Identifying patients with symptoms suspicious for COVID-19 at elevated risk of adverse events: The COVAS score

ObjectiveDevelop and validate a risk score using variables available during an Emergency Department (ED) encounter to predict adverse events among patients with suspected COVID-19.MethodsA retrospective cohort study of adult visits for suspected COVID-19 between March 1 – April 30, 2020 at 15 EDs in Southern California. The primary outcomes were death or respiratory decompensation within 7-days. We used least absolute shrinkage and selection operator (LASSO) models and logistic regression to derive a risk score. We report metrics for derivation and validation cohorts, and subgroups with pneumonia or COVID-19 diagnoses.Results26,600 ED encounters were included and 1079 experienced an adverse event. Five categories (comorbidities, obesity/BMI ≥ 40, vital signs, age and sex) were included in the final score. The area under the curve (AUC) in the derivation cohort was 0.891 (95% CI, 0.880–0.901); similar performance was observed in the validation cohort (AUC = 0.895, 95% CI, 0.874–0.916). Sensitivity ranging from 100% (Score 0) to 41.7% (Score of ≥15) and specificity from 13.9% (score 0) to 96.8% (score ≥ 15). In the subgroups with pneumonia (n = 3252) the AUCs were 0.780 (derivation, 95% CI 0.759–0.801) and 0.832 (validation, 95% CI 0.794–0.870), while for COVID-19 diagnoses (n = 2059) the AUCs were 0.867 (95% CI 0.843–0.892) and 0.837 (95% CI 0.774–0.899) respectively.ConclusionPhysicians evaluating ED patients with pneumonia, COVID-19, or symptoms suspicious for COVID-19 can apply the COVAS score to assist with decisions to hospitalize or discharge patients during the SARS CoV-2 pandemic.     

The Ottawa subarachnoid hemorrhage clinical decision rule for classifying emergency department headache patients

BackgroundSubarachnoid hemorrhage (SAH) is a serious cause of headaches. The Ottawa subarachnoid hemorrhage (OSAH) rule helps identify SAH in patients with acute nontraumatic headache with high sensitivity, but provides limited information for identifying other intracranial pathology (ICP).ObjectivesTo assess the performance of the OSAH rule in emergency department (ED) headache patients and evaluate its impact on the diagnosis of intracranial hemorrhage (ICH) and other ICP.MethodWe conducted a retrospective cohort study from January 2016 to March 2017. Patients with acute headache with onset within 14 days of the ED visit, were included. We excluded patients with head trauma that occurred in the previous 7 days, new onset of abnormal neurologic findings, or consciousness disturbance. According to the OSAH rule, patients with any included predictors required further investigation.ResultsOf 913 patients were included, 15 of them were diagnosed with SAH. The OSAH rule had 100% (95% CI, 78.2%–100%) sensitivity and 37.0% (95% CI, 33.8–40.2%) specificity for identifying SAH. Twenty-two cases were identified as SAH or ICH with 100% sensitivity (95% CI, 84.6%–100%) and 37.3% (95% CI, 34.1%–40.5%) specificity. As for non-hemorrhagic ICP, both the sensitivity and negative predictive values (NPV) decreased to 75.0% (95% CI, 53.3%–90.2%) and 98.2% (95% CI, 96.1%–99.3%), respectively.ConclusionsThe OSAH rule had 100% sensitivity and NPV for diagnosing SAH and ICH with acute headache. The sensitivity and specificity were lower for non-hemorrhagic ICP. The OSAH rule may be an effective tool to exclude acute ICH and SAH in our setting.     

