scholarly journals Can an emergency department clinical “triggers” program based on abnormal vital signs improve patient outcomes?

CJEM ◽  
2016 ◽  
Vol 19 (04) ◽  
pp. 249-255 ◽  
Author(s):  
Jason Imperato ◽  
Tyler Mehegan ◽  
Daniel J. Henning ◽  
John Patrick ◽  
Chase Bushey ◽  
...  
Keyword(s):  
Emergency Department ◽  
Inpatient Care ◽  
Rapid Assessment ◽  
Vital Signs ◽  
Special Care ◽  
Special Care Unit ◽  
Post Intervention ◽  
Care Level ◽  
Inpatient Outcomes ◽  
Improve Patient

AbstractBackgroundBecause abnormal vital signs indicate the potential for clinical deterioration, it is logical to make emergency physicians immediately aware of those patients who present with abnormal vital signs.ObjectivesTo determine if a clinical triggers program in the emergency department (ED) setting that utilized predetermined abnormal vital signs to activate a rapid assessment by an emergency physician-led multidisciplinary team had a measurable effect on inpatient hospital metrics.MethodsThe study design was a retrospective pre and post intervention study. The intervention was the implementation of an ED clinical “triggers” program. Abnormal vital sign criteria that warranted a trigger response included: heart rate <40 beats/minute or>130 beats/minutes, respiratory rate <8 breaths/minute or>30 breaths/minute, systolic blood pressure <90 mm Hg, or oxygen saturation <90% on room air. The primary outcome investigated was the median days admitted with secondary outcomes of median days in special care unit, in-hospital 30-day mortality and proportion of patients who required an upgrade in inpatient care level.ResultsThere was no difference in median days admitted for inpatient care (3.8 v. 4.0 days,p=0.21) or median days spent in a special care unit (5.0 v. 5.6 days,p=0.42) between the groups. There was no difference in the percentage of in-hospital patient deaths (6.0% v. 5.6%,p=0.66) or frequency of upgrade in level of care within 24 hours (4.9% v. 4.0%,p=0.52).ConclusionsIn our study, the implementation of an ED clinical triggers program did not result in a significant change in measured inpatient outcomes.

scholarly journals Can an emergency department clinical “triggers” program based on abnormal vital signs improve patient outcomes? – CORRIGENDUM

CJEM ◽  
2016 ◽  
Vol 19 (1) ◽  
pp. 80-80
Author(s):  
Jason Imperato ◽  
Tyler Mehegan ◽  
Daniel J. Henning ◽  
John Patrick ◽  
Chase Bushey ◽  
...  
Keyword(s):  
Emergency Department ◽  
Patient Outcomes ◽  
Vital Signs ◽  
Improve Patient

scholarly journals High burden of cryptococcal antigenemia and meningitis among patients presenting at an emergency department in Maputo, Mozambique

PLoS ONE ◽  
2021 ◽  
Vol 16 (4) ◽  
pp. e0250195
Author(s):  
Robert Deiss ◽  
Carolina V. Loreti ◽  
Ana G. Gutierrez ◽  
Eudoxia Filipe ◽  
Milton Tatia ◽  
...  
Keyword(s):  
Emergency Department ◽  
Cryptococcal Meningitis ◽  
Screening Program ◽  
Point Of Care ◽  
Rapid Assessment ◽  
Vital Signs ◽  
Cd4 Count ◽  
Sub Saharan Africa ◽  
Induction Treatment ◽  
Cryptococcal Antigen

