Emergency Department Door-to-Puncture Time Since 2014.
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ABSTRACT:
SUBMITTER: Czap AL
PROVIDER: S-EPMC8225226 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:RationaleEarly antibiotics improve outcomes for patients with sepsis. Factors influencing antibiotic timing in emergency department (ED) sepsis remain unclear.ObjectivesDetermine the relationship between prehospital level of care of patients with sepsis and ED door-to-antibiotic time.MethodsThis retrospective cohort study comprised patients admitted from the community to an academic ED June 2009 to February 2015 with fluid-refractory sepsis or septic shock. Transfer patients and those whose antibiotics began before ED arrival or after ED discharge were excluded. We used multivariable regression to evaluate the association between the time from ED arrival to antibiotic initiation and prehospital level of care, defined as the highest level of emergency medical services received: none, basic life support (BLS) ambulance, or advanced life support (ALS) ambulance. We measured variation in this association when hypotension was or was not present by ED arrival.ResultsAmong 361 community-dwelling patients with sepsis, the level of prehospital care correlated with illness severity. ALS-treated patients received antibiotics faster than patients who did not receive prehospital care (median, 103 [interquartile range, 75 to 135] vs. 144 [98 to 251] minutes, respectively) or BLS-only patients (168 [100-250] minutes; P < 0.001 for each pairwise comparison with ALS). This pattern persisted after multivariable adjustment, where ALS care (-43 min; 95% confidence interval [CI], -84 to -2; P = 0.033) but not BLS-only care (-4 min; 95% CI, -41 to +34; P = 0.97) was associated with less antibiotic delay compared with no prehospital care. ALS-treated patients more frequently received antibiotics within 3 hours of ED arrival (91%) compared with walk-in patients (62%; adjusted odds ratio, 3.11; 95% CI, 1.20 to 8.03; P = 0.015) or BLS-treated patients (56%; adjusted odds ratio, 4.51; 95% CI, 1.89 to 11.35; P < 0.001). ALS-treated patients started antibiotics faster than walk-in patients in the absence of hypotension by ED arrival (-41 min; 95% CI, -110 to -13; P = 0.009) but not when hypotension was present (+25 min; 95% CI, -43 to +92; P = 0.66).ConclusionsPrehospital ALS but not BLS-only care was associated with faster antibiotic initiation for patients with sepsis without hypotension. Process redesign for non-ALS patients may improve antibiotic timeliness for ED sepsis.
| S-EPMC6322022 | biostudies-literature
Project description:ObjectivesTo provide a better understanding of methods that can be used to improve patient outcomes by reducing the door-to-groin puncture (DTP) time and present the results of a stroke quality improvement project (QIP) conducted by Mayo Clinic Arizona's stroke center.MethodsWe conducted a systematic literature search of Ovid MEDLINE(R), Ovid EMBASE, Scopus, and Web of Science for studies that evaluated DTP time reduction strategies. Those determined eligible for the purpose of this analysis were assessed for quality. The strategies for DTP time reduction were categorized on the basis of modified Target: Stroke Phase III recommendations and analyzed using a meta-analysis. The Mayo Clinic QIP implemented a single-call activation system to reduce DTP times by decreasing the time from neurosurgery notification to case start.ResultsFourteen studies were selected for the analysis, consisting of 2277 patients with acute ischemic stroke secondary to large-vessel occlusions. After intervention, all the studies showed a reduction in the DTP time, with the pooled DTP improvement being the standardized mean difference (1.37; 95% confidence interval, 1.20-1.93; τ2=1.09; P<.001). The Mayo Clinic QIP similarly displayed a DTP time reduction, with the DTP time dropping from 125.1 to 82.5 minutes after strategy implementation.ConclusionComputed tomography flow modifications produced the largest and most consistent reduction in the DTP time. However, the reduction in the DTP time across all the studies suggests that any systematic protocol aimed at reducing the DTP time can produce a beneficial effect. The relative novelty of mechanical thrombectomy and the consequential lack of research call for future investigation into the efficacy of varying DTP time reduction strategies.
