Introduction:

Non Invasive Ventilation (NIV) use in acute respiratory failure (ARF) is mostly initiated in Emergency

Department (ED) before patient transfer to Intensive Care Unit (ICU) or Respiratory Ward (RW). In Tunisia, because of the limited ICU beds’ number and the absence of NIV in RW, patient requiring NIV are admitted in ED.

Aim: To describe our experience with non-invasive ventilation in emergency department (ED).

Methods:

A prospective observational monocentric study conducted for a six months period in the Emergency Department of the University Hospital FarhatHached, Sousse-Tunisia. We included patients consulting for non traumaticARF requiring NIV.

We analyzed the NIV characteristics in the first 24 hours and evaluated patients ‘outcomes. NIV success was defined as no need for endotracheal intubation (ETI).

Results:

During the study’s period, we included 63 patients. During the first 24 hours of the studied population’s ED

stay, 142 sessions were delivered with a mean duration of 9,47 ±3,38h. The median value of NIV initiating delay (defined by the time from the patients’ registration until NIV initiation) was one hour [0-3h]. The first-line ventilating mode used was BiPAP in 55 patients (87.3%) with a mean IPAP 11,8±1,2 cmH2O , a mean EPAP of 4,49±1,07 cmH2O and a mean FiO2= 39,38±11,26%.

NIV failed in 8 patients (12.7%) with a median value of intubation delay about 4 h [0-14].

After a median ED length of stay of 40 h [24-53 h] and total NIV duration of 15 h [8-31 h], 26 patients (41,3%) were transferred to ICU, 21 to medical ward and 13 patients (20,6%) were discharged at home. The global mortality in our studied population was 4.8% (3 patients).

Conclusion:

Our results confirm the global efficacy of NIV in an ED setting. Therefore, young emergency physicians should be provided with protocols and guidelines for NIV practice.

Background:

Current data on utilization of CT imaging point to a trend of increasing overutilization of CT Angiography for the diagnosis of pulmonary embolism (CTPA) over time. Multiple educational and institution-wide interventions addressing this overutilization have been proposed, implemented and evaluated, with mixed results in terms of long-term impact on physician ordering behaviour. The objective of this study is to examine the inter-physician variability in ordering rates and diagnostic yield of CTPA, under a working hypothesis that a small number of physicians are responsible for a disproportionately high number of CTPA ordered in the ED, and that disproportionately high ordering rates are associated with lower diagnostic yield.

Methodology:

Data was collected on all CTPA studies ordered by ED physicians at two very high volume community hospitals and an affiliated urgent care centre during the 2-year period between January 1, 2016 and December 31, 2017. Analysis was limited to those ED physicians who had a total of greater than 500 ED visits over the course of the 2-year period. For each physician, two calculations were made: 1) CT PE ordering rate (total number of CTPA ordered divided by the total number of ED visits), and 2) CTPA diagnostic yield (total number of CTPA positive for PE divided by the total number CTPA ordered). Additional analysis was carried out in order to identify the highest orderers of CTPA and their diagnostic yield.

Results:

A total of 2,789 CTPA were ordered by 84 physicians for 461,045 total ED visits. Preliminary results show a great deal of variation in ordering rates, ranging from 0.9 to 22.2 CTPA per 1000 ED visits (median = 4.8 CTPA per 1000 ED visits, IQR = 4.5 CTPA per 1000 ED visits). Similarly, there was a high degree of variation in CT PE yield, ranging from 0% to 50% (median = 9.6%, IQR = 13.1%). Those physicians in the top quartile for ordering rate had a lower mean diagnostic yield, when compared to the lower quartiles (8.9% when compared to 11.5%, 11.9% and 18.2% for the physicians in the third, second, and first quartile respectively).

Conclusion:

The findings of this study indicate a wide degree of variability in CTPA ordering patterns and diagnostic yields among physicians working within the same clinical environment. There is some suggestion that those physicians who order disproportionately higher numbers of CTPAs have lower diagnostic yields. However, the more interesting lessons from this initial study center on the challenges in creating an audit-and-feedback program targeting CTPA ‘overutilizers’.

Background

The diagnosis of community-acquired pneumonia (CAP) in the Emergency Department (ED) is often difficult due to limitations of clinical examination, chest X-ray and laboratory tests. A recent study showed that computerized tomography (CT) scan modified the clinical probability of CAP in 58% of the cases. However, CT scan is not applicable for all patients with suspected CAP in the ED. Thus, our goal was to investigate another tool, early Lung Ultrasound (LUS), to improve CAP diagnosis, by accessing changes in diagnostic probability and antibiotic initiation induced by LUS.

Methods

It was a prospective observational study in 4 French ED between 8/11/2016 and 31/12/2018. Included patients were a convenience sample of patients older than 18 years with a suspicion of CAP before medical exam. Exclusion criteria were documented palliative care or the need of immediate intensive care.

After informed consent approval and usual diagnosis procedure (UDP) (clinical, radiological and biology), the Emergency Physician established a CAP probability using a Likert scale (definite, probable, possible, excluded) and intention for antibiotics treatment initiation. A LUS was then performed, another probability (LUSP) for CAP diagnosis and treatment initiation was established. An adjudication committee established the final probability of CAP (COMP) at D28.

The main objective was the concordance rate between LUS and UDP probability according to COMP probability. Secondary objectives were probability changes induced by LUS and antibiotics changes. Categorical data expressed as percentage [95% confidence interval] were compared with Mac Nemar test.

The study was approved by the ethical committee and registered on clinicaltrial.gov (NCT03411824). There was no funding. For a probability concordance of 55% before LUS and 80% after with alpha 0.05 and beta 0.10, the required number of patients was 144.

Results

150 patients were recruited, two secondarily excluded because of wrong identification, leaving 148 analyzed patients: 70 women and 78 men, mean age 72 + 18 years old. UDP probability was definite in 34 patients (23%), probable in 52 (35%), possible in 56 (38%) and excluded in 6 (4%). LUS induced a probability modification in 109 patients (73 % [66-80%]). LUS probability was definite in 93 patients (63%), probable in 15 (10%), possible in 9 (6%) and excluded in 31 (21%). 82 of these modifications (77 % [68-84%]) were in accordance with the adjudication committee. COMP probability was definite in 81 patients (55%), probable in 16 (11%), possible in 12 (8%) and excluded in 39 (26%). When compared to COMP probability, 39 out of 148 UDP probabiliies were correct (27% [20-35]) while 109 LUSP were correct (77% [71-84]), p<10-4. There were 45 modifications in antibiotic prescription (30% [24-38%]): 21 were prescribed after LUS while 24 were discontinued.

Discussion and conclusion

In this population comparable to other studies in literature, LUS was a powerful tool to improve the diagnosis accuracy. In particular, it decreased the diagnostic uncertainty (possible and probable probability from 73 to 16% after LUS).

clinicaltrial.gov (NCT03411824) no funding

Background:

The absence of cardiac activity (CA) on point-of-care ultrasound (POCUS) during the cardiopulmonary resuscitation (CPR) is a known predictive factor for worse patient outcomes. However, the assessment of CA is challenging due to the urgency of the situation and lack of clear definition of CA. Although a previous study has shown the considerable variability in interpretation of CA among physician sonographers, it is not validated in different populations. The aim of our study is to examine the inter-person agreement of CA evaluation among physician sonographers.

Methods:

This was a cross-sectional questionnaire survey conducted between August 2018 and April 2019. The participants were recruited from 7 hospitals in Japan. All participants evaluated the 20 second echocardiographic video and answered the presence or absence of CA. This video consisted of 15 cases that were either CA positive (strong myocardial contraction, weak myocardial contraction, ventricular fibrillation) or CA negative (no cardiac motion, cardiac motion by bag valve mask ventilation, and valve flatter without myocardial contraction). Other questionnaire contents were as follows: specialty of the physician sonographer, self-reported general POCUS skill level, experience of echocardiography in CPR and post-graduated year (PGY). Our primary outcome was the overall inter-person agreement of CA evaluation. The inter-person agreement of CA evaluation was investigated using Krippendorff's alpha coefficient. Additionally, we conducted sensitivity analysis with different subgroups (specialty, self-reported general POCUS skill level, experience of echocardiography in CPR, PGY).

Results:

A total of 41 physician sonographers were recruited [23 emergency physicians (56.6%), 6 intensivists (12.2%), and 7 residents (17.1%)]. Self-reported general POCUS skill levels were basic (68.3%), advanced (29.3%), and expert (2.4%). The number of experiences of echocardiography in CPR was 0 (17.1%), 1-5 (17.1%), 6-10 (19.5%), 11-25 (14.6%), and >25 (31.7%). PGY was 1-2 (17.1%), 3-6 (36%), 7-10 (29.3%), and >11 (14.6%). The overall agreement rate of CA evaluation was moderate (α=0.53). Sensitivity analysis showed similar results [Self-reported general POCUS skill levels: basic (0.53), advanced (0.48), and expert (NA). The   number   of   experiences   of echocardiography in CPR: 0 (0.58), 1-5 (0.64), 6-10 (0.5), 11-25 (0.48), and >25 (0.5). PGY: 1-2 (0.66), 3-6 (0.56), 7-10 (0.49), and >11 (0.44)].

Discussion & Conclusions:

Similar to the previous study, there was a considerable variability in interpretation of CA among physician sonographers. Hence, it may be difficult to use this finding as a guide to terminating CPR. A clear definition of CA is warranted to precisely detect cardiac arrest patients with poor outcomes.

Trial Registration: This study wasn't registered because no patients involved. Funding: This study did not receive any specific funding. Ethical approval and informed consent: Not needed.

