Informing the design of clinical decision support services for evaluation of children with minor blunt head trauma in the emergency department: A sociotechnical analysis

Integration of clinical decision support services (CDSS) into electronic health records (EHRs) may be integral to widespread dissemination and use of clinical prediction rules in the emergency department (ED). However, the best way to design such services to maximize their usefulness in such a complex setting is poorly understood. We conducted a multi-site cross-sectional qualitative study whose aim was to describe the sociotechnical environment in the ED to inform the design of a CDSS intervention to implement the Pediatric Emergency Care Applied Research Network (PECARN) clinical prediction rules for children with minor blunt head trauma. Informed by a sociotechnical model consisting of eight dimensions, we conducted focus groups, individual interviews and workflow observations in 11 EDs, of which 5 were located in academic medical centers and 6 were in community hospitals. A total of 126 ED clinicians, information technology specialists, and administrators participated. We clustered data into 19 categories of sociotechnical factors through a process of thematic analysis and subsequently organized the categories into a sociotechnical matrix consisting of three high-level sociotechnical dimensions (workflow and communication, organizational factors, human factors) and three themes (interdisciplinary assessment processes, clinical practices related to prediction rules, EHR as a decision support tool). Design challenges that emerged from the analysis included the need to use structured data fields to support data capture and re-use while maintaining efficient care processes, supporting interdisciplinary communication, and facilitating family-clinician interaction for decision-making.     

Medical mortality in an emergency department in Nigeria: the transition is obvious!

IntroductionThe emergency department (ED), a major entry point into the hospital, provides an insight to the type of cases seen, the quality of care and mortality spectrum in a health institution. We aim to identify the spectrum of medical causes of mortality in our ED, the demographic pattern and duration of stay before death.MethodThis is a retrospective study that looked at medical mortality in the ED from January 2004 to December 2009. We obtained data on the demographics and causes of death from the medical records and case notes of the deceased.ResultsA total of 16587 patients were admitted during the period under review, of these 1262 (7.61%) died in the ED. The male to female ratio was 1.58:1.0 [772 males (61.2%), and 489 females (38.8%)]. Mortality was highest among the 20–45 years age range, followed by 46–65 years, >65 years and < 20 years in decreasing frequency [589(46.7%), 421(33.4%), 186 (14.8%) and 66(5.2%) respectively]. The three most common causes of death were stroke 315(25%), HIV related illnesses 126(10.0%), and heart failure 123(9.7%). Most deaths occurred less than 24hours of admission, 550(43.6%), followed by one day (36.0%) and two days (10.8%) post admissions respectively.ConclusionThe commonest cause of death in the ED was stroke. The burden of death was highest in the younger age group, with most occurring less than 24 hours of admission.     

Antimicrobial stewardship in the emergency department: characteristics and evidence for effectiveness of interventions

BackgroundEmergency departments (EDs) are the entrance gates for patients presenting with infectious diseases into the hospital, yet most antimicrobial stewardship programmes are primarily focused on inpatient management. With equally high rates of inappropriate antibiotic use, the ED is a frequently overlooked yet important unit for targeted antimicrobial stewardship (AMS) interventions.ObjectivesWe aimed to (a) describe the specific aspects of antimicrobial stewardship in the ED and (b) summarize the findings from improvement studies that have investigated the effectiveness of antimicrobial stewardship interventions in the ED setting.Sources: (a) a PubMed search for ‘antimicrobial stewardship’ and ‘emergency department’, and (b) published reviews on effectiveness combined with publications from the first source.Content: (a) An in depth analysis of selected publications provided four key antimicrobial use processes typically performed by front-line healthcare professionals in the ED: making a (tentative) clinical diagnosis, starting empirical therapy based on that diagnosis, performing microbiological tests before starting that therapy and following up patients who are discharged from the ED. (b) Further, we discuss the literature on improvement strategies in the ED focusing on guidelines and clinical pathways and multifaceted improvement strategies. We also summarize the evidence of microbiologic culture review.Implications: Based on our review of the literature, we describe four essential elements of antimicrobial use in the ED. Studying the various interventions targeting these care processes, we have found them to be of a variable degree of success. Nonetheless, while there is a paucity of AS studies specifically targeting the ED, there is a growing body of evidence that AS programmes in the ED are effective with modifications to the ED setting. We present key questions for future research.     