Single test rule-out of acute myocardial infarction using the limit of detection of a new high-sensitivity troponin I assay

ObjectivesTo determine the diagnostic accuracy of a high-sensitivity cardiac troponin I (hs-cTnI) assay in patients presenting to the Emergency Department (ED) with suspected acute coronary syndromes. Specifically, we evaluated the use of a single blood test at the time of arrival in the ED, using low hs-cTnI cut-offs.MethodsIn a prospective diagnostic test accuracy study at 14 centers, we included patients presenting to the ED with suspected ACS within 12 h of symptom onset. We drew blood for hs-cTnI (Siemens ADVIA Centaur, overall 99th percentile 47 ng/L, limit of quantification [LoQ] 2.50 ng/L) on arrival. Patients underwent serial cardiac troponin testing over 3–6 h. The primary outcome was an adjudicated diagnosis of acute myocardial infarction (AMI). We evaluated the incidence of major adverse cardiac events (MACE: death, AMI or revascularization) after 30 days. Test characteristics for hs-cTnI were calculated using previously reported cut-offs set at the LoQ and 5 ng/L.ResultsWe included 999 patients, including 131 (13.1%) with an adjudicated diagnosis of AMI. Compared to the LoQ (100.0% sensitivity [95% CI 95.9–100.0%]), 99.7% negative predictive value [NPV; 95% CI 97.6–100.0%]), a 5 ng/L cut-off had slightly lower sensitivity (99.2%; 95% CI 95.8–100.0%) and similar NPV (99.8%; 95% CI 98.6–100.0%) but would rule out more patients (28.6% at the LoQ vs 50.4% at 5 ng/L). MACE occurred in 2 (0.7%) patients with hs-cTnI below the LoQ and 7 (1.4%) patients with hs-cTnI < 5 ng/L. Accounting for time from symptom onset or ECG ischemia did not further improve sensitivity.ConclusionThe Siemens ADVIA Centaur hs-cTnI assay has high sensitivity and NPV to rule out AMI with a single blood test in the ED. At the LoQ cut-off a sensitivity > 99% can be achieved. At a 5 ng/L cut-off it may be possible to rule out AMI for over 50% patients.     

A predictive model for serious adverse events in adults with acute poisoning in prehospital and hospital care

ObjectiveThe objective of this study was to design a risk model with variables determined before hospital arrival to predict the risk of serious adverse events in patients with acute poisoning.MethodsA preliminary prospective, multicentre cohort study of adults with prehospital diagnosis of acute intoxication was conducted. The study was carried out in the Public Health System of the Community of Castilla-Leon (Spain), including seven advanced life support units and five hospitals, between April 1, 2018, and June 30, 2019. People aged >18 years with a main prehospital diagnosis of acute poisoning admitted to a referral hospital on advanced life support were included. The main outcome measure was prehospital and hospital serious adverse events in patients with acute poisoning.ResultsWe included 221 patients, with a median age of 47 years (interquartile range: 33–61). The most frequent cause of poisoning was psychopharmaceuticals (111 cases, 49.8%): 38 (17.2%) patients had a serious adverse event, with a hospital mortality of 4.1% (nine cases) in the 30 days after the index event. The final model included age ≥65 years (odds ratio [OR]: 9.59, 95% confidence interval [CI]: 3.48–26.45; p < 0.001), oxygen saturation/fraction of inspired oxygen index ≤300 (OR: 15.03, 95% CI: 5.74–39.33; p < 0.001), and point-of-care lactate ≥4 mmol/L (OR: 7.68, 95% CI: 2.88–20.45; p < 0.001). The poisoning Early Warning Score was constructed from these three variables, and 1 point was assigned to each variable. The area under the curve of the score was 0.896 (95% CI: 0.82–0.96; p < 0.001).ConclusionsThe poisoning Early Warning Score may help in decision-making and promote early identification of high-risk patients with acute poisoning in the prehospital context.     

Accuracy of Multi-organ Point-of-Care Ultrasound for Acute Kidney Injury Etiologies