Background Cryptococcal meningitis is a leading cause of HIV-related mortality in sub-Saharan Africa, however, screening for cryptococcal antigenemia has not been universally implemented. As a result, data concerning cryptococcal meningitis and antigenemia are sparse, and in Mozambique, the prevalence of both are unknown. Methods We performed a retrospective analysis of routinely collected data from a point-of-care cryptococcal antigen screening program at a public hospital in Maputo, Mozambique. HIV-positive patients admitted to the emergency department underwent CD4 count testing; those with pre-defined abnormal vital signs or CD4 count ≤ 200 cells/μL received cryptococcal antigen testing and lumbar punctures if indicated. Patients with CM were admitted to the hospital and treated with liposomal amphotericin B and flucytosine; their 12-week outcomes were ascertained through review of medical records or telephone contact by program staff made in the routine course of service delivery. Results Among 1,795 patients screened for cryptococcal antigenemia between March 2018—March 2019, 134 (7.5%) were positive. Of patients with cryptococcal antigenemia, 96 (71.6%) were diagnosed with CM, representing 5.4% of all screened patients. Treatment outcomes were available for 87 CM patients: 24 patients (27.6%) died during induction treatment and 63 (72.4%) survived until discharge; of these, 38 (60.3%) remained in care, 9 (14.3%) died, and 16 (25.3%) were lost-to follow-up at 12 weeks. Conclusions We found a high prevalence of cryptococcal antigenemia and meningitis among patients screened at an emergency department in Maputo, Mozambique. High mortality during and after induction therapy demonstrate missed opportunities for earlier detection of cryptococcal antigenemia, even as point-of-care screening and rapid assessment in an emergency room offer potential to improve outcomes.

Bed downtime: the novel use of a quality metric allows inpatient providers to improve patient flow from the emergency department

2021 ◽  
pp. emermed-2020-209425
Author(s):  
Benjamin Bodnar ◽  
Erin M Kane ◽  
Hetal Rupani ◽  
Henry Michtalik ◽  
Veena G Billioux ◽  
...  
Keyword(s):  
Emergency Department ◽  
System Analysis ◽  
Patient Flow ◽  
Tertiary Care ◽  
High Yield ◽  
Process Time ◽  
Academic Medical Centre ◽  
Inpatient Outcomes ◽  
Discharge Patterns ◽  
Improve Patient

BackgroundEmergency department (ED) boarding time is associated with increased length of stay (LOS) and inpatient mortality. Despite the documented impact of ED boarding on inpatient outcomes, a disparity continues to exist between the attention paid to the issue by inpatient and ED providers. A perceived lack of high yield strategies to address ED boarding from the perspective of the inpatient provider may discourage involvement in improvement initiatives on the subject. As such, further work is needed to identify inpatient metrics and strategies to address patient flow problems, and which may improve ED boarding time.MethodsAfter initial system analysis, our multidisciplinary quality improvement (QI) group defined the process time metric ‘bed downtime’—the time from which a bed is vacated by a discharged patient to the time an ED patient is assigned to that bed. Using the Lean Sigma QI approach, this metric was targeted for improvement on the internal medicine hospitalist service at a tertiary care academic medical centre.InterventionsInterventions included improving inpatient provider awareness of the problem, real-time provider notification of empty beds, a weekly retrospective emailed performance dashboard and the creation of a guideline document for admission procedures.ResultsThis package of interventions was associated with a 125 min reduction in mean bed downtime for incoming ED patients (254 min to 129 min) admitted to the intervention unit.ConclusionUse of the bed downtime metric as a QI target was associated with marked improvements in process time during our project. The use of this metric may enhance the ability of inpatient providers to participate in QI efforts to improve patient flow from the ED. Further study is needed to determine if use of the metric may be effective at reducing boarding time without requiring alterations to LOS or discharge patterns.

scholarly journals 986. Improvement in Administration of HIV Post-Exposure Prophylaxis in the Emergency Department Following Sexual Assault

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S521-S522
Author(s):  
Jennifer R Silva-Nash ◽  
Stacie Bordelon ◽  
Ryan K Dare ◽  
Sherrie Searcy
Keyword(s):  
Emergency Department ◽  
Sexual Assault ◽  
Hiv Transmission ◽  
Post Exposure Prophylaxis ◽  
Intervention Period ◽  
Post Intervention ◽  
Post Exposure ◽  
Assault Victims ◽  
Exposure Prophylaxis