Background: The Whole-Body computed tomography (WBCT) is a mainstay that guides the management of severely traumatized patients. However, its systematic use in the emergency department results in a high proportion of normal examinations. Its direct cost is significant and the irradiation of 20mSV exposes an adult to a risk of 1 in 1000 to develop cancer. The purpose of this study is to determine predictive criteria for normal examinations in trauma patients who have had an WBCT to rationalize its use. Methods: A monocentric retrospective study included trauma patients over 16 years of age for whom a WBCT was performed during their visit to the emergency department from 2016 to 2018. The endpoint for asserting the abnormality of the WBCT was at least one injury categorized 2 by the Abreviated Injury Scale. Anamnestic, clinical, radiological findings and patient management data were collected. Two approaches were used. The first was to define criteria based on scientific data to define a low-risk patient profile and to test the discriminating ability of this set of criteria. The second approach consisted in performing a multivariate analysis with a logistic regression model. On this occasion, the population was divided into two random samples corresponding to 50% of the initial population, one to create the model and the other to test it. The objective was to define a low-risk patient profile by testing the discriminating ability of this set of criteria to avoid the WBCT. Results: Out of 810 patients included 41% had an abnormal WBCT (n=329). Seventeen "a priori" criteria were tested simultaneously. The test performance showed a sensitivity of 96.9%, specificity of 25.8%, negative predictive value of 89.7%, positive predictive value of 48.2%. This method avoided one in seven WBCT. In the multivariate logistic regression model, 9 variables were selected. The performance of this model showed a sensitivity of 87%, specificity of 44%, negative predictive value of 81.3% and positive predictive value of 50%. The OCR curves showed an area under the curve of 0.8 for the learning sample and 0.73 for the test sample. This method avoided one in four WBCT in the learning group and one in five WBCT in the test group. Discussion: The "a priori" approach seems more robust in predicting the normality of the WBCT. False-negative patients in the multivariate model are more numerous and have more serious injuries missed. Rationalization of the WBCT in trauma patients is possible by a predictive algorithm. Conclusions: An external validation through a multicentric prospective study is required to validate this predictive model.

Background Detection of hydronephrosis by ultrasonography in patients with renal colic has good sensitivity and specificity for diagnosing ureter stones. This study investigated the effects of length of stay and total medical expense on patients with urolithiasis by applying the point-of-care ultrasonography urinary stone (POCUS-US) protocol in the emergency department (ED).

Methods We conducted a prospective randomized controlled trial for evaluating patients who visited the ED of the tertiary university hospital with acute renal colic between March and May 2019. The patients were separately enrolled according to day number of visitation in the ED. For those with odd day numbers (conventional group [CG]), we performed basic laboratory blood tests, urine analyses after history taking and physical examination, and additional tests, such as abdominal non-contrast computerized tomography (CT) based on the test results. For those with even day numbers (ultrasonography group [UG]), we performed bedside sonography simultaneously with physical examination and history taking to evaluate hydronephrosis. If hydronephrosis was detected, we proceeded to perform abdominal non-contrast CT promptly and laboratory tests, including only urine and creatinine blood level analyses. If patients in the UG did not have hydronephrosis, we examined them as we did the other patients in the CG. The patients were followed-up for acute renal failure and urinary tract infection and acutely missed or delayed high-risk diagnosis within 30 days. We investigated the ED length of stay and total medical costs as outcomes.

Results Ninety-one patients were enrolled, of which 72 were finally diagnosed as having ureter stones. The ED length of stay for the UG was 156 minutes (95% confidence interval [CI], 137–176 minutes) and was 78 minutes lesser than that for the CG (234 minutes; 95% CI, 210–259 minutes). The medical expense for the UG in the ED was approximately 30% lower than that for the CG (239 USD vs. 332 USD, respectively; P < 0.001). The incidence of complications within 30 days and acutely missed or delayed high-risk diagnosis were not significantly different between the two groups.

Conclusion Therefore, applying the initial diagnostic POCUS-US protocol for patients with acute renal colic in the ED can significantly reduce the ED length of stay and medical expense.

Abstract

 

OBJECTIVE: An observational study on the current diagnostic and procedural utility and impact of point of care ultrasound (POCUS) in Emergency Departments (ED).

 

BACKGROUND:Point of Care Ultrasound (POCUS) has been recognised as a useful noninvasive, bedside tool, providing additional information as well as it’s utility in procedural guidance for clinicians, However, its current use in the ED remains unknown.

 

METHODS: In October 2016, a 31-day prospective observational study was performed in three Monash Health Emergency Departments in Melbourne, Australia. Data regarding patients’ presenting complaints, frequency, operators’ qualifications, and POCUS module were collected and analysed. Factors associated with diagnostic impacts were identified.

 

RESULTS:A total of 390 (2.82%) POCUS examinations were performed among 13,822 adult presentationsin the three Monash Health EDs during the 31-day study period. 292 (74.9%) cases were retrieved from electronic medical records (Symphony), recorded as Clinician-Performed Ultrasound (CPU);and 98 (25.1%) cases from written records which were collected by research assistants. POCUS was performed as a diagnostic tool in 344 (88.2%) and procedural in 46 (11.8%) cases. eFAST/AAA and BELS were the two most frequently utilised diagnostic modalities. Overall, the majority of diagnostic POCUS cases were indicated for abdominal pain (35.3%), chest pain (14.0%) and trauma (5.8%). Procedural POCUS was most commonly used for vascular access (57.9%), where dyspnoea (21.6%) was the most common presenting complaint. Majority of the cases were performed by FACEMs (fellows of Australasian college of Emergency Medicine) (67.7%). 

 

CONCLUSIONS: Despite known diagnostic and procedural advantages, the prevalence of POCUS in our EDs was found to be lower than what was expected. However, as this is a sigle network/centre study in a limited period of time,it might have resulted in under-reporting of POCUS use. In our study, POCUS mostly served for diagnostic purposes. Prevalence was shown to be proportional to the level of clinical expertise among the operators. Training and utility of POCUS among physicians should be further advocated and supported.

 

Background. A number of studies reported a link between air quality and negative health effects. Particularly, high levels of air pollutants are related to a worsening of chronic respiratory diseases, leading to an increased number of hospital admissions and outpatient visits. Several factors influence the exposure to intra-urban air pollution, such as traffic density and climate.

Aim. To assess the influence of air pollutant levels and climate data on the number of hospital admissions due to chronic obstructive pulmonary disease (COPD) and asthma exacerbations in Valladolid (Spain).

Material and methods. Retrospective ecological study. Time series of the number of COPD and asthma patients hospitalized in the Pneumology service between July 2014 and December 2017 due exacerbation of their condition were analyzed. Weekly average levels of sulfur dioxide (SO₂), nitrogen dioxide (NO₂), carbon monoxide (CO), ozone (O₃), particulate matter with a diameter less than 2.5 (PM_2.5) and 10 (PM₁₀) micrometers, temperature (T), and rainfall (R) were obtained from publicly available data of the Valladolid city council. A generalized linear model with Poisson distribution was used to characterize the link between air pollution and climate variables with the number of admissions.

Results. A total of 1646 patients reported worsening of their COPD or asthma, which led to 2990 visits to the Emergency Department (ED) in the period of study: 1968 due to COPD and 1022 due to asthma exacerbation. 67.7% of patients visited ED one time, whereas 15.4% two times and 16.9% at least three times. Finally, 1644 individual admissions in the Pneumology service were assessed. Patients had a mean age of 66.0±5.9 years old (57.7% males). A significant correlation (p-value <0.05) between the number of hospitalizations and several independent variables (O₃, PM_2.5, NO₂, CO, T, and R) was obtained. The CO concentration showed a significant high correlation (Rho 0.45; p <0.01) as well as the highest influence on the number of COPD/asthma-related admissions (odds ratio 3.06; CI95% 2.90-3.22). After considering confounding factors, the influence of carbon monoxide remains (odds ratio 1.33; CI95% 1.24-1.44). Similarly, the temperature also achieved a significant negative correlation (Rho -0.593; p <0.05) and showed a relevant link (odds ratio 0.96; CI95% 0.96-0.97) with the number of admissions.

Conclusion. Our results suggest that there is a significant association between the number of hospital admissions due to COPD and asthma exacerbations and ambient levels of carbon monoxide and temperature.

Background: The use of Non-Invasive Ventilation (NIV) for acute respiratory failure has increased during the past few decades in emergency department (ED) and has become widespread considering its various benefits (reducing the need for mechanical ventilation, improving survival rate). On the over hand, with the newfound beneficial treatments come complications and side effects.  are reported but few studies were published.

The aim of our study was to assess the side effects and complications when using NIV in patients admitted to ED with acute respiratory failure

Methods:    prospective observational study over a seven month period.  Inclusion of all consecutive patients admitted to ED with acute respiratory failure requiring NIV (CPAP or Bi-PAP mode). Considered indications were acute exacerbation (AE) of chronic obstructive pulmonary disease (COPD), acute heart failure with pulmonary oedema or other indication). We didn’t include patients requiring NIV as a pre-oxygenation prior to intubation. A local protocol to perform NIV was followed. Demographics and clinical data were collected. Side effects and complications appearing during the NIV procedure were reported.

Results: Inclusion of 239 patients. Mean age 68±13. Sex ratio=1,6. Comorbidities n(%) : COPD 81(34), hypertension 139(58), diabetes 113(47), chronic heart disease 54(23), coronary heart disease 68(28,5). Indication of NIV n(%): AE COPD 59(25), acute pulmonary oedema 167(70).

CPAP was used in 172 patients (72%). CPAP complications and side effects (%): mouth dryness (34),tearing (18), face erythema (30), face pain and headache (26), skin erosion(9), nausea (7), vomiting (3), hypotension (2), rhinorrhea (2), abdominal pain(1). Success was obtained in 154 patients (89%). Bi-PAP NIV was required in 13 patients after CPAP failure. Invasive ventilation was performed in only four patients.

First line Bi-PAP ventilation was used in 67 (28). Bi-PAP complications and side effects (%): mouth dryness (28), face erythema (21), skin erosion (17), facial pain and headache (14), tearing (10), hypotension (4), rhinorrhea (4). Success was obtained in 83% of patients. Eleven patients was intubated.

Median hospital length stay was 28 hours [1-450]. Overall in-hospital mortality rate was 5,4%.