This study investigated the diagnostic performance of point-of-care ultrasound (POCUS) for acute kidney injury (AKI) etiological subgroups in emergency department (ED) patients. Multi-organ POCUS including kidney, bladder, inferior vena cava (IVC), lung and cardiac examinations were used to identify five AKI subgroups: hypovolemia, reduced cardiac output, systemic vasodilatation and renal vasomodulation, renal and post-renal. One hundred sixty-five AKI patients were included in the study. The most diagnostic parameter in the post-renal group was the presence of any hydronephrosis, with a sensitivity of 93.3% (95% confidence interval [CI]: 68.1–99.8) and specificity of 85.9% (95% CI: 79.3–91.1). For the reduced cardiac output group, the most diagnostic parameter was IVC maximum diameter >17 mm with a sensitivity of 100% (95% CI: 83.2–100) and specificity of 70.2% (95% CI: 61.6–77.7). For the hypovolemia group, the most diagnostic parameter was IVC maximum diameter ≤17.9 mm with a sensitivity of 81.2% (95% CI: 71.2–88.8) and specificity of 56.5% (95% CI: 44–68.4). For the systemic vasodilatation and renal vasomodulation group, the most diagnostic parameter was diffuse ascites with a sensitivity of 56.3% (95% CI: 29.9–80.2) and specificity of 89.9% (95% CI: 83.8–94.2). None of the parameters were significant for the renal group. We concluded that multi-organ POCUS is of diagnostic value for AKI subgroups.     

Predictors of return visits to the emergency department among different age groups of older adults

ObjectiveTo identify predictors of 30-day emergency department (ED) return visits in patients age 65–79 years and age ≥ 80 years.MethodsThis was a cohort study of older adults who presented to the ED over a 1-year period. A mixed-effects logistic regression model was used to identify predictors for returning to the ED within 30 days. We stratified the cohort into those aged 65–79 years and aged ≥80 years. Adjusted odds ratios (aORs) with 95% confidence intervals (CI) were reported. This study adhered to the STROBE reporting guidelines.ResultsA total of 21,460 ED visits representing 14,528 unique patients were included. The overall return rate was 15% (1998/13,300 visits) for age 65–79 years, and 16% (1306/8160 visits) for age ≥ 80 years. A history of congestive heart failure (CHF), dementia, or prior hospitalization within 2 years were associated with increased odds of returning in both age groups (for age 65–79: CHF aOR 1.36 [CI 1.16–1.59], dementia aOR 1.27 [CI 1.07–1.49], prior hospitalization aOR 1.36 [CI 1.19–1.56]; for age ≥ 80: CHF aOR 1.32 [CI 1.13–1.55], dementia aOR 1.22 [CI 1.04–1.42], and prior hospitalization aOR 1.27 [CI 1.09–1.47]). Being admitted from the ED was associated with decreased odds of returning to the ED within 30 days (aOR 0.72 [CI 0.64–0.80] for age 65–79 years and 0.72 [CI 0.63–0.82] for age ≥ 80).ConclusionAge alone was not an independent predictor of return visits. Prior hospitalization, dementia and CHF were predictors of 30-day ED return. The identification of predictors of return visits may help to optimize care transition in the ED.     

A novel predictive tool for prognosis in elderly patients with urinary tract infection: Modified PRACTICE

PurposeWe evaluated whether combining the serum albumin level and the Prediction Rule for Admission policy in Complicated urinary Tract InfeCtion LEiden (PRACTICE) class could be a prognostic predictor in elderly patients with urinary tract infection (UTI).MethodsWe retrospectively included adult patients (age ≥ 65 years) with UTI who were hospitalized in the emergency department (ED) between January 1, 2014 and December 31, 2018. We graded the serum albumin level and classified the PRACTICE score; the modified PRACTICE was defined as the sum of the albumin level grade and the PRACTICE class. We comparatively assessed the predictive value for in-hospital mortality and admission to the intensive care unit (ICU) in survivor and non-survivor groups.ResultsIn total, the study analysis included 1159 patients, and in-hospital mortality was 3.4% (n = 39). The modified PRACTICE score (4.0 [1.4] vs 6.1 [1.2], p < 0.001) was significantly increased in the non-survivor group. The area under the curve value of factors associated with in-hospital mortality were the Modified Early Warning Score (MEWS) 0.57 (95% CI 0.54–0.60), albumin 0.83 (95% CI 0.81–0.85), PRACTICE 0.71 (95% CI 0.69–0.74), and the modified PRACTICE 0.86 (95% CI 0.84–0.88). Factors associated with ICU admission were MEWS 0.65 (95% CI 0.62–0.68), albumin 0.66 (95% CI 0.64–0.69), PRACTICE 0.66 (95% CI 0.63–0.68), and the modified PRACTICE 0.72 (95% CI 0.69–0.74).ConclusionThe modified PRACTICE score can be a useful prognostic predictor in elderly patients with UTI.     

