Factors for return to emergency department and hospitalization in elderly urinary tract infection patients

BackgroundAppropriate decision of emergency department (ED) disposition is essential for improving the outcome of elderly urinary tract infection (UTI) patients. However, studies on early return visit (ERV) to the ED in elderly UTI patients are limited. Therefore, we aimed to identify factors for ERV and hospitalization after return visit (HRV) in this population.MethodsElderly patients discharged from the ED with International Classification of diseases 10th Revision codes of UTI were selected from the registry for evaluation of ED revisit in 6 urban teaching hospitals. Retrospective data were extracted from the electronic medical records and ERV and hospitalization to scheduled revisit (SRV) were compared.ResultAmong a total of 419 patients found in the study period, 45 were ERV patients and 24 were HRV patients. Absence of UTI-specific symptoms (odds ratio [OR] 2.789; 95% confidence interval [CI] 1.368–5.687; P = 0.005), C-reactive protein (CRP) levels >30 mg/L (OR 2.436; 95% CI 1.017–3.9; P = 0.024), and body temperature ≥ 38 °C (OR 1.992; 95% CI 1.017–3.9; P = 0.044) were independent risk factors for ERV, and absence of UTI-specific symptoms (OR 3.832; 95% CI 1.455–10.088; P = 0.007), CRP levels >30 mg/L (OR 3.224; 95% CI 1.235–8.419; P = 0.017), and systolic blood pressure ≤ 100 mmHg (OR 3.795;95% CI 1.156–12.462; P = 0.028) were independent risk factors for HRV. However, there was no significant difference in empirical antibiotic resistance in ERV and HRV patients, compared to SRV patients.ConclusionThe independent risk factors of ERV and HRV should be considered for ED disposition in elderly UTI patients; the resistance to empirical antibiotics was not found to affect ERV or HRV within 3 days.     

Association between adopting emergency department crowding interventions and emergency departments' core performance measures

ObjectivesTo estimate the association between adopting emergency department (ED) crowding interventions and emergency departments' core performance measures.MethodsWe analyzed the National Hospital Ambulatory Medical Care Survey (NHAMCS) data from 2007 to 2015. The outcome variables are ED length of stay for discharged and admitted patients, boarding time, wait time and percentage of patients who left ED before being seen (LWBS). The independent variables are whether or not a hospital adopted each of the 20 crowding interventions. Controlling for patient-level, hospital level and temporal confounders we analyze and report results using multivariable logit model.ResultsBetween 2007 and 2015, NHAMCS collected data for 269,721 ED visit encounters, representing a nationwide of about 1.18 billion separate ED visits. Of 20 crowding interventions we tested, using adopting bedside registration (OR = 0.89, 95% CI = 0.75–0.98, P < .05), electronic dashboard (OR = 0.86, 95% CI = 0.76–0.98, P < .05), kiosk check-in technology (OR = 0.56, 95% CI = 0.41–0.83, P < .001), physician based triage (OR = 0.86, 95% CI = 0.73–0.99, P < .05) full capacity protocol (OR = 0.91, 95% CI = 0.79–0.99, P < .05) are associated with decrease in the odds of prolonged wait time. Adopting kiosk check-in (OR = 0.55, 95% CI = 0.35–0.85, P < .05) is associated with a decrease in the odds of prolonged boarding time. Using wireless communication devices (OR = 0.77, 95% CI = 0.57–0.97, P < .05), bedside registration (OR = 0.77, 95% CI = 0.64–0.094, P < .05) and pooled nursing (OR = 0.84, 95% CI = 0.72–0.98, P < .05) are associated with decrease in the odds of a patient LWBS.ConclusionsMajority of interventions did not significantly associated with ED' core performance measures.     

