year, ED or hospitalization within the previous 14 days, access to homecare services, and previous hyperglycemia encounters in the past 5 years. Alcoholism and depression or anxiety were positive predictors for the 18-65 age group.

CONCLUSIONS

This population-level study identifies predictors of recurrent ED visits for hyperglycemia, including male sex, type 1 diabetes, regions with fewer visible minority groups and with less education or employment, higher hemoglobin A1C, higher previous healthcare system utilization (ED visits and hospitalization) for hyperglycemia, being rostered to a family physician, and access to homecare services. Knowledge of these predictors may be used to develop targeted interventions to improve patient outcomes and reduce healthcare system costs.

A retrospective audit of adult and paediatric anaphylaxis management from two Australian metropolitan mixed emergency departments

BACKGROUND

Anaphylaxis is a potentially life-threatening allergic reaction, with presentations to emergency departments (EDs) increasing across Australia. Understanding the features of those presenting with anaphylaxis and aspects related to its optimal clinical management across the admission, treatment and discharge settings is needed to minimise its impact. We aimed to evaluate the nature and management of presentations related to anaphylaxis across two Australian EDs.

METHODS

Retrospective audit of paediatric and adult patients presenting to a community or tertiary level ED with anaphylaxis from 1 May 2018 to 30 April 2019. Data extracted from medical records included demographic characteristics, causative agents, clinical features, treatments administered across community, ambulance or ED settings, as well as post-discharge care arrangements including provision of Adrenaline Auto-Injector (AAI) and Allergy/Anaphylaxis Action Plan (AAP).

RESULTS

A total of 369 (107 paediatric and 262 adult) ED presentations were identified. A total of 94 (36%) adult and 46 (43%) paediatric patients received pre-hospital adrenaline, with a further 91 (35%) adult and 29 (27%) paediatric patients receiving a dose of adrenaline in the ED. The most commonly administered treatment in ED were corticosteroids, given to 157 (60%) adult and 55 (51%) paediatric patients. Among those requiring an AAI for discharge, 123/210 (59%) adult and 57/91 (63%) of paediatric patients left hospital with an AAI. In contrast, among those requiring an allergy/anaphylaxis action plan (AAP) on discharge, 61/206 (30%) adult and 30/90 (33%) of paediatric patients left hospital with one. Factors associated with an increased likelihood of receiving AAI on discharge in paediatric and adult patients included receipt of any adrenaline, receipt of two or more doses of adrenaline, and longer duration of hospital stay. Adults presenting within business hours were more likely to be discharged with AAI, but no such difference was observed for paediatric patients. Similar findings were evident for provision of AAP on discharge.

CONCLUSION

These findings demonstrate the need to improve assessment and treatment in the ED. In particular, the observed large variability in provision of AAI and AAP on discharge presents opportunities to explore strategies to improve awareness and provision of these critical components of post-discharge care.

Factors associated with repeat emergency department visits for mental health care in adolescents: A scoping review

OBJECTIVES

The aim of this review was to identify factors associated with multiple visits to emergency department (ED) services for mental health care in adolescents.

METHODS

Electronic databases (MEDLINE, PsycINFO, Embase, CINAHL, Web of Science and ProQuest Dissertations & Thesis Global) were searched for evidence that presented an association between risk factors or correlates of multiple visits to the emergency departmental for mental health care by 10-24 year olds. High impact use was defined as at least one return ED visit for mental health care. Primary studies of any quantitative design were included, with no exclusions based on language or country and all possible risk factors were considered. Data were extracted and synthesised using quantitative methods; frequencies of positive, negative and null associations were summarised for categories of potential risk factors.

RESULTS

Sixty-five studies were included in the review. Most studies were from North America and reported a wide range of measures of high impact ED use, the most common being a binary indicator of multiple ED visits. Sex/gender and age were the most frequently reported risk factors. Measure of previous or concurrent access to mental health care was consistently positively associated with high impact use. Having private health insurance, compared with public or no insurance, was generally negatively associated with high impact use. Proxy measures of socioeconomic position (SEP) showed associations between lower SEP and more high impact use in a small number of studies. No other factors were consistently or uniformly associated with high impact use.

CONCLUSIONS

The review identified a substantial evidence base but due to the variability in study design and measurement of both risk factors and outcomes, no consistent risk factors emerged. More research is needed, particularly outside North America, using robust methods and high quality routinely collected data.

Diagnostic and prognostic significance of apelin-13, APJ for sepsis in the emergency department: A prospective study

Objectives

This study aimed to assess the diagnostic, risk stratification, and prognostic capabilities of apelin-13 and APJ in comparison to procalcitonin (PCT) for septic patients presenting to the emergency department (ED).

Methods

Two hundred and thirty-eight patients meeting the Third International Consensus Definition (Sepsis-3) criteria were enrolled from Beijing Chaoyang Hospital's ED, along with a control group of forty healthy individuals. Patients were categorized into two groups based on disease severity: those with sepsis or septic shock. Plasma levels of apelin-13, CD4+ Th cells, and PCT were measured. The expression levels of plasma APJ mRNA were quantified using real-time fluorescence quantitative PCR (RT-qPCR) methodology. The Sequential Organ Failure Assessment (SOFA) score was determined at the time of enrollment. The prognostic values of apelin-13 and APJ was evaluated in comparison to that of PCT and the SOFA score. All patients were followed up for a duration of 28 days.

Results

The plasma concentrations of apelin-13 and APJ exhibited a positive correlation with the severity of sepsis, while the number of CD4+ T cells decreased in septic patients. The areas under the receiver operating characteristic (AUC) curves for apelin-13 and APJ in the diagnosis and prediction of 28-day mortality were greater than that of PCT. In non-survivors at the 28-day follow-up, the plasma levels of apelin-13 and APJ were significantly higher compared to survivors. Furthermore, apelin-13 levels were notably higher in cases of sepsis-induced cardiomyopathy (SICM) than in those without SICM. Apelin-13 and APJ emerged as independent predictors of 28-day mortality among septic patients.

Conclusions

Apelin-13 and APJ demonstrate value in the assessment of risk stratification, early diagnosis, and prognosis of sepsis in the ED. Apelin-13 also proves to be an effective biomarker for assessing the prognosis of SICM in the ED. Sepsis may lead to immune function suppression.

Predictive performance of NEWS and qSOFA in immunocompromised sepsis patients at the emergency department

PURPOSE

Sepsis has a high incidence and a poor prognosis. Early recognition is important to facilitate timely initiation of adequate care. Sepsis screening tools, such as the (quick) Sequential Organ Failure Assessment ((q)SOFA) and National Early Warning Score (NEWS), could help recognize sepsis. These tools have been validated in a general immunocompetent population, while their performance in immunocompromised patients, who are particularly at risk of sepsis development, remains unknown.

METHODS

This study is a post hoc analysis of a prospective observational study performed at the emergency department. Inclusion criteria were age ≥ 18 years with a suspected infection, while ≥ two qSOFA and/or SOFA criteria were used to classify patients as having suspected sepsis. The primary outcome was in-hospital mortality.

