scholarly journals LO011: Identification of mild acute cerebrovascular syndrome (ACVS) in the emergency department: validation of an ACVS clinical classifier to help distinguish mimics

CJEM ◽  
2016 ◽  
Vol 18 (S1) ◽  
pp. S33-S34
Author(s):  
K. Votova ◽  
A. Penn ◽  
D.R. Harris ◽  
M. Bibok ◽  
M. Lesperance ◽  
...  
Keyword(s):  
Emergency Department ◽  
Clinical Data ◽  
Historical Data ◽  
Treatment Guidelines ◽  
National Guidelines ◽  
Industry Standard ◽  
Abcd2 Score ◽  
Class Labels ◽  
Victoria General Hospital ◽  
Sensitivity Specificity

Introduction: National guidelines (NICE, AHA) for management of Acute Cerebrovascular Syndrome (ACVS) in the Emergency Department (ED) recommend the use of ABCD2 score to risk stratify patients despite its poor specificity and low diagnostic accuracy. The SpecTRA project previously developed a clinical classifier for ACVS vs. Mimic derived from historical clinical data collected during a 5-year period at an outpatient stroke clinic (Victoria, BC). Here we present a prospective evaluation of the performance of our clinical classifier on prospectively collected ED patient data compared to the industry-standard ABCD2. Methods: The prospective cohort consisted of ED patients (N=555, Male=54%, Mean (SD) Age=68.7(15.5), ACVS=70%) enrolled between Jan 2014 and May 2015 at Victoria General Hospital (BC) and Foothills Medical Centre (Calgary, AB). ABCD2 and clinical classifier scores were calculated from clinical data from the ED. We compared the performance of the two classifiers using DeLong’s test of Dependent Receiver Operating Curves (ROC). In keeping with national guidelines, we used a score of 4 or more to assess sensitivity, specificity and accuracy (sens/spec and acc) of the ABCD2; for our clinical classifier, we used the cut point previously determined to maximize agreement between predictions and true class labels in the historical data. Results: Our new clinical classifier significantly outperformed the ABCD2 (z=2.44, p=0.015) with an AUC of 0.72, (95% CI: 0.68, 0.77) vs. 0.66 (0.61, 0.71). In terms of sens/spec and acc, our classifier achieved 0.78/0.55 with acc 71% compared to 0.75/0.46 with acc 66% for the ABCD2 (using the previously specified cut points). Conclusion: Our ACVS clinical classifier showed better performance than the ABCD2 score on a prospective sample of ED patients. The improved specificity of the clinical classifier relative to existing prognostic tools would reduce the number of non-ACVS patients referred for early treatment as well as conserve medical resources. Our ongoing multi-site study will evaluate the utility of the ACVS classifier embedded in a logic-enabled e-fillable form. This form will also provide risk-based thresholds guiding timely ordering of CTA as well as links to clinical treatment guidelines. Longer-term, the e-form and classifiers will be further enhanced to include plasma-based protein biomarker data.

Preventing emergency department visits and hospitalizations for asthma by use of oral corticosteroids at home: Are we adhering to national guidelines?

2010 ◽  
pp. 100913044943042-5
Author(s):  
Timothy H. Self ◽  
Cary R. Chrisman ◽  
Anna R. Jacobs ◽  
Ngan H. Vo ◽  
John C. Winton
Keyword(s):  
Emergency Department ◽  
Emergency Department Visits ◽  
National Guidelines ◽  
Oral Corticosteroids ◽  
At Home

The Red Legs RATED tool to improve diagnosis of lower limb cellulitis in the emergency department

2021 ◽  
Vol 30 (12) ◽  
pp. S22-S29
Author(s):  
Gillian O'Brien ◽  
Patricia White
Keyword(s):  
Emergency Department ◽  
Lower Limb ◽  
Treatment Guidelines ◽  
Positive Impact ◽  
Data Gathering ◽  
Pilot Project ◽  
Accurate Diagnosis ◽  
Evidence Based ◽  
Significant Burden ◽  
User Friendly