Clinical differentiation between acute renal infarction and acute ureteral stone in the emergency department: A single-center retrospective case-control study

BackgroundFew studies have compared renal infarction (RI) and ureteral stone (US), so there is insufficient evidence for emergency clinicians (ECs) to quickly suspect RI during the first assessment. Therefore, we compared the initial clinical presentation and laboratory findings of these diseases in the emergency department (ED) to determine a factor that may indicate RI.MethodsThis single-center retrospective case-control study included 42 patients with acute RI and 210 with US who visited the ED from 2014 to 2020. Medical record data from first ED arrival were investigated, and clinical presentations, blood and urine test results obtained in the ED were compared and analyzed using logistic regression analysis.ResultsECs never suspected the initial diagnosis of RI as RI. The most common initial diagnosis was US (40.5%). Among patients with US, 150 patients (71.4%) were suspected of having US (p < 0.001). Abdominal pain (61.9%) was the most common chief complaint in the RI group, and flank pain (73.8%) was the most common in the US group (p < 0.001). 27 factors showed significant differences between the groups. Among those, age ≥ 70 years (odds ratio [OR]: 311.2, 95% confidence interval [CI]: 2.0–47,833.1), history of A-fib (OR: 149872.8, 95% CI: 289.4–7.8E+07), fever ≥37.5 °C (OR: 297.3, 95% CI: 3.3–27,117.8), Cl⁻ ≤ 103 mEq/L (OR: 9.0, 95% CI: 1.0–80.1), albumin ≤4.3 g/dL (OR: 26.6, 95% CI: 2.1–330.3), LDH ≥500 IU/L (OR: 17.9, 95% CI: 1.8–182.5), and CRP ≥0.23 mg/dL (OR: 7.5, 95% CI: 1.1–52.3) showed significantly high ORs, whereas urine RBCs (OR: 0, 95% CI: 0–0.02) showed a low OR (p < 0.05). The regression model showed good calibration (chi-square: 6.531, p = 0.588) and good discrimination (area under the curve = 0.9913).ConclusionsWhen differentiating acute RI from US in the ED, age ≥ 70 years, history of A-fib, fever ≥37.5 °C, LDH ≥500 IU/L, Cl⁻ ≤ 103 mEq/L, albumin ≤4.3 g/dL, CRP ≥0.23 mg/dL and negative urine RBC result suggest the possibility of RI.     

Concurrent asthma and chronic obstructive pulmonary disease in adult ED patients: A national perspective

ObjectivesEmergency department (ED) visits for Asthma and Chronic Obstructive Pulmonary Disease (COPD) are common. The designation of Asthma-COPD overlap (ACO) has been used to describe patients with features of both diseases. Studies show that ACO patients may be at increased risk of poor outcomes relative to patients with either disease alone. We sought to characterize ED visits and ED-related outcomes of patients with ACO compared to patients with Asthma or COPD alone.MethodsWe conducted a secondary analysis of the National Hospital Ambulatory Medical Care Survey (NHAMCS, 2005–2018) characterizing ED visits in patients ≥35 years of age with Asthma Only, COPD Only or ACO. We performed univariable and multivariable analyses adjusting for demographics to assess relevant ED outcome variables.ResultsFrom 2005 to 2018, there were an estimated 8.15, 17.78 and 0.56 million ED visits for Asthma Only, COPD Only and ACO, respectively. ACO patients were younger than COPD Only patients (mean age 50.18 versus 61.79; p < 0.001). ACO patients differed in terms of sex, race and ethnicity from patients with either disease alone. When triaged, Asthma Only (adjusted odds ratio (aOR) = 11.45; 95% confidence interval (CI), 1.20–109.38) patients were more likely to require immediate care than ACO patients. Although admission rates were comparable between groups, ACO patients had a decreased mean length of ED visit compared to both Asthma Only (p < 0.001) and COPD Only (p < 0.05) patients. COPD Only patients were less likely than ACO patients to be seen in the ED in the last 72 h (aOR = 0.22; 95% CI, 0.056–0.89), receive nebulizer therapy (aOR = 0.55; 95% CI, 0.31–0.97), bronchodilators (aOR = 0.24; 95% CI, 0.12–0.48) and systemic corticosteroids (aOR = 0.18; 95% CI, 0.091–0.35). Asthma Only patients were less likely than ACO patients to undergo any imaging (aOR = 0.55; 95% CI, 0.31–0.96) and receive antibiotics (aOR = 0.46; 95% CI, 0.23–0.93).ConclusionsACO patients appear to differ demographically from patients with either disease alone in the ED. After adjustment for these demographic differences, ACO patients appear to differ with respect to several ED variables, notably respiratory therapies; however, clinical outcomes including admission and mortality rates appear to be comparable between groups.     

