Dataset Information

Which parameters support disposition decision in suspected COVID-19 cases in the emergency department (ED): a German clinical cohort study.

ABSTRACT:

Objectives

One major goal of the emergency department (ED) is to decide, whether patients need to be hospitalised or can be sent home safely. We aim at providing criteria for these decisions without knowing the SARS-CoV-2 test result in suspected cases.

Setting

Tertiary emergency medicine.

Participants

All patients were treated at the ED of the Charité during the pandemic peak and underwent SARS-CoV-2 testing. Patients with positive test results were characterised in detail and underwent a 14-day-follow-up.

Primary and secondary outcome measures

Logistic regression and classification and regression tree (CART) analyses were performed to identify predictors (primary endpoint), which confirm safe discharge. The clinical endpoint was all-cause mortality or need for mechanical ventilation during index stay or after readmission.

Results

The primary test population of suspected COVID-19 consisted of n=1255 cases, 45.2% were women (n=567). Of these, n=110 tested positive for SARS-CoV-2 (8.8%). The median age of SARS-CoV-2-positive cases was 45 years (IQR: 33-66 years), whereas the median age of the group tested negative for SARS-CoV-2 was 42 years (IQR: 30-60 years) (p=0.096). 43.6% were directly admitted to hospital care.CART analysis identified the variables oxygen saturation (<95%), dyspnoea and history of cardiovascular (CV) disease to distinguish between high and low-risk groups. If all three variables were negative, most patients were discharged from ED, and the incidence of the clinical endpoint was 0%. The validation cohort confirmed the safety of discharge using these variables and revealed an incidence of the clinical endpoint from 14.3% in patients with CV disease, 9.4% in patients with dyspnoea and 18.2% in patients with O₂ satuaration below 95%.

Conclusions

Based on easily available variables like dyspnoea, oxygen saturation, history of CV disease, approximately 25% of patients subsequently confirmed with COVID-19 can be identified for safe discharge.

Trial registration number

DRKS00023117.

SUBMITTER: Mockel M

PROVIDER: S-EPMC8015792 | biostudies-literature |

REPOSITORIES: biostudies-literature

ACCESS DATA

Similar Datasets

Project description:Following emergency department (ED) assessment, patients with infection may be directly admitted to the intensive care unit (ICU) or alternatively admitted to hospital wards or sent home. Those admitted to the hospital wards or sent home may experience future deterioration necessitating ICU admission.We used a prospectively collected registry from two hospitals within a single tertiary care hospital network between 2011 and 2014. Patient information, outcomes, and costs were stored in the hospital data warehouse. Patients were categorized into three groups: (1) admitted directly from the ED to the ICU; (2) initially admitted to the hospital wards, with ICU admission within 72 hours of initial presentation; or (3) sent home from the ED, with ICU admission within 72 hours of initial presentation. Using multivariable logistic regression, we sought to compare outcomes and total costs between groups. Total costs were evaluated using a generalized linear model.A total of 657 patients were included; of these, 338 (51.4%) were admitted directly from the ED to the ICU, 246 (37.4%) were initially admitted to the wards and then to the ICU, and 73 (11.1%) were initially sent home and then admitted to the ICU. In-hospital mortality was lowest among patients admitted directly to the ICU (29.5%), as compared with patients admitted to the ICU from wards (42.7%) or home (61.6%) (P?<?0.001). As compared with direct ICU admission, disposition to the ward was associated with an adjusted OR of 1.75 (95% CI, 1.22-2.50; P?<?0.01) for mortality, and disposition home was associated with an adjusted OR of 4.02 (95% CI, 2.32-6.98). Mean total costs were lowest among patients directly admitted to the ICU ($26,748), as compared with those admitted from the wards ($107,315) and those initially sent home ($71,492) (P?<?0.001). Cost per survivor was lower among patients directly admitted to the ICU ($37,986) than either those initially admitted to the wards ($187,230) or those sent home ($186,390) (P?<?0.001).In comparison with direct admission to the ICU, patients with suspected infection admitted to the ICU who have previously been discharged home or admitted to the ward are associated with higher in-hospital mortality and costs.

