An Emergency Department–Based Intensive Care Unit is Associated with Decreased Hospital and Intensive Care Unit Utilization for Diabetic Ketoacidosis

BackgroundMany emergency department (ED) patients in diabetic ketoacidosis (DKA) are admitted to an inpatient intensive care unit (ICU), while ICU capacity is under increasing strain. The Emergency Critical Care Center (EC3), a hybrid ED-ICU setting, opened with the goal of providing rapid initiation of ICU care in the ED.ObjectiveWe sought to evaluate the impact of an ED-ICU on disposition and safety outcomes for adult ED patients in DKA.MethodsThis was a retrospective pre–post cohort of ED visits from 2012–2018 at a single academic medical center. Adult ED patients in DKA (pH < 7.30, HCO₃ < 18 mEq/L, anion gap > 14, and glucose > 250 mg/dL) immediately before (pre-EC3) and after (post-EC3) opening of an ED-ICU were identified. ED disposition and safety data were collected and analyzed.ResultsWe identified 631 patient encounters: 217 pre-EC3 and 414 post-EC3. Baseline demographics were similar between cohorts. Fewer patients in the post-EC3 cohort were admitted to an ICU (11.6% vs. 23.5%, p < 0.001, number needed to treat [NNT] = 8) or general floor bed (58.0% vs. 73.3%, p < 0.001, NNT = 6), and more were discharged from the ED (27.1% vs. 1.4%, p < 0.001, NNT = 4). Rates of hypokalemia (10.1% vs. 6.0%, p = 0.08) and admission to non-ICU with transfer to ICU within 24 h (0.5% vs. 0%, p = 0.30) did not differ.ConclusionManagement of patients with DKA in an ED-ICU was associated with decreased ICU and hospital utilization with similar safety outcomes. Managing rapidly reversible critical illnesses in an ED-ICU may help obviate increasing strain facing many health care systems.     

Quantifying off-hour emergency physician coverage of in-hospital codes: a survey of community emergency departments

Background

Community emergency physicians (EPs) are often required to respond to unstable patients outside of their department during off-hours.

Objective

The primary objective of this study was to describe the critical care responsibility of community EPs outside of their departments.

Methods

A one-page survey was mailed to emergency department (ED) directors of 10 states and Washington, DC.

Results

Three hundred forty of 1169 surveys were returned. The median (interquartile range [IQR]) number of hospital and intensive care unit (ICU) beds was 145 (IQR 60–242) and 11 (IQR 6–20), respectively. Median ED annual volume and ICU admission percentage was reported to be 25 K (IQR 14–40) and 5% (IQR 2–10), respectively. Seventy-six percent of reporting institutions require EPs to leave their department and respond to medical codes on the floors after hours. In 57% of institutions, the EP was the only physician required to respond. In addition, 48% of EPs must respond to unstable patients in the ICUs after hours. Hospitals in which EPs were required to respond to medical codes and unstable ICU patients were more likely to have fewer hospital beds (137 vs. 275; p < 0.001), fewer ICU beds (12 vs. 27; p < 0.001), and have a smaller ED annual volume (24 K vs. 39 K; p < 0.001).

Conclusions

Many community EPs are responsible for covering critically ill patients outside of their ED. Further investigation is required to determine the impact on patient care.     

Topical Tranexamic Acid Compared With Anterior Nasal Packing for Treatment of Epistaxis in Patients Taking Antiplatelet Drugs: Randomized Controlled Trial

Objective

We evaluated the efficacy of topical application of the injectable form of tranexamic acid (TXA) compared with anterior nasal packing (ANP) for the treatment of epistaxis in patients taking antiplatelet drugs (aspirin, clopidogrel, or both) who presented to the emergency department (ED).

Methods

A randomized, parallel‐group clinical trial was conducted at two EDs. A total of 124 participants were randomized to receive topical TXA (500 mg in 5 mL) or ANP, 62 patients per group. The primary outcome was the proportion of patients in each group whose bleeding had stopped at 10 minutes. Secondary outcomes were the rebleeding rate at 24 hours and 1 week, ED length of stay (LOS), and patient satisfaction.