RESULTS

1516 patients, of which 40.5% used one or more immunosuppressives, were included. NEWS had a higher prognostic accuracy as compared to qSOFA for predicting poor outcome among immunocompromised sepsis patients. Of all tested immunosuppressives, high-dose glucocorticoid therapy was associated with a threefold increased risk of both in-hospital and 28-day mortality.

CONCLUSION

In contrast to NEWS, qSOFA underestimates the risk of adverse outcome in patients using high-dose glucocorticoids. As a clinical consequence, to adequately assess the severity of illness among immunocompromised patients, health care professionals should best use the NEWS.

Development and validation of a nomogram for assessing comorbidity and frailty in triage: a multicentre observational study

Assessing patient frailty in the Emergency Department (ED) is crucial; however, triage frailty and comorbidity assessment scores developed in recent years are unsatisfactory. The underlying causes of this phenomenon could reside in the nature of the tools used, which were not designed specifically for the emergency context and, thus, are difficult to adapt to the emergency environment. The objective of this study was to create and internally validate a nomogram for identifying different levels of patient frailty during triage. Multicenter, prospective, observational exploratory study conducted in two ED. The study was conducted from April 1 to October 31, 2022. Following the triage assessment, the nurse collected variables related to the patient's comorbidities and chronic conditions using a predefined form. The primary outcome was the 90-day mortality rate. A total of 1345 patients were enrolled in this study; 6% died within 90 days. In the multivariate analysis, the Charlson Comorbidity Index, an altered motor condition, an altered cognitive condition, an autonomous chronic condition, arrival in an ambulance, and a previous hospitalization within 90 days were independently associated with death. The internal validation of the nomogram reported an area under the receiver operating characteristic of 0.91 (95% CI 0.884-0.937). A nomogram was created for assessing comorbidity and frailty during triage and was demonstrated to be capable of determining comorbidity and frailty in the ED setting. Integrating a tool capable of identifying frail patients at the first triage assessment could improve patient stratification.

From Tragedy to Resilience in a University Hospital: Characteristics of Patients in the Aftermath of the 2023 Turkey Earthquake

OBJECTIVE

This study focuses on adults affected by the February 2023 Turkey earthquakes, aiming to uncover demographic and clinical traits.

METHODS

A retrospective analysis of data from adult patients who sought emergency care between February 6 and February 21, 2023, following the earthquakes, was conducted.

RESULTS

Among 3072 patients, 1544 (50.3%) of whom were women, trauma (31.1%) was the most prevalent cause of emergency department presentations. The median age of all patients was 44 y (interquartile range [IQR] 31-61 y). Hatay province accounted for 65.2% of trauma patients as origin. Most of the patients (66.8%) presented to the emergency department by their own means, while this was opposite for trauma patients, of whom 54.5% was transferred by means of Ambulance Service. Half of the total trauma patients were rescued from the debris, and 75.9% sustained limb injuries. Crush syndrome affected 24.7%, and emergency hemodialysis was performed on 9.1%, whereas emergency surgery was performed on 22.8% of all trauma cases. Overall, 10.2% of trauma patients lacked any identification. The rate of emergency department admittions due to respiratory and cardiovascular diseases was higher at the time of the earthquake compared with the previous year (P < 0.001).

CONCLUSIONS

The insights gained from this study hold valuable implications for disaster response strategies, emphasizing the importance of preparedness, timely intervention, and comprehensive patient care.

Anaphylaxis: first clinical presentation, subsequent referral practise, and suspected elicitor-an observational study

Anaphylaxis is an allergic manifestation characterised by rapid onset and progression. Rapid treatment may be challenging in patients with atypical symptoms or no previous history of anaphylaxis. This study aimed to describe the clinical prehospital presentation of first-time anaphylactic patients. To help target educational initiatives, we sought to identify which groups of medical professionals are most likely to encounter first-time anaphylactic patients and investigated the referral pattern for suspected anaphylactic patients for specialised treatment. A retrospective register-based study from the Region of Southern Denmark. Patients referred to the Allergy Centre, Odense University Hospital, from 2019 to 2021 were included. The medical records were manually reviewed for first contact with the emergency departments or the emergency medical service. 444 patients with suspected anaphylaxis were referred. 226 patients had grade 3-5 systemic allergic reactions as classified by the World Allergy Organisation; 90% had cutaneous symptoms, 63% symptoms from the central nervous system, 42% gastrointestinal symptoms, 40% cardiovascular symptoms, 36% had upper-airway symptoms, and 36% had lower-airway symptoms. Patients treated prehospitally had a significantly more severe degree of anaphylaxis than patients only treated within the hospital. More than half of the patients with suspected anaphylaxis were referred to the Allergy Centre from the emergency departments. Patients with allergies progressing to severe anaphylaxis most often are treated prehospitally before transport to emergency departments. From the emergency departments, they are referred to the allergy centre. Education concerning the immediate treatment of severe anaphylaxis should primarily be targeted towards prehospital care providers.

Free-for-all: Does crowding impact outcomes because hospital emergency departments do not prioritise effectively?

Unexpected peaks in volumes of attendances at hospital emergency departments (EDs) have been found to affect waiting times, intensity of care and outcomes. We ask whether these effects of ED crowding on patients are caused by poor clinical prioritisation or a quality-quantity trade-off generated by a binding capacity constraint. We study the effects of crowding created by lower-severity patients on the outcomes of approximately 13 million higher-severity patients attending the 140 public EDs in England between April 2016 and March 2017. Our identification approach relies on high-dimensional fixed effects to account for planned capacity. Unexpected demand from low-severity patients has very limited effects on the care provided to higher-severity patients throughout their entire pathway in ED. Detrimental effects of crowding caused by low-severity patients materialise only at very high levels of unexpected demand, suggesting that binding resource constraints impact patient care only when demand greatly exceeds the ED's expectations. These effects are smaller than those caused by crowding induced by higher-severity patients, suggesting an efficient prioritisation of incoming patients in EDs.

Prognostic value of cognitive impairment, assessed by the Clock Drawing Test, in emergency department patients presenting with non-specific complaints

BACKGROUND

Cognitive impairment (CI) is common among older patients presenting to the emergency department (ED). The failure to recognize CI at ED presentation constitutes a high risk of additional morbidity, mortality, and functional decline. The Clock Drawing Test (CDT) is a well-established cognitive screening test.

AIM

In patients presenting to the ED with non-specific complaints (NSCs), we aimed to investigate the usability of the CDT and its prognostic value regarding length of hospital stay (LOS) and mortality.

METHOD

Secondary analysis of the Basel Non-specific Complaints (BANC) trial, a prospective delayed type cross-sectional study with a 30-day follow-up. In three EDs, patients presenting with NSCs were enrolled. The CDT was administered at enrollment.

RESULTS

In the 1,278 patients enrolled, median age was 81 [74, 87] years and 782 were female (61.19%). A valid CDT was obtained in 737 (57.7%) patients. In patients without a valid CDT median LOS was higher (29 [9, 49] days vs. 22 [9, 45] days), and 30-day mortality was significantly higher than in patients with a valid CDT (n = 45 (8.32%) vs. n = 39 (5.29%)). Of all valid CDTs, 154 clocks (20.9%) were classified as normal, 55 (7.5%) as mildly deficient, 297 (40.3%) as moderately deficient, and 231 (31.3%) as severely deficient. Mortality and LOS increased along with the CDT deficits (p = 0.012 for 30-day mortality; p < 0.001 for LOS).

