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Marjanovic N, Jonchier M, Guenezan J, Delelis-Fanien H, Reuter PG, Mimoz O. Telemedicine in Nursing Home Residents Requiring a Call to an Emergency Medical Communication Center. J Am Med Dir Assoc 2024; 25:195-200.e1. [PMID: 38623779 DOI: 10.1016/j.jamda.2023.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 09/15/2023] [Accepted: 09/18/2023] [Indexed: 04/17/2024]
Abstract
OBJECTIVES To compare the proportion of nursing home residents dispatched to an emergency department (ED) after a call to the emergency medical communication center (EMCC) according to the availability or nonavailability of telemedicine. DESIGN This prospective, observational trial was conducted in the EMCC and 74 nursing homes in a French county. SETTING AND PARTICIPANTS All nursing home residents who needed to contact the EMCC between June 2019 and April 2020 were included in the study. We excluded calls notifying the death of a resident, for completing data from a previous call, and for nursing home staff. METHODS The primary outcome was the proportion of residents dispatched to an ED after their first call to the EMCC. The secondary outcomes were the proportion of second calls, proportion of residents dispatched to an ED after a second call, and proportion of death within 30 days. RESULTS We included 3103 calls in the final analysis (355 from equipped nursing homes and 2748 from unequipped nursing homes). The proportion of patients dispatched to an ED after the first call was lower among telemedicine-equipped than among telemedicine-unequipped nursing homes (41% vs 50%; odds ratio, 0.71; 95% CI, 0.56-0.90). The proportion of a second call for the same purpose within 72 hours, proportion of dispatching to an ED at the second call, and proportion of deaths within 30 days were similar between the groups. CONCLUSION AND IMPLICATIONS The use of telemedicine by nursing home residents requiring a call to the EMCC is associated with a reduction in the number of dispatches to an ED without any increase in the number of 72-hour callbacks or 30-day mortality rates.
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Affiliation(s)
- Nicolas Marjanovic
- Emergency Department and Prehospital Care, University Hospital of Poitiers, Poitiers, France.
| | - Maxime Jonchier
- Emergency Department and Prehospital Care, University Hospital of Poitiers, Poitiers, France
| | - Jérémy Guenezan
- Emergency Department and Prehospital Care, University Hospital of Poitiers, Poitiers, France
| | - Henri Delelis-Fanien
- Emergency Department and Prehospital Care, University Hospital of Poitiers, Poitiers, France
| | - Paul-Georges Reuter
- Emergency Department and Prehospital Care, University Hospital of Rennes, Rennes, France
| | - Olivier Mimoz
- Emergency Department and Prehospital Care, University Hospital of Poitiers, Poitiers, France
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Wang M, Hu Z, Miao L, Shi M, Gao Q. A systematic review of the applicability of emergency department assessment of chest pain score-accelerated diagnostic protocol for risk stratification of patients with chest pain. Clin Cardiol 2023; 46:1303-1309. [PMID: 37594309 PMCID: PMC10642332 DOI: 10.1002/clc.24126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 08/07/2023] [Accepted: 08/08/2023] [Indexed: 08/19/2023] Open
Abstract
The emergency department assessment of chest pain score-accelerated diagnostic protocol (EDACS-ADP) are commonly used for risk stratification in undifferentiated patients with acute chest pain. This systematic review aimed to investigate EDACS-ADP for risk stratification of emergency department (ED) patients with chest pain. The PubMed, Web of Science, Medline, Cochrane Library, China National Knowledge Infrastructure, and Wanfang databases were searched for related studies without restrictions on the publication year. The Quality Assessment of Diagnostic Accuracy Studies 2 tool was used to assess the risk of bias, and Stata 16.0 was used to determine the combined sensitivity, specificity, positive diagnostic likelihood ratio (DLR), and negative DLR. Twelve studies comprising 14 290 patients were identified. Of these, 7537 (52.74%) patients were considered low risk, and 67 (0.89%) had major adverse cardiovascular events (MACE), including myocardial infarction, stroke, and cardiovascular death within 30 days of the patients' ED presentation. EDACS-ADP showed a combined sensitivity of 0.97 (95% confidence interval [CI]: 0.95-0.99); specificity, 0.58 (0.53-0.63); positive DLR, 2.34 (2.08-2.63); negative DLR, 0.04 (0.02-0.09); diagnostic odds ratio, 53.11 (26.45-106.63); and summary receiver operating characteristic area under the curve, 0.83 (0.79-0.86). Despite the large statistical heterogeneity of the results, EDACS-ADP identified a considerable number of low-risk patients for early discharge, with a specificity >50% and an incidence of MACE within 30-days of patients' ED presentation <1%. Thus, it is a useful tool with a potential for clinical application.
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Affiliation(s)
- Minghu Wang
- Emergency DepartmentBeijing Rehabilitation Hospital of Capital Medical UniversityBeijingChina
| | - Zhiwei Hu
- School of Acupuncture‐Moxibustion and TuinaBeijing University of Chinese MedicineBeijingChina
| | - Lihui Miao
- Emergency DepartmentBeijing Rehabilitation Hospital of Capital Medical UniversityBeijingChina
| | - Manman Shi
- Emergency DepartmentBeijing Rehabilitation Hospital of Capital Medical UniversityBeijingChina
| | - Qiang Gao
- Department of Gastroenterology and HepatologyBeijing Rehabilitation Hospital of Capital Medical UniversityBeijingChina
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Koca G, Kumar M, Gubitz G, Kamal N. Optimizing acute stroke treatment process: insights from sub-tasks durations in a prospective observational time and motion study. Front Neurol 2023; 14:1253065. [PMID: 37965162 PMCID: PMC10641836 DOI: 10.3389/fneur.2023.1253065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 10/09/2023] [Indexed: 11/16/2023] Open
Abstract
Background Rapid treatment is critical in managing acute ischemic stroke (AIS) to improve patient outcomes. Various strategies have been used to optimize this treatment process, including the Acute Stroke Protocol (ASP) activation, and minimizing the duration of key performance metrices, such as door-to-needle time (DNT), CT-to-needle time (CTNT), CT-to-groin puncture time (CTGP), and door-to-groin puncture time (DGPT). However, identifying the delay-causing sub-tasks within the ASP could yield novel insights, facilitating optimization strategies for the AIS treatment process. Methods This two-phase prospective observational time and motion study aimed to identify sub-tasks and compare their respective durations involved in the treatment process for AIS patients within ASPs. The study compared sub-task durations between "routine working hours" and "evenings and weekends" (after-hours), as well as between stroke neurologists and non-stroke neurologists. Additionally, the established performance metrices of AIS were compared among the aforementioned groups. Results Phase 1 identified and categorized 34 sub-tasks into five broad categories, while Phase 2 analyzed the ASP for 389 patients. Among the 185 patients included in the study, 57 received revascularization treatment, with 30 receiving intravenous (IV) thrombolysis only, 20 receiving endovascular thrombectomy (EVT) only, and 7 receiving both IV thrombolysis and EVT. Significant delays were observed in sub-tasks including triage, registration, patient history sharing, treatment decisions, preparation of patients, preparation of thrombolytic agents, and angiosuite preparation. The majority of these significant delays (P < 0.05) were observed when were performed by a non-stroke neurologist and during after-hours operations. Furthermore, certain sub-tasks were exclusively performed during after-hours or when the treatment was provided by a non-stroke neurologist. Consequently, DNT, CTNT, and CTGP were significantly prolonged for both non-stroke neurologists and off-hours treatment. DGPT was significantly longer only when the ASP was conducted by non-stroke neurologists. Conclusions The study identified several sub-tasks that lead to significant delays during the execution of the ASP. These findings provide a premise to design targeted quality improvement interventions to optimize the ASP for these specific delay-causing sub-tasks, particularly for non-stroke neurologists and after-hours. This approach has the potential to significantly enhance the efficiency of the AIS treatment process.
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Affiliation(s)
- Gizem Koca
- Department of Industrial Engineering, Faculty of Engineering, Dalhousie University, Halifax, NS, Canada
| | - Mukesh Kumar
- Department of Industrial Engineering, Faculty of Engineering, Dalhousie University, Halifax, NS, Canada
| | - Gord Gubitz
- Division of Neurology, QEII – Halifax Infirmary (HI) Site, Nova Scotia Health, Halifax, NS, Canada
- Division of Neurology, Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Noreen Kamal
- Department of Industrial Engineering, Faculty of Engineering, Dalhousie University, Halifax, NS, Canada
- Division of Neurology, Department of Medicine, Dalhousie University, Halifax, NS, Canada
- Department of Community Health and Epidemiology, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
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Islam KR, Prithula J, Kumar J, Tan TL, Reaz MBI, Sumon MSI, Chowdhury MEH. Machine Learning-Based Early Prediction of Sepsis Using Electronic Health Records: A Systematic Review. J Clin Med 2023; 12:5658. [PMID: 37685724 PMCID: PMC10488449 DOI: 10.3390/jcm12175658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 08/13/2023] [Accepted: 08/23/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Sepsis, a life-threatening infection-induced inflammatory condition, has significant global health impacts. Timely detection is crucial for improving patient outcomes as sepsis can rapidly progress to severe forms. The application of machine learning (ML) and deep learning (DL) to predict sepsis using electronic health records (EHRs) has gained considerable attention for timely intervention. METHODS PubMed, IEEE Xplore, Google Scholar, and Scopus were searched for relevant studies. All studies that used ML/DL to detect or early-predict the onset of sepsis in the adult population using EHRs were considered. Data were extracted and analyzed from all studies that met the criteria and were also evaluated for their quality. RESULTS This systematic review examined 1942 articles, selecting 42 studies while adhering to strict criteria. The chosen studies were predominantly retrospective (n = 38) and spanned diverse geographic settings, with a focus on the United States. Different datasets, sepsis definitions, and prevalence rates were employed, necessitating data augmentation. Heterogeneous parameter utilization, diverse model distribution, and varying quality assessments were observed. Longitudinal data enabled early sepsis prediction, and quality criteria fulfillment varied, with inconsistent funding-article quality correlation. CONCLUSIONS This systematic review underscores the significance of ML/DL methods for sepsis detection and early prediction through EHR data.
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Affiliation(s)
- Khandaker Reajul Islam
- Department of Physiology, Faculty of Medicine, University Kebangsaan Malaysia, Kuala Lumpur 56000, Malaysia
| | - Johayra Prithula
- Department of Electrical and Electronics Engineering, University of Dhaka, Dhaka 1000, Bangladesh
| | - Jaya Kumar
- Department of Physiology, Faculty of Medicine, University Kebangsaan Malaysia, Kuala Lumpur 56000, Malaysia
| | - Toh Leong Tan
- Department of Emergency Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur 56000, Malaysia
| | - Mamun Bin Ibne Reaz
- Department of Electrical and Electronic Engineering, Independent University, Bangladesh Bashundhara, Dhaka 1229, Bangladesh
| | - Md. Shaheenur Islam Sumon
- Department of Biomedical Engineering, Military Institute of Science and Technology (MIST), Dhaka 1216, Bangladesh
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McMenamy J, Garada A, Kochkine S, Miles R, Naeger DM. A "High-Reliability Organization" Approach to Improve Trauma Imaging Performance. J Am Coll Radiol 2023; 20:789-795. [PMID: 37390883 DOI: 10.1016/j.jacr.2023.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 04/20/2023] [Accepted: 05/01/2023] [Indexed: 07/02/2023]
Abstract
PURPOSE CT is the gold standard for triaging critically ill patients, including in trauma, and its use has increased over time. CT turnaround times (TATs) are frequently targeted for improvement. As opposed to linear reductionist processes such as Lean and Six Sigma, a high-reliability organization (HRO) approach focuses on culture and teams to enable rapid problem solving. The authors evaluated the HRO model to rapidly generate, trial, select, and implement improvement interventions to improve trauma patient CT performance. METHODS All trauma patients presenting to a single institution's emergency department during a 5-month period were included. Project periods included 2-month preintervention, 1-month wash-in, and 2-month postintervention. Each initial trauma CT encounter during the wash-in and postintervention periods created job briefs in which the radiologist ensured that all involved had the pertinent clinical information and agreed on the imaging needed, thereby creating a shared mental model as well as an opportunity to raise concerns and provide ideas for improvement. RESULTS A total of 447 patients were included: 145 preintervention, 68 wash-in, and 234 postintervention. The seven selected interventions were trauma text alert; scripted CT technologist-radiologist communication; modification of CT acquisition, processing, sending, and interpretation; and trauma mobile phones. The seven selected interventions reduced trauma patient CT median TATs by 60% (78 vs 31 min, P < .001), demonstrating the effectiveness of an HRO approach to improvement. CONCLUSIONS An HRO-based approach was rapid in generating, trialing, selecting, and implementing improvement interventions, and the interventions were effective at substantially decreasing trauma patient CT TATs.