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.     

HIV postexposure prophylaxis practices by US ED practitioners

To determine how often US ED practitioners have prescribed HIV post-exposure prophylaxis (HIV PEP) and to discern how willing they are to offer it to patients, the authors surveyed 600 ED practitioners attending a national conference. According to their self-report, 11% had taken HIV PEP themselves. Sixty-eight percent had prescribed HIV PEP at some time. Of these, 92% had treated needlestick-injured health care workers, 48% sexual assault survivors, and 49% nonhealth care needlestick-injured persons. ED practitioners were more willing to offer HIV PEP after exposures to HIV-infected or high-risk sources than unknown or low- risk sources, as well as after sexual assault than consensual sex. Female practitioners, those who had themselves taken HIV PEP, resident physicians, and ED practitioners with fewer than 6 years of clinical practice were generally more apt to offer HIV PEP. Educational campaigns appear to be necessary to help ED practitioners determine when HIV PEP is appropriate.     

Predictors of Genitorectal Injury in Female Victims of Suspected Sexual Assault

OBJECTIVE: Legal decisions in sexual assault cases often hinge on the presence or absence of genitorectal injury. Unfortunately, the forensic literature does not explain why some victims sustain genitorectal injury and others do not. This study explores possible predictors of genitorectal injury in adult female sexual assault victims. METHODS: This retrospective cross-sectional analysis forms the derivation set for a larger planned prospective analysis. The authors extracted data describing consecutive female sexual assault victims who met inclusion criteria between July 1995 and July 1998. Exclusion criteria included male sex, lack of estrogen in females, consensual intercourse within the previous 72 hours, and lack of penetration during the assault. The authors explored associations between genitorectal injury and seven demographic variables, nine assault characteristics, and the time between assault and exam or postcoital interval (PCI). Variables thought to be predictive were incorporated into a logistic regression model. RESULTS: Five hundred forty-eight sexual assault victims were seen during the study time period; 209 of these met the inclusion criteria. Logistic regression controlling for important covariates showed an increase risk of genitorectal injury with a PCI < 24 hours (OR 7.47, 95% CI = 1.78 to 31.35), physical/verbal resistance (OR 5.96, 95% CI = 1.21 to 29.36), rectal penetration (OR 7.47, 95% CI = 1.05 to 53.07), and greater than high school education (OR 7.13, 95% CI = 1.03 to 49.65). CONCLUSIONS: This study presents an important first look at variables that may predict genitorectal injury in sexual assault victims. Future studies that examine more data are needed to corroborate this preliminary derivation set analysis.     

Resource utilization across the continuum of HIV care: An emergency department-based cohort study

