Dataset Information

Emergency Department Discharge of Pulmonary Embolus Patients.

ABSTRACT: BACKGROUND:Hospitalization for low-risk pulmonary embolism (PE) is common, expensive, and of questionable benefit. OBJECTIVE:The objective was to determine if low-risk PE patients discharged from the emergency department (ED) on rivaroxaban require fewer hospital days compared to standard of care (SOC). METHODS:Multicenter, open-label randomized trial in low-risk PE defined by Hestia criteria. Adult subjects were randomized to early ED discharge on rivaroxaban or SOC. Primary outcome was total number of initial hospital hours, plus hours of hospitalization for bleeding or venous thromboembolism (VTE), 30 days after randomization. A 90-day composite safety endpoint was defined as major bleeding, clinically relevant nonmajor bleeding, and mortality. RESULTS:Of 114 randomized subjects, 51 were early discharge and 63 were SOC. Of 112 (98.2%) receiving at least one dose of study drug, 99 (86.8%) completed the study. Initial hospital LOS was 4.8 hours versus 33.6 hours, with a mean difference of -28.8 hours (95% confidence interval [CI] = -42.55 to -15.12 hours) for early discharge versus SOC, respectively. At 90 days, mean total hospital days (for any reason) were less for early discharge than SOC, 19.2 hours versus 43.2 hours, with a mean difference of 26.4 hours (95% CI = -46.97 to -3.34 hours). At 90 days, there were no bleeding events, recurrent VTE, or deaths. The composite safety endpoint was similar in both groups, with a difference in proportions of 0.005 (95% CI = -0.18 to 0.19). Total costs were $1,496 for early discharge and $4,234 for SOC, with a median difference of $2,496 (95% CI = -$2,999 to -$2,151). CONCLUSIONS:Low-risk ED PE patients receiving early discharge on rivaroxaban have similar outcomes to SOC, but fewer total hospital days and lower costs over 30 days.

SUBMITTER: Frank Peacock W

PROVIDER: S-EPMC6175358 | biostudies-literature | 2018 Sep

REPOSITORIES: biostudies-literature

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Emergency Department Discharge of Pulmonary Embolus Patients.

Frank Peacock W W Coleman Craig I CI Diercks Deborah B DB Francis Samuel S Kabrhel Christopher C Keay Catherine C Kline Jeffrey A JA Manteuffel Jacob J Wildgoose Peter P Xiang Jim J Singer Adam J AJ

Academic emergency medicine : official journal of the Society for Academic Emergency Medicine 20180611 9

<h4>Background</h4>Hospitalization for low-risk pulmonary embolism (PE) is common, expensive, and of questionable benefit.<h4>Objective</h4>The objective was to determine if low-risk PE patients discharged from the emergency department (ED) on rivaroxaban require fewer hospital days compared to standard of care (SOC).<h4>Methods</h4>Multicenter, open-label randomized trial in low-risk PE defined by Hestia criteria. Adult subjects were randomized to early ED discharge on rivaroxaban or SOC. Prima ...[more]

PMID: 29757489

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Project description:Studies in Europe have found that immigrants, compared to the local population, are more likely to seek out medical care in Emergency Departments (EDs). In addition, studies show that immigrants utilize medical services provided by EDs for less acute issues. Despite these observed differences, little is known about the characteristics of ED use by North African (NA) immigrants. The main objective of this study was to examine whether there were differences in ED discharge outcomes and psychiatric referrals between NA immigrants and Swiss nationals. A retrospective analysis was conducted using patient records from NA and Swiss adults who were admitted to the ED of the University Hospital in Bern (Switzerland) from 2013?2016. Measures included demographic information as well as data on types of admission. Outcome variables included discharge type and psychiatric referral. A total of 77,619 patients generated 116,859 consultations to the ED, of which 1.1 per cent (n = 1338) were consultations by NA patients. Compared to Swiss national patients, NA patients were younger, with a median age of 38.0 (IQR 28?51 years vs. 52.0 (IQR 32?52) for Swiss and predominantly male (74.4% vs. 55.6% in the Swiss). NA patient admission type was more likely to be "walk-in" or legal admission (7.5% vs 0.8 in Swiss,). Logistic regressions indicated that NA patients had 1.2 times higher odds (95% CI 1.07?1.40, p < 0.003) of receiving ambulatory care. An effect modification by age group and sex was observed for the primary outcome "seen by a psychiatrist", especially for men in the 16?25 years age group, whereby male NA patients had 3.45 times higher odds (95% CI: 2.22?5.38) of having being seen by a psychiatrist. In conclusion differences were observed between NA and Swiss national patients in ED consultations referrals and outcomes, in which NA had more ambulatory discharges and NA males, especially young, were more likely to have been seen by psychiatrist. Future studies would benefit from identifying those factors underlying these differences in ED utilization.