CONCLUSION

The early identification of patients with CI may lead to improved patient management and resource allocation. The CDT could be used as a risk stratification tool for older ED patients presenting with NSCs, as it is a predictor for 30-day mortality and LOS.

Development and Implementation of a Pediatric Nursing Emergency Behavioral Health Assessment Tool

INTRODUCTION

The national pediatric mental and behavioral health crisis dramatically increased emergency department mental and behavioral health visits and changed emergency nursing practice. Acuity assessment determines patient severity level and supports appropriate resources and interventions. There are no established nursing tools that assess pediatric mental or behavioral health acuity in the emergency department setting. Our goal was to develop and implement the novel pediatric emergency nurse Emergency Behavioral Health Acuity Assessment Tool.

METHODS

This quality-improvement project used the plan, do, study, act model to design/refine the Emergency Behavioral Health Acuity Assessment Tool and a non-experimental descriptive design to assess outcomes. The setting was a 47-bed urban level 1 pediatric trauma center with more than 60,000 annual visits. The team designed the tool using published evidence, emergency nurse feedback, and expert opinion. The tool objectively captured patient acuity and suggested acuity-specific nursing interventions. Project outcomes included acuity, length-of-stay, restraint use, and patient/staff injuries. Analyses included descriptive statistics and correlations.

RESULTS

With over 3000 annual mental/behavioral-related visits, the emergency department had an average daily census of 23 mental and behavioral health patients. Implementation occurred in August 2021. The Emergency Behavioral Health Acuity Assessment Tool dashboard provided the number of patients, patient location, and acuity. Length-of-stay did not change; however, patient restraint use and patient/staff injuries declined. Number of restraints positively correlated with moderate acuity levels (r = 0.472, P = 0.036).

DISCUSSION

For emergency nurses, the Emergency Behavioral Health Acuity Assessment Tool provided an objective measure of patient acuity. Targeted interventions can improve the care of this population.

How much time do emergency department physicians spend on medication-related tasks? A time- and-motion study

BACKGROUND

Medication-related problems are an important cause of emergency department (ED) visits, and medication errors are reported in up to 60% of ED patients. Procedures such as medication reconciliation and medication review can identify and prevent medication-related problems and medication errors. However, this work is often time-consuming. In EDs without pharmacists, medication reconciliation is the physician's responsibility, in addition to the primary assignments of examining and diagnosing the patient. The aim of this study was to identify how much time ED physicians spend on medication-related tasks when no pharmacists are present in the EDs.

METHODS

An observational time-and-motion study of physicians in three EDs in Northern Norway was conducted using Work Observation Method by Activity Timing (WOMBAT) to collect and time-stamp data. Observations were conducted in predefined two-hour observation sessions with a 1:1 relationship between observer and participant, during Monday to Friday between 8 am and 8 pm, from November 2020 to October 2021.

RESULTS

In total, 386 h of observations were collected during 225 observation sessions. A total of 8.7% of the physicians' work time was spent on medication-related tasks, of which most time was spent on oral communication about medications with other physicians (3.0%) and medication-related documentation (3.2%). Physicians spent 2.2 min per hour on medication reconciliation tasks, which includes retrieving medication-related information directly from the patient, reading/retrieving written medication-related information, and medication-related documentation. Physicians spent 85.6% of the observed time on non-medication-related clinical or administrative tasks, and the remaining time was spent standby or moving between tasks.

CONCLUSION

In three Norwegian EDs, physicians spent 8.7% of their work time on medication-related tasks, and 85.6% on other clinical or administrative tasks. Physicians spent 2.2 min per hour on tasks related to medication reconciliation. We worry that patient safety related tasks in the EDs receive little attention. Allocating dedicated resources like pharmacists to contribute with medication-related tasks could benefit both physicians and patients.

Computed tomography in patients with sepsis presenting to the emergency department: exploring its role in light of patient outcomes

OBJECTIVES

This study aimed to explore the role of CT in septic patients presenting to the emergency department (ED).

MATERIALS AND METHODS

We performed a retrospective secondary analysis of 192 septic patients from a prospective observational study, i.e., the "LIFE POC" study. Sepsis was diagnosed in accordance with the Sepsis-3 definition. Clinical and radiological data were collected from the hospital administration and radiological systems. Information on mortality and morbidity was collected. Time-to-CT between CT scan and sepsis diagnosis (ttCTsd) was calculated. Diagnostic accuracy was assessed with the final sepsis source as reference standard. The reference standard was established through the treating team of the patient based on all available clinical, imaging, and microbiological data.

RESULTS

Sixty-two of 192 patients underwent a CT examination for sepsis focus detection. The final septic source was identified by CT in 69.4% (n = 43). CT detected septic foci with 81.1% sensitivity (95% CI, 68.0-90.6%) and 55.6% specificity (95% CI, 21.2-86.3%). Patients with short versus long ttCTsd did not differ in terms of mortality (16.1%, n = 5 vs 9.7, n = 3; p = 0.449), length of hospital stay (median 16 d, IQR 9 d 12 h-23 d 18 h vs median 13 d, IQR 10 d 00 h-24 d 00 h; p = 0.863), or duration of intensive care (median 3d 12 h, IQR 2 d 6 h-7 d 18 h vs median 5d, IQR 2 d-11 d; p = 0.800).

CONCLUSIONS

Our findings show a high sensitivity of CT in ED patients with sepsis, confirming its relevance in guiding treatment decisions. The low specificity suggests that a negative CT requires further ancillary diagnostic tests for focus detection. The timing of CT did not affect morbidity or mortality outcomes.

CLINICAL RELEVANCE STATEMENT

In patients with sepsis who present to the ED, CT can be used to identify infectious foci on the basis of clinical suspicion, but should not be used as a rule-out test. Scientific evidence for the optimal timing of CT beyond clinical decision-making is currently missing, as potential mortality benefits are clouded by differences in clinical severity at the time of ED presentation.

KEY POINTS

• In patients with sepsis who present to the ED, CT for focus identification has a high sensitivity and can thereby be valuable for patient management. • As the specificity is considerably lower, a thorough microbiological assessment is important in these cases. • The timing of CT did not affect morbidity and mortality outcomes in this study, which might be due to variability in clinical severity at the time of ED presentation.

Characterization of peer support services for substance use disorders in 11 US emergency departments in 2020: findings from a NIDA clinical trials network site selection process

INTRODUCTION

Emergency departments (ED) are incorporating Peer Support Specialists (PSSs) to help with patient care for substance use disorders (SUDs). Despite rapid growth in this area, little is published regarding workflow, expectations of the peer role, and core components of the PSS intervention. This study describes these elements in a national sample of ED-based peer support intervention programs.