BackgroundThe objective of this study was to determine the healthcare resource utilization for people living with HIV (PLWH) presenting to the emergency department (ED) across the HIV Care Continuum.MethodsThis prospective study enrolled PLWH presenting to an urban ED between June 2016 and March 2017. Subjects were categorized as being linked to care, retained in care, on antiretroviral therapy (ART), and virally suppressed (<200 copies/ml). Data on ED visit rates, duration of stay, and hospital admission rates were compared to local metrics.ResultsOverall, 94.3% of 159 enrollees had been linked to care, 75.5% retained in care, 81.1% on ART, and 62.8% virally suppressed. Compared to the general population of the city and of the ED, participants had a higher ED visit rate (3.0 v. 1.2 visits per person-per year) in the past two years, a higher median duration of ED stay (12.6 v. 7.6 h), and a higher hospital admission rate (36.5% v. 24.9%) during their index ED visit. Viral suppression was negatively associated with admission (OR = 0.35, 95% CI: 0.17, 0.72). Forty-eight (30.2%) participants who had at least eight ED visits in the past two years were more likely to have a diagnosed mental health disorder (79.2% v. 62.2%, p=0.036).ConclusionsOur results showed that PLWH use more ED resources than the general population and a better engagement in HIV care is linked to lesser ED resource utilization for PLWH, indicating the importance of improved HIV care engagement in healthcare utilization management.     

Predictors of linkage to care for a nontargeted emergency department hepatitis C screening program

ObjectiveWe implemented a nontargeted, opt-out HCV testing and linkage to care (LTC) program in an academic tertiary care emergency department (ED). Despite research showing the critical role of ED-based HCV testing programs, predictors of LTC have not been defined for patients identified through the nontargeted ED testing strategy. In order to optimize health outcomes for patients with HCV, we sought to identify predictors of LTC failure.MethodsThis was a retrospective cohort study of adult patients who were tested for HCV in the ED between August 2015 and September 2018 and were confirmed to have chronic HCV infection through RNA testing. We used logistic regression to assess the relationship between candidate predictors and the primary outcome, LTC failure, which was defined as a patient not being seen by an HCV treating provider after discharge from the ED.ResultsOf 53,297 patients tested, 1,674 (3.1%) had HCV on confirmatory testing, and 355 (21%) linked to care. Predictors of LTC failure included younger age (OR 0.96, 95% CI 0.95–0.97), white race (OR 1.65, 95% CI 1.23–2.22), homelessness (OR 1.91, 95% CI 1.19–3.08), substance use (OR 1.77, 95% CI 1.34–2.34), and comorbid psychiatric illness (OR 2.16, 95% CI 1.59–2.94). Patients with significant medical comorbidities (OR 0.57, 95% CI 0.41–0.78) or HIV co-infection (OR 0.11, 95% CI 0.03–0.46) were less likely to experience LTC failure.ConclusionsOne in five HCV-infected patients identified by ED-based nontargeted testing successfully linked to an HCV treating provider. Predictors of LTC failure may guide the development of targeted interventions to improve LTC success.     

Critically Ill Health Care-Associated Urinary Tract Infection: Broad vs. Narrow Antibiotics in the Emergency Department Have Similar Outcomes

BackgroundUrinary tract infection (UTI) is the second most common infection requiring intensive care unit (ICU) admission in emergency department (ED) patients. Optimal empiric management for health care-associated (HCA) UTI is unclear, particularly in the critically ill.ObjectiveTo compare clinical failure of broad vs. narrow antibiotic selection in the ED for patients presenting with HCA UTI admitted to the ICU.MethodsObservational cohort of patients started on empiric antibiotic for UTI with at least one HCA risk factor (recurrent UTI, chronic urinary catheter or dialysis, urologic procedures, previous antibiotic exposure, hospitalization, or group facility residence). Broad antibiotics covered Pseudomonas spp. and extended-spectrum beta-lactamase. Clinical failure was a composite of multiorgan dysfunction (MODS) by day 2 and in-hospital mortality. Secondary outcomes were length of stay (LOS), readmission, recurrent infection, development of multidrug-resistant organisms, and Clostridium difficile infection. Associations were reported with odds ratios (OR) and 95% confidence intervals (CI).ResultsThere were 272 patients included; 196 (72.1%) received broad and 76 (27.9%) received narrow therapy. There was no association between antibiotic selection and clinical failure (OR 1.05, 95% CI 0.5–2.25, p = 0.89) or between antibiotic selection and number of HCA risk factors (OR 0.98, 95% CI 0.73–1.31, p = 0.87). There was an association between clinical failure and MODS on ICU admission (OR 9.14, 95% CI 4.70–17.78, p < 0.001). Hospital LOS and readmission did not differ between antibiotic groups.ConclusionInitial empiric broad or narrow antibiotic coverage in HCA UTI patients who presented to the ED and required ICU admission had similar clinical outcomes.     