Project description:BACKGROUND:The HEART Pathway (history, ECG, age, risk factors, and initial troponin) is an accelerated diagnostic protocol designed to identify low-risk emergency department patients with chest pain for early discharge without stress testing or angiography. The objective of this study was to determine whether implementation of the HEART Pathway is safe (30-day death and myocardial infarction rate <1% in low-risk patients) and effective (reduces 30-day hospitalizations) in emergency department patients with possible acute coronary syndrome. METHODS:A prospective pre-post study was conducted at 3 US sites among 8474 adult emergency department patients with possible acute coronary syndrome. Patients included were ≥21 years old, investigated for possible acute coronary syndrome, and had no evidence of ST-segment-elevation myocardial infarction on ECG. Accrual occurred for 12 months before and after HEART Pathway implementation from November 2013 to January 2016. The HEART Pathway accelerated diagnostic protocol was integrated into the electronic health record at each site as an interactive clinical decision support tool. After accelerated diagnostic protocol integration, ED providers prospectively used the HEART Pathway to identify patients with possible acute coronary syndrome as low risk (appropriate for early discharge without stress testing or angiography) or non-low risk (appropriate for further in-hospital evaluation). The primary safety and effectiveness outcomes, death, and myocardial infarction (MI) and hospitalization rates at 30 days were determined from health records, insurance claims, and death index data. RESULTS:Preimplementation and postimplementation cohorts included 3713 and 4761 patients, respectively. The HEART Pathway identified 30.7% as low risk; 0.4% of these patients experienced death or MI within 30 days. Hospitalization at 30 days was reduced by 6% in the postimplementation versus preimplementation cohort (55.6% versus 61.6%; adjusted odds ratio, 0.79; 95% CI, 0.71-0.87). During the index visit, more MIs were detected in the postimplementation cohort (6.6% versus 5.7%; adjusted odds ratio, 1.36; 95% CI, 1.12-1.65). Rates of death or MI during follow-up were similar (1.1% versus 1.3%; adjusted odds ratio, 0.88; 95% CI, 0.58-1.33). CONCLUSIONS:HEART Pathway implementation was associated with decreased hospitalizations, increased identification of index visit MIs, and a very low death and MI rate among low-risk patients. These findings support use of the HEART Pathway to identify low-risk patients who can be safely discharged without stress testing or angiography. CLINICAL TRIAL REGISTRATION:URL: http://www.clinicaltrials.gov . Unique identifier: NCT02056964.