Conclusions: side effects were generally not severe but require the optimization of interfaces, use of humidifier or adequate positioning of patients. No infectious complications were reported. Severe side effects such as hypotension appear in less than 4% of patients. Trained both emergency physicians and paramedics is the key to reduce these complications.

Background. In 2018, “Hour-1 Bundle” was proposed by The Surviving Sepsis Campaign group. It encourages clinicians to complete initial treatment of sepsis and septic shock within 1 hour. However, there is controversy about its feasibility and effectiveness. 

Methods. This is a retrospective before-after study conducted at an emergency room (ER) in Kobe City General hospital from September 2017 to April 2019. Five elements of Hour-1 Bundle (measure lactate level, obtain blood cultures before administering antibiotics, administer broad-spectrum antibiotics, begin rapid administration of 30mL/kg crystalloid for hypotension or lactate level ≥ 4 mmol/L, apply vasopressors if hypotensive during or after fluid resuscitation to maintain MAP ≥ 65 mm Hg) were introduced by installing a timer in the ER, putting up original posters, providing short lectures about the bundle to staff members. We compared the outcomes and the compliance rates for the entire 1h bundle elements of consecutive suspected sepsis or septic shock patients treated in the ER and admitted to the ICU during 5 months after implementation of bundle (implementation group, from December 2018 to April 2019) with a control group treated during 6 months before the implementation group (from September 2017 to March 2018). The primary outcome was in-hospital mortality and the secondary outcome was the compliance rates for entire Hour-1 Bundle elements. Statistically significant differences were evaluated by chi-square test or Mann-Whitney U-test. P value < 0.05 was considered significant.

Results. There were 61, 65 patients in the control group and the implementation group with mean ages were 78 (IQR 65-83), 75 (67-85) years old, respectively. Sequential Organ Failure Assessment (SOFA) scores at ICU admission were 8(IQR 5-11), and 9(IQR 5-12), respectively. The compliance rates for the entire Hour-1 Bundle elements were 16% in the control group and 40% in the implementation group (p<0.05). In-hospital mortality was 28% in the control group and 40% in the implementation group (p=0.15). Infectious diseases were ruled out in 33% of the control group and 18% of the implementation group after admission based on microbiological investigations and clinical courses. The compliance rates for the conventional 3-hour bundle in the control group and in the implementation group were 70%, 91%, respectively.

Discussions and Conclusions. By introducing Hour-1 bundle to the ER, the compliance rates for the bundle significantly improved. However, it was difficult to make a definite diagnosis of sepsis or septic shock within 1 hour at the ER. No significant reduction of in-hospital mortality was observed. Implementation of novel Hour-1 Bundle in the ER was still difficult and may not improve outcomes of the sepsis or septic shock patients.

This trial was approved by research ethics committee at Kobe City General Hospital (no. zn190514). No funding.

Background:

Sepsis is a life-threatening condition, and it is essential that the healthcare system quickly identifies patients and treats them adequately. Unfortunately, the early detection of sepsis remains a challenging problem, and even experienced physicians have difficulties in detecting sepsis early and accurately. We aimed to develop an Artificial Intelligence-based Early Warning Score System (AI-EWS) for the early detection of sepsis that is better than the currently used Modified Early Warning Scores (MEWS) and Sequential Organ Failure Assessment (SOFA).

Methods:

In this register study, we included health data from the years 2010 to 2017 on all citizens 18 years or older with residency in one of four Danish municipalities (Odder, Hedensted, Skanderborg, and Horsens). All relevant hospital contacts from multiple hospitals within the region were identified by the unique national social security system number (1,002,450 contacts). 754,179 non-acute outpatient contacts and 89,202 inpatient contacts with a duration of less than six hours were removed. 134,983 contacts with no episodes of suspected infection were removed leaving 24,076 inpatient contacts included for analysis. After inclusion each inpatient contact underwent a binary classification process to denote them as either sepsis-positive or sepsis-negative. The classification was made based on patients meeting the gold standard for sepsis based on the Third International Consensus Definitions for Sepsis (Sepsis-3). 1,635 (6.8%) inpatient contacts were classified as sepsis positive. We included data about biochemical blood tests, vital signs and glasgow coma scores from the electronic health record.

We developed the AI-EWS early sepsis detection model as a deep neural network composed of an embedding layer followed by a temporal convolutional network (TCN). The TCN has four temporal blocks, each with 540 filters of kernel size 10. The dilation rate of the convolutional filters was exponentially increased for each of the stacked temporal blocks. The AI-EWS was trained using Adam optimization, with a learning rate of 0.0005 and a batch size of 200.

The AI-EWS was validated using 5-fold cross-validation. As comparative measures, we used the area under the receiver operating characteristic curve (AUROC) and the area under the precision-recall curve (AUPRC). The model was compared with TOKS (Tidlig Opsporing af Kritisk Sygdom), a Danish MEWS variant, and SOFA.

Results:

The following results are reported three, six, and twelve hours before sepsis with mean values and 95% confidence intervals. AI-EWS: (AUROC: 0.88(0.85;0.91), 0.83(0.79;0.87), 0.82(0.79;0.87); AUPRC: 0.41(0.40;0.43), 0.37(0.34-0.39), 0.30(0.26;0.33)), SOFA: (AUROC: 0.77(0.74;0.79), 0.73(0.71;0.74), 0.70(0.65;0-75); AUPRC 0.18(0.16;0.19), 0.16(0.15;0.18), 0.13(0.11;0.16)), and TOKS: (AUROC: 0.68(0.67;0.70), 0.59(0.58;0.59), 0.57(0.55;0.58); AUPRC: 0.12(0.10;0.14), 0.09(0.07;0.10), 0.10(0.09;0.10)). Furthermore, the AI-EWS reduced the number of false positives relatively by 84.6% and 79.4% compared to TOKS and SOFA, respectively, at the same sensitivity of 0.4.

Discussion and conclusions: 

The AI-EWS outperformed the SOFA and TOKS in the early detection of sepsis, with an increase in AUROC by 29.4% and AUPRC by 241.7% when compared to TOKS, the currently used early warning tool in Denmark. We conclude that the AI–EWS could be used to improve clinical utility by enabling earlier sepsis interventions and should be tested in a prospective randomized trial.

Trial Registration: Not registered. Register study. Funding: This work was supported by the Innovation Fund Denmark (case number 8053-00076B). Ethical approval and informed consent: Not needed

Background
It has not been investigated whether the quick sepsis-related organ failure assessment score (qSOFA), a new bedside tool for early sepsis detection, may help accelerating antibiotic initiation in ED patients with sepsis.

Methods
In this prospective pre/post quasi-experimental single-ED study, patients admitted with a suspected bacterial infection were managed using standard triage procedures only (baseline) or in association with qSOFA (intervention, with prioritization of patients with a qSOFA ≥2).

Results
A total of 151/328 (46.0%) and 185/350 (52.8%) patients with definite bacterial infection met the criteria for sepsis in the baseline and intervention periods, respectively. The sensitivity and specificity of a qSOFA ≥2 for sepsis prediction were 17.3% (95% confidence interval [CI], 13.6%-21.7%) and 98.8% (95% CI, 97.0%-99.5%). Eleven (7.3%) and 28 (13.5%) patients with sepsis in the baseline and intervention periods received a first antibiotic dose within one hour following triage (primary endpoint, absolute difference 6.2%, 95% CI [-0.5%, 12.7%], P = 0.08). The proportions of patients with sepsis receiving a first antibiotic dose within three hours following triage (39.7% [50/151] versus 36.8% [68/185], absolute difference -2.9%, 95% CI [-13.3%, 7.3%], P = 0.65), requiring ICU admission, or dying in the hospital were similar in both periods. The median ED occupation rate at triage was 104.3% (interquartile range [IQR], 80.4%-128.3%), with a median number of 157 ED visits per day (IQR, 147- 169).

Conclusions
A qSOFA-based triage procedure does not improve antibiotic timing and outcomes in patients with sepsis admitted to a high-volume ED. The qSOFA value at triage was poorly sensitive for early sepsis detection.

Trial registration (ClinicalTrials.gov) NCT03299894

Introduction

Altered pharmacokinetics, including increased volume of distribution and reduced tissue perfusion, in sepsis and septic shock patients resulted in inadequate serum drug concentration with the given standard meropenem dose. Even though higher dose regimen of hydrophilic antimicrobials was proposed, high-dose meropenem and its associated clinical outcomes in sepsis and septic shock patients admitted in the emergency department (ED), Mahidol university hospital, Thailand has not been examined.

Study objective

To compare the clinical outcomes of high-dose meropenem versus standard-dose in sepsis and septic shock patients who were admitted to the ED, Ramathibodi Hospital, Bangkok, Thailand.

Method

All sepsis and septic shock patients, in whom treatment with meropenem was indicated, were included in the study. Patients were randomized into two groups: the high-dose group (meropenem 2 g, infusion 3 hours, every 8 hours) and the standard-dose group (meropenem 1 g, infusion 3 hours, every 8 hours). Dose adjustment was done according to the renal dose adjustment protocol. Data were collected on 35 patients over 1 year. Primary and secondary outcomes included changes of modified sepsis-related organ failure assessment (mSOFA), mortality rate, ICU length of stay, mechanical ventilator days, vasopressor days and hospital stay.

Results

The study included 35 patients with 17 patients receiving standard-dose and 18 patients receiving high-dose meropenem. Age, gender, body weight, comorbidities, severity of illness, and source of infection were comparable between groups. Among identified pathogens, more than 80% were gram negative pathogens and all of them had meropenem minimal inhibitory concentration (MIC) < 0.5 mg/dL. Delta mSOFA scores were not different between two groups (-2 [range -6 to 2] in standard-dose group vs -2 [range -9 to 4] in high-dose group, P-Value = 0.99). There was no difference between standard-dose group and high-dose group in ICU mortality (17.6% vs 11.1%, P-value = 0.66), ICU free days (16.6±10.6 vs 14.5±11.8, P-value = 0.59), mechanical ventilator free days (18 [range0-28] vs 20.5 [range 0-28], P-value = 0.57), vasopressor free days (9.7±5.7 vs 8.9±5.8, P-value = 0.68) and hospital free days (50.8±33.5 vs 47.1±36.0, P-value = 0.75).