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Affiliation(s)
- John McMenamy
- Associate Director of Service, Department of Radiology, Denver Health, Denver, Colorado.
| | - Ahmad Garada
- Department of Radiology, University of Virginia, Charlottesville, Virginia
| | - Sergey Kochkine
- Department of Radiology, Columbia University, New York, New York
| | - Randy Miles
- Associate Director of Service, Department of Radiology, Denver Health, Denver, Colorado
| | - David M Naeger
- Director of Service, Department of Radiology, Denver Health, Denver, Colorado
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Krissberg JR, O'Shaughnessy MM, Smith AR, Helmuth ME, Almaani S, Aviles DH, Brathwaite KE, Cai Y, Cattran D, Gbadegesin R, Glenn DA, Greenbaum LA, Iragorri S, Jain K, Khalid M, Kidd J, Kopp J, Lafayette R, Lane JC, Lugani F, Nestor JG, Parekh RS, Reidy K, Selewski DT, Sethna CB, Sperati CJ, Tuttle K, Twombley K, Vasylyeva TL, Weaver DJ, Wenderfer SE, Gibson K. Racial and Ethnic Disparities in Acute Care Utilization Among Patients With Glomerular Disease. Am J Kidney Dis 2023; 81:318-328.e1. [PMID: 36191724 PMCID: PMC9974571 DOI: 10.1053/j.ajkd.2022.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 08/03/2022] [Indexed: 01/25/2023]
Abstract
RATIONALE & OBJECTIVE The effects of race, ethnicity, socioeconomic status (SES), and disease severity on acute care utilization in patients with glomerular disease are unknown. STUDY DESIGN Prospective cohort study. SETTING & PARTICIPANTS 1,456 adults and 768 children with biopsy-proven glomerular disease enrolled in the Cure Glomerulonephropathy (CureGN) cohort. EXPOSURE Race and ethnicity as a participant-reported social factor. OUTCOME Acute care utilization defined as hospitalizations or emergency department visits. ANALYTICAL APPROACH Multivariable recurrent event proportional rate models were used to estimate associations between race and ethnicity and acute care utilization. RESULTS Black or Hispanic participants had lower SES and more severe glomerular disease than White or Asian participants. Acute care utilization rates were 45.6, 29.5, 25.8, and 19.2 per 100 person-years in Black, Hispanic, White, and Asian adults, respectively, and 55.8, 42.5, 40.8, and 13.0, respectively, for children. Compared with the White race (reference group), Black race was significantly associated with acute care utilization in adults (rate ratio [RR], 1.76 [95% CI, 1.37-2.27]), although this finding was attenuated after multivariable adjustment (RR, 1.31 [95% CI, 1.03-1.68]). Black race was not significantly associated with acute care utilization in children; Asian race was significantly associated with lower acute care utilization in children (RR, 0.32 [95% CI 0.14-0.70]); no significant associations between Hispanic ethnicity and acute care utilization were identified. LIMITATIONS We used proxies for SES and lacked direct information on income, household unemployment, or disability. CONCLUSIONS Significant differences in acute care utilization rates were observed across racial and ethnic groups in persons with prevalent glomerular disease, although many of these difference were explained by differences in SES and disease severity. Measures to combat socioeconomic disadvantage in Black patients and to more effectively prevent and treat glomerular disease are needed to reduce disparities in acute care utilization, improve patient wellbeing, and reduce health care costs.
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Affiliation(s)
- Jill R Krissberg
- Division of Pediatric Nephrology, Anne & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.
| | - Michelle M O'Shaughnessy
- Department of Renal Medicine, Cork University Hospital, Ireland; and School of Medicine, University College Cork, Ireland
| | - Abigail R Smith
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | | | - Salem Almaani
- Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Diego H Aviles
- Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Kaye E Brathwaite
- Division of Pediatric/Nephrology, Children's Hospital at Montefiore/Einstein, Bronx, New York
| | - Yi Cai
- Pediatric Nephrology, Dialysis and Transplantation, Helen DeVos Children's Hospital, Grand Rapids, Michigan
| | - Daniel Cattran
- Division of Nephrology, University Health Network, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Rasheed Gbadegesin
- Department of Pediatrics, Division of Nephrology, Duke University Medical Center, Durham, North Carolina
| | - Dorey A Glenn
- Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Larry A Greenbaum
- Division of Pediatric Nephrology, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | | | - Koyal Jain
- Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Myda Khalid
- Department of Pediatrics, Division of Nephrology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jason Kidd
- Virginia Commonwealth University, Richmond, Virginia
| | - Jeffrey Kopp
- Kidney Disease Section, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Richard Lafayette
- Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Stanford, California
| | - Jerome C Lane
- Division of Pediatric Nephrology, Anne & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Francesca Lugani
- L'Unità Operativa Complessa Nefrology, Dialysis and Transplant, Laboratorio di Nefrologia Molecolare, Istituto Giannina Gaslini Istituto di Ricovero e Cura a Carattere Scientifico, Genoa, Italy
| | - Jordan G Nestor
- Department of Medicine, Division of Nephrology, Columbia University, New York, New York
| | - Rulan S Parekh
- Division of Nephrology, Department of Pediatrics and Medicine, Hospital for Sick Children, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Kimberly Reidy
- Division of Pediatric/Nephrology, Children's Hospital at Montefiore/Einstein, Bronx, New York
| | - David T Selewski
- Department of Pediatrics, Division of Nephrology, Medical University of South Carolina, Charleston, South Carolina
| | - Christine B Sethna
- Division of Pediatric Nephrology, Cohen Children's Medical Center, New Hyde Park, New York
| | - C John Sperati
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Katherine Tuttle
- Providence Health Care, Department of Medicine, Division of Nephrology, University of Washington, Spokane and Seattle, Washington
| | - Katherine Twombley
- Department of Pediatrics, Division of Nephrology, Medical University of South Carolina, Charleston, South Carolina
| | - Tetyana L Vasylyeva
- Department of Pediatrics, Texas Tech University Health Sciences Center, Amarillo, Texas
| | - Donald J Weaver
- Division of Pediatric Nephrology and Hypertension, Atrium Health Levine Children's, Charlotte, North Carolina
| | - Scott E Wenderfer
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Keisha Gibson
- Department of Medicine and Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Campagnoli M, Cerasuolo M, Renna M, Dell'Era V, Valletti PA, Garzaro M. ENT Referral From Emergency Department During COVID-19: A Single-Center Experience. Ear Nose Throat J 2023; 102:NP95-NP98. [PMID: 33570430 DOI: 10.1177/0145561320984560] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
PURPOSE COVID-19 pandemic transformed the health system response worldwide. The aim of this study is to report changes about numbers and reason for ENT consultations in emergency department (ED) during COVID-19 pandemic comparing with those occurred the previous year (2019). METHODS Data about patients admitted to adult and pediatric ED were collected from March 1 to May 31, 2019 and 2020. Patients referred for urgency from general practitioners were excluded from the study. RESULTS Global ED admission (except for dyspnea or COVID-19-related symptoms) dramatically decreased during pandemic (-50.9% among adults and -71.4% among pediatrics). At the same time, ENT consultancy significantly reduced too, by 71.5% (P < .01) among adults and 45.1% (P < .01) for pediatrics. Among adults, it was reported a statistically significant decrease in consultation for ear problems (-88.5%, P = .0146). Reduction in ENT referral for bone fracture (-40%, P = .059), vertigo (-77.8%, P = .637), and tonsillitis (-87.5%, P = .688) was consistent, but not significant. Among pediatric patients, it was observed an increase by 25% about foreign bodies (12 vs 15, P < .01). A reduction in numbers of consults for ear problem (-90.8%; P = .045), epistaxis (-80%; P = .196), and nasal fracture (-70%; P = .36) was also observed. CONCLUSION Fear of infection and the forced lock down caused a significant decrease in the number of ED accesses and in ENT consultancy. These data may suggest that some ED referral usually could be deferred, but on the other hand, pandemic will cause a great diagnostic delay.
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Affiliation(s)
| | | | - Martina Renna
- ENT Division, University of Eastern Piedmont, Novara, Italy
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Jurić O, Lisica Šikić N, Žufić V, Matak L, Karlo R, Mihanović J. Rectal prolapse as the initial presentation of rectal cancer-A case report. Front Surg 2023; 10:1176726. [PMID: 37114157 PMCID: PMC10126431 DOI: 10.3389/fsurg.2023.1176726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 03/23/2023] [Indexed: 04/29/2023] Open
Abstract
Herein we report the case of a 63-year-old female tourist who presented to our Emergency Department with complete rectal prolapse. She had complained of diarrhea with traces of blood and mucus and had experienced fatigue after hiking. After the initial evaluation, it became clear that prolapse bares a large rectal tumor as a leading point. The prolapse was reduced under general anesthesia, along with a tumor biopsy. Further workup confirmed locally advanced adenocarcinoma of the rectum, which was treated with neoadjuvant chemoradiation followed by curative surgery in another hospital after repatriation. Rectal prolapse affects people of all ages, but it is more common in older adults, particularly women. Treatment options vary depending on the severity of the prolapse and can range from conservative measures to surgical interventions. This case report highlights the importance of early recognition and appropriate management of rectal prolapse in the emergency setting and the possibility of an underlying malignancy.
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Affiliation(s)
- Oliver Jurić
- Department of Surgery, Zadar General Hospital, Zadar, Croatia
- Department of Health Studies, University of Zadar, Zadar, Croatia
| | - Nataša Lisica Šikić
- Department of Health Studies, University of Zadar, Zadar, Croatia
- Department of Pathology, Forensic Medicine and Cytology, Zadar General Hospital, Zadar, Croatia
| | - Vanja Žufić
- Department of Surgery, Zadar General Hospital, Zadar, Croatia
- Department of Health Studies, University of Zadar, Zadar, Croatia
| | - Luka Matak
- Department of Health Studies, University of Zadar, Zadar, Croatia
- Department of Obstetrics and Gynecology, General Hospital Zadar, Zadar, Croatia
| | - Robert Karlo
- Department of Surgery, Zadar General Hospital, Zadar, Croatia
- Department of Health Studies, University of Zadar, Zadar, Croatia
| | - Jakov Mihanović
- Department of Surgery, Zadar General Hospital, Zadar, Croatia
- Department of Health Studies, University of Zadar, Zadar, Croatia
- Correspondence: Jakov Mihanović
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Stanford KA, Mason JA, Friedman EE. Trends in STI testing and diagnosis rates during the COVID-19 pandemic at a large urban tertiary care center, and the role of the emergency department in STI care. Front Reprod Health 2023; 5:1082429. [PMID: 36890799 PMCID: PMC9986412 DOI: 10.3389/frph.2023.1082429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 01/20/2023] [Indexed: 02/22/2023] Open
Abstract
Introduction The COVID-19 pandemic has had profound effects on access to care, including outpatient sexually transmitted infection (STI) testing and treatment. Many vulnerable populations already relied on the emergency department (ED) for much of their care prior to the pandemic. This study examines trends in STI testing and positivity before and during the pandemic at a large urban medical center and evaluates the role of the ED in providing STI care. Methods This is a retrospective review of all gonorrhea, chlamydia, and trichomonas tests from November 1, 2018, through July 31, 2021. Demographic information and location and results of STI testing were extracted from the electronic medical record. Trends in STI testing and positivity were examined for 16 month periods before and after the COVID-19 pandemic started (March 15, 2020), with the latter divided into the early pandemic period (EPP: March 15 -July 31, 2020) and late pandemic period (LPP: August 1, 2020 - July 31, 2021). Results Tests per month decreased by 42.4% during the EPP, but rebounded by July 2020. During the EPP, the proportion of all STI testing originating in the ED increased from 21.4% pre-pandemic to 29.3%, and among pregnant women from 45.2% to 51.5%. Overall STI positivity rate increased from 4.4% pre-pandemic to 6.2% in the EPP. Parallel trends were observed for gonorrhea and chlamydia individually. The ED represented 50.5% of overall positive tests, and as much as 63.1% of positive testing during the EPP. The ED was the source of 73.4% of positive tests among pregnant women, which increased to 82.1% during the EPP. Conclusions STI trends from this large urban medical center paralleled national trends, with an early decrease in positive cases followed by a rebound by the end of May 2020. The ED represented an important source of testing for all patients, and especially for pregnant patients, throughout the study period, but even more so early in the pandemic. This suggests that more resources should be directed towards STI testing, education, and prevention in the ED, as well as to support linkage to outpatient primary and obstetric care during the ED visit.