Effect of an emergency department intensive care unit on medical intensive unit admissions and care: A retrospective cohort study

ObjectiveEvaluate the impact of an emergency critical care center (EC3) on the admissions of critically ill patients to a critical care medicine unit (CCMU) and their outcomes.MethodsThis was a retrospective before/after cohort study in a tertiary university teaching hospital. To improve the care of critically ill patients in the emergency department (ED), a 9-bed EC3 was opened in the ED in February 2015. All critically ill patients in the emergency department must receive intensive support in EC3 before being considered for admission to the CCMU for further treatment. Patients from the emergency department account for a significant proportion of the patients admitted to the CCMU. The proportions of patients admitted to the CCMU from the ED were analyzed 1 year before and 1 year after the opening of the EC3. We also compared the admission data, demographic data, APACHE III scores and patient outcomes among patients admitted from ED to the CCMU in the year before and the year after the opening of the EC3.ResultThe establishment of the EC3 was associated with a decreased proportion of patients admitted to the CCMU from the ED (OR 0.73 95% CI 0.63–0.84, p < 0.01), a decrease in the proportion of patients with sepsis admitted from the ED (OR 0.68, 95% CI, 0.54–0.87, p < 0.01) and a decrease in the proportion of patients with gastrointestinal bleeding admitted from the ED (OR 0.49, 95% CI 0.28–0.84, p < 0.05). Following the establishment of the EC3, patients admitted to the CCMU had a higher APACHE III score in 2015 (74.85 ± 30.42 vs 72.39 ± 29.64, p = 0.015). Fewer low-risk patients were admitted to the CCMU for monitoring following the opening of the EC3 (112 [6.8%] vs. 181 [9.3%], p < 0.01). Propensity score matching analysis showed that the opening of the EC3 was associated with improved 60-day survival (HR 0.84, 95% CI 0.70–0.99, p = 0.046).ConclusionFollowing the opening of the EC3, the proportion of CCMU admissions from the ED decreased. The EC3 may be most effective at reducing the admission of lower-acuity patients with GI bleeding and possibly sepsis. The EC3 may be associated with improved survival in ED patients.     

Effect of rapid fluid administration on the prognosis of septic shock patients with isolated hyperlactatemia: A prospective multicenter observational study

BackgroundWe aimed to investigate the association between initial fluid resuscitation in septic shock patients with isolated hyperlactatemia and outcomes.MethodsThis multicenter prospective study was conducted using the data from the Korean Shock Society registry. Patients diagnosed with isolated hyperlactatemia between October 2015 and December 2018 were included and divided into those who received 30 mL/kg of fluid within 3 or 6 h and those who did not receive. The primary outcome was in-hospital mortality; the secondary outcomes were intensive care unit (ICU) admission, length of ICU stay, mechanical ventilation, and renal replacement therapy (RRT).ResultsA total of 608 patients were included in our analysis. The administration of 30 mL/kg crystalloid within 3 or 6 h was not significantly associated with in-hospital mortality in multivariable logistic regression analysis ([OR, 0.8; 95% CI, 0.52–1.23, p = 0.31], [OR, 0.96; 95% CI, 0.59–1.57, p = 0.88], respectively). The administration of 30 mL/kg crystalloid within 3-h was not significantly associated with mechanical ventilation and RRT ([OR, 1.19; 95% CI, 0.77–1.84, p = 0.44], [OR, 1.2; 95% CI, 0.7–2.04, p = 0.5], respectively). However, the administration of 30 mL/kg crystalloid within 6 h was associated with higher ICU admission and RRT ([OR, 1.57; 95% CI, 1.07–2.28, p = 0.02], [OR, 2.08; 95% CI, 1.19–3.66, p = 0.01], respectively).ConclusionsInitial fluid resuscitation of 30 mL/kg within 3 or 6 h was neither associated with an increased or decreased in-hospital mortality in septic shock patients with isolated hyperlactatemia.     