Should age be incorporated into the adult triage algorithm in the emergency department?

ObjectiveTo compare resource utilization and mortality between older and younger adult patients with similar ED chief complaints and ESI triage levels.MethodsThis was an observational study of consecutive adult patients (age ≥ 40) who presented to an academic ED over a 1-year period with chest pain, abdominal pain, altered mental status, generalized weakness, or headache. Patients were categorized into 40–64, 65–79, and ≥ 80-year old groups. Mortality and utilization outcomes were compared between age groups through logistic regression models or Cox proportional hazards adjusting for ESI level and chief complaint. Odds ratios (OR) and hazard ratios (HR) were calculated with 95% confidence intervals (CI).ResultsA total of 9798 ED visits were included. As compared to younger adults (age 40–64), older adults, independently of ESI level and chief complaint, had higher ED laboratory use (OR 1.46 [CI 1.29, 1.66] for age 65–80; OR 1.33 [CI 1.15, 1.55] for age ≥ 80), ED radiology use (OR 1.40 [CI 1.26, 1.56]; OR 1.48 [CI 1.30, 1.69]), hospital admission (OR 1.56 [CI 1.42, 1.72]; OR 1.97 [CI 1.75, 2.21]), and ICU admission (OR 1.38 [CI 1.15, 1.65]; OR 1.23 [CI 0.99, 1.52]). Despite similar ESI and chief complaint, patients age 65–79 and ≥ 80 had higher 30-day mortality rates (HR 1.87 [CI 1.39 to 2.51] and 2.47 [CI 1.81 to 3.37], respectively).ConclusionsOlder adults with similar chief complaints and ESI levels than younger adults, have significantly higher ED resource use, hospitalization rates, and mortality.     

Diagnostic accuracy of combined WBC,ANC and CRP in adult emergency department patients suspected of acute appendicitis

ObjectivesTo assess the sensitivity, specificity, and negative predictive value (NPV) of normal total white blood cell count (WBC) and normal absolute neutrophil count (ANC) combined with a normal proprietary C-reactive protein (pCRP) level in adult emergency department (ED) patients with abdominal pain suspected of possible acute appendicitis.MethodsWe prospectively enrolled patients ≥18 years of age at seven U.S. emergency departments with ≤72 h of abdominal pain and other signs and symptoms suggesting possible acute appendicitis. Sensitivity, specificity, and NPV for normal WBC and ANC combined with normal pCRP were correlated with the final diagnosis of acute appendicitis.ResultsWe enrolled 422 patients with a prevalence of acute appendicitis of 19.1%. The combination of normal WBC and pCRP exhibited a sensitivity of 97.5% (95% CI, 91.3–99.3%), an NPV of 98.8% (95% CI, 95.9–99.7%) and a specificity of 50.0% (95% CI, 44.7–55.3%) for acute appendicitis. Normal ANC and pCRP resulted in a sensitivity of 100% (95% CI, 95.4–100%), a negative predictive value of 100% (95% CI, 97.5–100%) and a specificity of 44.4% (95% CI, 39.2–49.7%) for acute appendicitis. Normal WBC and pCRP correctly identified 171 of 342 (50.0%) patients who did not have appendicitis with 2 (2.5%) false negatives, while normal ANC and pCRP identified 150 of 338 (44.3%) of patients without appendicitis with no false negatives.ConclusionThe combination of normal WBC and ANC with normal pCRP levels exhibited high sensitivity and negative predictive value for acute appendicitis in this prospective adult patient cohort. Confirmation and validation of these findings with further study using commercially available CRP assays is needed.     