| S-EPMC9253412 | biostudies-literature
Project description:Background and Purpose- Endovascular thrombectomy (ET) door-to-puncture time (DTPT) is a modifiable metric. One of the most important, yet time-consuming steps, is documentation of large vessel occlusion by computed tomography angiography (CTA). We hypothesized that obtaining CTA on board a Mobile Stroke Unit and direct alert of the ET team shortens DTPT by over 30 minutes. Methods- We compared DTPT between patients having CTA onboard the Mobile Stroke Unit then subsequent ET from September 2018 to November 2019 and patients in Mobile Stroke Unit from August 2014 to August 2018, when onboard CTA was not yet being used. We also correlated DTPT with change in National Institutes of Health Stroke Scale between baseline and 24 hours. Results- Median DTPT was 53.5 (95% CI, 35-67) minutes shorter with onboard CTA and direct ET team notification: 41 minutes (interquartile range, 30.0-63.5) versus 94.5 minutes (interquartile range, 69.8-117.3; P<0.001). Median on-scene time was 31.5 minutes (interquartile range, 28.8-35.5) versus 27.0 minutes (interquartile range, 23.0-31.0) (P<0.001). Shorter DTPT correlated with greater improvement of National Institutes of Health Stroke Scale (correlation=-0.2, P=0.07). Conclusions- Prehospital Mobile Stroke Unit management including on-board CTA and ET team alert substantially shortens DTPT. Registration- URL: https://clinicaltrials.gov; Unique identifier: NCT02190500.
| S-EPMC7188560 | biostudies-literature
Project description:BACKGROUND:Prompt sepsis treatment is associated with improved outcomes but requires a complex series of actions by multiple clinicians. We investigated whether simply reorganizing emergency department (ED) care to expedite patients' initial evaluation was associated with shorter sepsis door-to-antibiotic times. METHODS:Patients eligible for this retrospective study received IV antibiotics and demonstrated acute organ failure after presenting to one of three EDs in Utah. On May 1, 2016, the intervention ED instituted "swarming" as the default model for initial evaluation of all mid- and low-acuity patients. Swarming involved simultaneous patient evaluation by the ED physician, nurse, and technician followed by a team discussion of the initial care plan. Care was unchanged at the two control EDs. A 30-day wash-in period separated the baseline (May 16, 2015 to April 15, 2016) and post-intervention (May 16, 2016 to November 15, 2016) analysis periods. We conducted a quasi-experimental analysis comparing door-to-antibiotic time for sepsis patients at the intervention ED after versus before care reorganization, applying difference-in-differences methods to control for trends in door-to-antibiotic time unrelated to the studied intervention and multivariable regression to adjust for patient characteristics. RESULTS:The analysis included 3,230 ED sepsis patients, including 1,406 from the intervention ED. Adjusted analyses using difference-in-differences methods to control for temporal trends unrelated to the studied intervention revealed no significant change in door-to-antibiotic time after care reorganization (-7 minutes, 95% CI -20 to 6 minutes, p = 0.29). Multivariable pre/post analyses using data only from the intervention ED overestimated the magnitude and statistical significance of outcome changes associated with ED care reorganization. CONCLUSIONS:Implementation of an ED care model involving parallel multidisciplinary assessment and early team discussion of the care plan was not associated with improvements in mid- and low-acuity sepsis patients' door-to-antibiotic time after accounting for changes in the outcome unrelated to the studied intervention.
| S-EPMC7199941 | biostudies-literature
Project description:Door-to-balloon (DTB) time significantly affects the prognosis of patients with ST-segment elevation myocardial infarction (STEMI). The effects of temporal differences in emergency department (ED) arrival time on DTB time and on different segments of DTB time remain inconclusive. Therefore, we performed a retrospective study in a tertiary hospital between January 2013 and December 2021 and investigated the relationship between a patient's arrival time and both their DTB time and different segments of their DTB time. Of 732 STEMI patients, 327 arrived during the daytime (08:01-16:00), 268 during the evening (16:01-24:00), and 137 at night (00:01-08:00). Significantly higher odds of delay in DTB time were observed during the nighttime (adjusted odds ratio (aOR): 2.87; 95% confidence interval (CI): 1.50-5.51, p = 0.002) than during the daytime. This delay was mainly attributed to a delay in cardiac catheterization laboratory (cath lab) activation-to-arrival time (aOR: 6.25; 95% CI: 3.75-10.40, p < 0.001), particularly during the 00:00-04:00 time range. Age, sex, triage level, and whether patients arrived during the COVID-19 pandemic also had independent effects on different segments of DTB time. Further studies are required to investigate the root causes of delay in DTB time and to develop specific strategies for improvement.