Abstract Background Nonoccupational post exposure prophylaxis (nPEP) following sexual assault can prevent HIV transmission. A standardized Emergency Department (ED) protocol for evaluation, treatment, and follow up for post assault victims was implemented to improve compliance with CDC nPEP guidelines. Methods A single-center observational study of post sexual assault patients before/after implementation of an ED nPEP protocol was conducted by comparing the appropriateness of prescriptions, labs, and necessary follow up. A standardized order-set based on CDC nPEP guidelines, with involvement of an HIV pharmacist and ID clinic, was implemented during the 2018-2019 academic year. Clinical data from pre-intervention period (07/2016-06/2017) was compared to post-intervention period (07/2018-08/2019) following a 1-year washout period. Results During the study, 147 post-sexual assault patients (59 Pre, 88 Post) were included. One hundred thirty-three (90.4%) were female, 68 (46.6%) were African American and 133 (90.4%) were candidates for nPEP. Median time to presentation following assault was 12.6 hours. nPEP was offered to 40 (67.8%) and 84 (95.5%) patients (P< 0.001) and ultimately prescribed to 29 (49.2%) and 71 (80.7%) patients (P< 0.001) in pre and post periods respectively. Renal function (37.3% vs 88.6%; P< 0.001), pregnancy (39.0% vs 79.6%; P< 0.001), syphilis (3.4% vs 89.8%; P< 0.001), hepatitis B (15.3% vs 95.5%; P< 0.001) and hepatitis C (27.1% vs 94.3%) screening occurred more frequently during the post period. Labratory, nPEP Prescription and Follow up Details for Patients Prescribed nPEP Conclusion The standardization of an nPEP ED protocol for sexual assault victims resulted in increased nPEP administration, appropriateness of prescription, screening for other sexually transmitted infectious and scheduling follow up care. While guideline compliance dramatically improved, further interventions are likely warranted in this vulnerable population. Disclosures Ryan K. Dare, MD, MS, Accelerate Diagnostics, Inc (Research Grant or Support)

scholarly journals Development and validation of an early warning tool for sepsis and decompensation in children during emergency department triage

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Louis Ehwerhemuepha ◽  
Theodore Heyming ◽  
Rachel Marano ◽  
Mary Jane Piroutek ◽  
Antonio C. Arrieta ◽  
...  
Keyword(s):  
Emergency Department ◽  
Severe Sepsis ◽  
Early Warning ◽  
Characteristic Curve ◽  
Vital Signs ◽  
Warning System ◽  
Receiver Operator Characteristic Curve ◽  
Warning Signs ◽  
Gradient Boosting ◽  
Stochastic Gradient Boosting

AbstractThis study was designed to develop and validate an early warning system for sepsis based on a predictive model of critical decompensation. Data from the electronic medical records for 537,837 visits to a pediatric Emergency Department (ED) from March 2013 to December 2019 were collected. A multiclass stochastic gradient boosting model was built to identify early warning signs associated with death, severe sepsis, non-severe sepsis, and bacteremia. Model features included triage vital signs, previous diagnoses, medications, and healthcare utilizations within 6 months of the index ED visit. There were 483 patients who had severe sepsis and/or died, 1102 had non-severe sepsis, 1103 had positive bacteremia tests, and the remaining had none of the events. The most important predictors were age, heart rate, length of stay of previous hospitalizations, temperature, systolic blood pressure, and prior sepsis. The one-versus-all area under the receiver operator characteristic curve (AUROC) were 0.979 (0.967, 0.991), 0.990 (0.985, 0.995), 0.976 (0.972, 0.981), and 0.968 (0.962, 0.974) for death, severe sepsis, non-severe sepsis, and bacteremia without sepsis respectively. The multi-class macro average AUROC and area under the precision recall curve were 0.977 and 0.316 respectively. The study findings were used to develop an automated early warning decision tool for sepsis. Implementation of this model in pediatric EDs will allow sepsis-related critical decompensation to be predicted accurately after a few seconds of triage.

Intervention of companion clowns in a special care unit: a 1-year pilot study

2021 ◽  
Author(s):  
Adélaide De Mauleon ◽  
Anne Lelievre ◽  
Sophie Hermabessiere ◽  
Yves Rolland
Keyword(s):  
Pilot Study ◽  
Special Care ◽  
Special Care Unit

scholarly journals 688 Rapid Implementation of Virtual Fracture Clinic During COVID 19 Reduces Both Face-To-Face Appointments and Facilitates Rapid Feedback and Education to Be Delivered to The Emergency Department

2021 ◽  
Vol 108 (Supplement_2) ◽  
Author(s):  
T Havenhand ◽  
L Hoggett ◽  
A Bhutta
Keyword(s):  
Emergency Department ◽  
Patient Flow ◽  
Prospective Data ◽  
Fracture Clinic ◽  
Face To Face ◽  
Return Rates ◽  
Acute Hospitals ◽  
Virtual Fracture Clinic ◽  
Improve Patient