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Affiliation(s)
- Kimberly A Stanford
- Department of Medicine, Section of Emergency Medicine, University of Chicago, Chicago, IL, United States
| | - Joseph A Mason
- Department of Medicine, Section of Infectious Diseases and Global Health, University of Chicago, Chicago, IL, United States
| | - Eleanor E Friedman
- Department of Medicine, Section of Infectious Diseases and Global Health, University of Chicago, Chicago, IL, United States
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Sneath E, Tippett V, Bowman RV, Fong KM, Hazell W, Masel PJ, Bunting D, Watt K, Yang IA. The clinical journey of patients with a severe exacerbation of chronic obstructive pulmonary disease (COPD): from the ambulance to the emergency department to the hospital ward. J Thorac Dis 2022; 14:4601-4613. [PMID: 36647501 PMCID: PMC9840047 DOI: 10.21037/jtd-22-328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 11/18/2022] [Indexed: 12/31/2022]
Abstract
Background Exacerbations of chronic obstructive pulmonary disease (COPD) are acute complications that often require emergency management by ambulance, emergency department (ED) and hospital services. Given the high mortality and morbidity of exacerbations, better understanding of the epidemiology of patients with COPD presenting to EDs is needed, as well as identification of predictive factors for adverse outcomes from exacerbations. Methods This retrospective observational study involved patients who presented to an ED in the state of Queensland and received either an ED or hospital diagnosis of COPD in 2015 and 2016. Administrative data from ambulance, ED, hospital and death registry databases were linked to provide a comprehensive picture of the emergency healthcare pathway for these patients. Results A total of 16,166 patients (49% female, 51% male) had 29,332 presentations to an ED in Queensland and received either an ED or hospital principal diagnosis of COPD during 2015 and 2016. These patients had a significant comorbidity burden with 54% having two or more comorbidities. Sixty-nine percent of ED presentations involved ambulance transport, and most of these (74%) involved administration of oxygen therapy and/or other medications by paramedics. Prehospital oxygen administration and ≥10 comorbidities were associated with >1 admission [odds ratio (OR) 1.3, 95% confidence interval (CI) 1.1-1.5; OR 4.3, 95% CI: 3.1-5.8, respectively], greater than average lengths of stay (OR 1.5, 95% CI: 1.3-1.6; OR 22.1, 95% CI: 18.1-27.2) and mortality (OR 1.6, 95% CI: 1.5-1.8; OR 5.3, 95% CI: 4.2-6.8). Of the ambulance presentations, 90% were admitted or received ongoing care. Conclusions COPD places considerable burden on the emergency healthcare pathway including ambulances and EDs in Queensland. Patients with COPD most commonly present to the ED by ambulance and receive extensive pre-hospital management. These patients have significant comorbidity burden and experience high rates of admission and mortality. More research is required to investigate the emergency pathway to further identify reversible factors and enhance healthcare practice and policy for COPD management.
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Affiliation(s)
- Emily Sneath
- Faculty of Medicine, The University of Queensland, Queensland, Australia;,Department of Emergency Medicine, The Prince Charles Hospital, Metro North Hospital and Health Service, Queensland, Australia
| | - Vivienne Tippett
- School of Clinical Sciences, Queensland University of Technology, Queensland, Australia
| | - Rayleen V. Bowman
- Faculty of Medicine, The University of Queensland, Queensland, Australia;,Department of Thoracic Medicine, The Prince Charles Hospital, Metro North Hospital and Health Service, Queensland, Australia
| | - Kwun M. Fong
- Faculty of Medicine, The University of Queensland, Queensland, Australia;,Department of Thoracic Medicine, The Prince Charles Hospital, Metro North Hospital and Health Service, Queensland, Australia
| | - Wayne Hazell
- Faculty of Medicine, The University of Queensland, Queensland, Australia;,Department of Emergency Medicine, The Prince Charles Hospital, Metro North Hospital and Health Service, Queensland, Australia
| | - Philip J. Masel
- Faculty of Medicine, The University of Queensland, Queensland, Australia;,Department of Thoracic Medicine, The Prince Charles Hospital, Metro North Hospital and Health Service, Queensland, Australia
| | - Denise Bunting
- Information Support, Research & Evaluation, Queensland Ambulance Service, Queensland, Australia
| | - Kerrianne Watt
- Information Support, Research & Evaluation, Queensland Ambulance Service, Queensland, Australia
| | - Ian A. Yang
- Faculty of Medicine, The University of Queensland, Queensland, Australia;,Department of Thoracic Medicine, The Prince Charles Hospital, Metro North Hospital and Health Service, Queensland, Australia
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11
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Reynolds L, Franco R, Prados M, Rodgers JB, Hand DT, Walter LA. Hepatitis C active viremia over time in an ED-based testing programme: Impact, disparities and surveillance tool. J Viral Hepat 2022; 29:1026-1034. [PMID: 36062383 DOI: 10.1111/jvh.13744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 08/17/2022] [Accepted: 08/20/2022] [Indexed: 12/09/2022]
Abstract
Hepatitis C virus (HCV) surveillance is a critical component of a comprehensive strategy to prevent and control HCV infection and HCV-related chronic liver disease. The emergency department (ED) has been increasingly recognized as a vital partner in HCV testing and linkage. We sought to consider active RNA HCV viremia over time in patients participating in an ED-based testing programme as a measure of local HCV surveillance and as a barometer of ED-testing programme impact. We performed a retrospective analysis of individuals participating in our ED-based HCV testing programme between 2015 and 2021. Chi-square tests were used to compare the demographic characteristics of HCV antibody positive tests with active viremia to those without active viremia. Cox proportional hazard models were used to estimate the trend in active viremia risk over time in the overall study population as well as in key subpopulations of interest. Of 5456 HCV antibody positive individuals, 3102 (56.8%) had active viremia. In the overall study population, we found that the risk of active viremia decreased by 4.8% per year during the study period (RR: 0.95, 95% CI: 0.93-0.97|p < .0001). Baby boomers experienced a 9% decrease in active viremia risk per year over the study period while non-baby boomers only had a 2% decrease in risk per year (p = .0009). Compared with insured patients, uninsured patients had a smaller decrease in risk of active HCV viremia per year (p = .003). No significant differences in the risk of active viremia over time were observed for gender (p = .4694) or by primary care provider status (p = .2208). In conclusion, this ED-based testing and linkage programme demonstrates significantly decreased active HCV viremia over time. It also highlights subpopulations, specifically non-baby boomers and uninsured patients, who may benefit from focused interventions to improve access to and adoption of definitive HCV care.
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Affiliation(s)
- Lindy Reynolds
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Ricardo Franco
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Myles Prados
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Joel B Rodgers
- Division of Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Delissa T Hand
- O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Lauren A Walter
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
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12
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Aguilón-Leiva JJ, Tejada-Garrido CI, Echániz-Serrano E, Mir-Ramos E, Torres-Pérez AM, Lafuente-Jiménez A, Martínez-Soriano M, Santolalla-Arnedo I, Czapla M, Smereka J, Juárez-Vela R, Satústegui-Dordá PJ. Clinical and sociodemographic profile of acute intoxications in an emergency department: A retrospective cross-sectional study. Front Public Health 2022; 10:990262. [PMID: 36339228 PMCID: PMC9628748 DOI: 10.3389/fpubh.2022.990262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 09/20/2022] [Indexed: 01/26/2023] Open
Abstract
Background Epidemiological studies about acute poisoning are useful for developing clinical toxicology, especially those carried out in hospital emergency departments. We aimed to evaluate acute intoxication clinical and sociodemographic profile in South Aragon Hospital, Spain. Methods We carried out a retrospective cross-sectional study. We included 442 patients treated for acute poisoning in the emergency department during the 3 years 2015-2018. In the inferential analysis, the Chi-square test was used to compare proportions, and the Mann-Whitney U-test was used to compare ranges. A confidence level of 95 per cent was considered in all tests. Results The mean age was 44.1 years. 57.2% were men. Drugs of abuse were present in 243 patients (55%), drugs in 172 (38.9%), chemicals in 57 (12.9%) and three patients (0.7%) were poisoned by mushrooms. Nine different drugs of abuse, 73 drugs, 15 chemical compounds and 2 varieties of mushrooms were registered. Of the intoxicated patients, 92.3% had symptoms, 84.2% received treatment and 78.7% were discharged from the emergency department. Conclusions We obtain a clear clinical and sociodemographic profile of intoxicated patients who come to the emergency department; the five toxins that cause most acute poisoning are: alcohol, benzodiazepines, antiarrhythmics, cannabis and carbon monoxide.
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Affiliation(s)
| | | | - Emmanuel Echániz-Serrano
- Research Group of the Transfercult, Department of Physiatry and Nursing, Faculty of Health Sciences, University of Zaragoza, Zaragoza, Spain
| | - Eduardo Mir-Ramos
- Health Emergencies 061 ARAGÓN, Aragon Health Service, Zaragoza, Spain
| | | | | | | | - Iván Santolalla-Arnedo
- Group in Research in Care (GRUPAC), Department of Nursing, University of La Rioja, Logrono, Spain
| | - Michal Czapla
- Group in Research in Care (GRUPAC), Department of Nursing, University of La Rioja, Logrono, Spain
- Department of Emergency Medical Service, Wroclaw Medical University, 51-618 Wroclaw, Poland
| | - Jacek Smereka
- Department of Emergency Medical Service, Wroclaw Medical University, 51-618 Wroclaw, Poland
| | - Raúl Juárez-Vela
- Group in Research in Care (GRUPAC), Department of Nursing, University of La Rioja, Logrono, Spain
| | - Pedro José Satústegui-Dordá
- Research Group Water and Environmental Health (B43_20R), Department of Physiatry and Nursing, Faculty of Health Sciences, University of Zaragoza, Zaragoza, Spain
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13
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Wójcik M, Rogalska A. Analgesic Treatment and the Patients' Opinion on the Hospital Emergency Department. Healthcare (Basel) 2022; 10:healthcare10040623. [PMID: 35455801 PMCID: PMC9030114 DOI: 10.3390/healthcare10040623] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 03/17/2022] [Accepted: 03/22/2022] [Indexed: 12/04/2022] Open
Abstract
Aim: The aim of the study was to analyze whether a patient’s opinion is related to the effect of analgesic treatment. Methods: The study was conducted using a survey questionnaire among adult patients admitted to the hospital emergency department in March 2021. The Numerical Rating Scale (NRS) was used to assess pain. Patients were asked to rate the intensity of pain during their stay in the emergency department in three situations: (1) at admission; (2) during the stay; and (3) upon discharge. The relationships between qualitative variables were assessed by the chi-squared test. Significance was set at p < 0.05. Results: There was no statistical dependence between the patient’s opinion about the medical institution and results of the effectiveness of analgesic treatments (p = 0.056). The highest percentage of patients satisfied with the received treatment were those who did not feel pain during ED discharge (94.12%), and the lowest were those who complained of severe pain during ED discharge (63.91%). The average mark for the functioning and organization of the emergency department was 7.44 (±2.04). Only 54 patients (29.83%) had taken pain medication before deciding to visit ED. Conclusions: No statistical dependency between the effect of the analgesic treatment and the patient’s opinion has been observed. The majority of patients with pain discomfort visit emergency departments without looking for consultation in other locations or without taking analgesics. In the considered institution, patients were satisfied with the analgesic treatment, staff performance, and with the organization of the department.