METHODS

A survey was conducted to assess PSS site characteristics as part of site selection process for a National Institute on Drug Abuse (NIDA) Clinical Trials Network (CTN) evaluating PSS effectiveness, Surveys were distributed to clinical sites affiliated with the 16 CTN nodes. Surveys were completed by a representative(s) of the site and collected data on the PSS role in the ED including details regarding funding and certification, services rendered, role in medications for opioid use disorder (MOUD) and naloxone distribution, and factors impacting implementation and maintenance of ED PSS programs. Quantitative data was summarized with descriptive statistics. Free-text fields were analyzed using qualitative content analysis.

RESULTS

A total of 11 surveys were completed, collected from 9 different states. ED PSS funding was from grants (55%), hospital funds (46%), peer recovery organizations (27%) or other (18%). Funding was anticipated to continue for a mean of 16 months (range 12 to 36 months). The majority of programs provided "general recovery support (81%) Screening, Brief Intervention, and Referral to Treatment (SBIRT) services (55%), and assisted with naloxone distribution to ED patients (64%). A minority assisted with ED-initiated buprenorphine (EDIB) programs (27%). Most (91%) provided services to patients after they were discharged from the ED. Barriers to implementation included lack of outpatient referral sources, barriers to initiating MOUD, stigma at the clinician and system level, and lack of ongoing PSS availability due to short-term grant funding.

CONCLUSIONS

The majority of ED-based PSSs were funded through time-limited grants, and short-term grant funding was identified as a barrier for ED PSS programs. There was consistency among sites in the involvement of PSSs in facilitation of transitions of SUD care, coordination of follow-up after ED discharge, and PSS involvement in naloxone distribution.

Trends in emergency department visits during cold weather seasons among patients experiencing homelessness in Ontario, Canada: a retrospective population-based cohort study

PURPOSE

Recent anecdotal reports suggest increasing numbers of people experiencing homelessness are visiting emergency departments (EDs) during cold weather seasons due to inadequate shelter availability. We examined monthly ED visits among patients experiencing homelessness to determine whether there has been a significant increase in such visits in 2022/2023 compared to prior years.

METHODS

We used linked health administrative data to identify cohorts experiencing homelessness in Ontario between October and March of the 2018/2019 to 2022/2023 years. We analyzed the monthly rate of non-urgent ED visits as a proxy measure of visits plausibly attributable to avoidance of cold exposure, examining rates among patients experiencing homelessness compared to housed patients. We excluded visits for overdose or COVID-19. We assessed level and significance of change in the 2022/2023 year as compared to previous cold weather seasons using Poisson regression.

RESULTS

We identified a total of 21,588 non-urgent ED visits across the observation period among patients experiencing homelessness in Ontario. Non-urgent ED visits increased 27% (RR 1.24 [95% CI 1.14-1.34]) in 2022/2023 compared to previous cold weather seasons. In Toronto, such visits increased by 70% (RR 1.68 [95% CI 1.57-1.80]). Among housed patients, non-urgent ED visits did not change significantly during this time period.

CONCLUSION

Rates of ED visits plausibly attributable to avoidance of cold exposure by individuals experiencing homelessness increased significantly in Ontario in 2022/2023, most notably in Toronto. This increase in ED visits may be related to inadequate access to emergency shelter beds and warming services in the community.

Exploring differences in the utilization of the emergency department between migrant and non-migrant populations: a systematic review

BACKGROUND

Migrants face several barriers when accessing care and tend to rely on emergency services to a greater extent than primary care. Comparing emergency department (ED) utilization by migrants and non-migrants can unveil inequalities affecting the migrant population and pave the way for public health strategies aimed at improving health outcomes. This systematic review aims to investigate differences in ED utilization between migrant and non-migrant populations to ultimately advance research on migrants' access to care and inform health policies addressing health inequalities.

METHODS

A systematic literature search was conducted in March 2023 on the Pubmed, Scopus, and Web of Science databases. The included studies were limited to those relying on data collected from 2012 and written in English or Italian. Data extracted included information on the migrant population and the ED visit, the differences in ED utilization between migrants and non-migrants, and the challenges faced by migrants prior to, during, and after the ED visit. The findings of this systematic review are reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines.

RESULTS

After full-text review, 23 articles met the inclusion criteria. All but one adopted a quantitative methodology. Some studies reported a higher frequency of ED visits among migrants, while others a higher frequency among non-migrants. Migrants tend to leave the hospital against medical advice more frequently than the native population and present at the ED without consulting a general practitioner (GP). They are also less likely to access the ED via ambulance. Admissions for ambulatory care-sensitive conditions, namely health conditions for which adequate, timely, and effective outpatient care can prevent hospitalization, were higher for migrants, while still being significant for the non-migrant population.

CONCLUSIONS

The comparison between migrants' and non-migrants' utilization of the ED did not suggest a clear pattern. There is no consensus on whether migrants access EDs more or less than non-migrants and on whether migrants are hospitalized at a higher or lower extent. However, migrants tend to access EDs for less urgent conditions, lack a referral from a GP and access the ED as walk-ins more frequently. Migrants are also discharged against medical advice more often compared to non-migrants. Findings of this systematic review suggest that migrants' access to care is hindered by language barriers, poor insurance coverage, lack of entitlement to a GP, and lack of knowledge of the local healthcare system.

A retrospective study of CT scan utilization in the emergency department for patients presenting with seizures

BACKGROUND/AIM

The indications for neuroimaging in emergency department (ED) patients presenting with seizures have not been clearly defined. In this study, we aimed to investigate the findings that may influence the emergency management of patients with seizures undergoing brain computed tomography (CT) and the factors that influence these findings.

MATERIAL AND METHODS

This is a retrospective, single-center study. Patients presenting to the ED with seizures-both patients with diagnosed epilepsy and patients with first-time seizures-who underwent brain CT were included. Demographic information and indications for CT scans were recorded. According to the CT findings, patients were classified as having or not having significant pathology, and comparisons were made. Intracranial mass, intraparenchymal, subdural, and subarachnoid hemorrhage, fracture, and cerebral edema were considered significant pathologies.

RESULTS

This study included 404 patients. The most common reason for a CT scan was head trauma. A significant pathology was found on the CT scan in 5.4% of the patients. A regression analysis showed that hypertension, malignancy, and a prolonged postictal state were the predictive factors for significant pathology on CT.

CONCLUSION

CT scanning of patients presenting to the ED with seizures has a limited impact on emergency patient management. Clinical decision-making guidelines for emergency CT scanning of patients with seizures need to be reviewed and improved to identify zero/near-zero risk patients for whom imaging can be deferred.

ERASE: a feasible early warning tool for elder abuse, developed for use in the Dutch emergency department

BACKGROUND

Elder abuse is a worldwide problem with serious consequences for individuals and society. To effectively deal with elder abuse, a timely identification of signals as well as a systematic approach towards (suspected) elder abuse is necessary. This study aimed to develop and test the acceptability and appropriateness of ERASE (EldeR AbuSE) in the emergency department (ED) setting. ERASE is an early warning tool for elder abuse self-administered by the healthcare professional in patients ≥ 70 years.