Background: Lower limb cellulitis poses a significant burden for the Irish healthcare system. Accurate diagnosis is difficult, with a lack of validated evidence-based tools and treatment guidelines, and difficulties distinguishing cellulitis from its imitators. It has been suggested that around 30% of suspected lower limb cellulitis is misdiagnosed. An audit of 132 patients between May 2017 and May 2018 identified a pattern of misdiagnosis in approximately 34% of this cohort. Objective: The aim of this pilot project was to develop a streamlined service for those presenting to the emergency department with red legs/suspected cellulitis, through introduction of the ‘Red Leg RATED’ tool for clinicians. Method: The tool was developed and introduced to emergency department clinicians. Individuals (n=24) presenting with suspected cellulitis over 4 weeks in 2018 were invited to participate in data gathering. Finally, clinician questionnaire feedback regarding the tool was evaluated. Results: Fourteen participants consented, 6 female and 8 male with mean age of 65 years. The tool identified 50% (n=7) as having cellulitis, of those 57% (n=4) required admission, 43% (n=3) were discharged. The remainder who did not have cellulitis (n=7) were discharged. Before introduction of the tool, all would typically have been admitted to hospital for further assessment and management of suspected lower limb cellulitis. Overall, 72% (n=10) of patients who initially presented with suspected cellulitis were discharged, suggesting positive impact of the tool. Clinician feedback suggested all were satisfied with the tool and contents. Conclusion: The Red Leg RATED tool is user friendly and impacts positively on diagnosis treatment and discharge. Further evaluation is warranted.

scholarly journals Antimicrobial resistance in Neisseria gonorrhoeae isolates and gonorrhoea treatment in the Republic of Belarus, Eastern Europe, 2009–2019

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Aliaksandra Aniskevich ◽  
Iryna Shimanskaya ◽  
Iryna Boiko ◽  
Tatyana Golubovskaya ◽  
Daniel Golparian ◽  
...  
Keyword(s):  
Antimicrobial Resistance ◽  
Neisseria Gonorrhoeae ◽  
Eastern Europe ◽  
Treatment Guidelines ◽  
Statistical Significance ◽  
Antimicrobial Treatment ◽  
National Guidelines ◽  
First Line ◽  
Exact Test ◽  
The Republic

Abstract Background Limited antimicrobial resistance (AMR) data for Neisseria gonorrhoeae are available in Eastern Europe. We investigated AMR in N. gonorrhoeae isolates in the Republic of Belarus from 2009 to 2019, antimicrobial treatment recommended nationally, and treatment given to patients with gonorrhoea. Methods N. gonorrhoeae isolates (n = 522) cultured in three regions of Belarus in 2009–2019 were examined. Determination of minimum inhibitory concentrations (MICs) of eight antimicrobials was performed using Etest. Resistance breakpoints from the European Committee on Antimicrobial Susceptibility Testing were applied where available. A Nitrocefin test identified β-lactamase production. Gonorrhoea treatment for 1652 patients was also analysed. Statistical significance was determined by the Z-test, Fisher’s exact test, or Mann-Whitney U test with p-values of < 0.05 indicating significance. Results In total, 27.8% of the N. gonorrhoeae isolates were resistant to tetracycline, 24.7% to ciprofloxacin, 7.0% to benzylpenicillin, 2.7% to cefixime, and 0.8% to azithromycin. No isolates were resistant to ceftriaxone, spectinomycin, or gentamicin. However, 14 (2.7%) isolates had a ceftriaxone MIC of 0.125 mg/L, exactly at the resistance breakpoint (MIC > 0.125 mg/L). Only one (0.2%) isolate, from 2013, produced β-lactamase. From 2009 to 2019, the levels of resistance to ciprofloxacin and tetracycline were relatively high and stable. Resistance to cefixime was not identified before 2013 but peaked at 22.2% in 2017. Only sporadic isolates with resistance to azithromycin were found in 2009 (n = 1), 2012 (n = 1), and 2018–2019 (n = 2). Overall, 862 (52.2%) patients received first-line treatment according to national guidelines (ceftriaxone 1 g). However, 154 (9.3%) patients received a nationally recommended alternative treatment (cefixime 400 mg or ofloxacin 400 mg), and 636 (38.5%) were given non-recommended treatment. Conclusions The gonococcal resistance to ciprofloxacin and tetracycline was high, however, the resistance to azithromycin was low and no resistance to ceftriaxone was identified. Ceftriaxone 1 g can continuously be recommended as empiric first-line gonorrhoea therapy in Belarus. Fluoroquinolones should not be prescribed for treatment if susceptibility has not been confirmed by testing. Timely updating and high compliance with national evidence-based gonorrhoea treatment guidelines based on quality-assured AMR data are imperative. The need for continued, improved and enhanced surveillance of gonococcal AMR in Belarus is evident.

scholarly journals TeleNeurological evaluation and Support for the Emergency Department (TeleNS-ED): protocol for an open-label clinical trial