Accidental hypothermia: Factors related to a prolonged hospital stay – A nationwide observational study in Japan

BackgroundThe incidence of accidental hypothermia (AH) is low, and the length of hospital stay in patients with AH remains poorly understood. The present study explored which factors were related to prolonged hospitalization among patients with AH using Japan's nationwide registry data.MethodsThe data from the Hypothermia STUDY 2018, which included patients ≥18 years old with a body temperature ≤ 35 °C, were obtained from a multicenter registry for AH conducted at 89 institutions throughout Japan, collected from December 1, 2018, to February 28, 2019. The patients were divided into a “short-stay patients” group (within 7 days) and “long-stay patients” group (more than 7 days). A logistic regression analysis after multiple imputation was performed to obtain odds ratios (ORs) for prolonged hospitalization with age, frailty, location, causes underlying the hypothermia, temperature, pH, potassium level, and disseminated intravascular coagulation (DIC) score as independent variables.ResultsIn total, 656 patients were included in the study, of which 362 were eligible for the analysis. The median length of hospital stay was 17 days. Of the 362 patients, 265 (73.2%) stayed in the hospital for more than 7 days. The factors associated with prolonged hospitalization were frailty (OR, 2.11; 95% confidence interval [CI], 1.09–4.10; p = 0.027), the occurrence of indoor (OR, 3.20; 95% CI, 1.58–6.46; p = 0.001), alcohol intoxication (OR, 0.17; 95% CI, 0.05–0.56; p = 0.004), pH (OR, 0.07; 95% CI, 0.01–0.76; p = 0.029), potassium level (OR, 1.36; 95% CI, 1.00–1.85; p = 0.048), and DIC score (OR, 1.54; 95% CI, 1.13–2.10; p = 0.006).ConclusionsFrailty, indoor situation, alcohol intoxication, pH value, potassium level, and DIC score were factors contributing to prolonged hospitalization in patients with AH. Preventing frailty may help reduce the length of hospital stay in patients with AH. In addition, measuring the pH value and potassium level by an arterial blood gas analysis at the ED is recommended for the early evaluation of AH.     

Association between access to primary care and unplanned emergency department return visits among patients 75 years and older

ObjectiveTo identify factors associated with unplanned return visits to the emergency department (ED) among the population aged 75 years and older. Moreover, it aims to determine the association between patients’ access to primary care and unplanned return visits.DesignData were collected from structured interviews, administrative databases, and medical charts at the index visits, and follow-up telephone calls were made at 3 months.SettingEmergency departments of the 3 tertiary care hospitals in Montréal, Que.ParticipantsCommunity-dwelling patients aged 75 years and older.Main outcome measuresZero-inflated negative binomial regression analysis was conducted of unplanned return visits within 3 months. Rate ratios (RRs) and odds ratios (ORs) with 95% CIs are presented.ResultsDuring the study period, 4577 patients were identified, 2303 were recruited, and 1998 were retained for the analysis. Among the analysis sample, 33% were 85 and older, 34% lived alone, and 91% had a family physician. Before their ED visits, 16% of patients attempted to contact their family physicians. More than half of the patients reported having difficulty seeing their physicians for urgent problems, more than 40% had difficulty speaking with their family physicians by telephone, and more than one-third had difficulty booking appointments for new health problems. Within 3 months, 562 patients (28%) had made 894 return visits. Factors associated with a lower return visit rate included age 85 years and older (RR=0.80; 95% CI 0.67 to 0.96), less severe triage score (RR=0.83; 95% CI 0.74 to 0.92), and hospitalization at the index visit (RR=0.76; 95% CI 0.64 to 0.90). Factors that resulted in a higher return visit rate were difficulty booking appointments for new problems with their family physicians (RR=1.19; 95% CI 1.01 to 1.41), having had ED visits within the previous 6 months (RR=1.47; 95% CI 1.28 to 1.68), and higher Charlson comorbidity index scores (RR=1.06; 95% CI 1.01 to 1.11). Having had ED visits within the previous 6 months (OR=2.11; 95% CI 1.27 to 3.49), having a higher Charlson comorbidity index score (OR=1.41; 95% CI 1.19 to 1.68), and having received community care services (OR=3.00; 95% CI 0.95 to 9.53) also increased the odds of return visits.ConclusionAlthough most people 75 years and older have a family physician, problems still exist in terms of timely access. Unplanned return visits to the ED are associated with having more comorbidities, having had previous ED visits, having already received community services, and having difficulty booking appointments with family physicians for new problems.     