Sensitivity of a bedside reagent strip for the detection of spontaneous bacterial peritonitis in ED patients with ascites

Study objectiveTo determine the sensitivity of a highly sensitive bedside leukocyte esterase reagent strip (RS) for detection of spontaneous bacterial peritonitis (SBP) in emergency department (ED) ascites patients undergoing paracentesis.MethodsWe conducted a prospective, observational cohort study of ED ascites patients undergoing paracentesis at two academic facilities. Two practitioners, blinded to each other's results, did a bedside RS analysis of the peritoneal fluid in each patient and documented the RS reading at 3-min according to manufacturer-specified colorimetric strip reading as either “negative”, “trace”, “small”, or “large”. The primary outcome measure was sensitivity of the RS strip for SBP (absolute neutrophil count ≥ 250 cells/mm³) at the “trace” threshold (positive equals trace or greater).ResultsThere were 330 cases enrolled, with 635 fluid analyses performed. Of these, 40 fluid samples had SBP (6%). Bedside RS had a sensitivity, specificity, positive predictive value, and negative predictive value of 95% (95% CI 82%–99%), 48% (95% CI 44%–52%), 11% (95% CI 10%–11%), and 99% (95% CI 97%–99%) respectively at the “trace” threshold for the detection of SBP.ConclusionBedside use of the RS in ED ascites patients demonstrated high sensitivity for SBP. Given the wide confidence intervals, we cannot currently recommend it as a stand-alone test. We recommend further study with a larger number of SBP patients, potentially combining a negative RS result with low clinical suspicion to effectively rule out SBP without formal laboratory analysis.     

Accuracy of point-of-care ultrasound for determining the adequacy of pediatric forearm fracture reductions

BackgroundThe objective of the present study was to the determine the accuracy of point-of-care ultrasound (POCUS) in assessing closed reduction (CR) of pediatric forearm fractures in a pediatric emergency setting.MethodsAfter determination of the need for CR using X-ray images by an orthopedic consultant, POCUS examinations were performed just before and after the reduction attempt. The transducer was positioned longitudinally over the dorsal, volar, and lateral surfaces of the radius and ulna to view the fracture site. The presence of angulation, displacement, or bayonetting of the fracture fragments was recorded. The adequacy of realignment according to the POCUS and the orthopedic consultant's final determination were recorded.ResultsSixty-two patients were enrolled in the study and 96 bones were evaluated. The sensitivity and specificity of POCUS for adequacy of CR were 95.8% [95% confidence interval (CI): 88.3–99.1)] and 95.8% (95% CI: 78.8–99.8), the positive predictive value was 98.5% (95% CI: 91.0–99.7), and the negative predictive value was 88.4% (95% CI: 71.6–95.8). The corresponding positive and negative likelihood ratios were 23 (3.37–156.77) and 0.04 (0.01–0.12). There was high agreement between POCUS and X-ray images for predicting adequacy of CR [κ: 0.892 (±0.053)]. There was also a significant correlation between POCUS and X-ray measurements of angulation and displacement performed before and after CR, respectively (p < 0.001).ConclusionOur study has reported the successful use of POCUS for the management of pediatric forearm fractures in a pediatric emergency department. Point-of-care ultrasound can minimize radiation exposure and appears to be an alternative and accurate tool for reduction attempts.     

Early mortality in critical illness – A descriptive analysis of patients who died within 24 hours of ICU admission

PurposeTo describe patients who die within 24 h of ICU admission in order to better optimize care delivery.MethodsThis was a retrospective cohort study of patients ≥18 years old admitted to 17 adult ICUs in Alberta, Canada from January 1, 2016 and June 30, 2017. Data were obtained from a provincial clinical information system and data repository. The primary outcome was incidence of ICU death within 24 h of admission. Secondary outcomes were patient and system factors associated with early death. Variables of interest were identified a priori and examined using multivariable logistic regression.ResultsOf 19,556 patients admitted to ICU in an 18-month period, 3.3% died within 24 h, representing 29.8% of ICU deaths. Factors associated with early death were age (adjusted-OR 0.99, 95% CI, 0.9–1.0), acuity (adjusted-OR 1.3, 95% CI, 1.3–1.4), admission from the Emergency Department (ED; adjusted-OR 1.5, 95% CI, 1.1–1.9) and surgical (adjusted-OR 2.27, 95% CI, 1.4–3.6), neurologic (adjusted-OR 4.6, 95% CI, 3.1–6.9) or trauma diagnosis (adjusted-OR 6.1, 95% CI, 2.4–15.6).ConclusionPatients who die within 24 h constitute one third of ICU deaths. Age, acuity, admission from the ED and surgical, neurologic or trauma-related admission diagnosis correlate with early death.     