Conclusion

Our study is the first study examining higher dosing of meropenem in the ED, Ramathibodi Hospital, Bangkok, Thailand. The high-dose group showed comparable clinical outcomes to the standard dose group. Even though higher dose of hydrophilic antimicrobials has been linked to the better clinical outcomes in sepsis and septic shock patients, high-dose meropenem in low MIC pathogen has not been associated with improved clinical outcomes. Further research might be needed in order to identify suitable septic shock patients who may benefit from receiving high-dose of meropenem.

References

1.Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med. 2017 Mar;43(3):304-377.

2.Roberts JA, Paul SK, Akova M, et al. DALI: defining antibiotic levels in intensive care unit patients: are current beta-lactam antibiotic doses sufficient for critically ill patients?. Clin Infect Dis. 2014 Apr;58(8):1072-83. 

This study was registered using ClinicalTrial.gov identifier NCT03374722 and we have got funding from Dr.Kasem Foundation, Thailand.

Background

Sepsis can be fatal without timely diagnosis and prompt intervention. Therefore, it is necessary to develop early predictive biomarkers to identify and risk-stratify patients with sepsis. Traditionally, albumin has been used as a nutritional biomarker in intensive care unit to predict the mortality of septic patients; however, its role in prognosticating patients with sepsis in the emergency department (ED) remains uncertain.

 

Objective

The aim of the current study is to evaluate the performance between conventional and novel biomarkers in predicting 28-days sepsis-associated mortality and bacteremia in the ED. 

 

Methods

This prospective hospital-based cohort study was conducted in the ED of two different tertiary medical centers in Northern Taiwan between 2012 and 2018. Patients with documented infectious diseases during initial 24 hours were enrolled. We applied the multiplex platform of Bio-Plex ProTM Assays to evaluate 14 novel biomarkers: angipoietin-2, pentraxin 3, triggering receptor expressed on myeloid cells 1 (TREM-1), intercellular adhesion molecule 1 (ICAM-1), vascular cell adhesion protein 1 (VCAM-1), soluble cluster of differentiation 14 and 163 (sCD14 and sCD163), E-selectin,  P-selectin, tumor necrosis factor alpha (TNF alpha), cluster of differentiation-64 (CD64), interleukin-6, interleukin-8 and interleukin-10. Besides, we assessed 7 conventional markers: albumin, procalcitonin (PCT), C-reactive protein (CRP), red cell distribution width (RDW), Sequential Organ Failure Assessment (SOFA) score, Systemic Inflammatory Response Syndrome (SIRS) and Chills, Hypothermia, Anemia, RDW and Malignancy (CHARM) score. Our main outcomes of biomarker performance included sensitivity, specificity, accuracy and area under the receiver operating characteristic curve (AUC). 

 

Results

We recruited 1478 patients in our study. Among them, 1155 subjects had SIRS (78.15%), 912 subjects had severe sepsis (or Sepsis 3.0, 61.71%), and 466 subjects had septic shock  (31.53%)  with a 28-day mortality rate of 8.15%. By using different cutoff values of albumin, we demonstrated relatively acceptable sensitivity, specificity and accuracy for sepsis-associated mortality prediction accordingly (albumin level of 2.5g/dL: 34.51%, 93.90%, 88.20%; albumin level of 3.5g/dL: 90.27%, 44.41%, 48.81%). Among all biomarkers, albumin alone possessed an AUC of 0.791 (95% CI 0.750-0.832) and its performance was similar to the SOFA score with an AUC of 0.792 (95% CI 0.750-0.833) in 28-days sepsis-associated mortality (p-value = 0.98). For bacteremia, procalcitonin had a higher AUC than CRP (0.799, 95% CI 0.744-0.854 versus 0.540, 95% CI 0.467-0.611; p-value < 0.0001), as well as other biomarkers and scoring systems.

 

Conclusion

Our finding suggests that albumin, as a single biomarker, is a promising early predictor for mortality in sepsis subjects, similar to SOFA score, and outweighs other markers. The role of biomarker in identifying bacteremia has proved that PCT is still a better tool in comparison with CRP. Further efforts are needed to evaluate and improve the reliability of combining two or more biomarkers in early prediction of sepsis-associated mortality.

The study was supported by the Ministry of Science and Technology (Taiwan) and Chang Gung Memorial Hospital (107-2314-B-182-052-MY2, 106-2314-B-182-028, CMRPG2H0311, CMRPG2H0321). The funder has no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Background: With regards to nutritional therapy in critical care, the guidelines recommend that hypocaloric nutrition (not exceeding 70% of the estimated needs) be administered in the early phase of acute critical illness. When indirect calorimetry (IC) was used to study resting energy expenditure (REE) in the acute phase of sepsis (within 72 hours of admission), it was found that patients showed lower energy expenditure than that calculated using simple weight-based equations (such as 20-25 kcal/kg/day). This study aimed to evaluate the characteristics of low energy expenditure in the acute phase of sepsis.

Method: This retrospective observational study included sepsis patients under ventilation in whom REE was measured using IC within the first 72 hours of admission. The patients were divided into two groups according to REE values: group A, REE <20 kcal/kg/day and group B, REE ≥20 kcal/kg/day. Age, sex, body mass index (BMI), comorbidities, Acute Physiology and Chronic Health Enquiry (APACHE II) score on admission, site of infection, causative microorganisms, ratio of positive blood culture, catecholamine administration, and corticosteroid therapy were compared between the two groups. The Wilcoxon rank-sum test and the Fisher’s exact test were used for statistical analysis. A p-value <0.05 was considered statistically significant. We conducted this study in accordance with the Declaration of Helsinki, and the study was approved by the institutional review board at Osaka University Hospital (approval no. 14186). The board waived the need for informed consent because this was a retrospective study using clinical data.

Results: This study included 28 patients. Group A included 39.3% (n=11) of the study population. Median (interquartile range) age was significantly higher in group A than in group B (81 [74-87] vs. 72 [62-76] years; p=0.02). APACHE II scores were significantly higher in group A than in group B (24 [22-34] vs. 19 [14-25], p=0.04). Median BMI was significantly lower in group A than in group B (19.6 [17.6-24.9] vs. 23.6 [21.4-27.7] kg/m2; p=0.05). Microorganism culture showed gram-negative rods in the following cases: seven cases in group A (63.6%) and three cases in group B (17.7%) (p=0.02). Sex, comorbidities, site of infection, ratio of positive blood culture, catecholamine administration, and corticosteroid therapy did not differ significantly between the two groups.

Conclusion: Low energy expenditure in the acute phase of sepsis was observed in patients with higher APACHE II scores and lower BMI. The type of causative microorganism could also be related to for metabolism.

Background

Accidental hypothermia is not only caused by environmental exposure but also by various medical conditions, including sepsis, endocrinologic disease, and multiple trauma. Bacteraemia in accidental hypothermia is considered to be associated with significant morbidity and mortality, but little is known about bacteraemia in patients with accidental hypothermia. We aimed to investigate the clinical characteristics of patients with both accidental hypothermia and bacteraemia.

Methods

We conducted a retrospective analysis of all adult patients with accidental hypothermia who were brought to an urban emergency department between July 2011 and March 2019 in Kobe, Japan. Hypothermia was defined as a body temperature below 35°C.We compared clinical characteristics (vital signs, comorbidities, and laboratory tests) between patients with and without bacteraemia. To assess whether bacteraemia was associated with in-hospital mortality, we analysed odds ratios using a logistic regression model. Based on biological plausibility and pre-existing knowledge, we selected the following confounding factors: age, sex, severity (the Swiss system), and Charlson comorbidity index.

Result

A total of 245 patients with accidental hypothermia were enrolled. Median age was 78 (interquartile range, 68 to 87) years, and 49% of patients were male. In the emergency department, blood culture samples were collected from 217 patients (89%); of these, 36 patients (16.6%) showed positive blood cultures. None of the patients for whom blood culture was not performed in the emergency department were diagnosed with bacteraemia after admission. Body temperatures were lower (28.9 vs 30.1°C, p=0.009) and C-reactive protein levels were higher (9.99 vs 3.76 mg/dL, p<0.001) in patients with bacteraemia than in those without bacteraemia. Other clinical characteristics were not different between the two groups. The mortality was 11/36 (31%) in patients with bacteraemia and 29/209 (14%) in patients without bacteraemia (adjusted odds ratio, 2.47 [95% confidence interval, 1.04–5.88]).

Discussion and conclusion

Our study demonstrated that bacteraemia was common in patients with accidental hypothermia and was a prognostic factor, even after adjusting for confounding factors. Furthermore, except for body temperature and one inflammatory marker, other clinical characteristics did not differ between patients with and without bacteraemia. High mortality has been reported in accidental hypothermia patients with bacteraemia, but limited information was available for correctly suspecting bacteraemia in the emergency department. Our results were clinically acceptable and also consistent with a multi-centre study that demonstrated that hypothermia was associated with higher mortality in sepsis patients. Although several previous studies have focused on the association between mortality and hypothermia from the standpoint of treating sepsis patients, we evaluated all patients who presented with accidental hypothermia. Therefore, the present study emphasizes the importance of suspecting bacteraemia in patients with accidental hypothermia who do not show signs of sepsis. In conclusion, our study found that bacteraemia was common in patients with accidental hypothermia and was associated with higher mortality. Based on these findings, we recommend that we take blood culture routinely and consider empirical antibiotic treatment in patients with accidental hypothermia.

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Recognition of sepsis through emergency medical service

Background:

Sepsis is a common and serious disease process for which early recognition and intervention can significantly improve clinical outcomes. Despite this, sepsis remains underrecognized and therefore undertreated in the prehospital setting. Recent recommendations by the Society of Critical Care and European Society of Intensive Care Medicine advocate use of the qSOFA (quick Sepsis-related Organ Failure Assessment) score in non-ICU settings to screen for septic patients at greater risk for poor outcomes. Accordingly emergency medical services (EMS) in Bavaria were trained to identify septic patients in the prehospital setting. This retrospective cohort study sought to evaluate the effectiveness of this training intervention.