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Affiliation(s)
- Michał Wójcik
- Emergency Department, Regional Hospital, 43-316 Bielsko-Biala, Poland;
| | - Anna Rogalska
- Department of Economics and Management in Health Care, School of Health Sciences in Bytom, Medical University of Silesia, 40-055 Katowice, Poland
- Correspondence:
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14
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Anand A, Cheng M, Ibitoye T, Maclullich AMJ, Vardy ERLC. Positive scores on the 4AT delirium assessment tool at hospital admission are linked to mortality, length of stay and home time: two-centre study of 82,770 emergency admissions. Age Ageing 2022; 51:6548791. [PMID: 35292792 PMCID: PMC8923813 DOI: 10.1093/ageing/afac051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Studies investigating outcomes of delirium using large-scale routine data are rare. We performed a two-centre study using the 4 'A's Test (4AT) delirium detection tool to analyse relationships between delirium and 30-day mortality, length of stay and home time (days at home in the year following admission). METHODS The 4AT was performed as part of usual care. Data from emergency admissions in patients ≥65 years in Lothian, UK (n = 43,946) and Salford, UK (n = 38,824) over a period of $\sim$3 years were analysed using logistic regression models adjusted for age and sex. RESULTS 4AT completion rates were 77% in Lothian and 49% in Salford. 4AT scores indicating delirium (≥4/12) were present in 18% of patients in Lothian, and 25% of patients in Salford. Thirty-day mortality with 4AT ≥4 was 5.5-fold greater than the 4AT 0/12 group in Lothian (adjusted odds ratio (aOR) 5.53, 95% confidence interval [CI] 4.99-6.13) and 3.4-fold greater in Salford (aOR 3.39, 95% CI 2.98-3.87). Length of stay was more than double in patients with 4AT scores of 1-3/12 (indicating cognitive impairment) or ≥ 4/12 compared with 4AT 0/12. Median home time at 1 year was reduced by 112 days (Lothian) and 61 days (Salford) in the 4AT ≥4 group (P < 0.001). CONCLUSIONS Scores on the 4AT used at scale in practice are strongly linked with 30-day mortality, length of hospital stay and home time. The findings highlight the need for better understanding of why delirium is linked with poor outcomes and also the need to improve delirium detection and treatment.
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Affiliation(s)
- Atul Anand
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Michael Cheng
- Salford Care Organisation, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Temi Ibitoye
- Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Alasdair M J Maclullich
- Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh, Edinburgh, UK
- Address correspondence to: Alasdair MacLullich, Professor of Geriatric Medicine, Ageing and Health, Usher Institute, University of Edinburgh, Room S1642, Royal Infirmary of Edinburgh, Edinburgh, UK. Tel: 0131 650 1000. Email ; Emma Vardy, Consultant in Geriatric Medicine, Salford Care Organisation, Northern Care Alliance NHS Foundation Trust, Stott Lane, Salford, Manchester, UK. Tel: 0161 789 7373.
| | - Emma R L C Vardy
- Salford Care Organisation, Northern Care Alliance NHS Foundation Trust, Stott Lane, Salford, UK
- NIHR Applied Research Collaboration Greater Manchester, University of Manchester, Manchester, UK
- Address correspondence to: Alasdair MacLullich, Professor of Geriatric Medicine, Ageing and Health, Usher Institute, University of Edinburgh, Room S1642, Royal Infirmary of Edinburgh, Edinburgh, UK. Tel: 0131 650 1000. Email ; Emma Vardy, Consultant in Geriatric Medicine, Salford Care Organisation, Northern Care Alliance NHS Foundation Trust, Stott Lane, Salford, Manchester, UK. Tel: 0161 789 7373.
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15
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Cohen J, Wright-Berryman J, Rohlfs L, Trocinski D, Daniel L, Klatt TW. Integration and Validation of a Natural Language Processing Machine Learning Suicide Risk Prediction Model Based on Open-Ended Interview Language in the Emergency Department. Front Digit Health 2022; 4:818705. [PMID: 35187527 PMCID: PMC8847784 DOI: 10.3389/fdgth.2022.818705] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 01/10/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Emergency departments (ED) are an important intercept point for identifying suicide risk and connecting patients to care, however, more innovative, person-centered screening tools are needed. Natural language processing (NLP) -based machine learning (ML) techniques have shown promise to assess suicide risk, although whether NLP models perform well in differing geographic regions, at different time periods, or after large-scale events such as the COVID-19 pandemic is unknown. OBJECTIVE To evaluate the performance of an NLP/ML suicide risk prediction model on newly collected language from the Southeastern United States using models previously tested on language collected in the Midwestern US. METHOD 37 Suicidal and 33 non-suicidal patients from two EDs were interviewed to test a previously developed suicide risk prediction NLP/ML model. Model performance was evaluated with the area under the receiver operating characteristic curve (AUC) and Brier scores. RESULTS NLP/ML models performed with an AUC of 0.81 (95% CI: 0.71-0.91) and Brier score of 0.23. CONCLUSION The language-based suicide risk model performed with good discrimination when identifying the language of suicidal patients from a different part of the US and at a later time period than when the model was originally developed and trained.
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Affiliation(s)
| | - Jennifer Wright-Berryman
- Department of Social Work, College of Allied Health Sciences, University of Cincinnati, Cincinnati, OH, United States
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16
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Tsai CL, Lu TC, Wang CH, Fang CC, Chen WJ, Huang CH. Trajectories of Vital Signs and Risk of In-Hospital Cardiac Arrest. Front Med (Lausanne) 2022; 8:800943. [PMID: 35047534 PMCID: PMC8761796 DOI: 10.3389/fmed.2021.800943] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 12/13/2021] [Indexed: 11/25/2022] Open
Abstract
Background: Little is known about the trajectories of vital signs prior to in-hospital cardiac arrest (IHCA), which could explain the heterogeneous processes preceding this event. We aimed to identify clinically relevant subphenotypes at high risk of IHCA in the emergency department (ED). Methods: This retrospective cohort study used electronic clinical warehouse data from a tertiary medical center. We retrieved data from 733,398 ED visits over a 7-year period. We selected one ED visit per person and retrieved patient demographics, triage data, vital signs (systolic blood pressure [SBP], heart rate [HR], body temperature, respiratory rate, oxygen saturation), selected laboratory markers, and IHCA status. Group-based trajectory modeling was performed. Results: There were 37,697 adult ED patients with a total of 1,507,121 data points across all vital-sign categories. Three to four trajectory groups per vital-sign category were identified, and the following five trajectory groups were associated with a higher rate of IHCA: low and fluctuating SBP, high and fluctuating HR, persistent hypothermia, recurring tachypnea, and low and fluctuating oxygen saturation. The IHCA-prone trajectory group was associated with a higher triage level and a higher mortality rate, compared to other trajectory groups. Except for the persistent hypothermia group, the other four trajectory groups were more likely to have higher levels of C-reactive protein, lactic acid, cardiac troponin I, and D-dimer. Multivariable analysis revealed that hypothermia (adjusted odds ratio [aOR], 2.20; 95% confidence interval [95%CI], 1.35–3.57) and recurring tachypnea (aOR 2.44; 95%CI, 1.24–4.79) were independently associated with IHCA. Conclusions: We identified five novel vital-sign sub-phenotypes associated with a higher likelihood of IHCA, with distinct patterns in clinical course and laboratory markers. A better understanding of the pre-IHCA vital-sign trajectories may help with the early identification of deteriorating patients.
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Affiliation(s)
- Chu-Lin Tsai
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Tsung-Chien Lu
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chih-Hung Wang
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Cheng-Chung Fang
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Wen-Jone Chen
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chien-Hua Huang
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
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17
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Machner B, Erber K, Choi JH, Sprenger A, Helmchen C, Trillenberg P. A Simple Gain-Based Evaluation of the Video Head Impulse Test Reliably Detects Normal Vestibulo-Ocular Reflex Indicative of Stroke in Patients With Acute Vestibular Syndrome. Front Neurol 2021; 12:741859. [PMID: 34777209 PMCID: PMC8585749 DOI: 10.3389/fneur.2021.741859] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 10/06/2021] [Indexed: 11/16/2022] Open
Abstract
Objective: The head impulse test (HIT) assesses the vestibulo-ocular reflex (VOR) and is used to differentiate vestibular neuritis (abnormal VOR) from stroke (normal VOR) in patients presenting with an acute vestibular syndrome (AVS). The video-oculography-based HIT (vHIT) quantifies VOR function and provides information imperceptible for the clinician during clinical bedside HIT. However, the vHIT—like an electrocardiogram—requires experienced interpretation, which is especially difficult in the emergency setting. This calls for a simple, reliable and rater-independent way of analysis. Methods: We retrospectively collected 171 vHITs performed in patients presenting with AVS to our emergency department. Three neuro-otological experts comprehensively assessed the vHITs including interpretability (artifacts), VOR gain (eye/head velocity ratio), velocity profile (abrupt decline) and corrective saccades (overt/covert). Their consensus rating (abnormal/peripheral vs. normal/central) was compared to a simple algorithm that automatically classified the vHITs based on a single VOR gain cutoff (0.7). Results: Inter-rater agreement between experts was high (Fleiss' kappa = 0.74). Five (2.9 %) vHITs were “uninterpretable” according to experts' consensus, 80 (46.8 %) were rated “normal” and 86 (50.3 %) “abnormal”. The algorithm had substantial agreement with the experts' consensus (Cohen's kappa = 0.75). Importantly, it correctly classified all of the normal/central vHITs denoted by the experts (100% specificity) and at the same time it had sufficient sensitivity (75.6%) in detecting abnormal/peripheral vHITs. Conclusion: A simple, automated, gain-based evaluation of the vHIT reliably detects normal/central VOR and may be a feasible and effective tool to screen AVS patients for potentially underlying stroke in the emergency setting.
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Affiliation(s)
- Björn Machner
- Department of Neurology, University Hospitals Schleswig-Holstein, Lübeck, Germany
| | - Kira Erber
- Department of Anesthesiology and Intensive Care, University Hospitals Schleswig-Holstein, Lübeck, Germany
| | - Jin Hee Choi
- Department of Neurology, University Hospitals Schleswig-Holstein, Lübeck, Germany
| | - Andreas Sprenger
- Department of Neurology, University Hospitals Schleswig-Holstein, Lübeck, Germany
| | - Christoph Helmchen
- Department of Neurology, University Hospitals Schleswig-Holstein, Lübeck, Germany
| | - Peter Trillenberg
- Department of Neurology, University Hospitals Schleswig-Holstein, Lübeck, Germany
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Simwatachela E, Ozoh JO, Mabuza LH, Kalinda C. Clinical Predictors of Abnormal Head Computed Tomography Findings in Non-trauma Patients Presenting to a South African Emergency Department. Front Radiol 2021; 1:759731. [PMID: 37492168 PMCID: PMC10364977 DOI: 10.3389/fradi.2021.759731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 09/22/2021] [Indexed: 07/27/2023]
Abstract
Background: Head computed tomography (head CT) examinations conducted at emergency departments (EDs) for non-trauma patients are expensive and expose patients to ionizing radiation. Identification of symptoms likely to yield abnormal head CT scans can reduce costs and prevent unnecessary patient irradiation. There is limited comprehensive data in the literature concerning the utilization of head CT in low- and middle-income countries (LMICs) EDs. Methods: A retrospective study of successive non-contrasted head CT scans from February 2017 through January 2018 performed on non-trauma ED patients aged 18 years and above without known pre-existing intracranial pathology was conducted. Univariate and multivariate logistic models were used to determine which presenting clinical features were likely to yield abnormal head CT findings. Clinical information was obtained from the history and physical examination findings entered on the requisition form by the ED clinicians and from previous head CT reports if present on the picture archiving and communication system (PACS). Results: A total of 396 consecutive patients who received head CT examinations had a median age of 49 years (IQR: 36-53), and 53.3% were male (n = 211/396). Of the head CT scans included, 73.5% of head CTs included were abnormal (n = 291/396). Age >61 years (aOR:1.54; 95%CI: 1.12-2.10), focal neurologic deficit (aOR: 2.46; 95%CI: 1.42-4.26), and loss of consciousness (aOR 2.82; 95%CI: 1.21-6.57) were the predictors of abnormal head CT findings. Conclusion: A head CT scan in a non-trauma patient presenting to an emergency department in a low-middle income country like South Africa is likely to yield abnormal findings if a patient presented with age above 61 years, loss of consciousness, or focal neurological deficit.