| S-EPMC10059039 | biostudies-literature
Project description:Background:Canadian Emergency Departments (EDs) have seen increasing use by children and youth for mental health concerns in recent years. This trend is likely a result of several complex factors, and researcher-posed potential explanations include gaps or access problems in primary care or mental health services, increasing prevalence or awareness of mental disorders and fear of potentially harmful outcomes, or expectations of need for urgent specialist care. Youth, parent, or caregiver perceptions and reasons for increasing mental health ED use may differ, and to date have been underrepresented in informing research directions. We sought to engage with youth and parents or caregivers served by a Canadian tertiary paediatric health centre to: 1) inform research directions for an emerging program of research in child and youth ED use for mental health care; and 2) develop strategies to support ongoing patient engagement in our research. Methods:Youth and parents were consulted to inform the development of a research engagement strategy. Partnerships with local community agencies facilitated supported engagement with both youth and parents. Group and individual in-person engagement opportunities were offered, as well as opportunities for written submissions and information sharing. Results:Youth and parents identified specific mechanisms to support engagement and for sharing ongoing opportunities and progress, including providing multiple platforms for engagement, offering separate opportunities for youth and parents or caregivers, and minimizing the potential for distress by ensuring appropriate supports and providing alternative opportunities for feedback, including written submissions. They identified lack of timely access to mental health care in primary care and community mental health settings, and accessibility, dependability, and familiarity of the ED as areas for further research. Conclusions:Strategies to mitigate potential concerns regarding distress, readiness for participation, literacy, and protection of privacy were highlighted as important considerations. Youth and parents were interested in ongoing research engagement through consultation and information sharing. Youth and parents identified areas of interest for research and refined the research team's proposed research directions by adding contextualizing information. Trial registration:Not applicable.
| S-EPMC7251901 | biostudies-literature
Project description:ObjectiveThe aims of this study were to describe overcrowding in regional emergency departments in Seoul, Korea and evaluate the effect of crowdedness on ambulance turnaround time.MethodsThis study was conducted between January 2010 and December 2010. Patients who were transported by 119-responding ambulances to 28 emergency centers within Seoul were eligible for enrollment. Overcrowding was defined as the average occupancy rate, which was equal to the average number of patients staying in an emergency department (ED) for 4 hours divided by the number of beds in the ED. After selecting groups for final analysis, multi-level regression modeling (MLM) was performed with random-effects for EDs, to evaluate associations between occupancy rate and turnaround time.ResultsBetween January 2010 and December 2010, 163,659 patients transported to 28 EDs were enrolled. The median occupancy rate was 0.42 (range: 0.10-1.94; interquartile range (IQR): 0.20-0.76). Overcrowded EDs were more likely to have older patients, those with normal mentality, and non-trauma patients. Overcrowded EDs were more likely to have longer turnaround intervals and traveling distances. The MLM analysis showed that an increase of 1% in occupancy rate was associated with 0.02-minute decrease in turnaround interval (95% CI: 0.01 to 0.03). In subgroup analyses limited to EDs with occupancy rates over 100%, we also observed a 0.03 minute decrease in turnaround interval per 1% increase in occupancy rate (95% CI: 0.01 to 0.05).ConclusionsIn this study, we found wide variation in emergency department crowding in a metropolitan Korean city. Our data indicate that ED overcrowding is negatively associated with turnaround interval with very small practical significance.
| S-EPMC4482653 | biostudies-literature
Project description:Importance:The Patient Protection and Affordable Care Act of 2010 brought attention to adverse drug events in national patient safety efforts. Updated, detailed, nationally representative data describing adverse drug events can help focus these efforts. Objective:To describe the characteristics of emergency department (ED) visits for adverse drug events in the United States in 2013-2014 and describe changes in ED visits for adverse drug events since 2005-2006. Design, Setting, and Participants:Active, nationally representative, public health surveillance in 58 EDs located in the United States and participating in the National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance project. Exposures:Drugs implicated in ED visits. Main Outcomes and Measures:National weighted estimates of ED visits and subsequent hospitalizations for adverse drug events. Results:Based on data from 42?585 cases, an estimated 4.0 (95% CI, 3.1-5.0) ED visits for adverse drug events occurred per 1000 individuals annually in 2013 and 2014 and 27.3% (95% CI, 22.2%-32.4%) of ED visits for adverse