METHODS

A systematic literature review was previously conducted to identify potential available instruments on elder abuse for use in the ED. Furthermore, a field consultation in Dutch hospitals was performed to identify practice tools and potential questions on the recognition of elder abuse that were available in clinical practice. Based on this input, in three subsequent rounds the ERASE tool was developed. The ERASE tool was tested in a pilot feasibility study in healthcare professionals (n = 28) working in the ED in three Dutch hospitals. A semi-structured online questionnaire was used to determine acceptability and appropriateness of the ERASE tool.

RESULTS

The systematic literature review revealed seven screening instruments developed for use in the hospital and/or ED setting. In total n = 32 (44%) hospitals responded to the field search. No suitable and validated instruments for the detection of elder abuse in the ED were identified. The ERASE tool was developed, with a gut feeling awareness question, that encompassed all forms of elder abuse as starting question. Subsequently six signalling questions were developed to collect information on observed signs and symptoms of elder abuse and neglect. The pilot study showed that the ERASE tool raised the recognition of healthcare professionals for elder abuse. The tool was evaluated acceptable and appropriate for use in the ED setting.

CONCLUSIONS

ERASE as early warning tool is guided by an initial gut feeling awareness question and six signalling questions. The ERASE tool raised the recognition of healthcare professionals for elder abuse, and was feasible to use in the ED setting. The next step will be to investigate the reliability and validity of the ERASE early warning tool.

Single intravenous dose ondansetron induces QT prolongation in adult emergency department patients: a prospective observational study

BACKGROUND

Ondansetron is one of the most commonly used drugs in the emergency department (ED) for treating nausea and vomiting, particularly in intravenous (IV) form. Nevertheless, it has been shown to prolong QT interval and increase the risk of ventricular dysrhythmias. This study evaluated the associations between single IV ondansetron dosage and subsequent QTc prolongation in the ED.

METHODS

In this prospective observational study, a total number of 106 patients presenting to the ED in a 3-month period with nausea and vomiting treated with IV ondansetron were enrolled. QT and QTc intervals were measured at baseline (QT0 and QTc0), and 60 min (QT60 and QTc60) following a single-dose administration of ondansetron at 4 or 8 mg doses. To evaluate the predictive ability of these variables, we employed receiver operating characteristic (ROC) curve analyses.

RESULTS

The predictive models for QTc prolongation 1-hour post-ondansetron administration showed the following: at baseline, the area under curve of 0.70 for QT, 0.71 for QTc, and 0.64 for dosage. Conversely, a QTc0 = 375 msec indicated a QTc60 > 480 msec with a specificity of 97%. Additionally, a QTc0 of 400 msec had a sensitivity of 100% in predicting a QTc60 < 480 msec, while a QTc0 > 460 msec predicted a QTc60 > 480 msec with a specificity of 98%. Moreover, 8 mg doses were associated with higher rates of QTc60 prolongation, while 4 mg doses favored maintaining QTc60 within normal limits.

CONCLUSIONS

Our study demonstrates the predictive capacity of QT0, QTc0, and ondansetron dosage in forecasting QTc60 prolongation (> 480 msec) post-ondansetron administration. These findings advocate for their incorporation into clinical protocols to enhance safety monitoring in adult ED patients.

Delirium screening in the emergency department: evaluation and intervention

BACKGROUND

Between 8-17% of older adults, and up to 40% of those arriving from nursing homes, present with delirium upon admission to the Emergency Department (ED). However, this condition often remains undiagnosed by ED medical staff. We investigated the prevalence of delirium among patients aged 65 and older admitted to the ED and assessed the impact of a prospective study aimed at increasing awareness.

METHODS

The study was structured into four phases: a "pre-intervention period" (T0); an "awareness period" (T1), during which information about delirium and its diagnosis was disseminated to ED staff; a "screening period" (T2), in which dedicated evaluators screened ED patients aged 65 and older; and a "post-intervention period" (T3), following the departure of the evaluators. Delirium screening was conducted using the Brief Confusion Assessment Method (bCAM) questionnaire.

RESULTS

During the T0 and T1 periods, the rate of delirium diagnosed by ED staff was below 1%. The evaluators identified a delirium rate of 14.9% among the screened older adults during the T2 period, whereas the rate among those assessed by ED staff was between 1.6% and 1.9%. Following the evaluators' departure in the T3 period, the rate of delirium diagnosis decreased to 0.89%.

CONCLUSIONS

This study underscores that a significant majority of older adult delirium cases remain undetected by ED staff. Despite efforts to increase awareness, the rate of diagnosis did not significantly improve. While the presence of dedicated delirium evaluators slightly increased the diagnosis rate among patients assessed by ED staff, this rate reverted to pre-intervention levels after the evaluators left. These findings emphasize the necessity of implementing mandatory delirium screening during ED triage and throughout the patient's stay.

The 'peptide for life' initiative in the emergency department study

AIMS

Natriuretic peptide (NP) uptake varies in Emergency Departments (EDs) across Europe. The 'Peptide for Life' (P4L) initiative, led by Heart Failure Association, aims to enhance NP utilization for early diagnosis of heart failure (HF). We tested the hypothesis that implementing an educational campaign in Western Balkan countries would significantly increase NP adoption rates in the ED.

METHODS AND RESULTS

This registry examined NP adoption before and after implementing the P4L-ED study across 10 centres in five countries: Bosnia and Herzegovina, Croatia, Montenegro, North Macedonia, and Serbia. A train-the-trainer programme was implemented to enhance awareness of NP testing in the ED, and centres without access received point-of-care instruments. Differences in NP testing between the pre-P4L-ED and post-P4L-ED phases were evaluated. A total of 2519 patients were enrolled in the study: 1224 (48.6%) in the pre-P4L-ED phase and 1295 (51.4%) in the post-P4L-ED phase. NP testing was performed in the ED on 684 patients (55.9%) during the pre-P4L-ED phase and on 1039 patients (80.3%) during the post-P4L-ED phase, indicating a significant absolute difference of 24.4% (95% CI: 20.8% to 27.9%, P < 0.001). The use of both NPs and echocardiography significantly increased from 37.7% in the pre-P4L-ED phase to 61.3% in the post-P4L-ED phase. There was an increased prescription of diuretics and SGLT2 inhibitors during the post-P4L-ED phase.

CONCLUSIONS

By increasing awareness and providing resources, the utilization of NPs increased in the ED, leading to improved diagnostic accuracy and enhanced patient care.

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.

Accelerated magnetocardiography in the evaluation of patients with suspected cardiac ischemia: The MAGNETO trial

Background

Diagnosing ischemia in emergency department (ED) patients with suspected acute coronary syndrome (sACS) is challenging with equivocal disposition of intermediate risk patients.

Objective

Compare sensitivity and specificity of magnetocardiography (MCG) versus standard of care (SOC) stress testing in diagnosing myocardial ischemia.

Methods

Multicenter, prospective, observational cohort study. ED patients with sACS and HEART score ≥ 3 underwent 90 s noninvasive MCG to detect myocardial ischemia. Results were blinded to the patient's clinicians. MCGs were read independently by 3 physicians blinded to clinical data. Myocardial ischemia was ≥70 % epicardial coronary artery stenosis, revascularization within 30 days, or 30-day major adverse cardiac events (MACE). Time to first test (TTT) and patient satisfaction for MCG and SOC were compared.