Results

Within 10 minutes of treatment, bleeding was stopped in 73% of the patients in the TXA group, compared with 29% in the ANP group (difference = 44%, 95% confidence interval, 26% to 57%; p < 0.001). Additionally, rebleeding was reported in 5 and 10% of patients during the first 24 hours in the TXA and the ANP groups, respectively. At 1 week, 5% of patients in the TXA group and 21% of patients in the ANP group had experienced recurrent bleeding (p = 0.007). Patients in the TXA group reported higher satisfaction scores (median [interquartile range {IQR}], 9 [8–9.25]) compared with the ANP group (median [IQR] = 4 [3–5]; p < 0.001). Discharge from the ED in <2 hours was achieved in 97% of patients in the TXA group versus 13% in the ANP group (p < 0.001). There were no adverse events reported in either group.

Conclusions

In our study population, epistaxis treatment with topical application of TXA resulted in faster bleeding cessation, less rebleeding at 1 week, shorter ED LOS, and higher patient satisfaction compared with ANP.     

Clinical effects of reported synthetic cannabinoid exposure in patients admitted to the intensive care unit

ObjectiveTo characterize the clinical presentation and hospital course of patients with reported synthetic cannabinoid (SC) exposure requiring Intensive Care Unit (ICU) admission.DesignRetrospective case series of patients admitted to medical or cardiac ICU.SettingUrban tertiary care center.ParticipantsAdults ≥18 years old admitted from the emergency department (ED) in 2015.MeasurementsDemographics, Sequential Organ Failure Assessment (SOFA) scores, and clinical parameters documenting the effects and hospital course.Results23 patients met inclusion criteria. Median age was 47 years (interquartile range [IQR], 32–54); 83% male; 78% black. Patients were generally tachycardic (HR > 100), (65%) and hypertensive (SBP > 140), (65%) on admission. The initial chest X-ray and ECG were abnormal in 43% and 68% of patients, respectively. Pulmonary edema and tachycardia were the most common findings. Head CT imaging was abnormal in 5% of patients. Troponin was elevated >1.0 ng/ml in 3 of 19 patients (16%). Other exposures detected on admission were marijuana (30%), alcohol (30%), and benzodiazepines (26%). The median SOFA score was 6 on admission and decreased over the next 3 days. SOFA scores were primarily driven by altered neurologic status and respiratory failure. 91% required mechanical ventilation, 30% had seizures as a part of presentation, 18% required vasopressors, and 5% needed dialysis. Median hospital and ICU lengths of stay were 2.6 (IQR 1.4–3.5) and 1.6 (IQR 0.9–2.5) days, respectively. The median hospital charge was $37,008. All patients survived the index hospitalization.ConclusionsPatients admitted to ICU after SC exposure exhibit significant organ dysfunction, particularly neurologic and respiratory. Prognosis is good with supportive care.     

Processes and impediments in moving patients from the emergency department: pilot study

Objective: To assess the impact of an ED‐designed interim orders sheet on patient flow through the ED, and the safety of ED‐directed admission. Methods: The flow of patients through the ED and inpatient length of stay (IPLOS) was retrospectively reviewed on 135 patients who were admitted using interim orders and 125 patients who were admitted after inpatient unit review in the ED. Results: The median time to admission to the ward in the non‐interim orders group was 5.7 h (interquartile range [IQR]: 3.8–8.5), with a range from 1.2 to 15.9 h, and in the interim orders group was 6.3 h (IQR: 4.8–8.0) with a range from 0.5 to 22 h (P = 0.27). The median IPLOS was 4 days (IQR: 2.0–7.0) in the interim orders group, and 4 days (IQR: 2.1–9.0) in the non‐interim orders group (P = 0.19). Conclusion: There was no difference in the time to patient admission, or IPLOS, with the different processes. Almost half of the average ED stay of adults and about one‐third of that of paediatric admissions occurred after the decision to admit was made. Transfer of patients to the ward without inpatient review is appropriate and effective.     

Intra-abdominal hypertension,fluid balance,and adverse outcomes after orthotopic liver transplantation

BackgroundIntra-abdominal hypertension (IAH) is frequently encountered in critically ill surgical patients. We aimed to evaluate the incidence of IAH after orthotopic liver transplant (OLT) and its impact on organ function, hospital length-of-stay (LOS), and death.MethodsThis prospective, observational, cohort study evaluated consecutive adult patients admitted in the ICU after undergoing OLT. Intra-abdominal pressure (IAP) was measured every 4–6 h for 3 days. Worsening IAP was defined as a gradual increase in IAP over a period of time. Daily fluid balance was the daily sum of all intakes minus the output.ResultsIAH was observed in 48% of the patients within the first 3 days after ICU admission, while ACS was diagnosed in 15%. Patients with IAH had a higher positive fluid balance at day 1 (1764 mL [812–2733 mL] vs. 1301 mL [241–1904 mL], p = 0.025). Worsening IAH was associated with fewer days free of organ dysfunction. IAH within 72 h after ICU admission was independently associated with a composite outcome of death or a longer ICU LOS (odds ratio 2.9; CI 95% 1.02–8.25, p = 0.043).ConclusionAfter OLT, nearly half of the patients presented IAH, that was associated with unfavorable outcomes.     