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Affiliation(s)
- Ekin Simwatachela
- Department of Diagnostic Radiology and Imaging, Sefako Makgatho Health Sciences University, Pretoria, South Africa
| | - John O. Ozoh
- Department of Diagnostic Radiology and Imaging, Sefako Makgatho Health Sciences University, Pretoria, South Africa
| | - Langalibalele H. Mabuza
- Department of Family Medicine and Primary Health Care, Sefako Makgatho Health Sciences University, Pretoria, South Africa
| | - Chester Kalinda
- Department of Public Health, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
- Bill and Joyce Cummings Institute of Global Health, University of Global Health Equity (UGHE), Kigali, Rwanda
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19
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El-Hadedy N, El-Husseiny M. Evidence-Based Design for Workplace Violence Prevention in Emergency Departments Utilizing CPTED and Space Syntax Analyses. HERD 2021; 15:333-352. [PMID: 34493118 DOI: 10.1177/19375867211042902] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Workplace violence (WPV) is a prevalent phenomenon in Egyptian emergency departments (EDs), an issue that threatens an already scarce resource of healthcare workers. Furthermore, changes and modifications are continuously taking place in hospitals, with no consideration to the important role those changes might play in reducing or encouraging WPV behaviors. OBJECTIVE This research serves as an initial step in offering answers on how the environmental design of an ED can be modified and manipulated to prevent and control WPV. Accordingly, the objective of this research is to identify the environmental features that potentially influence WPV in the ED. This could provide healthcare designers with the necessary tools to forecast the location of WPV and define the measures needed for a safer working environment. METHOD The study comprised a hybrid method approach that evaluates the implementation of crime prevention through environmental design (CPTED) through field observation and combined with space syntax analyses (SSAs) of the spatial attributes. RESULTS The results showed a positive relationship between the spatial properties (high integration and connectivity values) and WPV locations. The results also demonstrated that situational factors as natural surveillance played an important role in displacing the WPV locations. CONCLUSIONS The contribution of this research lies in elaborating the SSA and CPTED from a conceptual to an empirical level. Combining those tools will help identify the location of WPV in the ED and hence facilitates successful future environmental intervention strategies.
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Affiliation(s)
- Nada El-Hadedy
- Department Architectural Engineering, Cairo University, Giza, Egypt
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Dickson DA, Gantt L, Swanson M. Effectiveness of the Weighted Blanket With Psychiatric Patients in the Emergency Department: A Pilot Study. J Am Psychiatr Nurses Assoc 2021:10783903211026740. [PMID: 34166155 DOI: 10.1177/10783903211026740] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Restraint and seclusion continue to be used with patients demonstrating aggressive and violent behaviors while in the emergency department and as inpatients in behavioral health (BH) units. The use of sensory interventions such as the weighted blanket (WB) is garnering interest as alternatives to aid in managing anxiety, anger, and aggressive behaviors. Reports of the effectiveness of the WB have primarily been anecdotal, and results of research with children have been mixed. Only one study has been conducted with the WB with adults on an inpatient psychiatric unit. OBJECTIVES The aim of this pilot study was to assess the effectiveness of the WB by determining whether it decreases anxiety and/or anger in adult emergency department patients with preexisting psychiatric diagnoses. METHODS The study used a quasi-experimental, nonequivalent control group design with pre- and posttests for anxiety and anger. The intervention was a 15-pound WB. Participants (N = 15) were in one of three groups, which included no weighted blanket (NWB), WB for 15 minutes, or WB for 30 minutes. RESULTS All three groups showed a decrease in anxiety and anger scores. However, participants in the WB groups had a greater decrease in anxiety and anger posttest scores. CONCLUSIONS The small sample size in this study did not allow for the determination of any differences between groups on anxiety or anger scores that could be viewed as a significant finding.
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Affiliation(s)
- Debra A Dickson
- Debra A. Dickson, RN, PMHCNS-BC, East Carolina University, Vidant Medical Center, Greenville, NC, USA
| | - Laura Gantt
- Laura Gantt, PhD, RN, CEN, CHSE, East Carolina University College of Nursing, Greenville, NC, USA
| | - Melvin Swanson
- Melvin Swanson, BS, PhD, East Carolina University College of Nursing, Greenville, NC, USA
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Reisinger N, Lohani S, Hagemeier J, Panebianco N, Baston C. Lung Ultrasound to Diagnose Pulmonary Congestion Among Patients on Hemodialysis: Comparison of Full Versus Abbreviated Scanning Protocols. Am J Kidney Dis 2021; 79:193-201.e1. [PMID: 34090905 DOI: 10.1053/j.ajkd.2021.04.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 04/09/2021] [Indexed: 12/26/2022]
Abstract
RATIONALE & OBJECTIVE Pulmonary congestion contributes to morbidity and mortality in patients with kidney failure on hemodialysis, but physical assessment is an insensitive approach to its detection. Lung ultrasound is useful for assessing the presence and severity of pulmonary congestion, but the most widely validated 28-zone study is cumbersome. We sought to compare abbreviated 4-, 6-, and 8-zone studies to 28-zone studies. STUDY DESIGN Diagnostic test study. SETTING & PARTICIPANTS Convenience sample of 98 patients with kidney failure on hemodialysis presenting to an emergency department in the United States. TESTS COMPARED 4-, 6-, and 8-zone lung ultrasound studies versus a 28-zone lung ultrasound. OUTCOME Prediction of pulmonary congestion and 30-day mortality. RESULTS All patients completed a 28-zone lung ultrasound. Correlation coefficients (nonparametric Spearman) between each of the studies were high (all values > 0.84). Bland-Altman analysis showed good agreement. Each of the short-form studies discriminated well with area under the receiver-operator characteristic curve > 0.83 for no-to-mild versus moderate-to-severe pulmonary congestion. During a median follow-up period of 778 days, 46 (47%) died. Patients with moderate-to-severe pulmonary congestion on lung ultrasound had a 30-day mortality rate similar to that observed among patients with no-to-mild pulmonary congestion (OR, 0.95 [95% CI, 0.70-1.29]). LIMITATIONS Single-center study conducted in an emergency care setting, convenience sample of patients, and lack of long-term follow-up data. CONCLUSIONS Among hemodialysis patients presenting to an emergency department, 4-, 6-, or 8-zone lung ultrasounds were comparable to 28-zone studies for the assessment of pulmonary congestion. The mortality rates did not differ between those with no-to-mild and moderate-to-severe pulmonary congestion.
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Affiliation(s)
| | | | - Jesper Hagemeier
- University at Buffalo, State University of New York, Buffalo, NY
| | | | - Cameron Baston
- Penn Medicine, University of Pennsylvania, Philadelphia, PA
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22
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Abstract
Aerosol delivery is a vital therapeutic strategy for both adult and pediatric patients presenting to the emergency department with respiratory distress. Aerosolized bronchodilators are frequently used as rescue medications for patients with diagnoses of asthma, chronic obstructive pulmonary disease (COPD), or pneumonia. Historically, emergency department providers utilized jet nebulizers (JNs) for medication delivery, but were challenged by a need for increasingly higher bronchodilator doses to elicit the desired response. Advancements in technology have led to the development of newer specialized aerosol delivery devices and treatment strategies which provide clinicians with improved options for aerosol delivery but may also cause some uncertainty regarding appropriate device selection. Initial investigations comparing these devices presented valuable evidence of in vitro benefit but were unable to demonstrate corresponding improvement in clinical results. More recently there has been an influx of clinical evidence that suggests improved clinical outcomes associated with more efficient aerosol delivery devices such as vibrating mesh nebulizers (VMN) compared to the standard JN device. VMN will likely become an increasingly important tool in emergency department treatment of patients with respiratory distress. Additional controlled studies are needed both to examine the effects of VMN on patient outcomes, as well as to analyze how performance differences between aerosol devices may affect dosing strategies. Future efforts should also focus on applying new evidence in the form of updated consensus guidelines and standardized treatment strategies.
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Affiliation(s)
- Patricia A Dailey
- Department of Medical Affairs, Senior Medical Science Liaison, Galway, Ireland
| | - Courtney M Shockley
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, UT Health San Antonio, San Antonio, TX, USA
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Abstract
BACKGROUND BRASH syndrome, a relatively new entity, has been described in the recent literature. It is defined as a combination of bradycardia, renal failure, atrioventricular nodal blockade, shock, and hyperkalemia. Although it is apparent that clinical symptomatology includes shock, it is still unclear whether all patients will initially present with all five components mentioned in the BRASH acronym. CASE REPORT An elderly woman presented to our Emergency Department (ED) with hyperkalemia, acute renal failure, and metabolic acidosis with bradycardia, which was refractory to antikalemic measures and atropine. The montage of clinical features put together showed a clear picture of BRASH syndrome, which helped us to streamline the management and achieve a better patient outcome. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Renal failure with various metabolic derangements is commonly seen in the ED. We should be aware of this new clinical entity, as its incidence will certainly increase, and the management is a bit different. Prognosis is excellent with timely recognition and management of this rare clinical entity.
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Affiliation(s)
- V K Vishnu
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Nayer Jamshed
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - V T Amrithanand
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Soumitra Thandar
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
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Haddad R, Parker S, Farooqi A, DeLaroche AM. Diagnostic Evaluation Low Yield for Patients with a Lower-Risk Brief Resolved Unexplained Event. Glob Pediatr Health 2021; 8:2333794X20967586. [PMID: 33614835 PMCID: PMC7868487 DOI: 10.1177/2333794x20967586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 09/23/2020] [Accepted: 09/29/2020] [Indexed: 11/18/2022] Open
Abstract
In contrast to patients with an apparent life-threatening event (ALTE), the American Academy of Pediatrics recommends very limited evaluation for patients categorized as lower-risk brief resolved unexplained event (BRUE). This retrospective review aims to explore potential missed diagnostic opportunities for patients with a lower-risk BRUE (n = 10) through comparison with a subset of patients with ALTE (n = 72). None of the patients with a lower-risk BRUE had laboratory, imaging or ancillary studies that were diagnostic. Among patients with ALTE, 5 had laboratory and 3 had imaging studies that were diagnostic. None of the patients with a lower-risk BRUE had recurrent events during hospitalization or a serious underlying diagnosis identified within the 90 day follow-up period. As recommended by the AAP, patients with a lower-risk BRUE do not need diagnostic evaluation and can be discharged home with outpatient follow-up.
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Affiliation(s)
- Rita Haddad
- Children's Hospital of Michigan, Detroit, MI, USA
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Lipe DN, Elsayem A, Cruz-Carreras MT, Thomas J, Feliciano A, Ren J, Gaeta SM, Rajha E, Manasanch E, Kheder E, Brock P, Reyes-Gibby C. Characteristics of cancer patients with COVID-19 in a cancer hospital. Ann Palliat Med 2020; 10:1763-1771. [PMID: 33222454 DOI: 10.21037/apm-20-1447] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 10/26/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND Cancer patients are vulnerable to the coronavirus disease (COVID-19) given their compromised immune system. The purpose of this study was to describe the presenting symptoms, inpatient stay trajectory, and survival outcomes, for cancer patients infected with COVID-19; who presented to the emergency department (ED) of a single center during the early months of the pandemic. METHODS We reviewed the electronic medical records of all cancer patients diagnosed with COVID-19 at our institution for demographic information, clinical presentation, laboratory findings, treatment intervention and outcomes. All patients had at least 14 days of follow-up. We determined their survival outcomes as of August 5, 2020. RESULTS Twenty-eight cancer patients were diagnosed with COVID-19, and 16 (57%) presented to the ED during the study period. The median age of patients who presented to the ED was 61 years, 69% were women, and the median length of hospitalization was 11 days. There was no difference between the groups (ED vs. no ED visit) for demographics, treatment status or solid tumor versus hematologic malignancies or treatments. Dyspnea was a significant symptom with 67% of ED patients experiencing it versus only 17% of those that did not come to the ED (P=0.009). Do not resuscitate orders were initiated in eight patients, as early as two days from ED presentation and two of these patients died, while 88% of patients were discharged alive. CONCLUSIONS Most cancer patients with COVID-19 infection admitted though the ED experienced dyspnea and were discharged from the hospital. We did not notice a statistically significant difference between cancer types or type of therapy. A broad differential is of utmost importance when caring for cancer patients with COVID-19 due to the complexity of this population. Early goals of care discussion should be initiated in the ED.