Methods:

We performed a retrospective study of all patients transported by EMS to our ED during two 6-month periods. All patients with a suspected or proven infection and sepsis after the ED workup were included. 303 patients were included during the 6 month period before the EMS training for sepsis recognition and 459 patients were included in the 6 month period following the EMS training. The sensitivity and specificity of a qSOFA score ≥2 for ED identification of patients at risk of complication was calculated.

Results:

During the 12 month study period 3.1% of all EMS-transported patients were diagnosed with sepsis in the ED. Mean age of the study cohort was 72 ±13 years, 59.4% were male, 60% needed intensive care, hospital mortality was 37.7%. No significant differences in clinical and outcome variables between the two study periods were noted. The proportion of patients identified with sepsis by EMS did not increase in the study period following the EMS training. In both study periods the identification of a septic disease in the pre-hospital setting was missed in 82% of the patients. Only in 3.8% a qSOFA score ≥2 was documented. Respiratory rate was the vital parameter most often missed by EMS (60%). In the ED the sensitivity and specificity of a qSOFA score ≥2 for identification of septic patients with poor outcome was 37.2% and 84.2%, respectively.

Conclusions:

A single EMS training period for identification of septic patients in the prehospital setting is not sufficient. A qSOFA score ≥2 had a low identification sensitivity in selecting septic patients at risk of complication upon arrival in the ED. An improved method for pre-hospital identification of septic patients is needed.

Funding: University of Augsburg research fund

Background

Prospective studies of the incidence of sepsis and the prognostic accuracy of the different sepsis screening tools after the introduction of Sepsis-3 are limited. Definition of sepsis is now based on organ dysfunction characterized by a rise in the Sequential Organ Failure Assessment (SOFA) score of two or more. The new definition also proposed QuickSOFA (qSOFA) as a bedside screening tool to identify patient with potential risk of having sepsis. We have estimated the incidence based on qSOFA, SOFA and Systemic Inflammatory Response Syndrome (SIRS), and compared the prognostic accuracy in predicting the 28-day mortality.

 

Methods

A prospective observational cohort study of infected patients aged 18 years or older admitted to the emergency department (ED) of Slagelse Hospital during 01.10.2017 – 31.03.2018. The adult (≥18 years) population in the area was 198,000. All patients with suspected or documented infection on arrival to the ED, and treated with antibiotics, were included. Admission variables included in the qSOFA, SOFA and SIRS criteria were obtained from the triage forms and patient records. The applied SOFA values were calculated based on the clinical and paraclinical parameters at admission and with correction for chronic dysfunction of organs included in the SOFA score. Survival status was obtained from the Danish Civil Registration System. Incidence was estimated as (number of patients with sepsis/population in the area x 0.5) x 100.000.  The prognostic accuracy was assessed by analyses of sensitivity, specificity and area under the receiver-operating curve (AUROC) with 95% confidence intervals (CI).

Results

A total of 2,112 patients with median age of 73.1 years were included. The incidence of sepsis based on a qSOFA ≥2, a SOFA ≥2 and SIRS ≥ 2 was 175/100,000 (95% CI 150-203/100,000), 714/100,000 (95% CI 663-768/100,000) and 1,012/100,000 (95% CI 951-1076/100,000), respectively. The 28-day mortality in patients with qSOFA ≥2, SOFA ≥2 and SIRS ≥2 was 17.7% (95% CI 12.4-24.2), 13.6% (95% CI 11.2-16.3) and 8.3% (95% CI 6.7-10.2), respectively. qSOFA ≥2 had a sensitivity of 19.5% (95% CI 13.6-26.5) and a specificity of 92.6% (95% CI 91.4-93.7), SOFA ≥2 had a sensitivity of 61.0% (95% CI 53.0-68.6) and specificity of 68.4 (95% CI 66.3-70.59), and SIRS ≥2 had a sensitivity of 52.8% (95% CI 44.8-60.8) and a specificity of 52.5% (95% CI 50.2-54.7). The AUROC was 0.63 (95% CI 0.59-0.67) for qSOFA, 0.69 (95% CI 0.64-0.73) for SOFA and 0.52 (95% CI 0.48-0.57) for SIRS.

 

Discussion and conclusion

The sepsis-3 criteria have reduced the number of patients classified as having sepsis and the prognostic accuracy to predict 28-day mortality has been increased. However, the prognostic accuracy to predict patients with risk of death is still poor, regardless of the scoring system used. 

The study received financial support from Region Zealand Health Research Foundation (RSSF), Denmark and “Naestved, Slagelse and Ringsted Hospitals” Research Fund, Denmark.

Background: Early education and training are mandatory to raise the knowledge and awareness of the healthcare staff. Iran is a disaster prone area with a high number of emergencies. This study aimed to assess the need for disaster and emergency management education for Iranian medical students.

Methods: Using two-round Delphi technique in 2018, 15 experts within the field of disaster and emergency management were asked for their opinions concerning the education required for Iranian medical students. Highly important educational domains and their sub-domains selected with an agreement of above 70-80% were prioritized by AHP technique.

Results: Of 41 identified and prioritized educational subjects, four main groups were obtained: 1) crisis and disaster primary concepts, 2) disease control skills, 3) management skills, and 4) medical care skills. The medical care skills had the highest priority (with a weight of 0.546) compared to other areas after the final analysis.

Discussion and Conclusion: Different areas of competency are needed to raise awareness and preparedness in medical students in combating crisis and disasters. We propose a curriculum for Iranian medical students and suggest it to be used other professionals, who are involved in the process of disaster management.

Registration: Nil. Funding: This project has partly been supported by a grant from the Shiraz University of Medical Sciences. Ethical approval and informed consent: Informed consent was obtained from all individual participants included in the study.

ABSTRACT

Objective(s)

There is no data about the intra-hospital crowding effect of pre-hospital mass-gathering support systems. Our objective was to evaluate the impact on emergency departments (EDs) of the Rouen Armada event 2013 (RAE2013), a major French happening.

Methods

We performed a multicenter, observational study based on the prospective collection of data on-site (8 first aid stations) and from 5 EDs in the Rouen area.

The main study endpoint was the total number of patients presenting to EDs for an Armada-related reason (ARR). Secondary endpoints were: demographics, care pathways, final diagnosis, care characteristics and outcomes. Then, we performed a focussed analysis on two subgroups (with vs without pre-hospital examination).

Results

Among 1,261 patients examined on-site, 246 presented to ED with an ARR (63 % with accidental injury, 85% discharged home). Only 6 patients had severe injuries. 88% of patients required some technical support in the ED. In the subgroup without pre-hospital examination (49%), we found significantly higher rates of young and local patients, which mainly presented to a private hospital. In the other subgroup, we fund a higher significant rate of discomfort and more use of ED technical support (biology, EKG).

Conclusions

RAE2013 pre-hospital support system efficiently protected EDs from overcrowding. Most of the ED visits were appropriate. This study highlights the importance of sufficient on-site resources for the most common presentations, and the relevance of intra-hospital registers.

Introduction: out-of-hospital cardiac arrest (OHCA) is a major public health problem. In Spain there are about 15,000 cases per year. The survival with a good neurological status of the OHCA is low, around 10%. Several studies have shown the relationship between the levels of training of citizens, the number of witnesses performing cardiopulmonary resuscitation (CPR) and the survival to the OHCA. The objective of this study was to determine the level of knowledge in basic life support (BLS) maneuvers of the Spanish population and their general attitude towards emergencies.

Methods: Descriptive study of cross-sectional survey by means of randomized sampling. 1,500 telephone interviews were made to subjects 18 years of age and older living in Spain. The sample was selected randomly from an automatic telephone number generator. The questionnaire used was designed specifically for the study. The information was collected by means of a computer-assisted telephone interview (CATI) through a structured and pre-codified questionnaire. Descriptive statistics was used to show the results.

Results: 51.3% of the people surveyed were men, the predominant age was between 35 and 54 years (44.9%), 59.7% were in active labor status and 32.8% had university studies. 75.6% of the population considers the training that Spanish people have in relation to first aid is "insufficient" or "very insufficient". 98.7% of respondents consider "very important" or "important" that citizens have knowledge of first aid. 60.8% of the population does not feel able to respond to a cardiac arrest. Only 41.3% of citizens recognize that they would know how to use an AED in case of need. 34.7% of Spanish people don´t know which is the unique European emergency number. 53.8% of the population has not received any training course related to first aid or BLS. 53.6% of citizens believe that caring for a person who has an emergency, without sufficient knowledge, could pose legal problems. 81.6% of the respondents believe that in our country everything is not done so that citizens have adequate training in first aid. 81.7% of the population believes that training in BLS should be initiated in the school (Primary Education and ESO).

Conclusions: Although the knowledge on BLS of the Spanish population and their ability to respond to an emergency situation has increased in the recent years, we are far from other European countries. The implementation of a National Plan of training and awareness in BLS along with public defibrillation programs, telephone CPR and public information and dissemination campaigns could increase the level of knowledge, the ability to respond, the number of witnesses that perform correctly CPR and use an AED, and, with all these things, can increase the survival of cardiac arrest.

The study was funded by the Mapfre Foundation

Background

The over 65 demographic have demonstrated the largest increase in emergency hospital admissions of any age group. Measures of acute illness severity using only physiological parameters have shortcomings in the older patient. Accurate risk scores combining acute physiology e.g. National Early Warning Score (NEWS), co-morbidities, and Clinical Frailty Score (CFS) in this cohort may support clinical decision making and inform discussions with patients and carers. This study aimed to derive and externally validate an in-hospital mortality risk score for the acutely unwell older patient.