Project description:IntroductionThe COVID-19 pandemic compelled health systems to protect patients and medical personnel during transit in hospitals by minimising transfers, prompting the use of telehealth systems. In the field of neurology, telemedicine has been used in emergency settings for acute stroke management between spoke and hub hospital networks, where good outcomes have been achieved. However, data on the use of telemedicine in non-stroke acute neurological conditions accessing the emergency department (ED) are currently missing.Methods and analysesThis is an interventional, open-label trial on the use of teleconsultation in the ED for neurological diseases other than stroke. The study aims to develop a remote consultancy system (TeleNeurological Evaluation and Support, TeleNS) for patients with acute neurological symptoms referred to hospital facilities without a 24-hour availability of a neurologist consultant (spoke hospitals). The study population will include 100 ED patients referred to two spoke hospitals in 6 months, who will be asked to perform teleconsultation instead of inperson visits. As a control group, retrospectively available data from patients admitted to the ED of spoke hospitals during the same time period over the last 2 years will be evaluated. The primary objective is to assess whether a TeleNS for the ED guarantees a faster but qualitatively non-inferior diagnostic/therapeutic work-up if compared with inperson examination, assuring the availability of all the necessary examinations and treatments with consistent time-saving.Ethics and disseminationThe trial was designed following the national guidelines on clinical investigation on telemedicine provided by the Italian Ministry of Health and according to the Standard Protocol Items for Randomized Trials statement guidelines. This research protocol was approved by Comitato Etico Area Vasta Emilia Nord in September 2020 (number/identification: 942/2020/DISP/AOUMO SIRER ID 805) and was written without patient involvement. Patients' associations will be involved in the dissemination of study design and results. The results of the study will be presented during scientific symposia or published in scientific journals.Trial registration numberNCT04611295.

Project description:ObjectiveThe objective of this qualitative study is to gauge physician sentiment about an emergency department (ED) clinical decision support (CDS) system implemented in multiple adult EDs within a university hospital system. This CDS system focuses on predicting patients' likelihood of ED recidivism and/or adverse opioid-related events.MethodsThe study was conducted among adult emergency physicians working in three EDs of a single academic health system in Rhode Island. Qualitative, semistructured interviews were conducted with ED physicians. Interviews assessed physicians' prior experience with predictive analytics, thoughts on the alert's placement, design, and content, the alert's overall impact, and potential areas for improvement. Responses were aggregated and common themes identified.ResultsTwenty-three interviews were conducted (11 preimplementation and 12 postimplementation). Themes were identified regarding each physician familiarity with predictive analytics, alert rollout, alert appearance and content, and on alert sentiments. Most physicians viewed these alerts as a neutral or positive EHR addition, with responses ranging from neutral to positive. The alert placement was noted to be largely intuitive and nonintrusive. The design of the alert was generally viewed positively. The alert's content was believed to be accurate, although the decision to respond to the alert's call-to-action was physician dependent. Those who tended to ignore the alert did so for a few reasons, including already knowing the information the alert contains, the alert offering information that is not relevant to this particular patient, and the alert not containing enough information to be useful.ConclusionUltimately, this alert appears to have a marginally positive effect on ED physician workflow. At its most beneficial, the alert reminded physicians to deeply consider the care provided to high-risk populations and to potentially adjust their care and referrals. At its least beneficial, the alert did not affect physician decision-making but was not intrusive to the point of negatively impacting workflow.

Project description:ObjectiveTo map the physician approach when determining disposition for a patient who presents without the level of definite medical acuity that would generally warrant hospitalisation.Data sources/study settingSince 2018, our US academic county hospital/trauma centre has maintained a database in which hospitalists ('triage physicians') document the rationale and outcomes of requests for admission to the acute care medical ward during each shift.Study designNarrative text from the database was analysed using a grounded theory approach to identify major themes and subthemes, and a conceptual model of the admission decision-making process was constructed.ParticipantsDatabase entries were included (n=300) if the admission call originated from the emergency department and if the triage physician characterised the request as potentially inappropriate because the patient did not have definite medical acuity.ResultsAdmission decision making occurs in three main phases: evaluation of unmet needs, assessment of risk and re-evaluation. Importantly, admission decision making is not solely based on medical acuity or clinical algorithms, and patients without a definite medical need for admission are hospitalised when physicians believe a potential issue exists if discharged. In this way, factors such as homelessness, substance use disorder, frailty, etc, contribute to admission because they raise concern about patient safety and/or barriers to appropriate treatment. Physician decision making can be altered by activities such as care coordination, advocacy by the patient or surrogate, interactions with other physicians or a change in clinical trajectory.ConclusionsThe decision to admit ultimately remains a clinical determination constructed between physician and patient. Physicians use a holistic process that incorporates broad consideration of the patient's medical and social needs with emphasis on risk assessment; thus, any analysis of hospitalisation trends or efforts to impact such should seek to understand this individual-level decision making.