BMJ Open ◽  
2021 ◽  
Vol 11 (5) ◽  
pp. e048293
Author(s):  
Jessica Mandrioli ◽  
Mario Santangelo ◽  
Antonio Luciani ◽  
Stefano Toscani ◽  
Elisabetta Zucchi ◽  
...  
Keyword(s):  
Emergency Department ◽  
Clinical Investigation ◽  
Neurological Diseases ◽  
Medical Personnel ◽  
Primary Objective ◽  
Control Group ◽  
National Guidelines ◽  
Open Label ◽  
Time Saving ◽  
Hospital Networks

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.

scholarly journals Airway Management in the Emergency Department During Coronavirus Disease (COVID-19)

2020 ◽  
Vol 28 (2) ◽  
pp. 5-11
Author(s):  
Sohil Pothiawala
Keyword(s):  
Emergency Department ◽  
Airway Management ◽  
Viral Infections ◽  
Transmission Risk ◽  
National Guidelines ◽  
Hospital Policy ◽  
Resource Limited ◽  
Increased Risk ◽  
Emerging Viral Diseases ◽  
Evidence Based Guidelines

Front-line health-care workers in the Emergency Department (ED) are at an increased risk of infection during the airway management of patients with known or suspected Emerging Viral Diseases (EVD) like Coronavirus Disease 2019 (COVID-19). The primary route for transmission of the virus from an infected patient to the ED staff is due to aerosolized droplets, and the transmission risk is high despite wearing adequate Personal Protective Equipment (PPE). There are limited evidence-based guidelines for airway management during these viral infections, especially with a focus on the principles of airway management in a busy, fast-paced ED. This article provides an overview of the principles of airway management in suspected or confirmed EVD patients, including COVID-19, particularly in the context of ED, and also considering strategies in resource limited setting. These principles should be adapted to suit your local department and hospital policy on airway management as well as national guidelines.

scholarly journals Evaluation of Older Adult Patients With Falls in the Emergency Department: Discordance With National Guidelines

2015 ◽  
Vol 22 (4) ◽  
pp. 461-467 ◽  
Author(s):  
Gregory Tirrell ◽  
Jiraporn Sri-on ◽  
Lewis A. Lipsitz ◽  
Carlos A. Camargo ◽  
Christopher Kabrhel ◽  
...  
Keyword(s):  
Emergency Department ◽  
Older Adult ◽  
Adult Patients ◽  
National Guidelines

scholarly journals Anaphylactic Reactions in the Emergency Department of a Portuguese Tertiary Hospital: Clinical Characterization and Disease Notification

2019 ◽  
Vol 32 (2) ◽  
pp. 91
Author(s):  
Ana Teresa Fróis ◽  
Teresa Cardoso
Keyword(s):  
Emergency Department ◽  
Adverse Reactions ◽  
Tertiary Care ◽  
Tertiary Hospital ◽  
Clinical Approach ◽  
National Guidelines ◽  
Disease Notification ◽  
Health Products ◽  
Mandatory Notification ◽  
Clinical Records

Introduction: Anaphylaxis is significantly underdiagnosed, and the medical community’s knowledge about it is precarious. The aim of this study is to characterize the patient population and the Emergency Department approach of anaphylaxis.Material and Methods: Retrospective study of adult patients attending the Emergency Department of a tertiary care Portuguese hospital, over a year, with anaphylaxis. Data were obtained from each patient’s clinical records and anonymized. A questionnaire evaluating knowledge about the notification of anaphylaxis was applied to Emergency Department physicians.Results: The study included 69 patients. Cutaneous (97%) and respiratory features (80%) were most prevalent; 22% of patients presented with shock or related symptoms. There were no reported biphasic reactions or deaths. The likely allergen was identified in 73%, most commonly food; 12% of reactions were related to a previously known allergen. Epinephrine was administered to 15%. Referral to an Immunoallergologist was done in 36% of patients, and 10% received or already possessed an epinephrine autoinjector. Among six parameters recommended for auditing clinical practice, 70% of cases fulfilled less than half. Only 13% of physicians knew it was mandatory to register all cases in the Portuguese Catalogue of Allergies and Other Adverse Reactions, and only 4% knew how to do it; regarding notification to the National Authority of Medicines and Health Products results were slightly better.Discussion: Many patients with anaphylaxis present to the Emergency Department every year, and their clinical approach is not in agreement with national guidelines. Conclusion: An educational program to increase medical awareness of the national guidelines and mandatory notification of all anaphylactic reactions should be implemented.