Methods

This multicentre cohort study collected data on non-elective admissions in those aged ≥65 years from the emergency departments of two UK district general hospitals (2017-2018), which were treated as independent populations to derive and validate the score. Accessible and clinically significant variables underwent regression analysis for in-hospital mortality. Independent predictors of mortality from the derivation cohort were used to create GERAS. Model performance was assessed for discrimination and calibration in the validation cohort. Area under curve (AUC) analysis is presented with 95% confidence intervals. Secondary outcomes measured were 48-hour and seven-day mortality, 30-day readmission, and extended hospital stay.

Results

17,905 admissions were analysed in both derivation (n= 8,974) and validation (n=8,931) cohorts. GERAS was stratified into low, medium, high, and severe risk with corresponding mortality in each group of 0.4, 3.9, 9.3, and 24.1 percent, respectively. GERAS AUC for in-hospital mortality was 0.79 (0.77-0.80), compared to NEWS at 0.65 (0.62-0.67) and CFS at 0.76 (0.74-0.77) alone. GERAS demonstrated better calibration than NEWS and Clinical Frailty Score, Hosmer-Lemeshow: 0.302 vs 0.157 and 0.008, respectively. AUCs for mortality prediction at 48-hours and 7-days were 0.84 (0.78-0.90) and 0.83 (0.79-0.86), respectively. AUCs for 30-day re-admission and extended hospital stay were 0.68 (0.65-0.70) and 0.52 (0.50-0.54), respectively.

Conclusion

GERAS is an easy to use, high discriminating risk score that could be integrated into existing electronic hospital systems for use within hours of admission. Future studies could validate GERAS in external populations and consider impact analysis.

 

Ethical approval: NHS South Central - Hampshire B Research Ethics Committee (REC reference 18/SC/0513)

ackground Nonspecific complaint (NSC) is a common presenting complaint in the emergency setting, especially in the elderly population. Individual studies have shown that it is associated with significant morbidity and mortality. This systematic review aims to draw a synthesis of reported outcomes for patients presenting with NSC.

Methods We conducted a literature search for publications, abstracts and conference presentations from Ovid, Scopus and Web of Science for the period of past 20 years. Included were studies with adult patients presenting to the Emergency Medical Services or Emergency Department with NSC. 2057 studies were screened for eligibility and quality was assessed with the SIGN assessment for bias tool. We excluded any low-quality studies resulting in 9 studies for quantitative analysis. We analyzed included studies for in-hospital mortality, triage category, emergency department length of stay, admission rate, hospital length of stay, intensive care admissions and revisitation rate and compared outcomes to patients presenting with specific complaints (SC), where data was available. We grouped discharge diagnoses by ICD-10 categories.

Results We found that patients presenting with NSC were mostly older adults. Mortality for patients with NSC was significantly increased compared to patients presenting with SC [OR 4.22 (95% CI 1.39-12.88)]. They were triaged as urgent less often than SC patients [OR 2.10 (95% CI 1.06- 4.15)]. Emergency department length of stay was increased in two out of three studies. Hospital length of stay was increased by 1-3 days. Admission rates were high in most studies, 55 to 84%, and increased in comparison to patients with SC [OR 4.93(95% CI 1.97-12.31)]. These patients seemed to require more resources than patients with SC. There was no significant increase in intensive care admissions. Data was insufficient to make conclusions regarding revisitation rates. Discharge diagnoses were spread throughout ICD-10 main chapters, infections being the most prevalent.

Conclusions Patients with NSC have a high risk of mortality, their care in the Emergency Department is slower and requires more resources than for patients with SC. We suggest that NSC should be considered a major emergency presentation.

The protocol has been registered with Prospero ID CRD42019123552 The authors report no confict of interest

Background

 

Internationally, emergency and urgent care of older people is a public health priority. The management of older people in the Emergency and Urgent Care system remains sub-optimal in the UK. Strategies are needed to manage older patients sensitively, effectively, and efficiently, understanding both their clinical and broader, holistic needs. It is important to consider the strategies and interventions that have been used in the emergency care of older people, and to evaluate the evidence as to their outcomes, costs, and implementation.

 

Methods

 

A number of reviews have previously taken place in this topic area, assessing diverse interventions with differing methods and variable outcomes. We developed and registered (PROSPERO, CRD42018111461) a protocol for a review of reviews. Database searches and complementary methods identified evidence from review articles and conference abstracts, which were screened according to pre-defined inclusion criteria relating to both subject and reporting standards. Data describing interventions for older people in Emergency Departments (ED) were extracted and summaries generated in tabular and narrative form. The quality and reporting of the reviews were assessed using AMSTAR2 and Joanna Briggs Institute tools. Due to the heterogeneity of interventions and outcomes, findings were analysed narratively. McCusker’s Elder-Friendly Emergency Department assessment tool was used as a framework to classify ED interventions.

 

Results

 

Eighteen review articles and three conference abstracts met our topic and reporting standard inclusion criteria. The majority were described as systematic reviews, with four of these using meta-analysis. Fourteen of the reviews reported interventions that were either initiated or wholly delivered within the ED. The remaining four reviews reported non-interventional studies focussed predominantly on quality indicators or patient preferences.

 

Confidence in (US-dominated) research was limited to each review’s interpretation of primary studies. Descriptions of interventions were inconsistent, and there was high variability in the standards to which reviews were conducted and reported. Interventions mostly focussed on screening and assessment, discharge planning, referrals and follow-up, and multi-disciplinary team composition and professional activities. In total, 26 patient and health service outcomes were reported, including admissions and readmissions, length of stay, mortality, functional decline, and quality of life.

 

Discussion

 

Our review of reviews demonstrated that the current, extensive evidence base of primary and review studies is lacking in complexity, with limited or no evidence for the effectiveness of ED interventions; a common feature of the reviews was a call for more primary research using rigorous evaluation methods. There is little evidence in review studies for factors that influence the implementation of interventions.

 

There was evidence that among interventions initiated in the ED, those which were continued into the community yielded better outcomes. Service metrics (as valued by care commissioners) were evaluated as outcomes of interventions more frequently than person-centred attributes (as valued by older people). The interventions were broadly holistic in nature, consistent with international literature supporting Comprehensive Geriatric Assessment to improve outcomes for older people with acute care needs.

We undertook this review within a project which received NIHR Health Services and Delivery Research funding (17/05/96). JvO was supported by an NIHR Academic Clinical Fellowship.

Background

Optimisation of care for older adults who present to emergency departments, is an area of increasing interest and a top-ranking priority in a recent research priority setting exercise, led by the UK Royal College of Emergency Medicine and the James Lind Alliance.  

Questionnaires that enable patients to report the quality of their healthcare experience are known as Patient Reported Experience Measures (PREMs).  Each year millions of patients attend Emergency Departments (EDs), however no sufficiently reliable or validated PREM has yet been developed for use in this context. The Patient Reported Experience Measure for Adults aged over 65 years (PREM-ED 65+), is intended to be a validated and reliable PREM for use amongst older adults attending the ED. However, in order to generate items for the PREM, determinants of experience for older adults attending the ED need to be captured.

This study aims to describe the experiences of adults, aged 65 years or over, who attend the ED, focusing specifically on the feasibility and challenges of administering qualitative interviews in this clinical context (ED).

Methods

The study was conducted in a single large UK ED (100,000 attendances/year). English speaking patients aged 65 years or older, who consented to participate, were recruited between December 2018 and April 2019.  Sampling was purposive based on age, gender, presentation type and frailty score. Semi- structured interviews were conducted within the ED before discharge or inpatient disposition. Interviews were audio recorded and a standard question guide used. Ethics approval was obtained from the UK NHS Health Research Authority (18/LO/1194).

A ‘needs based’ conceptual model for patient experience, developed from a prior meta-synthesis of qualitative literature, informed our analysis, building on the descriptive themes which are ‘communication needs’, ‘emotional needs’, ‘physical/ environmental needs’, and ‘care needs’. Our intention is to triangulate new or emerging themes with the views of staff members, to inform PREM-ED 65+.

Results:

In total, 24 patient interviews were conducted. The average age of participants was 75 years (range 65—89years), 15/25 (60%) were female, and all lived in their own home prior to attending the ED.  The average clinical frailty scale score was 3/9 (Range 1—6).  A total of 10 hours of data was obtained during interviews which averaged 25mins in length (range 9min—51min).

Discussion & Conclusions

Initial findings from the thematic analysis will be presented. This will include key themes related to older adults’ experiences of ED care and suggested items for inclusion within a new PREM, aimed at older adults attending the ED. 

We conclude that ‘in-situ’ qualitative interviews are feasible within the Emergency Department, potentially being less affected by recall bias than retrospective interviewing. However, conducting qualitative research within emergency departments which are crowded, with high levels of ambient noise and with frequent interruptions, are key limitations to the recruitment of frail older adults into qualitative research.

The first author is in receipt of a personal doctoral research fellowship, awarded by the UK Royal College of Emergency Medicine. This study did not receive any additional funding.

Background

Low-energy falls (LEF) in the older patient are a common reason for presentation to an emergency department (ED). Head injuries, including traumatic intracranial hemorrhage (tICH) are among the common fall related injuries in this population. Current clinical decision rules consider anticoagulation (AC) or antiplatelet (AP) therapy as potential risk factor for a tICH. The objective of the study was to analyze the prevalence and severity of tICH and the association to AC/AP therapy in a large cohort of older patients with LEF presenting without trauma-team activation.

Methods

We performed a bicentric retrospective study on patients of 65 years and older presenting to the ED with a LEF between 01 January 2016 and 31 December 2016. Patients presenting to one of the two tertiary care centers (Emergency Departments of the University Hospital Basel and the University Hospital Munich) who obtained cranial computed tomography (cCT) examinations were included. Primary data were retrieved from radiology databases, detailed chart review abstractions were conducted by two independent observers to obtain information about medication, clinical signs of head injury and final diagnosis in both study centers. The prevalence and severity of tICH of patients with and without AC/AP therapy were compared. Multivariate regression models were used to measure the association between AC/AP therapy and the risk for tICH after adjustment for known predictors.