Associations between urinary 3-indoxyl sulfate,a gut microbiome-derived biomarker,and patient outcomes after intensive care unit admission

Purpose3-indoxyl sulfate (3-IS) is an indole metabolism byproduct produced by commensal gut bacteria and excreted in the urine; low urinary 3-IS has been associated with increased mortality in bone marrow transplant recipients. This study investigated urinary 3-IS and patient outcomes in the ICU.Materials and methodsProspective study that collected urine samples, rectal swabs, and clinical data on 78 adult ICU patients at admission and again 72 h later. Urine was analyzed for 3-IS by mass spectrometry.ResultsMedian urinary 3-IS levels were 17.1 μmol/mmol creatinine (IQR 9.5 to 26.2) at admission and 15.6 (IQR 4.2 to 30.7) 72 h later. 22% of patients had low 3-IS (≤6.9 μmol/mmol) on ICU admission and 28% after 72 h. Low 3-IS at 72 h was associated with fewer ICU-free days (22.5 low versus 26 high, p = 0.03) and with death during one year of follow-up (36% low versus 9% high 3-IS, p < 0.01); there was no detectable difference in 30-day mortality (18% low versus 5% high, p = 0.07).ConclusionsLow urinary 3-IS level 72 h after ICU admission was associated with fewer ICU-free days and with increased one-year but not 30-day mortality. Further studies should investigate urinary 3-IS as an ICU biomarker.     

Phenobarbital for Acute Alcohol Withdrawal: A Prospective Randomized Double-blind Placebo-controlled Study

Background

Acute alcohol withdrawal syndrome (AAWS) is encountered in patients presenting acutely to the Emergency Department (ED) and often requires pharmacologic management.

Objective

We investigated whether a single dose of intravenous (i.v.) phenobarbital combined with a standardized lorazepam-based alcohol withdrawal protocol decreases intensive care unit (ICU) admission in ED patients with acute alcohol withdrawal.

Methods

This was a prospective, randomized, double-blind, placebo-controlled study. Patients were randomized to receive either a single dose of i.v. phenobarbital (10 mg/kg in 100 mL normal saline) or placebo (100 mL normal saline). All patients were placed on the institutional symptom-guided lorazepam-based alcohol withdrawal protocol. The primary outcome was initial level of hospital admission (ICU vs. telemetry vs. floor ward).

Results

There were 198 patients enrolled in the study, and 102 met inclusion criteria for analysis. Fifty-one patients received phenobarbital and 51 received placebo. Baseline characteristics and severity were similar in both groups. Patients that received phenobarbital had fewer ICU admissions (8% vs. 25%, 95% confidence interval 4–32). There were no differences in adverse events.

Conclusions

A single dose of i.v. phenobarbital combined with a symptom-guided lorazepam-based alcohol withdrawal protocol resulted in decreased ICU admission and did not cause increased adverse outcomes.     

Comparison of phenobarbital-adjunct versus benzodiazepine-only approach for alcohol withdrawal syndrome in the ED

ObjectivesTo compare a phenobarbital-adjunct versus benzodiazepine-only approach for the management of alcohol withdrawal syndrome in the emergency department (ED) with regard to the need for intensive care unit (ICU) admission, severity of symptoms on ED discharge, and complications.MethodsThis was a retrospective cohort study conducted in two academic EDs in the United States. Adult patients seen in the ED with a diagnosis of alcohol withdrawal syndrome were included. Patients were categorized into two groups based on whether phenobarbital was administered in the ED: 1) phenobarbital group (with or without benzodiazepines) or 2) non-phenobarbital group. The primary outcome measure was the need for ICU admission. Secondary outcomes included Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scores at ED discharge, and complications. Complications were a composite of death, need for intubation, hypotension or vasopressor use, seizures, and hospital acquired pneumonia.ResultsThe study cohort included 209 patients (phenobarbital = 97, non-phenobarbital = 112). The mean (standard deviation) age was 49 (12) years and 85% (n = 178) were male. A similar proportion of patients in the phenobarbital (14%, n = 14) and non-phenobarbital (11%, n = 12) groups required ICU admission (p = 0.529). The median CIWA-Ar score on ED discharge was 7 (IQR 4–12) points in the phenobarbital group and 7 (IQR 4–14) points in the non-phenobarbital group (p = 0.752). The occurrence of complications was also similar in the phenobarbital (9%, n = 9) and non-phenobarbital groups (11%, n = 10).ConclusionAdjunctive phenobarbital use in the ED for alcohol withdrawal syndrome did not result in decreased ICU admission, severity of symptoms, or complications.     