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Affiliation(s)
- Demis N Lipe
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Ahmed Elsayem
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Maria T Cruz-Carreras
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jomol Thomas
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Adianes Feliciano
- Department of Emergency Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Jenny Ren
- Baylor College of Medicine, Houston, TX, USA
| | - Susan M Gaeta
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eva Rajha
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elisabet Manasanch
- Department of LymphomaMyeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ed Kheder
- Department of General Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Patricia Brock
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Cielito Reyes-Gibby
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Lillebuen L, Schick-Makaroff K, Thompson S, Molzahn A. Facilitators and Barriers to Care in Rural Emergency Departments in Alberta for Patients on Peritoneal Dialysis (PD): An Interpretive Descriptive Study. Can J Kidney Health Dis 2020; 7:2054358120970098. [PMID: 33224512 PMCID: PMC7649850 DOI: 10.1177/2054358120970098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 09/24/2020] [Indexed: 12/04/2022] Open
Abstract
Background: Home dialysis offers many advantages to patients, but they require support to manage a home-based therapy such as peritoneal dialysis (PD). A rural emergency department provides an important safety net for patients requiring medical care, including managing complications of PD, such as peritonitis. Patients living in northern Alberta are spread out geographically and can be far from a PD training center, yet anecdotally, many rural sites do not provide care for these patients. Objective: Our aim was to identify the facilitators and barriers to nursing care in rural emergency departments in northern Alberta for patients receiving PD. Design: A qualitative interpretive descriptive approach was used. Setting: Rural emergency departments across northern Alberta. Participants: Purposeful sampling was used to seek participants from 1 of 4 rural acute care hospital emergency departments in northern Alberta. Six registered nurses and 1 licensed practical nurse agreed to participate in the study. They ranged in experience from 2 to 18 years. Two of the participants were unit managers, 2 were clinical nurse educators (CNEs), and the other 3 were staff nurses with 1 of them in a leadership position. Methods: Individual semistructured interview were conducted over the telephone. The interview guide was developed based on a review of the literature. Interviews continued until no new information was obtained, that is, data were saturated. Interviews were audio recorded and transcribed verbatim. Field notes were recorded. A constant comparative approach was used for analysis. The coding process was both deductive (drawing from the literature) and inductive. Results: Seven participants were interviewed, and there were 4 main themes and 1 subtheme that emerged from the analysis: education (along with the subtheme of resources) was seen as both facilitators and barriers; patient/family ability to perform PD; infrequent exposure; and physician supports. Continuing education about PD was a facilitator, and the lack of education was a barrier to provision of PD care. Similarly, availability of resource materials about PD and access to a CNE were facilitators, while lack of these resources was a barrier to offering PD care. As PD was not always seen regularly, infrequent exposure was a barrier to offering PD care. Lack of physician supports, both from the locum physicians who were sometimes reluctant to care for these patients and the delays in reaching nephrologists were barriers. Limitations: The findings represent the perceptions of the emergency department nurses who participated. These perceptions may differ from those of nurses who work in other regions of the country. Furthermore, most participants were in a leadership role, and it may be that their perspectives differ from those of front-line nurses. Conclusions: The findings from our study highlight the need for availability of education and resource materials/persons to care for these patients. There is also a need for greater physician support from both local physicians as well as nephrologists to offer high-quality PD care. Trial registration: Not applicable. This study is not a clinical trial. It did not involve prospective assignment of participants to a treatment group.
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Affiliation(s)
- Lisa Lillebuen
- Faculty of Nursing, University of Alberta, Edmonton, Canada
| | | | - Stephanie Thompson
- Division of Nephrology, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Canada
| | - Anita Molzahn
- Faculty of Nursing, University of Alberta, Edmonton, Canada
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27
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Goel NN, Durst MS, Vargas-Torres C, Richardson LD, Mathews KS. Predictors of Delayed Recognition of Critical Illness in Emergency Department Patients and Its Effect on Morbidity and Mortality. J Intensive Care Med 2020; 37:52-59. [PMID: 33118840 DOI: 10.1177/0885066620967901] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE Timely recognition of critical illness is associated with improved outcomes, but is dependent on accurate triage, which is affected by system factors such as workload and staffing. We sought to first study the effect of delayed recognition on patient outcomes after controlling for system factors and then to identify potential predictors of delayed recognition. METHODS We conducted a retrospective cohort study of Emergency Department (ED) patients admitted to the Intensive Care Unit (ICU) directly from the ED or within 48 hours of ED departure. Cohort characteristics were obtained through electronic and standardized chart abstraction. Operational metrics to estimate ED workload and volume using census data were matched to patients' ED stays. Delayed recognition of critical illness was defined as an absence of an ICU consult in the ED or declination of ICU admission by the ICU team. We employed entropy-balanced multivariate models to examine the association between delayed recognition and development of persistent organ dysfunction and/or death by hospitalization day 28 (POD+D), and multivariable regression modeling to identify factors associated with delayed recognition. RESULTS Increased POD+D was seen for those with delayed recognition (OR 1.82, 95% CI 1.13-2.92). When the delayed recognition was by the ICU team, the patient was 2.61 times more likely to experience POD+D compared to those for whom an ICU consult was requested and were accepted for admission. Lower initial severity of illness score (OR 0.26, 95% CI 0.12-0.53) was predictive of delayed recognition. The odds for delayed recognition decreased when ED workload is higher (OR 0.45, 95% CI 0.23-0.89) compared to times with lower ED workload. CONCLUSIONS Increased POD+D is associated with delayed recognition. Patient and system factors such as severity of illness and ED workload influence the odds of delayed recognition of critical illness and need further exploration.
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Affiliation(s)
- Neha N Goel
- Division of Pulmonary, Critical Care, & Sleep Medicine, Department of Medicine, 5925Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Matthew S Durst
- Division of Pulmonary, Critical Care, & Sleep Medicine, Department of Medicine, Northwell Health, 232890Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Carmen Vargas-Torres
- Department of Emergency Medicine, 5925Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Lynne D Richardson
- Department of Emergency Medicine, 5925Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Population Health Science and Policy, 5925Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kusum S Mathews
- Division of Pulmonary, Critical Care, & Sleep Medicine, Department of Medicine, 5925Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Emergency Medicine, 5925Icahn School of Medicine at Mount Sinai, New York, NY, USA
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28
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Elliott MJ, Love S, Donald M, Manns B, Donald T, Premji Z, Hemmelgarn BR, Grinman M, Lang E, Ronksley PE. Outpatient Interventions for Managing Acute Complications of Chronic Diseases: A Scoping Review and Implications for Patients With CKD. Am J Kidney Dis 2020; 76:794-805. [PMID: 32479925 DOI: 10.1053/j.ajkd.2020.04.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 04/02/2020] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE Patients with chronic kidney disease (CKD) have high rates of emergency department (ED) use and hospitalization. Outpatient care may provide an alternative to ED and inpatient care in this population. We aimed to explore the scope of outpatient interventions used to manage acute complications of chronic diseases and highlight opportunities to adapt and test interventions in the CKD population. STUDY DESIGN Scoping review of quantitative and qualitative studies. SETTING & POPULATION Outpatient interventions for adults experiencing acute complications related to 1 of 5 eligible chronic diseases (ie, CKD, chronic respiratory disease, cardiovascular disease, cancer, and diabetes). SELECTION CRITERIA FOR STUDIES MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, grey literature, and conference abstracts were searched to December 2019. DATA EXTRACTION Intervention and study characteristics were extracted using standardized tools. ANALYTICAL APPROACH Quantitative data were summarized descriptively; qualitative data were summarized thematically. Our approach observed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) extension for scoping reviews. RESULTS 77 studies (25 randomized controlled trials, 29 observational, 12 uncontrolled before-after, 5 quasi-experimental, 4 qualitative, and 2 mixed method) describing 57 unique interventions were included. Of identified intervention types (hospital at home [n = 16], observation unit [n = 9], ED-based specialist service [n = 4], ambulatory program [n = 18], and telemonitoring [n = 10]), most were studied in chronic respiratory and cardiovascular disease populations. None targeted the CKD population. Interventions were delivered in the home, ED, hospital, and ambulatory setting by a variety of health care providers. Cost savings were demonstrated for most interventions, although improvements in other outcome domains were not consistently observed. LIMITATIONS Heterogeneity of included studies; lack of data for outpatient interventions for acute complications related to CKD. CONCLUSIONS Several interventions for outpatient management of acute complications of chronic disease were identified. Although none was specific to the CKD population, features could be adapted and tested to address the complex acute-care needs of patients with CKD.
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Affiliation(s)
- Meghan J Elliott
- Department of Medicine, University of Calgary, Calgary, AB, Canada; Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.
| | - Shannan Love
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Maoliosa Donald
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Bryn Manns
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Teagan Donald
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Zahra Premji
- Department of Libraries and Cultural Resources, University of Calgary, Calgary, AB, Canada
| | - Brenda R Hemmelgarn
- Department of Medicine, University of Calgary, Calgary, AB, Canada; Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Michelle Grinman
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Eddy Lang
- Department of Emergency Medicine, University of Calgary, Calgary, AB, Canada
| | - Paul E Ronksley
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
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Stein Duker LI, Schmidt AR, Pham PK, Ringold SM, Nager AL. Use of Audiobooks as an Environmental Distractor to Decrease State Anxiety in Children Waiting in the Pediatric Emergency Department: A Pilot and Feasibility Study. Front Pediatr 2020; 8:556805. [PMID: 33585358 PMCID: PMC7874121 DOI: 10.3389/fped.2020.556805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 12/07/2020] [Indexed: 11/13/2022] Open
Abstract
Objectives: Anxiety and anticipatory stressors are commonly experienced by children visiting the Pediatric Emergency Department (PED), but little research exists that addresses the efficacy of interventions to decrease this stress. This one-sample pretest-postest pilot study gathered preliminary data on the feasibility and effectiveness of utilizing audiobooks to reduce fear and state anxiety in children in the PED. Methods: Participants were 131 children in kindergarten through 8th grade (M = 9.4 years, 54% female), triaged urgent or emergent, presenting to the PED. Participants self-reported fear (Children's Fear Scale) and state anxiety (modified State-Trait Anxiety Inventory for Children; mSTAIC) before and after listening to an age-appropriate audiobook (two options). Data regarding patient experience were also collected. Paired samples t-test was used to examine pre-post intervention changes in fear and state anxiety. Results: Significant, albeit small, improvements in fear and the mSTAIC states of nervous, calm, happy, and relaxed were found after use of the audiobook (Cohen's d z = 0.22-0.35). Small, yet significant correlations were found between child age/grade level and improvements in fear and in the mSTAIC states of scared and relaxed, suggesting that the audiobook was more beneficial for older participants. Over 60% of participants liked the audiobook content "a lot" as well as enjoyed listening to the audiobook "a lot." Without prompting, 15% of participants requested to listen to an additional audiobook. Conclusions: Listening to an audiobook is feasible and could be effective in decreasing fear and state anxiety for children during a waiting period in the PED. The technology is low-cost, simple, and portable. The results of this study should be interpreted with prudence due to the lack of a control group and results that, although significant, were modest based on effect size conventions; future studies should explore the impact of audiobooks on patient stress with an expanded sample size and control group.