Clinical and Cancer-Related Predictors for Venous Thromboembolism in Cancer Patients Presenting to the Emergency Department

BackgroundThe accurate detection of cancer-associated venous thromboembolism (VTE) can avoid unnecessary diagnostic imaging or laboratory tests.ObjectiveWe sought to determine clinical and cancer-related risk factors of VTE that can be used as predictors for oncology patients presenting to the emergency department (ED) with suspected VTE.MethodsWe retrospectively analyzed all consecutive patients who presented with suspicion of VTE to The University of Texas MD Anderson Cancer Center ED between January 1, 2009, and January 1, 2013. Logistic regression models were used to identify risk factors that were associated with VTE. The ability of these factors to predict VTE was externally validated using a second cohort of patients who presented to King Hussein Cancer Center ED between January 1, 2009, and January 1, 2016.ResultsCancer-related covariates associated with the occurrence of VTE were high-risk cancer type (odds ratio [OR] 3.64 [95% confidence interval {CI} 2.37–5.60], p < 0.001), presentation within 6 months of the cancer diagnosis (OR 1.92 [95% CI 1.62–2.28], p < 0.001), active cancer (OR 1.35 [95% CI 1.10–1.65], p = 0.003), advanced stage (OR 1.40 [95% CI 1.01–1.94], p = 0.044), and the presence of brain metastasis (OR 1.73 [95% CI 1.32–2.27], p < 0.001). When combined, these factors along with other clinical factors showed high prediction performance for VTE in the external validation cohort.ConclusionsCancer risk group, presentation within 6 months of cancer diagnosis, active and advanced cancer, and the presence of brain metastases along with other related clinical factors can be used to predict VTE in patients with cancer presenting to the ED.     

Impact of the nurse-led case management program with retention in care on mortality among people with HIV-1 infection: a prospective cohort study

BackgroundLong-term retention of patients in care is emerging as an important factor for the mortality among persons with human immunodeficiency virus (HIV) infection.ObjectivesThe study was to determine the impact of the case management with retention in care on mortality among HIV infected patients.Design and settingsA longitudinal prospective cohort study was conducted at a tertiary referral HIV-designated hospital in Taiwan.ParticipantsCharts from 1040 patients who had made at least one visit for HIV care at the HIV Clinic in the study hospital in 2009 were abstracted.MethodsA computerized data collection form was used to retrospectively retrieve the electronic demographic and clinical data generated during each clinic visit. Follow-up ended at death or at the last clinic visit as of December 31, 2009.ResultsLess than half (44.2%) of 961 HIV-infected patients were retained for follow-up from 2005 to 2009. Patients who received case management were 4.78 times more likely to remain consistently in care than those who did not receive case management, after controlling for other confounding variables. In the Cox proportional hazard analysis, higher hazards of death were independently associated with older age (hazard ratio [HR]: 1.04; 95% confidence interval [CI]: 1.026–1.055), entering care before 2005 (HR: 1.73; 95% CI: 1.035–2.885), low baseline CD4 cell count (HR: 0.997; 95% CI: 0.995–0.998), without antiretroviral therapy (HR: 0.55; 95% CI: 0.334–0.909), irregular attendance of HIV care or loss to follow-up (HR: 0.058; 95% CI: 0.023–0.148), acquisition of HIV infection through sexual contact (HR: 2.95; 95% CI: 1.517–5.746), and irregular attendance or lost to follow-up and did not enrolled in the case management program (HR: 3.76; 95% CI: 1.015–14.777).ConclusionRetention in care is independently predictive of survival, and case management is a mediator affecting retention on survival. Case managers need to identify high risk patients for irregular attendance and to retain them in HIV care in order to maximize their health outcomes.     