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.     

The Critical Care Resuscitation Unit Transfers More Patients From Emergency Departments Faster and Is Associated With Improved Outcomes

BackgroundTransfer delays of critically ill patients from other hospitals' emergency departments (EDs) to an appropriate referral hospital's intensive care unit (ICU) are associated with poor outcomes.ObjectivesWe hypothesized that an innovative Critical Care Resuscitation Unit (CCRU) would be associated with improved outcomes by reducing transfer times to a quaternary care center and times to interventions for ED patients with critical illnesses.MethodsThis pre–post analysis compared 3 groups of patients: a CCRU group (patients transferred to the CCRU during its first year [July 2013 to June 2014]), a 2011-Control group (patients transferred to any ICU between July 2011 and June 2012), and a 2013-Control group (patients transferred to other ICUs between July 2013 and June 2014). The primary outcome was time from transfer request to ICU arrival. Secondary outcomes were the interval between ICU arrival to the operating room and in-hospital mortality.ResultsWe analyzed 1565 patients (644 in the CCRU, 574 in the 2011-Control, and 347 in 2013-Control groups). The median time from transfer request to ICU arrival for CCRU patients was 108 min (interquartile range [IQR] 74–166 min) compared with 158 min (IQR 111–252 min) for the 2011-Control and 185 min (IQR 122–283 min) for the 2013-Control groups (p < 0.01). The median arrival-to-urgent operation for the CCRU group was 220 min (IQR 120–429 min) versus 439 min (IQR 290–645 min) and 356 min (IQR 268–575 min; p < 0.026) for the 2011-Control and 2013-Control groups, respectively. After adjustment with clinical factors, transfer to the CCRU was associated with lower mortality (odds ratio 0.64 [95% confidence interval 0.44–0.93], p = 0.019) in multivariable logistic regression.ConclusionThe CCRU, which decreased time from outside ED's transfer request to referral ICU arrival, was associated with lower mortality likelihood. Resuscitation units analogous to the CCRU, which transfer resource-intensive patients from EDs faster, may improve patient outcomes.     

Impact of an emergency short stay unit on emergency department performance of poisoned patients

Objectives

This was a before and after study which sought to assess the impact of opening an ED short stay unit (ESSU) on the ED performance of poisoned patients.

Prognostic value of soluble urokinase plasminogen activator receptor in patients presenting to the emergency department with chest pain suggestive of acute coronary syndrome

IntroductionSoluble urokinase plasminogen activator receptor (suPAR) is a prognostic biomarker of cardiovascular disease. Objectives: We aimed to evaluate the early prognostic value of suPAR in patients presenting to the emergency department (ED) with chest pain suggestive of acute coronary syndrome (ACS).Patients and methodsIn a post-hoc analysis from a multicenter study including patients with a chest pain < 6 h, suPAR concentrations at ED admission were studied according to the outcome at 30-days.Results198 patients (median age 56 years) in whom 16% had an ACS, were included. Fifteen (7.3%) patients presented a 30-day event. At ED admission, median (IQR) suPAR concentrations were higher in patients with a 30-day event in comparison to patients without event (4.54 (3.09–8.61) vs. 2.72 (2.10–3.43) ng/mL, p < 0.001). The ROC curve AUC of suPAR for the prediction of a 30-days event was 0.775 [95%CI: 0.710–0.831]. The optimal threshold was 3.3 ng/mL, with a sensitivity of 73 [45–92] % and a specificity of 72 [65–79] %. The association of a suPAR < 3.3 ng/mL AND a NT-proBNP < 160 ng/L AND a HEART score < 4 had a negative predictive value of 99 [91–100] %. A suPAR value at admission above 3.3 ng/mL was independently and significantly associated with a 30-day event in chest pain emergency patients (OR 4.87 [1.35–17.51], p = 0.015).ConclusionsuPAR is a promising biomarker for early prediction of events in chest pain emergency patients.     