Results

Overall 2567 patients met inclusion criteria, of these 1424 (55%) had an AC/AP therapy. Prevalence for a tICH detected by cCT was 176/2567 (6.9%). Multivariate regression models showed no differences for the risk of a tICH (OR: 1.05, 95% CI: 0.76–1.47, p = 0.76) or association with head specific injury severity (IRR: 1.08, 95% CI: 0.97–1.19, p = 0.15) in patients with or without AC/AP therapy. CT-detected skull fracture and injury signs above clavicle were the strongest predictors for tICH (OR: 4.28, 95% CI: 2.79- 6.51 respectively OR: 1.88, 95% CI: 1.3–2.73).

Discussion and Conclusion

In this retrospective bicentric cohort analysis we found an overall prevalence of 6.9% for tICH in older patients with LEF and ED presentation without trauma-team activation. Therapy with AP/AC agents resulted in a prevalence of 7.2%, compared to 6.8% in patients without AP/AC therapy. Multivariate analysis revealed that neither AC, nor AP therapy or the combined treatment with AC and AP were risk factors for tICH in older patients with LEF. Injury signs above the clavicle were the strongest clinical predictor for a tICH and should therefore be considered to trigger imaging of the head in older patients with LEF, independently of AC or AP medication history.

The study was planned using STROBE guidelines, in accordance with the declaration of Helsinki, approved by local ethic committees (EKNZ 2017-01078, EK LMU 17-217).

Background: With increasing fiscal restraints and the need for efficient delivery models, women are being discharged sooner postpartum. As a consequence, complications that would easily be dealt with are now being captured later. These patients present to the Emergency Department (ED) to access quicker care to manage these complications. The purpose of this study was to review the reasons that postpartum women present to the ED in the short term (≤10 days post delivery).

Methods: This was a retrospective study based out of a large community hospital, which has the highest birth rate in the province of Ontario, Canada. Research ethics approval was obtained. Women who delivered at William Osler Health Services (WOHS) between January 1, 2018 and December 31, 2018 and who presented to the ED within 10 days of delivery. Patient demographics, obstetrical parameters, type of delivery, time of ED visit, and management were all extracted. The primary outcome is the rate of and reasons for postpartum visits to the emergency department. The secondary outcome is to identify maternal characteristics that are associated with postpartum visits to the emergency department. Descriptive statistics were used to summarize the findings.

Results/Findings: In 2018, there were approximately 8000 deliveries across WOHS. There were 429 unique postpartum ED visits between January 1 and December 31, 2018, of which 382 were included in the analysis. The mean age was 31.21 years (range 19.00 to 43.00, SD 4.83). The mean gravidity was 2.28, and the median gestational age at delivery was 39.14 weeks (range 20.00 to 41.43, SD 2.29). Most of the patients delivered via spontaneous vaginal delivery (52.36%), and the rate of operative vaginal delivery and caesarean section was 7.85% and 39.79% respectively. Group B Streptococcus status was positive in 17.80% of all patients. The median time of presentation to the ED was 5.00 days (IQR 4.00 to 8.00, SD 2.51). The most common reasons for presentation were abdominal pain (17.02%), wound issue (13.09%), and fever or vaginal/rectal pain (9.95%). Only a quarter of cases required an obstetrical consultation, and 85.86% of all visits were discharged home. The rate of admission and transfer to another centre is 12.04% and 2.09% respectively.

Conclusion: This study was the first in a busy community setting that looked at return ED visits in the short-term postpartum period. Educating patients on pain management and wound care can potentially decrease the rate of ED visits by this patient population given the high incidence of patients presenting with this problem. Further studies are needed to review the role of patient education, home care, and the need for early obstetrical follow up to reduce ED visits.

Background: Patients presenting to the Emergency Department (ED) with wounds prone to tetanus infection, are administered prophylaxis according to specific guidelines, which are based on the immune status of the patient. In some Hospitals, the immune status of the patient can be known through the use of a Point of Care Testing (POCT), the Tetanos Quick Stick (TQS). However, several studies demonstrated that tetanus prophylaxis guidelines were correctly followed only in a minority of the EDs.

 

Methods: This study takes into account the data of 4248 patients who referred to the ED of the Brugmann University Hospital between January 2017 and December 2018, with wounds potentially at risk for tetanus infection. 

Results: In the 12 months of 2017, 2800 patients presented with wounds; of these 2800 patients, 915 were not protected against tetanus infection, while 1885 were still immunized. 

In the 6 months of 2018 which were taken into account, 1448 patients presented with wounds; of these 1448 patients, 426 were not protected against tetanus infection, while 1022 were still immunized. 

Therefore, in the overall period, out of 4248 patients, 1341 patients were not protected by an active immunity against tetanus infection. 

Out of these 1341 non-protected patients, 213 did not receive the vaccine, and were therefore left unprotected. 

On the other hand, out of the 2907 who were already protected by active immunity, 12 patients received an unmotivated vaccine dose.

 

Discussion and Conclusions: These results underline either the incompliance with the prophylaxis administration guidelines or the difficulty in understanding which prophylaxis should be administered. We observed that in some cases, the healthcare practitioners tend to interpret positive tetanus tests as negative ones, and this could be due to the tendency of wanting to be on the “safe” side, and not wanting to commit any error. However, when we administer useless vaccine doses to patients who are already protected, we are committing an error in terms of costs and of patients’ safety, since we need to remember that no prophylaxis comes without possible side effects. 

In order to avoid type 1 errors (incorrect rejection of the true null hypothesis that the patient is vaccinated, and therefore administering a further vaccination dose) and type 2 errors (failure to reject the false null hypothesis that the patient is vaccinated and therefore not administering the needed vaccine dose, which in this context is of course more dangerous), could be done through a better training of the healthcare providers on the TQS results and on its reliability.

Non clinical work This study did not receive any specific funding.

Introduction : Choosing wisely (CW) is an international initiative to avoid overdiagnosis and overtreatment. In partnership with professional societies, CW develops and identifies recommendations of potentially avoidable prescriptions. We evaluated the number of avoidable examinations or treatments prescribed in 3 Emergency Departments (ED) in Ile de France Region, using 3 CW recommendations. Our hypothesis was that, in France, the percentage of potentially avoidable prescriptions was around 20%, as described in the literature.
Our first aim was to evaluate the prescription of a potentially low value test in a ED. Thus, our hypothesis was that a potentially avoidable prescriptions represented a loss of patient time in the ED.

Methods: This was a multi-centric retrospective review of medical record for patients who visited the ED of two academic hospitals and one regional hospital between the 1st of January and the 31st of December 2016. We examined a random sample of patients aged 15 to 65 years old, who consulted either for non traumatic low back pain, minor head injury or acute sinusitis. For each patient we extracted from the medical record the medical history and clinical examination to assess whether they should have had an exam prescription or a treatment according to CW recommendations. We also assessed whether patients were actually prescribed lumbar imaging, brain imaging or antibiotic therapy to determine the number of potentially avoidable prescriptions. Data are described with median and interquartile (IQR) for quantitative variables and number (%) for qualitative variables.

Results: A total of 1601 patients [43% of women] were included in the study. The median age was 38 years old IQR [28-49]. Consultation motives were low back pain, minor head injury or acute sinusitis for 710 (44%), 679 (43%), and 211 (13%) cases, respectively. A total of 549 (82%), 514 (76%) and 149 (71%) patients with low back pain, head trauma and sinusitis were treated in accordance with the CW recommendations, respectively.
For 70 (10%), 57 (8%) and 39 (8%) patients with low back pain, head trauma and sinusitis, respectively, a prescription could be considered as low value care and could have been avoided. These potentially avoidable prescriptions significantly increased length of stay in the ED for these patients: the subjects for whom an imaging exam was not indicated but obtained, stayed approximatively 5.2h IQR [3.2-9.5], and subjects for whom an exam was not indicated and non obtained stayed 4.3h IQR [2.1-6.8] (p<0.03).

Discussion & Conclusions: Approximately 10% of patients who consult in ED for non-traumatic back pain, minor head injury or acute sinusitis received a potentially avoidable prescription according to the CW criteria. This is the first study in France to evaluate over-diagnosis and over-treatment in the ED, using CW recommendations. Other international studies used administrative database, with more important number of subjects, and the avoidable prescriptions were between 4-40%.
Reducing the avoidable prescriptions in the ED improves the patients’ quality of life and the length of a stay in the ED.

Trial Registration: non clinical work. Funding:“This study did not receive any specific funding.”

Background

Intravenous contrast media is frequently administered when using computed tomography (CT) to diagnosis acute critical conditions of patients in the emergency room (ER). Because of the unstable conditions of patients who visit the ER and limitation of accessibility to the medical information of these patients, clinicians sometimes hesitate to use contrast media owing to concerns of contrast-induced nephropathy (CIN). This study’sobjective was to evaluate the development and site-related risks of CIN after intravenous contrast media administration for CT.

Methods

This single-center, retrospective cohort study was performed in a university-affiliated tertiary hospital with an average census of 1,025,110 visits per year. Patients who underwent contrast-enhanced CT (CECT) were included and divided into two groups based on the site of where CECT was executed: the ER group and ward group. Linear regression analysis was used to examine the association between the site of where CT was executed and changes in the serum creatinine level after CECT. Logistic regression analysis was performed to determine whether the site of where CT was executed was associated with the development of CIN.

Results

We investigated 79,849 patients in this study. Overall, 43,037patients underwent CECT in the ER, and 36,812underwentCECT in a ward. CECT performed in the ER was negatively associated with changes in the serum creatinine level (β coefficient -0.01, standard error 0.00, p<0.05) and development of CIN (odds ratio 0.91 95% confidence interval 0.86-0.95, p<0.05).

Discussion and Conclusions

Unlike the general prediction, performing CECT in the ER is not associated with a higher risk of CIN than performing CECT in a ward after admission. Therefore, based on our findings, the weight attributed to potential contrast-induced renal injuries in the clinical decision-making process of clinicians who work in the ER should be adjusted.

 

no appropriate register. This study did not receive any specific funding.