Clinical spectrum of intra-abdominal abscesses in children admitted to the pediatric emergency department

BackgroundTo analyze clinical spectrum of intra-abdominal abscesses in children and find helpful clinical parameters could aid physicians in earlier detection and differential diagnosis.MethodsFrom 2004 to 2011, we retrospectively analyzed 66 pediatric patients, aged 18 years or younger with intra-abdominal abscesses. The data were obtained and studied: demographics, clinical presentations, etiologies, laboratory tests, microbiology, imaging studies, treatment modalities, complications and long-term outcomes.ResultsThere were 66 patients (mean age, 9.27 ± 4.16 years) diagnosed as intra-abdominal abscesses. The two most common presented symptoms were fever and abdominal pain (90.9%; 78.8%, respectively). Most patients presented with leukocytosis (81.8%) and elevated C-reactive protein (CRP) levels (95.5%). In patients with abscesses in solid organs, urine white blood cell counts, nitrate and leukocyte esterase were all significant parameters (all P < 0.05), and urine pH and specific gravity were both lower than those in non-solid organs (P = 0.026; P = 0.043, respectively). Escherichia coli (E. coli) was the most common organism cultured from renal abscess. Streptococcus viridans was the most common organism cultured from liver abscess. Moreover, the two most predominant bacteria in periappendical and intraperitoneal abscesses were E. coli and Bacteroides fragilis.ConclusionsWe suggest that primary physicians should keep this disease in mind when children present with predisposing risk factors, fever, abdominal pain, leukocytosis and elevated CRP level. Besides, we recommend the urinary analysis or ultrasonography (US) is valuable in patients with fever and abdominal pain.     

Implementation of a health-literate patient decision aid for chest pain in the emergency department

ObjectiveThe aim of this study was to investigate the implementation of a new health-literacy-tested patient decision aid for chest pain in Emergency Department (ED) patients. Outcomes included disposition, knowledge, decisional conflict and satisfaction prior to discharge. Patient health literacy was explored as a factor that may explain disparities in sub-group analysis of all outcomes.MethodsA health-literacy adapted tool was deployed using a pre/post intervention design. Patients enrolled during the intervention period were given the adapted chest pain decision aid that was used in conversation with their emergency medicine physician to decide on their course of action prior to being discharged.ResultsA total of 169 participants were surveyed and used in the final analysis. Patients in the usual care group were 2.6 times more likely to be admitted for chest pain than patients in the intervention group. Knowledge scores were higher in the intervention group, while no significant differences were observed in decisional conflict and patient satisfaction, or by patient health literacy level.Conclusion and practice implicationsUsing the adapted chest pain decision tool in emergency medicine may improve knowledge and reduce admissions, while addressing known barriers to understanding related to patient health literacy.     

Interventions for rapid recognition and treatment of sepsis in the emergency department: a narrative review

