scholarly journals P028: Antibiotic prescribing and use of corticosteroids for the emergency department management of acute pharyngitis

CJEM ◽  
2020 ◽  
Vol 22 (S1) ◽  
pp. S74-S74
Author(s):  
C. Sheridan ◽  
K. Grewal ◽  
B. Borgundvaag ◽  
S. McLeod
Keyword(s):  
Emergency Department ◽  
Clinical Decision Making ◽  
Group A Streptococcus ◽  
Retrospective Chart Review ◽  
Clinical Decision ◽  
Mount Sinai Hospital ◽  
Antibiotic Prescribing ◽  
Throat Culture ◽  
Acute Pharyngitis ◽  
Centor Score

Introduction: Acute pharyngitis is a common emergency department (ED) presentation. The Centor (Modified/McIsaac) score uses five criteria (age, tonsillar exudates, swollen tender anterior cervical nodes, absence of a cough, and history of fever) to predict Group A Streptococcus (GAS) infection. The recommendation is patients with a Centor score of 0-1 should not undergo testing and should not be given antibiotics, patients with a score of 2-3 may warrant throat cultures, and for patients with a score ≥ 4, empiric antibiotics may be appropriate. Associated pain is often first managed with acetaminophen or non-steroidal anti-inflammatory drugs, however recent evidence suggests a short course of low-to-moderate dose corticosteroids as adjunctive therapy may reduce inflammation and provide pain relief. The objective of this study was to describe the ED management of acute pharyngitis for adult patients presenting to an academic ED over a two-year study period. Methods: This was a retrospective chart review of all adult (> 17 years) patients presenting to Mount Sinai Hospital ED with a discharge diagnosis of acute pharyngitis (ICD-10 code J02.9) from January 1st 2016 to December 31st 2018. Trained research personnel reviewed medical records and extracted data using a computerized, data abstraction form. Results: Of the 638 patients included in the study, 286 (44.8%) had a Centor score of 0-1, 328 (51.4%) had a score of 2-3, and 24 (3.8%) had a score of ≥ 4. Of those with a Centor score of 0-1, 83 (29.0%) had a throat culture, 88 (30.8%) were prescribed antibiotics, 15 (5.2%) were positive for GAS and 74 (25.9%) were given corticosteroids in the ED or at discharge. Of those with a Centor score of 2-3, 156 (47.6%) had a throat culture, 220 (67.1%) were prescribed antibiotics, 44 (13.4%) were positive for GAS, and 145 (44.2%) were given corticosteroids. Of those with a Centor score ≥ 4, 14 (58.3%) had a throat culture, 18 (75.0%) were prescribed antibiotics, 7 (29.2%) were positive for GAS and 12 (50.0%) were given corticosteroids. Conclusion: As predicted, a higher Centor score was associated with higher risk of GAS infection, increased antibiotic prescribing and use of corticosteroids. Many patients with low Centor scores were prescribed antibiotics and also had throat cultures. Further work is required to understand clinical decision making for the management of acute pharyngitis.

scholarly journals Positive Rate of Tests for Group a Streptococcus and Viral Features in Children with Acute Pharyngitis

Children ◽  
2021 ◽  
Vol 8 (7) ◽  
pp. 599
Author(s):  
Dasom Wi ◽  
Soo-Han Choi
Keyword(s):  
Laboratory Testing ◽  
Older Patients ◽  
Group A Streptococcus ◽  
Throat Culture ◽  
Acute Pharyngitis ◽  
Rapid Antigen Detection Test ◽  
Positive Rate ◽  
Group A ◽  
Centor Score ◽  
Low Prevalence

Group A streptococcus (GAS) is an important cause of acute pharyngitis. We investigated the positive rate of GAS tests and clinical viral features in children with acute pharyngitis. A retrospective review was conducted for patients <15 years old with both rapid antigen detection test (RADT) and throat culture results. Patients were excluded if they were diagnosed with influenza or had received antibiotics within two weeks before these tests. A total of 377 patients were eligible. The median age of patients was 3.5 years, and 45.4% of total patients were <3 years old. Among all patients, 68.7% had at least one viral feature, and 39% had more than two. The overall positiv rate for GAS was 11.4%. The GAS positive rate was significantly lower in patients <3 years old than in older patients (1.8% vs. 19.4%, p < 0.0001). The overall sensitivity and specificity of RADT were 75.0% (95% CI: 57.8–87.9) and 97.9% (95% CI: 95.8–99.2), respectively. The GAS positive rate was not significantly different between patients with and without viral features (12.4% vs. 9.3%, p = 0.4854). In patients aged 3–14 years, the GAS positive rate was not associated with the modified Centor score or the frequency of clinical viral features. Despite a low prevalence of GAS pharyngitis, testing for GAS was frequently performed in children <3 years old in this study. Appropriate use of laboratory testing for GAS pharyngitis and judicious prescription of antibiotics were imperative.