Project description:ImportanceSepsis guidelines and research have focused on patients with sepsis who are admitted to the hospital, but the scope and implications of sepsis that is managed in an outpatient setting are largely unknown.ObjectiveTo identify the prevalence, risk factors, practice variation, and outcomes for discharge to outpatient management of sepsis among patients presenting to the emergency department (ED).Design, setting, and participantsThis cohort study was conducted at the EDs of 4 Utah hospitals, and data extraction and analysis were performed from 2017 to 2021. Participants were adult ED patients who presented to a participating ED from July 1, 2013, to December 31, 2016, and met sepsis criteria before departing the ED alive and not receiving hospice care.ExposuresPatient demographic and clinical characteristics, health system parameters, and ED attending physician.Main outcomes and measuresInformation on ED disposition was obtained from electronic medical records, and 30-day mortality data were acquired from Utah state death records and the US Social Security Death Index. Factors associated with ED discharge rather than hospital admission were identified using penalized logistic regression. Variation in ED discharge rates between physicians was estimated after adjustment for potential confounders using generalized linear mixed models. Inverse probability of treatment weighting was used in the primary analysis to assess the noninferiority of outpatient management for 30-day mortality (noninferiority margin of 1.5%) while adjusting for multiple potential confounders.ResultsAmong 12 333 ED patients with sepsis (median [IQR] age, 62 [47-76] years; 7017 women [56.9%]) who were analyzed in the study, 1985 (16.1%) were discharged from the ED. After penalized regression, factors associated with ED discharge included age (adjusted odds ratio [aOR], 0.90 per 10-y increase; 95% CI, 0.87-0.93), arrival to ED by ambulance (aOR, 0.61; 95% CI, 0.52-0.71), organ failure severity (aOR, 0.58 per 1-point increase in the Sequential Organ Failure Assessment score; 95% CI, 0.54-0.60), and urinary tract (aOR, 4.56 [95% CI, 3.91-5.31] vs pneumonia), intra-abdominal (aOR, 0.51 [95% CI, 0.39-0.65] vs pneumonia), skin (aOR, 1.40 [95% CI, 1.14-1.72] vs pneumonia) or other source of infection (aOR, 1.67 [95% CI, 1.40-1.97] vs pneumonia). Among 89 ED attending physicians, adjusted ED discharge probability varied significantly (likelihood ratio test, P < .001), ranging from 8% to 40% for an average patient. The unadjusted 30-day mortality was lower in discharged patients than admitted patients (0.9% vs 8.3%; P < .001), and their adjusted 30-day mortality was noninferior (propensity-adjusted odds ratio, 0.21 [95% CI, 0.09-0.48]; adjusted risk difference, 5.8% [95% CI, 5.1%-6.5%]; P < .001). Alternative confounder adjustment strategies yielded odds ratios that ranged from 0.21 to 0.42.Conclusions and relevanceIn this cohort study, discharge to outpatient treatment of patients who met sepsis criteria in the ED was more common than previously recognized and varied substantially between ED physicians, but it was not associated with higher mortality compared with hospital admission. Systematic, evidence-based strategies to optimize the triage of ED patients with sepsis are needed.

Project description:BACKGROUND:Previous studies have demonstrated that patients have poor understanding of the discharge instructions provided from the emergency department (ED). The aims of this study are to determine if patient factors, such as income and level of education, correlate with patient understanding of discharge instructions and to explore if different patient populations prefer different resources for receiving discharge instructions. METHODS:We conducted live observations of physicians providing discharge instructions in the ED to 100 patients followed by a patient survey to determine their understanding in four domains (diagnosis, treatment plan, follow-up instructions, and return to ED (RTED) instructions) and collect patient demographics. We enrolled patients over the age of 18 being discharged home. We excluded non-English- or French-speaking patients and those with significant psychiatric history or cognitive impairment. We performed a two-way ANOVA analysis of patient factors and patient understanding. RESULTS:We found that patients had poor understanding of discharge instructions, ranging from 24.0% having poor understanding of their follow-up plan to 64.0% for RTED instructions. Almost half (42%) of patients did not receive complete discharge instructions. Lower income was correlated with a significant decrease in patient understanding of discharge diagnosis (p?=?0.01) and RTED instructions (p?=?0.04). Patients who did not complete high school trended towards lower levels of understanding of their diagnosis and treatment plan (p?=?0.06). Lower income patients had a preference for receiving a follow-up phone call by a nurse, while higher income patients preferred online resources. CONCLUSIONS:Lower income patients and those who have not completed high school are at a higher risk of poor understanding discharge instructions. As new technological solutions emerge to aid patient understanding of discharge instructions, our study suggests they may not aid those who are at the highest risk of failing to understand their instructions.

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Emergency Department Discharge of Pulmonary Embolus Patients.

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Emergency Department Discharge of Pulmonary Embolus Patients.

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