Early versus delayed administration of intravenous magnesium sulfate for pediatric asthma

ObjectiveThis study aims to describe and examine the factors associated with the early administration of intravenous magnesium sulfate (IV Mg) in children presenting to the pediatric emergency department (ED) for an asthma exacerbation.MethodsRetrospective cohort study of children aged 5–11 years who received IV Mg in the pediatric ED between September 1, 2018 and August 31, 2019 for management of an asthma exacerbation. Primary outcome was administration of IV Mg in ≤60 min from ED triage (‘early administration’). Comparison of clinical management and therapies in children who received early versus delayed IV Mg and the factors associated with early administration of IV Mg were examined.ResultsEarly (n = 90; 31.6%) IV Mg was associated with more timely bronchodilators (47 versus 68 min; p ≤ 0.001) and systemic corticosteroids (36 versus 46.5 min; p ≤ 0.001). There was no difference between the two cohorts in returns to the ED within 72 h (1.1% versus 2.1%; p = .99) or readmissions within 1 week one week (2.2% versus 0.5%; p = .2). Hypoxia (aOR = 3.76; 95% CI = 2.02–7.1), respiratory rate (aOR = 1.04; 95% CI = 1.02–1.07), retractions (aOR = 2.21; 95% CI = 1.25–3.94), and prior hospital use for asthma-related complaints (aOR = 2.1; 95% CI = 1.16–3.84) were significantly associated with early IV Mg.ConclusionsEarly administration of IV Mg was associated with more timely delivery of first-line asthma therapies, was safe, and improved ED throughput without increasing return ED visits or hospitalizations for asthma.     

Gender distribution of editorial board members in critical care journals: Assessment of gender parity

PurposeTo reveal factors related to gender parity on editorial boards of critical care journals indexing in SCI-E.MethodsThe genders were defined according to data obtained from journals' websites between 01—30 September 2022. Publisher properties and journal metrics were analyzed by using Chi-square, Fisher exact, Mann–Whitney U tests, and Spearman's correlation coefficient. Logistic regression analysis was used to reveal independent factors.ResultsWomen's representation on editorial boards was 23.6%. The USA (OR, 0.04, 95% CI, 0.01–0.15, p < 0.001) and Netherlands (OR, 0.04, 95% CI, 0.01–0.16, p < 0.001) as publisher's countries, an IF >5 (OR, 0.25, 95% CI, 0.17–0.38, p < 0.001), publication duration <30 years (OR, 0.09, 95% CI, 0.06–0.12, p < 0.001), multidisciplinary perspective of editorial policy (OR, 0.46, 95% CI, 0.32–0.65, p < 0.001), journals categorized also in nursing (OR, 0.38, 95% CI, 0.22–0.66, p < 0.001), and being a section editor (OR, 0.49, 95% CI, 0.32–0.74, p = 0.001) were associated with gender parity. Europe as a journal continent (OR, 36.71, 95% CI, 8.39–160.53, p < 0.001) was related to gender disparity.ConclusionsFurther efforts are needed to expand diversity policies in critical care medicine.