BackgroundSepsis is a major cause of morbidity and mortality worldwide. Early recognition and treatment of sepsis is associated with improved outcome. The emergency department (ED) is the department where patients with sepsis seek care. However, recognition of sepsis in the ED remains difficult. Different alert and triage systems, screening scores and intervention strategies have been developed to assist clinicians in early recognition of sepsis and to optimize management.ObjectivesThis narrative review describes currently applied interventions or interventions we can start using today, such as screening scores, (automated) triage systems, sepsis teams and clinical pathways in sepsis care; and it summarizes evidence for the effect of implementation of these interventions in the ED on patient management and outcomes.SourcesA systematic literature search was conducted in PubMed, resulting in 39 eligible studies.ContentThe main sepsis interventions in the ED are (automated) triage systems, sepsis teams and clinical pathways, the most integrative being a clinical pathway. Implementation of any of these interventions in sepsis care will generally lead to increased protocol adherence. Presumably increased adherence to sepsis guidelines and bundles will lead to better patient outcomes, but the level of evidence to support this improvement is low, whereas implementation of interventions is often complex and costly. No studies comparing different interventions were identified. Two essential factors for success of interventions in the ED are obtaining the support from all professionals and providing ongoing education. The vulnerability of these interventions lies in the lack of accurate tools to identify sepsis; diagnosing sepsis ultimately still relies on clinical assessments. A lack of specificity or sepsis alerts may lead to alert fatigue and/or overtreatment.ImplicationsThe severity and poor outcome of sepsis as well as the frequency of its presentation in EDs make a structured, protocol-based approach towards these patients essential, preferably as part of a clinical pathway.     

Factors associated with late presentation to the emergency department in patients complaining of chest pain

ObjectiveWe investigated which factors predict late presentation (LP) to the emergency department (ED) in patients with non-traumatic chest pain (CP).MethodsAll CP cases attended at a single ED (2008–2017) were included. LP was considered if time from CP onset to ED arrival was>6 h. We analyzed associations between 42 patient/CP-related characteristics and LP in the whole cohort and in patients with CP due to acute coronary syndrome (ACS).ResultsThe cohort included 25,693 cases (LP=50.6%; ACS=19.0%). Twenty factors were associated with LP, and 8 were also found in patients with ACS: CP of short-duration, aggravated by exertion or breathing/movement, undulating or recurrent CP increased the risk of LP, whereas CP accompanied by diaphoresis, irradiated to the throat, and chronic treatment with nitrates decreased the risk of LP. Exertional and recurrent CP were associated with both, LP and ACS.ConclusionSome characteristics, mainly CP-related, may lead to LP to the ED. CP aggravated by exercise and recurrent CP were associated with both LP and a final diagnosis of ACS.Practice implicationsPatient educational initiatives should consider these two features as potential warnings for ACS and thereby encourage patients to seek early medical consultation.     

Bordetella trematum bacteremia in an infant: A cause to look for

Bordetella trematum spp. nov. has been isolated from wounds, ear infections and diabetic ulcers. We report a case of a 7-month-old infant with fever, vomiting and abnormal body movements with bacteremia caused by this novel species. The infant responded to fluoroquinolone and macrolide combination therapy.     

Renal safety of a single dose of gentamicin in patients with sepsis in the emergency department

ObjectivesTo determine the effect of a single dose of gentamicin on the incidence and persistence of acute kidney injury (AKI) in patients with sepsis in the emergency department (ED).MethodsWe retrospectively studied patients with sepsis in the ED in three hospitals. Local antibiotic guidelines recommended a single dose of gentamicin as part of empirical therapy in selected patients in one hospital, whereas the other two hospitals did not. Multivariate analysis was used to evaluate the effect of gentamicin and other potential risk factors on the incidence and persistence of AKI after admission. AKI was defined according to the KDIGO (Kidney Disease Improving Global Outcomes) criteria.ResultsOf 1573 patients, 571 (32.9%) received a single dose of gentamicin. At admission, 181 (31.7%) of 571 of the gentamicin-treated and 228 (22.8%) of 1002 of the non–gentamicin-treated patients had AKI (p < 0.001). After admission, AKI occurred in 64 (12.0%) of 571 patients who received gentamicin and in 82 (8.9%) of 1002 people in the control group (p 0.06). Multivariate analysis showed that shock (odds ratio (OR), 2.72; 95% CI, 1.31–5.67), diabetes mellitus (OR, 1.49; 95% CI, 1.001–2.23) and higher baseline (i.e. before admission) serum creatinine levels (OR, 1.007; 95% CI, 1.005–1.009) were associated with the development of AKI after admission, but not receipt of gentamicin (OR, 1.29; 95% CI, 0.89–1.86). Persistent AKI was rare in both the group that received gentamicin (16/260, 6.2%) and the group that did not (15/454, 3.3%, p 0.09).ConclusionsWith regard to renal function, a single dose of gentamicin in patients with sepsis in the ED is safe. The development of AKI after admission was associated with shock, diabetes mellitus and higher baseline creatinine level.     