Feasibility of point-of-care knee ultrasonography for diagnosing anterior cruciate and posterior cruciate ligament tears in the ED

ObjectiveTo evaluate the feasibility of point-of-care knee ultrasonography (POCUS) compared with knee magnetic resonance imaging (MRI) for diagnosing anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) tears in patients with acute knee trauma.Material and methodsA prospective study was conducted in a tertiary hospital emergency department; acute (within 1-week) knee trauma patients with suspected ACL or PCL tear were recruited. Two POCUS performers (a board-certified emergency physician and a musculoskeletal radiologist) independently evaluated the ACL and PCL using POCUS. Findings were classified as normal appearance or ligament tear. Final radiology reports of knee MRI were used as the reference standard. We calculated the diagnostic values (sensitivity, specificity, and accuracy) for POCUS obtained by both POCUS performers. Kappa values (k) were calculated for inter-observer agreement between the two POCUS performers.ResultsSixty-two patients were enrolled. Compared with the reference standard, POCUS showed acceptable sensitivity (90.6–100%), specificity (90.0–97.7%), and accuracy (91.9–96.8%). Inter-observer agreement between the two POCUS performers was excellent (k = 0.853–0.903).ConclusionPOCUS demonstrates excellent precision as compared to MRI in the diagnosis of ACL and PCL tears. The findings of POCUS could be used for immediate diagnosis and further pre-operative imaging in patients with acute knee trauma.     

Risk of Acute Kidney Injury Associated With Medication Administration in the Emergency Department

BackgroundPatients who develop acute kidney injury (AKI) have a 2-fold increased risk for major adverse events within 1 year. An estimated 19–26% of all cases of hospital-acquired AKI may be attributable to drug-induced kidney disease (DIKD). Patients evaluated in the emergency department (ED) are often prescribed potentially nephrotoxic drugs, yet the role of ED prescribing in DIKD is unknown.ObjectiveWe sought to measure the association between ED medication administration and development of AKI.MethodsThis was a retrospective 5-year cohort analysis at a single center. Patients with a serum creatinine measurement at presentation in the ED and 24–168 h later were included. Outcome was incidence of AKI as defined by Kidney Disease Improving Global Outcomes criteria in the 7 days after ED evaluation. Medication administration risk was estimated using Cox proportional hazards model.ResultsThere were 46,965 ED encounters by 30,407 patients included in the study, of which 6461 (13.8%) patients met the criteria for AKI. For hospitalized patients, administration of a potentially nephrotoxic medication was associated with increased risk of AKI (hazard ratio [HR] 1.30 [95% confidence interval {CI} 1.20–1.41]). Diuretics were associated with the largest risk of AKI (HR 1.64 [95% CI 1.52–1.78]), followed by angiotensin-converting enzyme inhibitors (HR 1.39 [95% CI 1.26–1.54]) and antibiotics (HR 1.13 [95% CI 1.05–1.22]). For discharged patients, administration of antibiotics was strongly associated with increased risk of AKI (HR 3.19 [95% CI 1.08–9.43]).ConclusionED administration of potentially nephrotoxic medications was associated with an increased risk of AKI in the following 7 days. Diuretics, angiotensin-converting enzyme inhibitors, and antibiotics were independently associated with increased risk of AKI. Nephroprotective practices in the ED may mitigate kidney injury and long-term adverse outcomes.     