Abstract Introduction COVID-19 has dictated a shift towards virtual clinics. Pennine Acute Hospitals NHS Trust serves over a million patients with a significant number of face-to-face fracture clinics. Introduction of a Virtual Fracture Clinic (VFC) reduces hospital return rates and improves patient experience. The referral data can be used to give immediate monthly feedback to the referring department to further improving patient flow. Method Prospective data was collected for all referrals to VFC during March 2020. Data included referral diagnosis, actual diagnosis, referrers grade, and final outcome. Results 630 referrals were made to VFC. 347 (55%) of those referrals were directly discharged without the need for physical consultation. Of these 114 (32%) were injuries which can be discharged by the Emergency Department with an advice leaflet using existing pathways. Of the remaining discharges 102 (29%) were query fractures or sprains; and 135 (39%) were minor fractures; which needed only advice via a letter and no face to face follow up. Conclusions Implementation of VFC leads to a decrease in physical appointments by 55% saving 347 face to face appointments. The new system has also facilitated effective audit of referrals in order to further improve patient flow from the Emergency Department via feedback mechanisms and education.

scholarly journals 1120. Impact of Training Residents to Improve HIV Screening in a Teaching Hospital in Mexico City

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S590-S590
Author(s):  
Lorena Guerrero-Torres ◽  
Isaac Núñez-Saavedra ◽  
Yanink Caro-Vega ◽  
Brenda Crabtree-Ramírez
Keyword(s):  
Emergency Department ◽  
Time Series ◽  
Hiv Testing ◽  
Teaching Hospital ◽  
Educational Intervention ◽  
Temporal Trends ◽  
Hiv Screening ◽  
Hiv Diagnosis ◽  
Post Intervention ◽  
Hiv Test

Abstract Background Among 230,000 people living with HIV in Mexico, 24% are unaware of their diagnosis, and half of newly diagnosed individuals are diagnosed with advanced disease. Early diagnosis is the goal to mitigate HIV epidemic. Missed opportunities may reflect a lack of clinicians’ consideration of HIV screening as part of routine medical care. We assessed whether an educational intervention on residents was effective to 1) improve the knowledge on HIV screening; 2) increase the rate of HIV tests requested in the hospitalization floor (HF) and the emergency department (ED); and 3) increase HIV diagnosis in HF and ED. Methods Internal Medicine and Surgery residents at a teaching hospital were invited to participate. The intervention occurred in August 2018 and consisted in 2 sessions on HIV screening with an expert. A questionnaire was applied before (BQ) and after (AQ) the intervention, which included HIV screening indications and clinical cases. The Institutional Review Board approved this study. Written informed consent was obtained from all participants. BQ and AQ scores were compared with a paired t-test. To evaluate the effect on HIV test rate in the HF and ED, an interrupted time series analysis was performed. Daily rates of tests were obtained from September 2016 to August 2019 and plotted along time. Restricted cubic splines (RCS) were used to model temporal trends. HIV diagnosis in HF and ED pre- and post-intervention were compared with a Fisher’s exact test. A p< 0.05 was considered significant. Results Among 104 residents, 57 participated and completed both questionnaires. BQ score was 79/100 (SD±12) and AQ was 85/100 (SD±8), p< .004. Time series of HIV testing had apparent temporal trends (Fig 1). HIV test rate in the HF increased (7.3 vs 11.1 per 100 episodes) and decreased in the ED (2.6 vs 2.3 per 100 episodes). HIV diagnosis increased in the HF, from 0/1079 (0%) pre-intervention to 5/894 (0.6%) post-intervention (p< .018) (Table 1). Fig 1. HIV test rates. Gray area represents post-intervention period. Table 1. Description of episodes, HIV tests and rates pre- and post-intervention in the Emergency Department and Hospitalization Floor. Conclusion A feasible educational intervention improved residents’ knowledge on HIV screening, achieved maintenance of a constant rate of HIV testing in the HF and increased the number of HIV diagnosis in the HF. However, these results were not observed in the ED, where administrative barriers and work overload could hinder HIV screening. Disclosures All Authors: No reported disclosures

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