Project description:ImportanceFatal human rabies infections can be prevented through appropriate rabies postexposure prophylaxis (PEP). Errors in patient selection and administration of human rabies immune globulin in the emergency department (ED) setting were identified in a previous study of rabies PEP administration.ObjectiveTo test the a priori hypothesis that implementation of a rabies PEP bundle in the ED would improve full adherence to 6 human rabies immune globulin quality indicators compared with preimplementation controls.Design, setting, and participantsThis quality improvement study was conducted in 15 EDs in a US multihospital health system. Patients who received human rabies immune globulin or rabies vaccine in the ED from January 2015 to June 2018 were included in the preimplementation control group and from December 2019 to November 2020 were included in the postimplementation intervention group. Data were analyzed in January 2021.ExposureThe PEP bundle was implemented in December 2019 and consisted of electronic health record enhancements, including clinical decision support, ED staff education, and patient education.Main outcomes and measuresFull adherence to 6 human rabies immune globulin quality indicators: patient selection, dose, timing, infiltration into wounds, administration distant from rabies vaccine site, and administration that avoids the buttock.ResultsThe study included 324 patients; 254 patients were in preimplementation group (mean [SD] age, 39 [21] years; 135 [53%] women) and 70 in the postimplementation group (mean [SD] age, 38 [19] years; 33 [47%] women). Most patients presented to EDs embedded in a community hospital (231 patients [71%]). Full adherence increased from 37% in the preimplementation group to 61% postimplementation (absolute increase, 24%; 95% CI, 11% to 37%; P < .001). Adherence improved for quality indicators for infiltration into wounds (137 of 254 patients [54%] to 50 of 70 patients [71%]; P = .009), administration distant from rabies vaccine site (180 of 254 [71%] to 58 of 70 [83%]; P = .04), and administration that avoids the buttock (168 of 254 [66%] to 58 of 70 [83%]; P = .007). No instances of sciatic nerve injury or compartment syndrome were observed.Conclusions and relevanceIn this quality improvement study, implementation of a rabies PEP bundle was associated with improved patient selection and delivery of human rabies immune globulin in EDs across a multihospital health system. Although the bundle included ED staff education and patient discharge education, the observed improvement was likely driven by clinical decision support from the rabies PEP ED order set. Future research should evaluate implementation of this clinical decision support at other health systems.

Project description:ObjectiveAdoption of clinical decision support (CDS) tools by clinicians is often limited by workflow barriers. We sought to assess characteristics associated with clinician use of an electronic health record-embedded clinical decision support system (CDSS).MethodsIn a prospective study on emergency department (ED) activation of a CDSS tool across 14 hospitals between 9/1/14 to 4/30/15, the CDSS was deployed at 10 active sites with an on-site champion, education sessions, iterative feedback, and up to 3 gift cards/clinician as an incentive. The tool was also deployed at 4 passive sites that received only an introductory educational session. Activation of the CDSS - which calculated the Pulmonary Embolism Severity Index (PESI) score and provided guidance - and associated clinical data were collected prospectively. We used multivariable logistic regression with random effects at provider/facility levels to assess the association between activation of the CDSS tool and characteristics at: 1) patient level (PESI score), 2) provider level (demographics and clinical load at time of activation opportunity), and 3) facility level (active vs. passive site, facility ED volume, and ED acuity at time of activation opportunity).ResultsOut of 662 eligible patient encounters, the CDSS was activated in 55%: active sites: 68% (346/512); passive sites 13% (20/150). In bivariate analysis, active sites had an increase in activation rates based on the number of prior gift cards the physician had received (96% if 3 prior cards versus 60% if 0, p<0.0001). At passive sites, physicians < age 40 had higher rates of activation (p=0.03). In multivariable analysis, active site status, low ED volume at the time of diagnosis and PESI scores I or II (compared to III or higher) were associated with higher likelihood of CDSS activation.ConclusionsPerforming on-site tool promotion significantly increased odds of CDSS activation. Optimizing CDSS adoption requires active education.