Current Issue : April-June Volume : 2023 Issue Number : 2 Articles : 6 Articles
Background: Patients presenting with infection to the ambulance are common, but risk factors for poor outcome are not known. The primary aim of the current study was to study the association between variables measured in the ambulance and mortality among adult patients with and without infection. The secondary aim was to study the association between these variables and mortality in a subgroup of patients who developed sepsis within 36 h. Methods: Prospective cohort study of 553 ambulance patients with, and 318 patients without infection, performed in Stockholm during 2017–2018. The association between 21 variables (8 keywords related to medical history, 6 vital signs, 4 blood tests, and age, gender, comorbidity) and in-hospital mortality was analysed using logistic regression. Results: Among patients with infection, inability of the patient to answer questions relating to certain symptoms such as pain and gastrointestinal symptoms was significantly associated with mortality in univariable analysis, in addition to oxygen saturation < 94%, heart rate > 110 /min, Glasgow Coma Scale (GCS) < 15, soluble urokinase Plasminogen Activator Receptor (suPAR) 4.0–7.9 ng/mL, suPAR ≥ 8.0 ng/mL and a Charlson comorbidity score ≥ 5. suPAR ≥ 8.0 ng/mL remained significant in multivariable analysis (OR 25.4; 95% CI, 3.2–199.8). Among patients without infection, suPAR ≥ 8.0 ng/mL and a Charlson comorbidity score ≥ 5 were significantly associated with mortality in univariable analysis, while suPAR ≥ 8.0 ng/mL remained significant in multivariable analysis (OR 56.1; 95% CI, 4.5–700.0). Among patients who developed sepsis, inability to answer questions relating to pain remained significant in multivariable analysis (OR 13.2; 95% CI, 2.2–78.9), in addition to suPAR ≥ 8.0 ng/mL (OR 16.1; 95% CI, 2.0–128.6). Conclusions: suPAR ≥ 8.0 ng/mL was associated with mortality in patients presenting to the ambulance both with and without infection and in those who developed sepsis. Furthermore, the inability of the ambulance patient with an infection to answer questions relating to specific symptoms was associated with a surprisingly high mortality. These results suggest that suPAR and medical history are valuable tools with which to identify patients at risk of poor outcome in the ambulance and could potentially signal the need of enhanced attention....
Background: Head injury (HI) in older adults due to low-energy falls result in a substantial number of emergency department (ED) attendances. However, mortality associated with minor HI is very low. Reducing conveyance to hospital is important for older adults and is a priority for the National Health Service (NHS). Therefore, paramedics are required to make accurate decisions regarding conveyance to the ED. This study used routine data and semistructured interviews to explore the factors that influence paramedic decision-making when considering whether to convey an adult aged 65 years and over with a minor HI to the ED. Methods: Semi-structured telephone interviews were completed with ten UK paramedics from a single EMS (ambulance) provider organisation. Interviews explored the factors influencing the paramedics’ conveyance decision-making in adults aged 65 years and over with a minor HI. Data were initially analysed inductively to develop a thematic framework. A retrospective analysis of ambulance service data was also completed to determine the scope and scale of the issue in Southwest England. An in-depth audit of 100 conveyed patient records was used to determine the proportion of patients conveyed to the ED who met National Institute for Health and Care Excellence (NICE) and Joint Royal Colleges Ambulance Liaison Committee (JRCALC) guidelines. Results: In 2019 South Western Ambulance Service NHS Foundation Trust (SWASFT) attended 15,650 emergency calls to patients aged 65 and over with minor HI, with 70.5% conveyed to ED. 81% of conveyed patients met NICE and JRCALC guideline criteria for conveyance, with the remainder conveyed due to wound care or other medical concerns. The framework developed from the interviews comprised four themes: resources; patient factors; consequences; paramedic factors. Important factors included: the patient’s social situation; guidelines; clinical support availability; the history and presentation of the patient; risk. Conclusion: This study examined paramedic conveyance decisions for older people with minor HI. It identified multiple influencing factors, highlighting the complex nature of these decisions, and may serve as a basis for developing an intervention to safely decrease ED conveyance in this patient group....
Background: There is limited research on individual patient characteristics, alone or in combination, that contribute to the higher levels of mortality in post-transfer patients. The purpose of this work is to identify significant combinations of diagnoses that identify subgroups of post-interhospital transfer patients experiencing the highest levels of mortality. Methods: This was a retrospective cross-sectional study using structured electronic health record data from a regional health system between 2010–2017. We employed a machine learning approach, association rules mining using the Apriori algorithm to identify diagnosis combinations. The study population includes all patients aged 21 and older that were transferred within our health system from a community hospital to one of three main receiving hospitals. Results: Overall, 8893 patients were included in the analysis. Patients experiencing mortality post-transfer were on average older (70.5 vs 62.6 years) and on average had more diagnoses in 5 of the 6 diagnostic subcategories. Within the diagnostic subcategories, most diagnoses were comorbidities and active medical problems, with hypertension, atrial fibrillation, and acute respiratory failure being the most common. Several combinations of diagnoses identified patients that exceeded 50% post-interhospital transfer mortality. Conclusions: Comorbid burden, in combination with active medical problems, were most predictive for those experiencing the highest rates of mortality. Further improving patient level prognostication can facilitate informed decision making between providers and patients to shift the paradigm from transferring all patients to higher level care to only transferring those who will benefit or desire continued care, and reduce futile transfers....