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Affiliation(s)
- Leah I Stein Duker
- Division of Occupational Science and Occupational Therapy, University of Southern California, Los Angeles, CA, United States
| | - Anita R Schmidt
- Division of Emergency and Transport Medicine, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, United States
| | - Phung K Pham
- Division of Emergency and Transport Medicine, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, United States
| | - Sofronia M Ringold
- Division of Emergency and Transport Medicine, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, United States
| | - Alan L Nager
- Division of Emergency and Transport Medicine, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, United States.,Keck School of Medicine at the University of Southern California, Los Angeles, CA, United States
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30
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Mathew R, Jamshed N, Aggarwal P, Patel S, Pandey RM. Profile of acute poisoning cases and their outcome in a teaching hospital of north India. J Family Med Prim Care 2019; 8:3935-3939. [PMID: 31879639 PMCID: PMC6924236 DOI: 10.4103/jfmpc.jfmpc_832_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 09/27/2019] [Accepted: 10/11/2019] [Indexed: 01/02/2023] Open
Abstract
Objectives: Aim of this study was to characterize acute poisoning and snakebite cases and their outcome in the Emergency Department (ED). Methods: This was a prospective study done in the ED of a tertiary healthcare center. Study included 184 patients of acute poisoning and 16 cases of snakebite. Data regarding demographics, type, time, and mode of poisoning, lag time in reaching the hospital, initiation of treatment, first aid, in-hospital treatment, and comorbid illness were obtained. Data regarding requirement of antidote, duration of hospitalization, and outcome were also obtained. Results: Out of 200 cases, 181 (90.5%) were adults and 19 (9.5%) were of pediatric age group. Poisoning was common among males (57%) than females (43%). Majority (40%) were from the age group of 21–30 years. Out of 200, 115 (57.5%) poisonings were suicidal, 68 (34%) were accidental, and 17 (8.5%) were homicidal. Acute poisonings included corrosive 54 (27%), drug overdose 26 (13%), organophosphorus compounds 20 (10%), rodenticides 20 (10%), and symptomatic snakebite 16 (8%). Seventy-two (36%) were admitted with a median hospital stay of 6 days with 5 (2.5%) deaths. Logistic regression analysis revealed poorer outcome for 15–30 years age [OR 12.6 (1.6–97.5), P = 0.015], males [OR 2.5 (1.4–4.4) P = 0.04], patients coming from >30 km [OR 4.3 (1.5–12.1), P = 0.006]. Conclusion: Our study demonstrated an increased incidence of corrosive ingestion. With increasing rates of suicidal ingestions, there is a need for holistic approach to manage mental health issues at primary care level.
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Affiliation(s)
- Roshan Mathew
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Nayer Jamshed
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Praveen Aggarwal
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Shivam Patel
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - R M Pandey
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
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31
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Abstract
Syncope is a common presentation to Emergency Departments (EDs). Estimates on the frequency of visits (0.6–1.7%) and subsequent rates of hospitalizations (12–85%) vary according to country. The initial ED evaluation for syncope consists of a detailed history, physical examination and 12-lead electrocardiogram (ECG). The use of additional diagnostic testing and specialist evaluation should be based on this initial evaluation rather than an unstructured approach of broad-based testing. Risk stratification performed in the ED is important for estimating prognosis, triage decisions and to establish urgency of any further work-up. The primary approach to risk stratification focuses on identifying high- and low-risk predictors. The use of prediction tools may be used to aid in physician decision-making; however, they have not performed better than the clinical judgment of emergency room physicians. Following risk stratification, decision for hospitalization should be based on the seriousness of the underlying cause for syncope or based on high-risk features, or the severity of co-morbidities. For those deemed intermediate risk, access to specialist assessment and related testing may occur in a syncope unit in the emergency department, as an outpatient, or in a less formal care pathway and is highly dependent on the local healthcare system. For syncope patients presenting to the ED, ~0.8% die and 10.3% suffer a non-fatal severe outcome within 30 days.
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Affiliation(s)
| | - Robert S Sheldon
- Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
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Wang L, Song W, Wang Y, Han J, Lv K. Lung ultrasonography versus chest radiography for the diagnosis of pediatric community acquired pneumonia in emergency department: a meta-analysis. J Thorac Dis 2019; 11:5107-5114. [PMID: 32030227 DOI: 10.21037/jtd.2019.11.62] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Pediatric community acquired pneumonia (pCAP) is a major public health and economic problem with a considerable impact on morbidity and mortality in children. Recently many studies and meta-analyses have shown promising results on the accuracy of lung ultrasonography (LU) in diagnosing pneumonia and potentially replacing chest radiography (CR) in pediatric population. However, previous studies establishing the accuracy of LU often used CR as reference standard and took into account different clinical settings all together. To make a more objective and specific analysis, we performed a systematic review and meta-analysis to compare the diagnostic accuracy of LU and CR for pCAP in the emergency department (ED) setting. Methods A literature search of PubMed and Embase databases up to December 2018 was conducted. Pooled sensitivity, specificity, positive and negative likelihood ratio, and diagnostic odds ratio of LU and CR were calculated, and summary receiver operating characteristic (SROC) curves were drawn. Results A total of six studies, which included 575 pCAPs from 701 patients, were finally analyzed. The pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio and diagnostic odds ratios of LU were 96.7%, 87.3%, 8.10, 0.05, 256.68, while they were 89.7%, 93.7%, 9.97, 0.12, 175.07 for CR, respectively. The area under the SROC curves in diagnosing pCAP in the ED setting were 0.99 [95% confidence interval (CI), 0.98-1.00] and 0.97 (95% CI, 0.95-1.00) for LU and CR, respectively. Conclusions Our meta-analysis suggests that LU is an accurate tool in the diagnosis of pCAP in the ED setting with a superior sensitivity over CR.
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Affiliation(s)
- Liang Wang
- Department of Ultrasound, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital, Beijing 100730, China
| | - Wei Song
- Department of Radiology, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital, Beijing 100730, China
| | - Yong Wang
- Department of Ultrasound, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Jie Han
- Department of Ultrasound, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Ke Lv
- Department of Ultrasound, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital, Beijing 100730, China
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Sneath E, Bunting D, Hazell W, Tippett V, Yang IA. Pre-hospital and emergency department pathways of care for exacerbations of chronic obstructive pulmonary disease (COPD). J Thorac Dis 2019; 11:S2221-S2229. [PMID: 31737349 DOI: 10.21037/jtd.2019.10.37] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Exacerbations are serious complications of chronic obstructive pulmonary disease (COPD) that often require acute care from pre-hospital and emergency department (ED) services. Despite being a frequent cause of emergency presentations, gaps remain in both literature and practice for emergency care pathways of COPD exacerbations. This review seeks to address these gaps and focuses on the literature of pre-hospital and ED systems of care and how these intersect with patients experiencing an exacerbation of COPD. The literature in this area is expanding rapidly; however, more research is required to further understand exacerbations and how they are addressed by emergency medical services worldwide. For the purpose of this review, the pre-hospital domain includes ambulance and other emergency transport services, and encompasses medical interventions delivered prior to arrival at an ED or hospital. The ED domain is defined as the area of a hospital or free-standing centre where patients arrive to receive emergent medical care prior to admission. In many studies there is a significant overlap between these two domains and frequent intersection and collaboration between services. In both of these domains, for the management of COPD exacerbations, several overarching themes have been identified in the literature. These include: the appropriate delivery of oxygen in the emergency setting; strategies to improve the provision of care in accordance with diagnostic and treatment guidelines; strategies to reduce the requirement for emergency presentations; and, technological advances including machine learning which are helping to improve emergency healthcare systems.
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Affiliation(s)
- Emily Sneath
- Faculty of Medicine, The University of Queensland, Brisbane, Australia.,Department of Thoracic Medicine, The Prince Charles Hospital, Metro North Hospital and Health Service, Brisbane, Australia
| | - Denise Bunting
- Research & Evaluation Unit, Queensland Ambulance Service, Brisbane, Australia
| | - Wayne Hazell
- Faculty of Medicine, The University of Queensland, Brisbane, Australia.,Department of Emergency Medicine, The Prince Charles Hospital, Metro North Hospital and Health Service, Brisbane, Australia
| | - Vivienne Tippett
- School of Clinical Sciences, Queensland University of Technology, Brisbane, Australia
| | - Ian A Yang
- Faculty of Medicine, The University of Queensland, Brisbane, Australia.,Department of Thoracic Medicine, The Prince Charles Hospital, Metro North Hospital and Health Service, Brisbane, Australia
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Xie F, Liu N, Wu SX, Ang Y, Low LL, Ho AFW, Lam SSW, Matchar DB, Ong MEH, Chakraborty B. Novel model for predicting inpatient mortality after emergency admission to hospital in Singapore: retrospective observational study. BMJ Open 2019; 9:e031382. [PMID: 31558458 PMCID: PMC6773418 DOI: 10.1136/bmjopen-2019-031382] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES To identify risk factors for inpatient mortality after patients' emergency admission and to create a novel model predicting inpatient mortality risk. DESIGN This was a retrospective observational study using data extracted from electronic health records (EHRs). The data were randomly split into a derivation set and a validation set. The stepwise model selection was employed. We compared our model with one of the current clinical scores, Cardiac Arrest Risk Triage (CART) score. SETTING A single tertiary hospital in Singapore. PARTICIPANTS All adult hospitalised patients, admitted via emergency department (ED) from 1 January 2008 to 31 October 2017 (n=433 187 by admission episodes). MAIN OUTCOME MEASURE The primary outcome of interest was inpatient mortality following this admission episode. The area under the curve (AUC) of the receiver operating characteristic curve of the predictive model with sensitivity and specificity for optimised cut-offs. RESULTS 15 758 (3.64%) of the episodes were observed inpatient mortality. 19 variables were observed as significant predictors and were included in our final regression model. Our predictive model outperformed the CART score in terms of predictive power. The AUC of CART score and our final model was 0.705 (95% CI 0.697 to 0.714) and 0.817 (95% CI 0.810 to 0.824), respectively. CONCLUSION We developed and validated a model for inpatient mortality using EHR data collected in the ED. The performance of our model was more accurate than the CART score. Implementation of our model in the hospital can potentially predict imminent adverse events and institute appropriate clinical management.
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Affiliation(s)
- Feng Xie
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
| | - Nan Liu
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
- Health Services Research Centre, Singapore Health Services, Singapore, Singapore
| | - Stella Xinzi Wu
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
| | - Yukai Ang
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
| | - Lian Leng Low
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
- Department of Family Medicine and Continuing Care, Singapore General Hospital, Singapore, Singapore
| | - Andrew Fu Wah Ho
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | - Sean Shao Wei Lam
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
- Health Services Research Centre, Singapore Health Services, Singapore, Singapore
| | - David Bruce Matchar
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
- Duke University Medical Center, Duke University, Durham, North Carolina, USA
| | - Marcus Eng Hock Ong
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | - Bibhas Chakraborty
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
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Krug B, Colliers A, Matthys J, Anthierens S, Philips H, Damen J, Coenen S, Remmen R. Video-recording consultations for educational purposes in out-of-hours primary care: patients and physicians are willing to participate. Acta Clin Belg 2019; 74:65-69. [PMID: 29609529 DOI: 10.1080/17843286.2018.1459231] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Background Video-recordings of consultations are used by general practitioner (GP) trainees to enable reflection on aspects of knowledge, skills and attitudes. Typically, these recordings are made during office hours in general practice, but little is known about using video-recording during out of hours (OOH) care, which is an important and distinct part of a GP's work. To be able to record consultations during OOH care (i.e. at the emergency department (ED) and at the General Practitioner Cooperative (GPC)), patients must be willing to cooperate and give informed consent. Therefore, it was of interest to investigate potential barriers in these OOH settings. Methods A questionnaire on demographics and attitudes regarding consent was administered to patients and physicians at the ED and at the GPC in Sint-Niklaas, Belgium. Results A total of 346 questionnaires were completed, 23 by physicians and 323 by patients. A majority of the patients (225/286 (79%)) would consent to video-recording the consultation, without physical examination. Almost all physicians (21/23) would agree to participate. Overall, 85% (260/323) of the patients agree when only the doctor was being recorded. Patients were neutral in recording in 79% (88/224) at the GPC and 57% (56/99) at the ED. Shyness or embarrassment was present in 32% (71/224), and 28% (28/99) at the GPC and ED, respectively. We did not find any significant differences in giving consent or feelings between patients at the GPC and ED. Conclusion A vast majority of both patients and physicians would consent to video-recording their consultation in OOH primary care settings (GPC and ED), with possible concerns about privacy, shame and discomfort.