Objective. To examine whether physicians adhere to the urgency classification as determined by the Canadian Triage and Acuity Scale (CTAS).

Design and Method. A retrospective-archive study was conducted in a tertiary hospital from January 2011 to December 2015. For each patient, we examined the relation between the urgency rating set by the triage nurse and the waiting time for the physician by using univariate and multivariate analysis. Ccomparisons were performed for several subgroups: patient arrival time, season, assigned care area, and first consultant to examine the patient.

Results. There were 392,687 unique visits during the study period. The distribution of the classification was heterogeneous: 7,133 (1.8%) patients were classified as P1; 17,318 as P2 (4.4%); 148,657 as P3 (37.8%); 113,502 as P4 (28.9%); and 106,077 as P5 (27%). Median and interquartile ranges for time from triage until physician assessment, by triage group, were: P1, 0.7 minutes (0.2-24); P2, 35 minutes (13-76); P3, 44 minutes (21-88); P4, 45 minutes (20-87); and P5, 46 minutes (22-88). Percentages of visits that met the evaluation time goals, by triage classification, were: P1, 61%; P2, 27%; P3, 37%; P4, 61%; and P5, 85%. No clear differences among subgroups emerged.

Conclusion. The standard goals for time to physician evaluation are not being met, and there is little difference in time to evaluation between the P3, P4, and P5 classifications. This is likely because the physicians are not consulting the triage classification when deciding whom to evaluate next. System-wide changes in physician workflow and awareness should be initiated.

 

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Objective

A large proportion of patients affected with hypertension go undetected. Screening remains a challenge. During an emergency department (ED) consultation, one in three adults has elevated blood pressure. A systematic review was conducted to assess the performance of a screening strategy in adults (positive predictive values, follow-up rates) using blood pressure (BP) measurement at the time of an ED consultation. The secondary objectives are to describe BP measurement methods employed at the time of the initial consultation in the ED and the means used to monitor it, and also to describe the means used to confirm a diagnosis of HTN

Method

A systematic literature search on Embase, CINHAL, and Medline was carried out. This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses - Diagnostic Test Accuracy (PRISMA-DTA). Intervention studies with non-pregnant adults including at least one BP measurement for all participants were included. A procedure had to have been carried out to assess the validity of the elevated BP value within the next few days of the initial visit.  In order to assess the quality of the studies identified, we adapted the tool Quality Assessment of Diagnostic Accuracy Studies-2 (Quadas-2).

Results

Out of 1,030 articles identified, 10 articles published between 1987 and 2014 met the inclusion criteria. There were no randomized clinical trials. Mean age of participants was 51.6 years (95% CI 46.7 - 56.5 years). A single study reports that BP screening was measured according to all the recommendations from the guidelines. The average follow-up rate was 61.9% (95% CI 45.5 - 78.3). For diagnostic confirmation, four studies used a BP measurement method based on the guidelines.  Half of the patients (50.2% (95% CI 35.9 - 64.45)) with elevated BP during the ED visit had BP corresponding to uncontrolled elevated blood pressure at follow-up measurement.

Conclusion

In the context of emergency care, the measurement of blood pressure is usually performed in a non-standardized way. Despite this, in adults with high BP during ED consultation, half of them will have uncontrolled hypertension confirmed at follow-up. The contribution of ED to the screening for HTN, by making a referral for diagnostic confirmation, could provide a major opportunity to eventually reduce the burden associated with HTN and its complication.

André Michaud has received grants from Ministère de l’éducation et de l’enseignement supérieur du Québec (MÉES), the Réseau de recherche en soins infirmiers du Québec (RRISQ) and the Société Québécoise d’Hypertension artérielle (SQHA) in order to support his PhD studies.

Objectives:

To study the characteristics of an initial visit of children presenting to the emergency department (ED) that are associated with a revisit with a serious illness, and to develop a clinical prediction model. 

 

Methods:

We performed a prospective multicentre observational study in five European EDs (the TRIAGE study). Standardised data on patient characteristics, Manchester Triage System urgency classification, vital signs, clinical interventions and procedures, and outcomes were collected for consecutive children aged

 

Results:

109,482 children with an index visit were included, of whom 98,561 children (90%) were discharged. 1,026 children (1.0%) returned to the ED with serious illness out of a total of 7,891 representing children (13.0%). Rates of revisits with serious illness varied between the hospitals (range 0.7–2.2%). 

Characteristics of the index visit associated with a revisit with serious illness included: age (children

A model predicting the risk of a revisit with serious illness based on clinical characteristics had an AUC of 0.73 (95% CI 0.71–0.75). 1,634 children had a risk of >= 5%, which was useful for ruling in a revisit with serious illness, with positive likelihood ratio 5.65 (95% CI 4.62–6.91) and specificity 0.98 (95% CI 0.98–0.98). 31,876 children had a risk <0.5%, which was useful for ruling out a revisit with serious illness (negative likelihood ratio 0.25 (95% CI 0.20–0.31), sensitivity 0.92 (95% CI 0.90–0.93)). A model also including intravenous medications, clinical interventions, and laboratory investigations had improved AUC of 0.75 (95% CI 0.74–0.77; p <0.001).

 

Conclusion: 

Multiple characteristics of an index visit were associated with the risk of a revisit with serious illness. We developed a prediction model that can aid physicians identifying those children at highest and lowest risks for developing a serious illness after initial discharge from the ED, allowing for more targeted safety netting advice and follow-up. 

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Introduction:
For patients suspected of pulmonary embolism (PE), several strategies have been developed to limit the use of imaging tests and especially CT-Scan (PERC, YEARS, ADJUST-PE …) and are based on clinical data and threshold values of D-dimers. Each of these strategies is based on a different method of assessing the clinical probability (CP) that limits their combination.
Objective:
Our goal is to derive and validate a single clinical probability score allowing optimization of clinical data and D-dimer measurement and safely reduction of imaging testing.

Methods:
Based on the negative likelihood ratios of D-dimers, four levels of clinical probability were previously defined in order to obtain a strategy with a false negative rate < 1.9%: [1] without D-dimer test (very low CP, false negative <1,9%), [2] with D-dimer <1000 μg/L (low CP, false negative <15%), [3] with D-dimer <500 μg/L or < (age x10) after 50 years (moderate CP, false negative <60%), [4] and a last level (high CP) that can not safely exclude pulmonary embolism on the basis of clinical data and D-dimers.
A derivation and an internal validation cohorts were obtained from four European and American
prospective studies, including 11.066 patients suspected of PE. An external validation cohort was obtained
from a fifth prospective study of 1744 patients.
Statistically significant variables associated with PE in univariate analysis were included in a multivariate
logistic regression model. Points were assigned according to the regression coefficients, constituting the
PEPS score. The score was validated in the internal and external validation.

Results:
The score include 13 variables : age <50 years (-2), age between 50-64 years (-1), heart rate <80beats/min
(-1), chronic respiratory pathology (-1), chest pain and recent dyspnea (+1), male (+2), syncope (+2),
thromboembolic history (+2), immobilization (+2), estrogen therapy (+2), SpO2 <95% (+3), calf pain (+3),
and PE is the most likely diagnosis (+5).
A score <0 corresponds to a very low CP, between 0 and 4 to a low CP, between 5 and 11 to a moderate
CP and ≥12 to a high CP.
In external validation, the prevalence of PE was 11.7% (95% CI: 10.3-13.4) and, for each category, it was
respectively 1.4% (0.6-3.3), 7.2 % (5.7-9.1), 24.9% (21-29.2) and 51.1% (37-65).
The application of the PEPS strategy in the external validation cohort would have resulted in a false
negative rate of 0.85% (0.5-1.5) and 21.4% (19.4-23.5) D-dimer tests reduction and 26.6% (23.5-29.9)
imaging testing reductions.
We compare previous strategies applied to our external cohort and observed a reduction of imaging tests
by 20.8% (18-23.9) for YEARS, 7.8% (6.1-9.9) for PERC, 6.2% (4.7-8.1) for ADJUST-PE, 4.3% (21.4-27.5) for
PERC combined to YEARS, 13% (10.8-15.6) to PERC combined to ADJUST-PE.

Conclusion :
The strategy based on the PEPS score may lead to a safely substantial reduction of imaging testing
comparatively to previous strategies. It should now be tested in an outcome interventional study.

Background

Pneumonia is still the leading cause of death among infectious diseases worldwide. There has been importance on disposition based on several severity scores. Though many severity scores have been used already, novel machine-learning based models are needed for more accurate predictive power. The aim of this study is to prove effectiveness of machine-learning based model to predict 30-day mortality of pneumonia on Emergency Department setting.

 

Methods

This study was a retrospective analysis of adult medical patients with pneumonia registry on EMR arriving at Samsung Medical Center’s Emergency department(ED), a 63-bed unit, a tertiary referral center in Seoul, Korea from January 1, 2016 to December 31 2017. Patients aged 18 years or order those who have pneumonia registry on EMR was enrolled in the study. We collected data including demographic information, mental status, and laboratory finding. The primary outcome was the 30-day mortality and ICU admission from ED. Clinical factors were analyzed using logistic regression analysis. The ROC curve was fit to the sensitivity and specificity of machine-learning based model for mortality. Machine learning model was developed based on Random Forest(RF) algorithm from a training set, and its performance was evaluated by area under receiver operating characteristic curve (AUROC) from the test set.

 

Results

Of 1,974 pneumonia patients, 1,732 patients were eligible for study inclusion and 1,723 patients were analyzed finally. Of 1,723 patients, 564 were died within 30-day or ICU admission from ED initially. The AUC of CURB-65 was 0.593, and the AUC of novel machine-learning based model by RF was 0.84. The machine-learning model had 91.4% sensitivity, 47.9% specificity, 78.1% positive predictive value and 73.4% negative predictive value.

  

Discussion & Conclusions

Classification by machine-learning based model can help to predict the mortality of pneumonia patients on ED more accurate than pre-existing CURB-65. It also has fewer variables than the model PSI, another predictive tool which has 30 variables, and it is expected to be more suitable for ED setting.