Background: Prolonged emergency department length of stay (EDLOS) in critically ill patients leads to increased mortality. This nationwide study investigated patient and hospital characteristics associated with prolonged EDLOS and in-hospital mortality in adult patients admitted from the emergency department (ED) to the intensive care unit (ICU). Methods: We conducted a retrospective cohort study using data from the National Emergency Department Information System. Prolonged EDLOS was defined as an EDLOS of ≥ 6 h. We constructed multivariate logistic regression models of patient and hospital variables as predictors of prolonged EDLOS and in-hospital mortality. Results: Between 2016 and 2019, 657,622 adult patients were admitted to the ICU from the ED, representing 2.4% of all ED presentations. The median EDLOS of the overall study population was 3.3 h (interquartile range, 1.9–6.1 h) and 25.3% of patients had a prolonged EDLOS. Patient characteristics associated with prolonged EDLOS included nighttime ED presentation and Charlson comorbidity index (CCI) score of 1 or higher. Hospital characteristics associated with prolonged EDLOS included a greater number of staffed beds and a higher ED level. Prolonged EDLOS was associated with in-hospital mortality after adjustment for selected confounders (adjusted odds ratio: 1.18, 95% confidence interval: 1.16–1.20). Patient characteristics associated with in-hospital mortality included age ≥ 65 years, transferred-in, artificially ventilated in the ED, assignment of initial triage to more urgency, and CCI score of 1 or higher. Hospital characteristics associated with in-hospital mortality included a lesser number of staffed beds and a lower ED level. Conclusions: In this nationwide study, 25.3% of adult patients admitted to the ICU from the ED had a prolonged EDLOS, which in turn was significantly associated with an increased in-hospital mortality risk. Hospital characteristics, including the number of staffed beds and the ED level, were associated with prolonged EDLOS and in-hospital mortality....
Background: Venous Thromboembolic disease (VTE) poses a diagnostic challenge for clinicians in acute care. Over reliance on reference standard investigations can lead to over treatment and potential harm. We sought to evaluate the pragmatic performance and implications of using an age adjusted D-dimer (AADD) strategy to rule out VTE in patients with suspected disease attending an emergency department (ED) setting. We aimed to determine diagnostic test characteristics and assess whether this strategy would result in proportional imaging reduction and potential cost savings. Methods: Design: Single centre retrospective diagnostic cohort study. All patients > 50 years old evaluated for possible VTE who presented to the emergency department over a consecutive 12-month period between January and December 2016 with a positive D-dimer result. Clinical assessment records and reference standard imaging results were followed up by multiple independent adjudicators and coded as VTE positive or negative. Results: During the study period, there were 2132 positive D-dimer results. One thousand two hundred thirty-six patients received reference standard investigations. A total increase of 314/1236 (25.1%) results would have been coded as true negatives as opposed to false positive if the AADD cut off point had been applied, with 314 reference standard tests subsequently avoided. The AADD cut off had comparable sensitivity to the current cut off despite this increase in specificity; sensitivities for the diagnosis of DVT were 99.28% (95% CI 96.06–99.98%) and 97.72% for PE (95% CI 91.94% to 97.72). There were 3 false negative results using the AADD strategy. Conclusions: In patients with suspected VTE with a low or moderate pre-test probability, the application of AADD appears to increase the proportion of patients in which VTE can be excluded without the need for reference standard imaging. This management strategy is likely to be associated with substantial reduction in anticoagulation treatment, investigations and cost/time savings....
Background: Airway management of patients with direct airway trauma caused by penetrating neck injuries is always challenging. When a failed airway occurs and surgery access is difficult, it is crucial to find the optimal approach to save the life. We propose the concept “Cannot intubate, Cannot oxygenate, Difficult surgery access” to describe this emergency scenario. Case presentation: We report a case of a 24-year-old woman who presented with partial tracheal rupture and pneumothorax caused by a knife stab injury to the neck. A "double setup" strategy, simultaneous preparation for orotracheal intubation and tracheotomy, was carried out before rapid sequence induction. A tracheotomy under local anesthesia or an awake intubation was not preferred in consideration that the patient had a high risk of being uncooperative owing to existing mental disease and potential smothering sensation during operation. During rapid sequence intubation, distal part of the tube penetrates the tear and creates a false lumen outside the trachea then a failed airway subsequently occurred. Rescue tracheotomy was successfully performed by an otolaryngology surgeon, with the help of limited ventilation using sequential bag–mask and laryngeal mask airway ventilation provided by an anesthesiologist, without severe sequelae. Conclusions: The endotracheal tube have a risk of penetrating the tear outside the trachea in patient with partial tracheal rupture during orotracheal intubation, and once it occurs, proceeding directly to an emergency invasive airway access with optimizing oxygenation throughout procedure might increase the chance of success in rescuing the airway....
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