Results

Of enrolled patients (N = 390) (mean age 59 ± 12 years, 45 % female), 99 (25 %) underwent a non-invasive stress test: 42 (14 %) diagnosed with ischemia. MCG sensitivity was 66.7 % (50.5-80.4 %, 95 % CI) and specificity 57.1 % (50.0-63.3 %, 95 % CI) for detecting coronary ischemia. Noninvasive stress testing (stress echo, nuclear stress, and exercise stress) had the same sensitivity 66.7 % (95 % CI 29.9 % to 92.5 %) and a specificity of 89.9 % (95 % CI 81.7-95.3 %). Mean TTT was shorter for MCG, 3.18 h (SD 1.91) vs. SOC stress testing 22.71 (SD 15.23), p < 0.0001. Mean patient experience was MCG 4.7 versus 3.0 SOC stress testing (p < 0.0001).

Conclusion

MCG provides similar sensitivity and lower specificity as non-invasive stress testing in ED sACS patients. Time to test is shorter for MCG with higher patient satisfaction scores.

[Maternal deaths and management by emergency departments in France 2016-2018]

In France, 272 maternal deaths occurred during the period 2016-2018, of which 131 were initially treated by healthcare professionals not specialized in obstetric. Fifty-six files were excluded because they did not concern emergency services or because there was insufficient data to allow analysis. Seventy-five cases of maternal deaths initially treated by emergency services (in-hospital emergency department [ED] or emergency medical ambulance [SAMU]) were analyzed. Fifty-six cases were treated by the SAMU and 22 by an ED (both in 3 cases). The causes of death were 20 cardiovascular events, 18 pulmonary embolisms, 9 neurological failures and 8 hemorrhagic shocks. The event occurred during pregnancy in 48 cases (64%) and during per or postpartum period in 27 cases (36%). The motivations for consultation at the ED were mainly pain (n=9), respiratory distress (n=6) or faintness (n=3). The reasons for calling emergency dispatching service (SAMU) were cardiorespiratory arrest in 32 cases (57%) and neurological failure (coma or status epilepticus) in 6 cases (11%). Among the 56 patients treated outside the hospital, 17 died on scene and 39 were transported to a resuscitation room (n=13), a specialized department (n=13), an obstetrics department (n=8) and less often in the ED (n=2). This was considered appropriate in 35 out of 39 cases (90%). Concerning the 75 files analyzed (ED and SAMU), death was considered unavoidable in 37 cases (49%) and potentially avoidable in 29 cases (38%) (maybe=23, probably=6). Avoidability could not be established in 9 cases. Among the 29 potentially avoidable deaths (38%), one of the criteria of avoidability concerned emergency services in 14 cases (ED=9, SAMU/SMUR=5, 18% of the files studied). ED's cares were considered optimal in 11 cases (50%) and non-optimal in 11 cases (50%). SAMU's cares were considered optimal in 45 cases (80%).

Assessment of discordance between radiologists and emergency physicians of RADIOgraphs among discharged patients in an emergency department: the RADIO-ED study

BACKGROUND

The possibility to perform standard X-rays is mandatory for all French Emergency Department (ED). Initial interpretation is under the prescriber emergency physician-who continually works under extreme conditions, but a radiologist needs to describe a report as soon as possible. We decided to assess the rate of discordance between emergency physicians and radiologists among discharged patients.

METHODS

We performed a monocentric study on an adult ED among discharged patients who had at least one X-ray during their consult. We used an automatic electronic system that classified interpretation as concordant or discordant. We review all discordant interpretation, which were classified as false negative, false positive, or more exam needed.

RESULTS

For 1 year, 8988 patients had 12,666 X-rays. We found a total of 742 (5.9%) discordant X-rays, but only 277 (2.2%) discordance had a consequence (new consult or exam not initially scheduled). We found some factors associated with discordance such as male sex, or ankle, foot, knee, finger, wrist, ribs, and elbow locations.

CONCLUSIONS

On discharged patients, using a systematic second interpretation of X-ray by a radiologist, we found a total of 2.2% discordance that had an impact on the initial care.

The usefulness of lactate/albumin ratio, C-reactive protein/albumin ratio, procalcitonin/albumin ratio, SOFA, and qSOFA in predicting the prognosis of patients with sepsis who presented to EDs

PURPOSE

Early identification of sepsis with a poor prognosis in the emergency department (ED) is crucial for prompt management and improved outcomes. This study aimed to examine the predictive value of sequential organ failure assessment (SOFA), quick SOFA (qSOFA), lactate to albumin ratio (LAR), C-reactive protein to albumin ratio (CAR), and procalcitonin to albumin ratio (PAR), obtained in the ED, as predictors for 28-day mortality in patients with sepsis and septic shock.

MATERIALS AND METHODS

We included 3499 patients (aged ≥19 years) from multicenter registry of the Korean Shock Society between October 2015 and December 2019. The SOFA score, qSOFA score, and lactate level at the time of registry enrollment were used. Albumin, C-reactive protein, and procalcitonin levels were obtained from the initial laboratory results measured upon ED arrival. We evaluated the predictive accuracy for 28-day mortality using the area under the receiver operating characteristic (AUROC) curve. A multivariable logistic regression analysis of the independent predictors of 28-day mortality was performed. The SOFA score, LAR, CAR, and PAR were converted to categorical variables using Youden's index and analyzed. Adjusting for confounding factors such as age, sex, comorbidities, and infection focus, adjusted odds ratios (aOR) were calculated.

RESULTS

Of the 3499 patients, 2707 (77.4%) were survivors, whereas 792 (22.6%) were non-survivors. The median age of the patients was 70 (25th-75th percentiles, 61-78), and 2042 (58.4%) were male. LAR for predicting 28-day mortality had the highest AUROC, followed by the SOFA score (0.715; 95% confidence interval (CI): 0.69-0.74 and 0.669; 95% CI: 0.65-0.69, respectively). The multivariable logistic regression analysis revealed that the aOR of LAR >1.52 was 3.75 (95% CI: 3.16-4.45), and the aOR, of SOFA score at enrollment >7.5 was 2.67 (95% CI: 2.25-3.17).

CONCLUSION

The results of this study showed that LAR is a relatively strong predictor of sepsis prognosis in the ED setting, indicating its potential as a straightforward and practical prognostic factor. This finding may assist healthcare providers in the ED by providing them with tools to risk-stratify patients and predict their mortality.

Benzodiazepine Alone for the Treatment of Moderate Alcohol Withdrawal in the Emergency Department

BACKGROUND

Phenobarbital has been used in the emergency department (ED) as both a primary and adjunctive medication for alcohol withdrawal, but previous studies evaluating its impact on patient outcomes are limited by heterogenous symptom severity.

OBJECTIVES

We compared the clinical outcomes of ED patients with moderate alcohol withdrawal who received phenobarbital, with or without benzodiazepines, with patients who received benzodiazepine treatment alone.

METHODS

This is a retrospective cohort study conducted at a single academic medical center utilizing chart review of ED patients with moderate alcohol withdrawal between 2015 and 2020. Patient encounters were classified into two treatment categories based on medication treatment: phenobarbital alone or in combination with benzodiazepines vs. benzodiazepines alone. Chi-square test or Fisher's exact was used to analyze categorical variables and the Student's t-test for continuous data.