The patient, the doctor and the emergency department: a cross-sectional study of patient-centredness in 1990 and 2005

OBJECTIVE: To compare and contrast the duration and content of physician-patient interaction for patients presenting to an emergency department with problems of low acuity in 1990 and 2005 treated by different grades of physician. METHODS: Observational study with data collection in May-July 1990 and May-July 2005. Patients identified at nurse triage as presenting with 'primary care' problems were allocated by time of arrival to senior house officers (1990, n=7; 2005, n=10), specialist registrars/staff grades (1990, n=4; 2005, n=7) or sessionally employed general practitioners (1990, n=8; 2005, n=12) randomly rostered to work in a consulting room that had a wall-mounted video camera. A stratified sample of 430 video-taped consultations (180 (42%) from 1990 and 250 (58%) from 2005) was analysed using the Roter Interaction Analysis System. Main outcome measures -- length of consultation; numbers of utterances of physician and patient talk related to building a relationship, data gathering, activating/partnering (i.e. actively encouraging the patient's involvement in decision-making), and patient education/counselling. RESULTS: On average consultation length was 251s (95% CI for difference: 185-316) longer in 2005 than in 1990. The difference was especially marked for senior house officers (mean duration 385s in 1990 and 778s in 2005; 95% CI of difference: 286-518). All groups of physician showed increased communication related to activating and partnering and building a therapeutic relationship with the patient. While senior house officers demonstrated a greatly increased focus on data gathering, only general practitioners substantially increased the amount of talk centred on patient education and counselling; compared to senior house officers, the odds ratio for the number of such utterances included in consultations was 2.8 (95% CI: 1.4, 5.3). CONCLUSION: Although patient-centredness together with consultation length increased for all three physician groups over the duration of this study, senior house officers and specialist registrars/staff grades continued to place less emphasis on advice-giving and counselling than did general practitioners. The extent to which these observed changes in practice were determined by policy, management and training initiatives, and their impact on patient outcome, needs further study. PRACTICE IMPLICATIONS: Video-recording consultations is feasible in an acute hospital setting, and could be used to support training and workforce development. General practitioners can make a distinctive contribution to the workforce of emergency departments. Their consulting style differs from that of hospital physicians and may benefit patient care through a greater focus on patient education and counselling.     

The effectiveness of pharmacist- led discharge medication counselling in the emergency department (ExPLAIN): A pilot quasi-experimental study

ObjectiveTo evaluate the effectiveness of pharmacist-led discharge medication counselling using a structured, multimodal educational strategy with teach-back (intervention) against standard care.MethodsThis was a quasi-experimental study in a public, metropolitan ED. Participants discharged home with new medications were allocated to receive the intervention or standard care using convenience sampling. Participant characteristics (i.e. age, sex, socio-economic status, medications) and health literacy were collected. The outcomes measured were satisfaction with information, ED re-presentation and length of stay.ResultsThere were 51 participants: 14 received intervention, 37 had standard care. Overall, 12% had inadequate health literacy. Group characteristics and health literacy were similar. Participants who received the intervention were significantly reported higher satisfaction with information about their new medications compared to standard care (p = 0.009). Specifically, the intervention was associated with a 98% increase in satisfaction with information relating to side-effects. There were no differences in re-presentation and length of stay.ConclusionPharmacist-led discharge medication counselling incorporating a structured, multimodal educational strategy and teach-back was effective in improving patient satisfaction with medication information in the ED.Practice implicationsA similar intervention could be trialled in other EDs, but outcomes other beyond satisfaction should be considered.     