Case mix and outcomes for admissions to UK adult,general critical care units with chronic obstructive pulmonary disease: a secondary analysis of the ICNARC Case Mix Programme Database

Introduction

Chronic obstructive pulmonary disease (COPD) is a common cause of admission to intensive care units (ICUs) in the UK. This report describes the case mix and outcomes of these patients and explores associations of measures of case mix available in the first 24 hours with outcome.

Method

We conducted a secondary analysis of a high quality clinical database, the ICNARC Case Mix Programme Database, of 129,647 admissions to 128 adult, general critical care units across England, Wales and Northern Ireland for the period from 1995 to 2001.

Results

Nonsurgical admissions with COPD accounted for 3752 admissions (2.9% of all admissions). Patients were acidotic (median pH 7.26, interquartile range [IQR] 7.18–7.33), hypercapnic (median arterial CO₂ tension 8.7, IQR 6.9–10.7) and hypoxic (median arterial O₂ tension/fractional inspired oxygen gradient 22.9, IQR 17.2–29.6). Overall, 2775 (73.9%) were definitely intubated and 278 (7.4%) were probably intubated in the first 24 hours in the ICU. The median (IQR) ICU length of stay was 4.0 (1.6–9.4) days and the hospital length of stay was 16 (9–29) days. a total of 827 patients (23.1%) died in the admitting ICU and 1322 (38.3%) died during hospital admission. Age, presence of severe respiratory disease, length of stay in hospital before critical care admission, cardiopulmonary resuscitation within 24 hours before admission, intubation status in first 24 hours in critical care, pH, arterial oxygen tension/fractional inspired oxygen gradient, albumin, cardiovascular organ failure, neurological organ failure and renal organ failure all had independent associations with hospital mortality. Respiratory organ failure had a significant independent association with decreased hospital mortality.

Conclusion

Nonsurgical patients with COPD represent an important group of patients admitted to UK ICUs. The presence of single organ respiratory failure in the first 24 hours in critical care identifies patients with a 70% chance of surviving to leave hospital.

     

Early intervention on the outcomes in critically ill cancer patients admitted to intensive care units

Purpose

To determine whether earlier intervention was associated with decreased mortality in critically ill cancer patients admitted to an intensive care unit (ICU).

Methods

A retrospective observational study was performed of 199 critically ill cancer patients admitted to the ICU from the general ward between January 2010 and December 2010. A logistic regression model was used to adjust for potential confounding factors in the association between time to intervention and in-hospital mortality.

Results

In-hospital mortality was 52?%, with a median Simplified Acute Physiology Score 3 (SAPS 3) of 80 [interquartile range (IQR) 67–93], and a median Sequential Organ Failure Assessment (SOFA) score of 8 (IQR 5–11). Median time from physiological derangement to intervention (time to intervention) prior to ICU admission was 1.5 (IQR 0.6–4.3)?h. Median time to intervention was significantly shorter in survivors than in non-survivors (0.9 vs. 3.0?h; p?p?2/FiO₂ ratio. Even after adjusting for potential confounding factors, time to intervention was still significantly associated with hospital mortality (adjusted odds ratio 1.445, 95?% confidence interval 1.217–1.717).

Conclusions

Early intervention before ICU admission was independently associated with decreased in-hospital mortality in critically ill cancer patients admitted to the ICU.     

Risk stratification and prognostic performance of the predisposition,infection, response,and organ dysfunction (PIRO) scoring system in septic patients in the emergency department: a cohort study

Introduction

The predisposition, infection, response and organ dysfunction (PIRO) staging system was designed as a stratification tool to deal with the inherent heterogeneity of septic patients. The present study was conducted to assess the performance of PIRO in predicting multiple organ dysfunction (MOD), intensive care unit (ICU) admission, and 28-day mortality in septic patients in the emergency department (ED), and to compare this scoring system with the Mortality in Emergency Department Sepsis (MEDS) and Acute Physiology and Chronic Health Evaluation (APACHE II) scores.