scholarly journals Treatment of Pediatric Diabetic Ketoacidosis in Canada: A Review of Treatment Protocols from Canadian Pediatric Emergency Departments

CJEM ◽  
2015 ◽  
Vol 17 (6) ◽  
pp. 656-661 ◽  
Author(s):  
Steven A Skitch ◽  
Rahim Valani
Keyword(s):  
Diabetic Ketoacidosis ◽  
Cerebral Edema ◽  
Treatment Guidelines ◽  
Treatment Protocol ◽  
Serum Glucose ◽  
National Guidelines ◽  
Fluid Bolus ◽  
Treatment Protocols ◽  
Maintenance Fluid ◽  
Potassium Replacement

ABSTRACTObjectiveDiabetes is the most common pediatric endocrine disorder, and diabetic ketoacidosis (DKA) is the leading cause of diabetes-related morbidity and mortality. This article reviews pediatric DKA treatment protocols from across Canada and identifies similarities and differences.MethodsPediatric tertiary centres in Canada were asked for a copy of their DKA treatment protocol. For each protocol, we collected information on the amount of initial fluid bolus, maintenance fluid rate, insulin infusion rate, potassium replacement, monitoring and adjustment for serum glucose, administration of bicarbonate, and treatment for cerebral edema.ResultsResponses were obtained from 13 sites. Treatment guidelines were consistent in their recommendations on timing and dosage of intravenous insulin, potassium replacement, monitoring and adjusting for serum glucose, and management of cerebral edema. Variability in treatment protocols was found chiefly in volume of initial fluid bolus (range: 5–20 mL/kg) and length of time boluses should be administered (20–120 min), maintenance fluid rates (based on weight or a 48-hr deficit), and the role of bicarbonate administration.ConclusionsThis is the first review of treatment protocols for pediatric DKA in Canada. It identified many common approaches but noted specific differences in fluid boluses, maintenance fluid rates, and bicarbonate administration. The extent of variation indicates the need for further study, as well as national guidelines that are evidence-based and consistent with best practices.

Preventing Emergency Department Visits and Hospitalizations for Asthma by Use of Oral Corticosteroids at Home: Are We Adhering to National Guidelines?

2010 ◽  
Vol 47 (10) ◽  
pp. 1123-1127 ◽  
Author(s):  
Timothy H. Self ◽  
Cary R. Chrisman ◽  
Anna R. Jacobs ◽  
Ngan H. Vo ◽  
John C. Winton
Keyword(s):  
Emergency Department ◽  
Emergency Department Visits ◽  
National Guidelines ◽  
Oral Corticosteroids ◽  
At Home

scholarly journals Comprehensive geriatric assessment in the emergency department

2020 ◽  
Vol 49 (6) ◽  
pp. 936-938 ◽  
Author(s):  
Siobhan Harding
Keyword(s):  
Emergency Department ◽  
Secondary Care ◽  
Evidence Base ◽  
Community Dwelling ◽  
Multiple Sources ◽  
National Guidelines ◽  
Post Discharge ◽  
Post Intervention ◽  
Quasi Experimental ◽  
The Impact

Abstract Completing comprehensive geriatric assessments (CGA) for frail patients admitted to acute hospitals has well-established benefits and is advocated by national guidelines. There is high-quality evidence demonstrating an association between inpatient CGAs and the patient being alive and community-dwelling at 12-month follow-up. However, less well-known is the effectiveness of CGAs conducted within the emergency department (ED), with the primary purpose of facilitating admission avoidance, on reducing 30-day reattendance or readmission. This commentary provides an overview of five studies that measure the impact of conducting an ED-CGA on subsequent secondary care attendance. Two randomised-controlled trials, one case-matched cohort study and two quasi-experimental pre- and post-intervention studies were reviewed. The studies reported variable success in preventing subsequent secondary care use. No studies meeting the criteria had been conducted within the UK, affecting generalisability of the findings. There is no clear evidence that conducting a CGA within ED reduced reattendances or admissions 30 days post-discharge. The existing evidence base is methodologically and clinically heterogeneous and is vulnerable to multiple sources of bias. Further research is needed to understand whether screening to identify target populations or whether increased intensity of interventions delivered improves outcomes. ED-CGA may not have a beneficial effect on cost improvement or service delivery metrics, but it may have positive outcomes that are of high importance to the patients. This warrants further study.

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