RESULTS

Among the 287 encounters that met inclusion criteria, 100 received phenobarbital, compared with 187 that received benzodiazepines alone. Patients who received phenobarbital were provided significantly more lorazepam equivalents. There was a significant difference in the percentage of patient encounters that required admission to the hospital in the phenobarbital cohort compared with the benzodiazepine cohort (75% vs. 43.3%, p < 0.001). However, there was no difference in admission level of care to the floor (51.2% vs. 52.0%), stepdown (33.8% vs. 28%), or intensive care unit (15% vs. 20%), respectively.

CONCLUSIONS

Patients who received phenobarbital for moderate alcohol withdrawal were more likely to be admitted to the hospital, but there was no difference in admission level of care when compared with patients who received benzodiazepines alone. Patients who received phenobarbital were provided greater lorazepam equivalents in the ED.

Do we need the radiologist?

INTRODUCTION

Chest x-rays are widely used for diagnosing chest pathology worldwide. Pediatricians frequently interpret chest radiographs in the emergency department, guiding patient management. This study aims to assess the competency of non-radiologists in interpreting emergency chest x-rays and compare it with trainees of different levels to determine the necessity of radiologist input.

METHODOLOGY

A cross-sectional online survey was conducted in Saudi Arabia from September to October 2023, involving 385 participants, including pediatricians and medical interns from various regions. Carefully selected questions addressed a range of x-ray abnormalities in pediatric emergencies, assessing fundamental understanding of x-ray interpretation, such as inspiratory vs. expiratory and AP or PA films.

RESULTS

The study included 385 participants, primarily Saudi nationals in the eastern region, with an equal gender distribution and ages ranging from 20 to 29 years. Approximately 29.09% demonstrated fair knowledge, with 28% being Junior Pediatrics Residents, 18% Pediatric Consultants, and 15% Senior Pediatrics Residents. Fair knowledge was significantly associated with individuals aged 20-29 years, residents of the western region, and Junior Pediatrics Residents. Clinical knowledge varied among different groups, with 59% correctly identifying atypical pneumonia and 65% recognizing asymmetrical hyperinflation. However, rates for other conditions differed, with low identification of potential foreign body aspiration and film type. Accuracy in identifying tension pneumothorax and hyperlucency varied among clinicians. Pleural effusion films had a 65% identification rate for the diagnosis, but only 28% accurately described the X-ray and selected the correct answer for lung opacity.

CONCLUSION

The study concluded that 29.9% of the participating physicians exhibited fair knowledge of common pediatric emergency radiological films. Junior pediatric residents showed the best knowledge, and Tetralogy of Fallot, asymmetrical hyperinflation, and pleural effusion had the highest recognition rates. In conclusion, there is still a need for radiologists in the pediatric emergency department to ensure optimal functioning.

Adherence to quality indicators for emergency department treatment of acute poisoning according to patient sex

OBJECTIVES

To study differences in the emergency department treatment of acute poisoning according to biological sex of patients and to assess adherence to care quality indicators.

MATERIAL AND METHODS

Retrospective observational study including all cases of acute poisoning diagnosed in patients over the age of 14 years treated in a tertiary care hospital emergency department over a period of 4 years. We analyzed demographic variables, substance type and reason for acute poisoning, degree of adherence to quality indicators, and discharge destination.

RESULTS

A total of 1144 cases were included; 710 patients (62.1%) were female and 434 (37.9%) were male. The proportion of deliberate self-poisoning was higher in females (52.3% vs 41.4% in males; P .001); unintentional poisoning was less frequent in females (in 24.9% vs in 30.3% of males; P = .047). Benzodiazepine poisoning was more frequent in females (in 49.6% vs 41.2%; P = .007). Street drug and alcohol poisoning was less common in females. Adherence to quality indicators was high (> 85%) for both sexes.

CONCLUSION

The epidemiologic profile of poisoning is different in females and males. General emergency department adherence to quality indicators can be considered optimal. We detected no qualitative sex-related differences in the care of patients with acute poisoning.

E-scooter accidents-epidemiology and injury patterns: 3-year results from a level 1 trauma center in Germany

INTRODUCTION

Since the introduction of e-scooters in Germany in 2019, they are becoming more and more popular and associated injuries have increased significantly. The aim of this study was to assess the injury patterns after e-scooter accidents.

MATERIALS AND METHODS

From May 2019 to October 2022, all consecutive patients who presented at our emergency department (ED) following e-scooter accidents were included in our study and retrospectively analyzed.

RESULTS

A total of 271 patients were included in our study. The mean age was 33 years. 38% of the patients were female and 62% were male. Most common injuries were traumatic brain injuries in 38% of the patients together with fractures affecting the upper limb (17%). An operative treatment was necessary in 40 patients. Most of the patients presented at night and about 30% were under the influence of alcohol.

CONCLUSIONS

Our study shows one of the largest cohort of patients suffering e-scooter accidents in Europe. Compulsory helmet use, stricter alcohol controls and locking periods could contribute significantly to safety.

The prognostic value of the phosphate-to-albumin ratio in patients with OHCA: A multicenter observational study

PURPOSE

In patients with out-of-hospital cardiac arrest (OHCA), early and accurate outcome prediction is crucial for making treatment decisions and informing their relatives. A previous study reported an association between high phosphate levels and unfavorable neurological outcomes after return of spontaneous circulation (ROSC); however, its prognostic value was insufficient when used independently. Therefore, this study aimed to validate the usefulness of the phosphate-to-albumin ratio (PAR) in predicting neurological outcomes and in-hospital mortality by incorporating albumin, another known prognostic indicator.

MATERIALS AND METHODS

This multicenter observational study included adult OHCA survivors from October 2015 to June 2021. The primary endpoint was an unfavorable neurological outcome at hospital discharge, defined as a cerebral performance category score of 3-5. The in-hospital mortality rates were also evaluated.

RESULTS

Of the 2397 adult OHCA survivors, PAR differed significantly between the unfavorable and favorable neurological outcome groups, as well as between the non-survival and survival to hospital discharge groups (2.4 vs 1.4, 2.5 vs 1.6, respectively). The area under the receiver operating characteristic curve (AUROC) value of the PAR for predicting unfavorable neurological outcome was 0.81 (95% confidence interval [CI], 0.79-0.83), and the AUROC value for predicting in-hospital mortality was 0.76 (95% CI, 0.74-0.78). In multivariable analysis, the PAR was independently associated with unfavorable neurological outcome (odds ratio [OR] 1.30, 95% CI 1.15-1.37; p < 0.001) and in-hospital mortality (OR 1.24, 95% CI 1.12-1.38; p < 0.001).

CONCLUSION

The PAR is a readily obtainable and independent prognostic indicator for patients with ROSC after OHCA, helping healthcare providers in predicting outcomes.