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Affiliation(s)
- Bertwin Krug
- Faculty of Medicine and Health Sciences, Department of Primary and Interdisciplinary Care (ELIZA) – Centre for General Practice (CHA), University of Antwerp – Campus Drie Eiken, Antwerp, Belgium
| | - Annelies Colliers
- Faculty of Medicine and Health Sciences, Department of Primary and Interdisciplinary Care (ELIZA) – Centre for General Practice (CHA), University of Antwerp – Campus Drie Eiken, Antwerp, Belgium
| | - Jan Matthys
- Department of Family Medicine and Primary Healthcare, University of Ghent – UZ Gent, Ghent, Belgium
| | - Sibyl Anthierens
- Faculty of Medicine and Health Sciences, Department of Primary and Interdisciplinary Care (ELIZA) – Centre for General Practice (CHA), University of Antwerp – Campus Drie Eiken, Antwerp, Belgium
| | - Hilde Philips
- Faculty of Medicine and Health Sciences, Department of Primary and Interdisciplinary Care (ELIZA) – Centre for General Practice (CHA), University of Antwerp – Campus Drie Eiken, Antwerp, Belgium
| | - Jorn Damen
- Emergency Department, AZ Nikolaas, Sint-Niklaas, Belgium
| | - Samuel Coenen
- Faculty of Medicine and Health Sciences, Department of Primary and Interdisciplinary Care (ELIZA) – Centre for General Practice (CHA), University of Antwerp – Campus Drie Eiken, Antwerp, Belgium
- Faculty of Medicine and Health Sciences, Department of Epidemiology and Social Medicine (ESOC), University of Antwerp – Campus Drie Eiken, Antwerp, Belgium
- Faculty of Medicine and Health Sciences, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp – Campus Drie Eiken, Antwerp, Belgium
| | - Roy Remmen
- Faculty of Medicine and Health Sciences, Department of Primary and Interdisciplinary Care (ELIZA) – Centre for General Practice (CHA), University of Antwerp – Campus Drie Eiken, Antwerp, Belgium
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Ramsay JM, Ou JY, Fluchel MN, Kirchhoff AC. Respiratory emergency department use from diagnosis through survivorship in children, adolescents, and young adults with cancer. Cancer 2018; 124:3924-3933. [PMID: 30291801 DOI: 10.1002/cncr.31650] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 04/22/2018] [Accepted: 05/20/2018] [Indexed: 01/24/2023]
Abstract
BACKGROUND Children and adolescents and young adults (AYAs) with cancer often experience severe respiratory morbidity and mortality from the therapies used to treat their cancers. Few studies have examined respiratory outcomes among this population using emergency department (ED) visits as an objective measure of respiratory health. METHODS ED visits for respiratory conditions were identified for children and AYAs diagnosed with cancer, 0-25 years of age, from 1997 through 2012 (2535 cases) and compared with a birthdate-matched and sex-matched cohort without cancer drawn from the general population (7605 controls). Negative binomial regression with robust standard errors was used to estimate incidence rates, rate ratios (RRs), and 95% confidence intervals for primary respiratory ED visits, combined and by diagnosis (asthma, respiratory disease, and respiratory infection) from 1997 through 2015. Analyses were performed for new cases (0 to <5 years from diagnosis) and survivors (5-18 years from diagnosis). RESULTS Subjects were followed for an average of 8 years (range, 0-18 years). Relative to the comparison cohort, cancer cases had higher incidence rates for all types of respiratory ED visits over both follow-up times. New cases had significantly higher RRs for any respiratory condition (RR, 4.14), respiratory disease (RR, 4.62), and respiratory infection (RR, 4.74). Among survivors, the RRs for any respiratory condition (RR, 2.00) and respiratory infection (RR, 2.10) were significantly elevated, although the magnitude tended to decline in survivorship. Demographic and clinical risk factors found to be associated with respiratory ED visits included Hispanic/other race/ethnicity, male sex, exposure to chemotherapy, diagnosis at a younger age, and a diagnosis of leukemia. CONCLUSIONS The results of the current study demonstrated that children and AYAs with cancer face an increased burden of respiratory complications compared with a comparison cohort without cancer from diagnosis through survivorship.
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Affiliation(s)
- Joemy M Ramsay
- Cancer Control and Population Sciences, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Judy Y Ou
- Cancer Control and Population Sciences, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Mark N Fluchel
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Anne C Kirchhoff
- Cancer Control and Population Sciences, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah.,Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Utah, Salt Lake City, Utah
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Hsieh TM, Kuo PJ, Hsu SY, Chien PC, Hsieh HY, Hsieh CH. Effect of Hypothermia in the Emergency Department on the Outcome of Trauma Patients: A Cross-Sectional Analysis. Int J Environ Res Public Health 2018; 15:ijerph15081769. [PMID: 30126107 PMCID: PMC6121888 DOI: 10.3390/ijerph15081769] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 07/31/2018] [Accepted: 08/11/2018] [Indexed: 11/21/2022]
Abstract
This study aimed to assess whether hypothermia is an independent predictor of mortality in trauma patients in the condition of defining hypothermia as body temperatures of <36 °C. Data of all hospitalized adult trauma patients recorded in the Trauma Registry System at a level I trauma center between 1 January 2009 and 12 December 2015 were retrospectively reviewed. A multivariate logistic regression analysis was performed in order to identify factors related to mortality. In addition, hypothermia and normothermia were defined as temperatures <36 °C and from 36 °C to 38 °C, respectively. Propensity score-matched study groups of hypothermia and normothermia patients in a 1:1 ratio were grouped for mortality assessment after adjusting for potential confounders such as age, sex, preexisting comorbidities, and injury severity score (ISS). Of 23,705 enrolled patients, a total of 401 hypothermic patients and 13,368 normothermic patients were included in this study. Only 3.0% of patients had hypothermia upon arrival at the emergency department (ED). Compared to normothermic patients, hypothermic patients had a significantly higher rate of abbreviated injury scale (AIS) scores of ≥3 in the head/neck, thorax, and abdomen and higher ISS. The mortality rate in hypothermic patients was significantly higher than that in normothermic patients (13.5% vs. 2.3%, odds ratio (OR): 6.6, 95% confidence interval (CI): 4.86–9.01, p < 0.001). Of the 399 well-balanced propensity score-matched pairs, there was no significant difference in mortality (13.0% vs. 9.3%, OR: 1.5, 95% CI: 0.94–2.29, p = 0.115). However, multivariate logistic regression analysis revealed that patients with low body temperature were significantly associated with the mortality outcome. This study revealed that low body temperature is associated with the mortality outcome in the multivariate logistic regression analysis but not in the propensity score matching (PSM) model that compared patients with hypothermia defined as body temperatures of <36 °C to those who had normothermia. These contradicting observations indicated the limitation of the traditional definition of body temperature for the diagnosis of hypothermia. Prospective randomized control trials are needed to determine the relationship between hypothermia following trauma and the clinical outcome.
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Affiliation(s)
- Ting-Min Hsieh
- Division of Trauma Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta Pei Road, Niao-Song District, Kaohsiung 833, Taiwan.
| | - Pao-Jen Kuo
- Division of Plastic Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123 Ta Pei Road, Niao-Song District, Kaohsiung 833, Taiwan.
| | - Shiun-Yuan Hsu
- Division of Plastic Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123 Ta Pei Road, Niao-Song District, Kaohsiung 833, Taiwan.
| | - Peng-Chen Chien
- Division of Plastic Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123 Ta Pei Road, Niao-Song District, Kaohsiung 833, Taiwan.
| | - Hsiao-Yun Hsieh
- Division of Plastic Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123 Ta Pei Road, Niao-Song District, Kaohsiung 833, Taiwan.
| | - Ching-Hua Hsieh
- Division of Plastic Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123 Ta Pei Road, Niao-Song District, Kaohsiung 833, Taiwan.
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Li L, McCaughey E, Iles-Mann J, Sargeant A, Westbrook JI, Georgiou A. Does Point-of-Care Testing Impact Length of Stay in Emergency Departments (EDs)?: A Before and After Study of 26 Rural and Remote EDs. Stud Health Technol Inform 2018; 252:99-104. [PMID: 30040690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
The implementation of Point-of-Care Testing (PoCT) services across rural and remote emergency departments (EDs) by NSW Health Pathology has the potential to significantly improve timely access to results for certain types of pathology laboratory tests and help to deliver timely patient care. The aim of this study was to examine the impact of the implementation of PoCT on the length of stay (LOS) of patients in rural and remote EDs. A total of 3808 patients with a circulatory system illness were treated and discharged at any one of 22 rural and remote EDs during the study period. Generalised Estimating Equation (GEE) modelling was applied to examine whether the implementation of PoCT impacted the ED LOS with adjustment for a range of clinical variables. More patients were treated and discharged from these rural and remote EDs within 4-hours after the PoCT implementation (post-PoCT 86.8% versus pre-PoCT 84.3%). Although average ED LOS was 11 minutes shorter in the post-PoCT period, the impact of PoCT on ED LOS was not conclusive after considering other important clinical factors (p=0.07). This study is the one of the few to examine changes in LOS following the introduction of PoCT in EDs in Australia. The study also identified areas where more robust methods could be applied in the future as the quality of PoCT data improves to further assess the potential effects of this technology on practice and outcomes.
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Affiliation(s)
- Ling Li
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia
| | | | | | | | - Johanna I Westbrook
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia
| | - Andrew Georgiou
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia
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Meunier MJ, Brant JM, Audet S, Dickerson D, Gransbery K, Ciemins EL. Life after PACE (Program of All-Inclusive Care for the Elderly): A retrospective/prospective, qualitative analysis of the impact of closing a nurse practitioner centered PACE site. J Am Assoc Nurse Pract 2016; 28:596-603. [PMID: 27232590 DOI: 10.1002/2327-6924.12379] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 03/28/2016] [Indexed: 11/05/2022]
Abstract
BACKGROUND AND PURPOSE Caring for frail older adults is a significant healthcare concern as the frailest 10% of the population account for over 70% of healthcare expenditures. Research reveals the use of comprehensive models, such as Program of All-Inclusive Care for the Elderly (PACE), leads to improved functional outcomes for participants and cost savings through decreased utilization. This study examines how closing a PACE program impacts health outcomes of previously enrolled participants. METHODS Data were collected every 6 months for 2 years via phone surveys on 34 former participants enrolled in the program at the time of the closure. The survey included questions regarding satisfaction with care, activities of daily living (ADLs), instrumental ADLs (IADLs), emergency department (ED) visits, hospitalizations, and use of home health services. Deaths and nursing home placements were monitored. Outcomes were compared during and post-PACE. CONCLUSIONS Higher numbers of ED visits, hospitalizations, and nursing home placements occurred post-PACE. PACE/post-PACE differences in ADL and IADL scores were not significant, nor were death rates. Higher satisfaction existed with PACE versus non-PACE care. IMPLICATIONS FOR PRACTICE Comprehensive care programs such as PACE are effective in reducing healthcare utilization, thus limiting costs. Further work is required to maintain, develop, and support comprehensive models similar to PACE.
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Hoagland P, Jin D, Polansky LY, Kirkpatrick B, Kirkpatrick G, Fleming LE, Reich A, Watkins SM, Ullmann SG, Backer LC. The costs of respiratory illnesses arising from Florida gulf coast Karenia brevis blooms. Environ Health Perspect 2009; 117:1239-43. [PMID: 19672403 PMCID: PMC2721867 DOI: 10.1289/ehp.0900645] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2009] [Accepted: 05/01/2009] [Indexed: 05/21/2023]
Abstract
BACKGROUND Algal blooms of Karenia brevis, a harmful marine algae, occur almost annually off the west coast of Florida. At high concentrations, K. brevis blooms can cause harm through the release of potent toxins, known as brevetoxins, to the atmosphere. Epidemiologic studies suggest that aerosolized brevetoxins are linked to respiratory illnesses in humans. OBJECTIVES We hypothesized a relationship between K. brevis blooms and respiratory illness visits to hospital emergency departments (EDs) while controlling for environmental factors, disease, and tourism. We sought to use this relationship to estimate the costs of illness associated with aerosolized brevetoxins. METHODS We developed a statistical exposure-response model to express hypotheses about the relationship between respiratory illnesses and bloom events. We estimated the model with data on ED visits, K. brevis cell densities, and measures of pollen, pollutants, respiratory disease, and intra-annual population changes. RESULTS We found that lagged K. brevis cell counts, low air temperatures, influenza outbreaks, high pollen counts, and tourist visits helped explain the number of respiratory-specific ED diagnoses. The capitalized estimated marginal costs of illness for ED respiratory illnesses associated with K. brevis blooms in Sarasota County, Florida, alone ranged from $0.5 to $4 million, depending on bloom severity. CONCLUSIONS Blooms of K. brevis lead to significant economic impacts. The costs of illness of ED visits are a conservative estimate of the total economic impacts. It will become increasingly necessary to understand the scale of the economic losses associated with K. brevis blooms to make rational choices about appropriate mitigation.
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Affiliation(s)
- Porter Hoagland
- Marine Policy Center, Woods Hole Oceanographic Institution, Woods Hole, Massachusetts 02543, USA.
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