drug events resulted in hospitalization. An estimated 34.5% (95% CI, 30.3%-38.8%) of ED visits for adverse drug events occurred among adults aged 65 years or older in 2013-2014 compared with an estimated 25.6% (95% CI, 21.1%-30.0%) in 2005-2006; older adults experienced the highest hospitalization rates (43.6%; 95% CI, 36.6%-50.5%). Anticoagulants, antibiotics, and diabetes agents were implicated in an estimated 46.9% (95% CI, 44.2%-49.7%) of ED visits for adverse drug events, which included clinically significant adverse events, such as hemorrhage (anticoagulants), moderate to severe allergic reactions (antibiotics), and hypoglycemia with moderate to severe neurological effects (diabetes agents). Since 2005-2006, the proportions of ED visits for adverse drug events from anticoagulants and diabetes agents have increased, whereas the proportion from antibiotics has decreased. Among children aged 5 years or younger, antibiotics were the most common drug class implicated (56.4%; 95% CI, 51.8%-61.0%). Among children and adolescents aged 6 to 19 years, antibiotics also were the most common drug class implicated (31.8%; 95% CI, 28.7%-34.9%) in ED visits for adverse drug events, followed by antipsychotics (4.5%; 95% CI, 3.3%-5.6%). Among older adults (aged ?65 years), 3 drug classes (anticoagulants, diabetes agents, and opioid analgesics) were implicated in an estimated 59.9% (95% CI, 56.8%-62.9%) of ED visits for adverse drug events; 4 anticoagulants (warfarin, rivaroxaban, dabigatran, and enoxaparin) and 5 diabetes agents (insulin and 4 oral agents) were among the 15 most common drugs implicated. Medications to always avoid in older adults according to Beers criteria were implicated in 1.8% (95% CI, 1.5%-2.1%) of ED visits for adverse drug events. Conclusions and Relevance:The prevalence of emergency department visits for adverse drug events in the United States was estimated to be 4 per 1000 individuals in 2013 and 2014. The most common drug classes implicated were anticoagulants, antibiotics, diabetes agents, and opioid analgesics.
| S-EPMC6490178 | biostudies-literature
Project description:ObjectiveTelemedicine is used by emergency departments (EDs) to connect patients with specialty consultation and resources not available locally. Despite its utility, uptake of telemedicine in EDs has varied. We studied characteristics associated with telemedicine adoption during a 4-year period.MethodsWe analyzed data from the 2014 National Emergency Department Inventory (NEDI)-New England survey and follow-up data from 2016 and 2017 NEDI-USA and 2018 NEDI-New England surveys, with data from the Center for Connected Health Policy. Among EDs not using telemedicine in 2014, we examined characteristics associated with adoption by 2018.ResultsOf the 159 New England EDs with available data, 80 (50%) and 125 (79%) reported telemedicine receipt in 2014 and 2018, respectively. Among the 79 EDs without telemedicine in 2014, academic EDs were less likely to adopt by 2018 (odds ratio, 0.12; 95% confidence interval, 0.03-0.46). State policy environment was not associated with likelihood of adoption. In 2018, all 7 freestanding EDs received telemedicine, whereas only 1 of 9 academic EDs (11%) did.ConclusionsTelemedicine use by EDs continues to grow rapidly and by 2018, >3 quarters of EDs in our sample were receiving telemedicine. From 2014 to 2018, the initiation of telemedicine receipt was less common among higher volume and academic EDs.
| S-EPMC7771831 | biostudies-literature
Project description:ObjectiveTo understand the prevalence of child maltreatment-related emergency department (ED) visits in the United States, we examined data from the 2007 to 2014 Nationwide Emergency Department Sample.MethodsBased on existing literature, International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9 CM) ED discharge codes for children less than 10 years of age were characterized as specified child maltreatment, defined as visits with an explicit maltreatment ICD-9 CM or external causes of injury codes. The prevalence of child maltreatment visits per 100,000 children in the United States (based on Center for Disease Control Wide-ranging ONline Data for Epidemiologic Research estimates) overall and by sociodemographic factors was examined, and tests for trends over time were evaluated with Cochran-Armitage tests. Analyses were conducted in 2019.ResultsThe prevalence of child maltreatment based in ICD-9 CM discharge codes ED visits dropped from 69.2 visits per 100,000 in 2007 to 65.9 visits per 100,000 in 2014; this trend was statistically significant. The prevalence was lowest in 2010 (60.1 visits per 100,000 children). There were increases observed for some demographic groups in this period. Throughout the 8-year period examined, the prevalence of child maltreatment visits was highest for physical abuse compared with other forms of maltreatment, higher for boys compared with girls; highest for children younger than 1 year, and higher for children living in neighborhoods with the lowest median income compared with children in higher-income neighborhoods.ConclusionsThe Nationwide Emergency Department Sample data set is a valuable surveillance tool for examining trends in child maltreatment. Future studies should explore what factors may explain variations in child maltreatment over time to best develop prevention strategies.
| S-EPMC9347219 | biostudies-literature