Emergency Department Triage Early Warning Score (TREWS) predicts in-hospital mortality in the emergency department

AimThe purpose is to assess the adequacy of the National Early Warning Score (NEWS) in the emergency department (ED) and the usefulness of the Triage in Emergency Department Early Warning Score (TREWS) that has been developed using the NEWS in the ED.MethodsIn this retrospective observational cohort study, we performed univariable and multivariable regression analyses with 81,520 consecutive ED patients to develop a new scoring system, the TREWS. The primary outcome was in-hospital mortality within 24 h, and secondary outcomes were in-hospital mortality within 48 h, 7 days, and 30 days. The prognostic properties of the TREWS were compared with those of the NEWS, Modified Early Warning Score (MEWS), and Rapid Emergency Medicine Score (REMS) using the area under the receiver operating characteristic curve (AUC) technique.ResultsThe AUC of the TREWS for in-hospital mortality within 24 h was 0.906 (95% CI, 0.903–0.908), those of the NEWS, MEWS, and REMS were 0.878 (95% CI, 0.875–0.881), 0.857 (95% CI, 0.854–0.860), and 0.834 (95% CI, 0.831–0.837), respectively. Differences in the AUC between the TREWS and NEWS, the TREWS and MEWS, and the TREWS and REMS were 0.028 (95% CI, 0.022–0.033; p < .001), 0.049 (95% CI, 0.041–0.057; p < .001), and 0.072 (95% CI, 0.063–0.080; p < .001), respectively. The TREWS showed significantly superior performance in predicting secondary outcomes.ConclusionThe TREWS predicts in-hospital mortality within 24 h, 48 h, 7 days, and 30 days better than the NEWS, MEWS, and REMS for patients arriving at the ED.     

Retrospective review of patients with lung cancer identified in the emergency department

BackgroundObtaining a diagnosis of cancer following an emergency department (ED) visit is associated with poor outcomes and advanced stage. Limited data is available from EDs in the United States. We describe a cohort of patients that obtained a diagnosis of lung cancer because of an ED visit.MethodsThis is a single center, retrospective cohort of patients with lung cancer who presented to the ED between December 2016 and December 2019. We investigated demographics, access to primary care, previous cancer screening, cancer type/stage, mortality, and imaging study that suggested cancer. The primary outcome is the percentage of lung cancer diagnoses over a 4-year period that resulted from an ED visit.ResultsAmong the 268 patients with lung cancer, 152 patients (57.6%) had presented to the ED with a workup that was concerning for lung cancer. Patients were generally elderly (median 62-years old), African American (n = 77, 51%), and smokers (n = 145, 95.4%) with a median smoking pack years of 40. Only 24 patients (15.8%) had seen a primary care physician within 1 year of diagnosis, and only 8 patients were appropriately screened for lung cancer. The most common type of cancer was non-small-cell carcinoma (111, 73.0%), with 61.3% of those being adenocarcinoma (n = 68). Patients were most likely to be stage IV (n = 86, 56.6%), and the overall mortality was 53.3% (n = 81, 1 year follow-up). Most patients (88/152, 57.9%) of patients were admitted to the hospital, and Medicare patients (OR 2.7, 95% CI 1.37–5.23) and patients with stage IV disease (OR 2.22, 95% CI1.15–4.29) were more likely to be admitted. Patients were more likely to have a concerning finding on computed tomography (CT) versus chest x-ray (55.9% versus 36.8%, respectively). CT scan reports were more likely to mention malignancy (OR 5.9, 95% CI 2.5–14.0) or metastasis (OR 30, 95% CI 7.1–127.1) than chest x-ray.ConclusionPatients that have lung cancer diagnosed through the ED are more likely to be advanced stage at time of diagnosis and are more likely to have CT scans demonstrate concerning findings. Given the lack of previous cancer screening, the advanced stage at presentation of lung cancer to the ED, and high mortality rates, the ED may serve a public health role in addressing lung cancer screening.     