Methods

Consecutive septic patients (n = 680) admitted to the ED of Beijing Chao-Yang Hospital were enrolled. PIRO, MEDS, and APACHE II scores were calculated for each patient on ED arrival. Organ function was reassessed within 3 days of enrollment. All patients were followed up for 28 days. Outcome criteria were the development of MOD within 3 days, ICU admission or death within 28 days after enrollment. The predictive ability of the four components of PIRO was analyzed separately. Receiver operating characteristic (ROC) curve and logistic regression analysis were used to assess the prognostic and risk stratification value of the scoring systems.

Results

Organ dysfunction independently predicted ICU admission, MOD, and 28-day mortality, with areas under the ROC curve (AUC) of 0.888, 0.851, and 0.816, respectively. The predictive value of predisposition, infection, and response was weaker than that of organ dysfunction. A negative correlation was found between the response component and MOD, as well as mortality. PIRO, MEDS, and APACHE II scores significantly differed between patients who did and did not meet the outcome criteria (P < 0.001). PIRO and APACHE II independently predicted ICU admission and MOD, but MEDS did not. All three systems were independent predictors of 28-day mortality with similar AUC values. The AUC of PIRO was 0.889 for ICU admission, 0.817 for MOD, and 0.744 for 28-day mortality. The AUCs of PIRO were significantly greater than those of APACHE II and MEDS (P < 0.05) in predicting ICU admission and MOD.

Conclusions

The study indicates that PIRO is helpful for risk stratification and prognostic determinations in septic patients in the ED.     

Triage to electrocardiogram sign-off time in patients with acute coronary syndrome at a metropolitan Sydney hospital

Objective

To compare the time from triage to ECG sign-off in patients with acute coronary syndrome, before and after the introduction of an electronic medical record-integrated ECG workflow system (Epiphany). Additionally, to assess for any correlation between patient characteristics and ECG sign-off times.

Methods

A retrospective, single-centre cohort study was performed at Prince of Wales Hospital, Sydney. Patients were included if they were over 18 years, presented to Prince of Wales Hospital ED during 2021, had an ED diagnosis code of ‘ACS’, ‘UA’, ‘NSTEMI’ or ‘STEMI’ and were subsequently admitted under the cardiology team. ECG sign-off times and demographic data were compared between patients presenting prior to 29 June (pre-Epiphany group) and those presenting after (post-Epiphany group). Those without ECGs signed-off were excluded.

Results

There were 200 patients (100 each group) included in the statistical analysis. There was a significant decrease in the median triage to ECG sign-off time, from 35 min (IQR 18–69) pre-Epiphany, to 21 min (IQR 13–37) post-Epiphany. There were only 10 (5%) patients in the pre-Epiphany group and 16 (8%) in the post-Epiphany group, who had ECG sign-off times less than the 10-min. There was no correlation between gender, triage category, age or time of shift with triage to ECG sign-off time.

Conclusions

The introduction of the Epiphany system has significantly reduced the triage to ECG sign-off time in the ED. Despite this, there remains a large proportion of patients with acute coronary syndrome who do not have an ECG signed-off within the guideline-recommended 10 min.     

Emergency Department Visits Among Lung Transplant Patients: A 4-Year Experience

BackgroundEmergency department (ED) visits by lung transplant (LT) patients have not been well documented in the literature.ObjectivesTo analyze outcomes among LT recipients with ED visits, to better inform clinicians regarding evaluation and treatment.MethodsThis was a retrospective cohort study of LT patients at our ED (2015–2018). Demographics, transplant indication, laboratory studies, ED interventions, disposition, death, and revisit data were collected. Logistic regression models were used to identify univariable and multivariable predictors of ED revisit, intensive care unit (ICU) admission, or death.ResultsFor 505 ED visits among 160 LT recipients, respiratory-related concerns were most frequent (n = 152, 30.1%). Infection was the most common ED diagnosis (n = 101, 20.0%). Many patients were sent home from the ED (n = 235, 46.5%), and 31.3% (n = 158) returned to the ED within 30 days. Fourteen patients (2.8%) needed advanced airway measures. One patient died in the ED, and 18 died in the hospital. On multivariable analysis, more previous ED visits significantly increased the probability of 30-day ED revisit. Heart rate faster than 100 beats/min and systolic blood pressure < 90 mm Hg were significantly associated with ICU admission or death.ConclusionInfection should be prominent on the differential diagnosis for LT patients in the ED. A large proportion of patients were discharged from the ED, but a higher number of previous ED visits was most predictive of ED revisit within 30 days. Mortality rate was low in our study, but higher heart rate and lower systolic blood pressure were associated with ICU admission or death.