Community-acquired pneumonia in the emergency department: an algorithm to facilitate diagnosis and guide chest CT scan indication

ObjectiveThe aim was to create and validate a community-acquired pneumonia (CAP) diagnostic algorithm to facilitate diagnosis and guide chest computed tomography (CT) scan indication in patients with CAP suspicion in Emergency Departments (ED).MethodsWe performed an analysis of CAP suspected patients enrolled in the ESCAPED study who had undergone chest CT scan and detection of respiratory pathogens through nasopharyngeal PCRs. An adjudication committee assigned the final CAP probability (reference standard). Variables associated with confirmed CAP were used to create weighted CAP diagnostic scores. We estimated the score values for which CT scans helped correctly identify CAP, therefore creating a CAP diagnosis algorithm. Algorithms were externally validated in an independent cohort of 200 patients consecutively admitted in a Swiss hospital for CAP suspicion.ResultsAmong the 319 patients included, 51% (163/319) were classified as confirmed CAP and 49% (156/319) as excluded CAP. Cough (weight = 1), chest pain (1), fever (1), positive PCR (except for rhinovirus) (1), C-reactive protein ≥50 mg/L (2) and chest X-ray parenchymal infiltrate (2) were associated with CAP. Patients with a score below 3 had a low probability of CAP (17%, 14/84), whereas those above 5 had a high probability (88%, 51/58). The algorithm (score calculation + CT scan in patients with score between 3 and 5) showed sensitivity 73% (95% CI 66–80), specificity 89% (95% CI 83–94), positive predictive value (PPV) 88% (95% CI 81–93), negative predictive value (NPV) 76% (95% CI 69–82) and area under the curve (AUC) 0.81 (95% CI 0.77–0.85). The algorithm displayed similar performance in the validation cohort (sensitivity 88% (95% CI 81–92), specificity 72% (95% CI 60–81), PPV 86% (95% CI 79–91), NPV 75% (95% CI 63–84) and AUC 0.80 (95% CI 0.73–0.87).ConclusionOur CAP diagnostic algorithm may help reduce CAP misdiagnosis and optimize the use of chest CT scan.     

Parallel declines in HIV and hepatitis C virus prevalence,but not in herpes simplex virus type 2 infection: A 10-year,serial cross-sectional study in an inner-city emergency department

BackgroundThe Johns Hopkins Hospital Emergency Department (JHHED) has served as an observational window on the HIV epidemic in a socioeconomically depressed, urban population. We previously reported that HIV incidence among JHHED patients is decreasing and that prevalence has declined from 11.4% in 2003–5.6% in 2013.ObjectivesThis study sought to observe temporal trends in hepatitis C virus (HCV) and herpes simplex virus type 2 (HSV-2) seroprevalence, which are surrogate markers for parenteral and sexual risk behavior, respectively.Study designIdentity unlinked-serosurveys were conducted over 6–8 weeks in the adult JHHED in 2003, 2007, and 2013. Excess sera from 10,274 patients, previously tested for HIV, were assayed for HSV-2 and HCV antibodies.ResultsOverall HCV seroprevalence declined steadily from 22.0% in 2003–13.8% in 2013 (P_trend < 0.01), and was significant by all gender and race strata. Overall HSV-2 prevalence declined from 55.3% in 2003–50.0% in 2013 (P_trend < 0.01), but was non-significant after adjustment for demographics. Among HIV+ individuals <45 years of age, there was a significant decrease in the proportion of individuals with HCV co-infection [without HSV-2] (P_trend = 0.02) from 2003 to 2013, however, there was an increase in individuals with HSV-2 co-infection [without HCV] (P_trend  <  0.01).DiscussionLittle change in age-specific HSV-2 prevalence suggests the decrease in HIV prevalence was likely not associated with changes in sexual risk behavior. In addition to clinical interventions, strategies to address sexual health disparities and continued parenteral harm-reduction efforts are needed to further drive the decline in HIV.