Predictive value of the National Early Warning Score–Lactate for mortality and the need for critical care among general emergency department patients

Study objectivesWhat is the predictive value of the National Early Warning Score–Lactate (NEWS-L) score for mortality and the need for critical care in general emergency department (ED) patients?MethodsIn this retrospective cohort study, we enrolled all adult patients who visited the ED of an urban academic tertiary-care university hospital in South Korea over 2 consecutive months. The primary outcome was 2-day mortality. The secondary outcomes were the need for critical care (advanced airway use, vasopressor or inotropic agent use, intensive care unit admission) during an ED stay; 2-day composite outcome (2-day mortality and the need for critical care); 7-day mortality; and in-hospital mortality.ResultsDuring the study period, 4624 adult patients visited the ED. Of these, 87 (1.9%) died within 2 days. In total, 481 patients (10.4%) required critical care during their ED stay. The 2-day composite outcome, 7-day mortality, and in-hospital mortality were 10.9% (503/4624), 2.5% (116/4624), and 3.9% (182/4624), respectively. The NEWS-L demonstrated excellent predictive value for 2-day mortality with an area under the receiver operating characteristic curve (AUROC) of 0.96 (95% confidence interval [CI], 0.94-0.98); this value was better than that of the NEWS alone (AUROC 0.94 [95% CI, 0.91-0.96], P = .002). The AUROC of the NEWS-L for the need for critical care was 0.83 (95% CI, 0.81-0.85); for the 2-day composite outcome, it was 0.84 (95% CI, 0.82-0.86); for 7-day mortality, it was 0.94 (95% CI, 0.92-0.96); and for in-hospital mortality, it was 0.87 (95% CI, 0.85-0.90). Logistic regression results confirmed that the ratio of the NEWS to the initial lactate level was 1:1. Similar results were obtained in the subgroup analyses (disease-infection, disease–vascular and heart, disease-others, and nondisease). The high-risk NEWS-L group (NEWS-L ≥ 7, 9.4% of all patients) had an adjusted odds ratio of 28.67 (12.66-64.92) for 2-day mortality in the logistic regression model adjusted for basic characteristics.ConclusionThe NEWS-L can provide excellent discriminant value for predicting 2-day mortality in general ED patients, and it has the best discriminant value regarding the need for critical care and composite outcomes. The NEWS-L may be helpful in the early identification of at-risk general ED patients.     

Short-term (90 min) diagnostic performance for acute non-ST segment elevation myocardial infarction and 30-day prognostic evaluation of a novel third-generation high sensitivity troponin I assay

ObjectivesWe evaluated a third-generation high sensitivity “guidelines acceptable” troponin I assay (hs-cTnI) against a contemporary “clinically usable” troponin assay (cTnI).Design and methodsRemnant samples of undifferentiated emergency department (ED) patients with suspected acute coronary syndrome were enrolled. Baseline and 90-minute samples were analyzed for cTnI and hs-cTnI. Sensitivity, specificity, positive and negative predictive values for AMI and 30-day adverse cardiac events (ACE) were compared.ResultsOf 486 ED patients, there were 465 patients who had blood remaining at the presentation for the hs-cTnI assays, with 12 AMIs. At presentation, the clinical sensitivity and specificity for AMI was 75% and 97% for cTnI and 83.3 and 82.1% for hs-cTnI. There were 407 patients who had paired baseline and 90-minute blood samples for cTnI and hs-cTnI including 9 of the 12 AMI patients. The sensitivity and specificity was 77.7% and 96.5% for cTnI and 100% and 81.9% for hs-cTnI at 90 min. A Δ change of 30% increase from baseline to 90 min improved the specificity to 94.5% (95% CI 92%–96%) without lowering the sensitivity. When AMI was defined as a Δ30% change of hs-cTnI at t = 0 and 90 min and one hs-cTnI result > 99th percentile cutoff, more than 3 times as many patients met the diagnostic criteria for AMI compared to results from the normal sensitive troponin assay; 28 (6.9%) for hs-cTnI vs. 9 (2.2%) with cTnI. There were 37 in-hospital or 30-day events, producing an OR of 3.03, 95% CI: 0.86–9.59 for cTnI, and 2.54, 95% CI: 1.27–5.10 for hs-cTnI, which detected 11 more cases.ConclusionsThe hs-cTnI assay achieved a 90-minute rule out for AMI and detected more 3 times as many AMI cases. The specificity increased with the Δ30% criteria. The hs-cTnI assay also detected more cases of patient at risk for adverse cardiac events at 30 days.