Assessing the precision of artificial intelligence in ED triage decisions: Insights from a study with ChatGPT

BACKGROUND

The rise in emergency department presentations globally poses challenges for efficient patient management. To address this, various strategies aim to expedite patient management. Artificial intelligence's (AI) consistent performance and rapid data interpretation extend its healthcare applications, especially in emergencies. The introduction of a robust AI tool like ChatGPT, based on GPT-4 developed by OpenAI, can benefit patients and healthcare professionals by improving the speed and accuracy of resource allocation. This study examines ChatGPT's capability to predict triage outcomes based on local emergency department rules.

METHODS

This study is a single-center prospective observational study. The study population consists of all patients who presented to the emergency department with any symptoms and agreed to participate. The study was conducted on three non-consecutive days for a total of 72 h. Patients' chief complaints, vital parameters, medical history and the area to which they were directed by the triage team in the emergency department were recorded. Concurrently, an emergency medicine physician inputted the same data into previously trained GPT-4, according to local rules. According to this data, the triage decisions made by GPT-4 were recorded. In the same process, an emergency medicine specialist determined where the patient should be directed based on the data collected, and this decision was considered the gold standard. Accuracy rates and reliability for directing patients to specific areas by the triage team and GPT-4 were evaluated using Cohen's kappa test. Furthermore, the accuracy of the patient triage process performed by the triage team and GPT-4 was assessed by receiver operating characteristic (ROC) analysis. Statistical analysis considered a value of p < 0.05 as significant.

RESULTS

The study was carried out on 758 patients. Among the participants, 416 (54.9%) were male and 342 (45.1%) were female. Evaluating the primary endpoints of our study - the agreement between the decisions of the triage team, GPT-4 decisions in emergency department triage, and the gold standard - we observed almost perfect agreement both between the triage team and the gold standard and between GPT-4 and the gold standard (Cohen's Kappa 0.893 and 0.899, respectively; p < 0.001 for each).

CONCLUSION

Our findings suggest GPT-4 possess outstanding predictive skills in triaging patients in an emergency setting. GPT-4 can serve as an effective tool to support the triage process.

A "Tie-Over" Hemostatic Approach in Emergency Department: An Alternative Option for Recurrent Episodes of Postoperative Intraoral Hemorrhage

Objective

This case series aimed to describe a hemostatic technique that has been applied in patients admitted to emergency department (ED) of a tertiary hospital due to recurrent episodes of intraoral hemorrhage (IOH) after various dentoalveolar operations. The "tie-over" approach involved the intraoral use of Xeroform® gauze (as compressive bolster dressing) and the oral rinsing with a liquid mixture of hemostatic agents.

Materials and Methods

Between February 1, 2014, and July 31, 2017, we retrospectively reviewed the medical data and records of patients in ED who chiefly complained about IOH. The inclusion criteria were cases secondary to dentoalveolar surgeries that have been exclusively treated by tie-over bolster approach. Data such as frequency and severity of hemorrhage episodes, pain, and discomfort were assessed pre- and postoperatively.

Results

The presented technique was applied in 23 patients, but 20 of them complied with follow-up evaluation. The mean age of those patients was 60.57 years (15-82 years) with a mean follow-up time of 5.05 days. Eighteen patients were taking antithrombotic medications, either per os (oral antiplatelets and anticoagulants-OAA group) or subcutaneously (heparin group). One patient from OAA group and 2 from heparin group experienced in total 4 bleeding events postoperatively. Three of those events were recorded as minimal (oozing) and did not last over 20 min. All the patients declared satisfaction about the non-bleeding oral status.

Conclusions

In addition to its compelling outcomes, we advocate that this approach conferred physiological benefits on patients who visited ED with symptoms of anxiety and malaise, secondary to multiple, lasting, or uncontrolled episodes of IOH related to extensive surgical trauma. The presence of the gauze intraorally was short-term and created minimal discomfort.

Substance use and type of Road Traffic Injury in Mexico City

Limited data are available in Mexico on the prevalence of alcohol and drug use and the possible differences in their effects on types of road traffic injury (RTI), such as those involving pedestrians, drivers or passengers of motorcycles or other motor vehicles, and the association between substance use and driving behaviors, for preventive purposes. The sample comprised 433 adult RTI patients, admitted to the emergency department (ED) of a public hospital in Mexico City (January to April 2022). Breath Alcohol Concentration (BAC) was measured using a breath tester, and six types of drugs (amphetamines, barbiturates, benzodiazepines, cannabis, cocaine, and methamphetamine) were assessed using a saliva screen test. RTI patients also self-reported their alcohol and drug use in the six hours prior to the accident. Approximately 62% of respondents had been involved in a motorcycle crash. One in three patients self-reported or had traces of a substance in their saliva or breath. The most common substance was alcohol (23.6%), followed by cannabis and stimulants (10.9%). One in five patients reported having used a cell phone ten minutes before the injury. One in three had not been using any safety device, the only behavior exacerbated by substance use. We found a high prevalence of substance use in the sample of RTI patients admitted to the ED, regardless of the type of the RTI, together with high cell phone rates. Motorcycle passengers under the influence were particularly likely not to have been wearing a helmet.

Comparison of the clinical chemistry score to other biomarker algorithms for rapid rule-out of acute myocardial infarction and risk stratification in patients with suspected acute coronary syndrome

BACKGROUND

The clinical chemistry score (CCS) comprising high-sensitivity cardiac troponins (hs-cTn), glucose and estimated glomerular filtration rate has been previously validated with superior accuracy for detection and risk stratification of acute myocardial infarction (AMI) compared to hs-cTn alone.

METHODS

The CCS was compared to other biomarker-based algorithms for rapid rule-out and prognostication of AMI including the hs-cTnT limit-of-blank (LOB, <3 ng/L) or limit-of-detection (LOD, <5 ng/L) and a dual marker strategy (DMS) (copeptin <10 pmol/L and hs-cTnT ≤14 ng/L) in 1506 emergency department (ED) patients with symptoms suggestive of acute coronary syndrome. Negative predictive values (NPV) and sensitivities for AMI rule-out, and 12-month combined endpoint rates encompassing mortality, myocardial re-infarction, as well as stroke were assessed.

RESULTS

NPVs of 100% (95% CI: 98.3-100%) were observed for CCS = 0, hs-cTnT LoB and hs-cTnT LoD with rule-out efficacies of 11.1%, 7.6% and 18.3% as well as specificities of 13.0% (95% CI: 9.9-16.6%), 8.8% (95% CI: 7.3-10.5%) and 21.4% (95% CI: 19.2-23.8%), respectively. A CCS ≤ 1 achieved a rule-out in 32.2% of all patients with a NPV of 99.6% (95% CI: 98.4-99.9%) and specificity of 37.4% (95% CI: 34.2-40.5%) compared to a rule-out efficacy of 51.2%, NPV of 99.0 (95% CI: 98.0-99.5) and specificity of 59.7% (95% CI: 57.0-62.4%) for the DMS. Rates of the combined end-point of death/AMI within 30 days ranged between 0.0% and 0.7% for all fast-rule-out protocols.

CONCLUSIONS

The CCS ensures reliable AMI rule-out with low short and long-term outcome rates for a specific ED patient subset. However, compared to a single or dual biomarker strategy, the CCS displays reduced efficacy and specificity, limiting its clinical utility.