scholarly journals Necrotizing fasciitis: presentation, microbiology and outcomes in a community hospital

2020 ◽  
Vol 7 (8) ◽  
pp. 2471
Author(s):  
Mercy N. Jimenez ◽  
Emily S. Seltzer ◽  
Bhavana Devanabanda ◽  
Martine Louis ◽  
Nageswara Mandava
Keyword(s):  
New York ◽  
Necrotizing Fasciitis ◽  
Clinical Decision Making ◽  
Community Hospital ◽  
Average Length ◽  
Retrospective Chart Review ◽  
Patient Characteristics ◽  
Clinical Decision ◽  
Blood Cultures ◽  
Average Length Of Stay

Background: Necrotizing fasciitis (NF) is an aggressive and often fatal, soft tissue infection. Delayed surgical therapy leads to worsened outcomes. This study evaluates the mortality, outcomes, and characteristics of patients with NF in a diverse New York City Community Hospital Network.Methods: Retrospective chart review from 2012 to 2019 using ICD-9 and ICD-10 codes of gas gangrene, Fournier’s gangrene, and necrotizing fasciitis was done. Of the 297 patients reviewed 28 met inclusion criteria of imaging findings, operative reports, and clinical diagnosis of NF by an attending surgeon.Results: On average patients in ER were seen by the surgical team within less than 12 hours. Most patients were debrided within 10 hours of surgical consultation and on average received 2.2 procedures. Of the wound cultures obtained 65.38% were polymicrobial in nature. The average length of stay was 17.4 days and 32% of patients required ICU admission. The surgical mortality rate was 7.61%.Conclusions: Necrotizing fasciitis is a rare entity and increasing provider knowledge on patient characteristics as well as the complexity of these patients and the types and number of procedures they require may help guide clinical decision making. We identified that while most of our patients had negative blood cultures on admission, those that had positive blood cultures had multiple organisms growing. Knowing that these patients are complex and likely require multiple procedures, prompt operative intervention is key.

scholarly journals Clinical decision making in the emergency department setting using rapid PCR: Results of the CLADE study group

2018 ◽  
Vol 102 ◽  
pp. 42-49 ◽  
Author(s):  
Glen T. Hansen ◽  
Johanna Moore ◽  
Emily Herding ◽  
Tami Gooch ◽  
Diane Hirigoyen ◽  
...  
Keyword(s):  
Decision Making ◽  
Emergency Department ◽  
Clinical Decision Making ◽  
Clinical Decision ◽  
Study Group ◽  
Rapid Pcr ◽  
Emergency Department Setting

Appropriateness of Tympanostomy Tubes in the Boston Metropolitan Area: Are the AAO-HNSF Guidelines Being Met?

2017 ◽  
Vol 157 (6) ◽  
pp. 1041-1047 ◽  
Author(s):  
Amy L. Hughes ◽  
David Roberson ◽  
Cassandra Bannos ◽  
Emily K. Trudell ◽  
Louis Vernacchio
Keyword(s):  
Chart Review ◽  
Clinical Decision Making ◽  
Retrospective Chart Review ◽  
Clinical Decision ◽  
Neck Surgery ◽  
Middle Ear Effusion ◽  
Tympanostomy Tubes ◽  
Risk Patients ◽  
Speech Learning ◽  
Ear Effusion

Introduction Otitis media (OM) is the most common reason children receive general anesthesia, with bilateral tympanostomy tube (TT) insertion the second most common surgery in children. Prior research suggests overuse of TT. As part of a project designed to improve appropriateness of OM referrals, we evaluated appropriateness of TT insertion in a patient cohort. Methods Patients younger than 9 years with initial otolaryngology (ORL) visits in academic and private office settings for OM from January 1, 2012, to August 31, 2013, were identified through claims database. A detailed retrospective chart review of patients undergoing TT insertion was performed to determine appropriateness of TT insertion per the 2013 American Academy of Otolaryngology—Head and Neck Surgery Foundation (AAO-HNSF) guidelines. Results A total of 120 patients undergoing TT insertion were randomly chosen for detailed chart review; 32 patients were excluded. Sixty-six (75%) of 88 patients available for analysis met AAO-HNSF guidelines for TT. Recurrent acute OM with middle ear effusion was the most common indication (56%). Other indications included chronic OME and TT in at-risk patients with speech, learning, or behavioral delays. Of the 22 patients undergoing TT insertion not meeting AAO-HNSF guidelines, 11(50%) had abnormal exams, but were 1 to 2 infections short of meeting guidelines; 7 (33%) had normal exams but met criteria for number of infections. Discussion Contrary to prior publications, 75% of patients undergoing TT insertion had an appropriate indication per AAO-HNSF guidelines. In only 5% was TT insertion a substantial departure from guidelines. Implications for Practice The study outcomes suggest appropriate clinical decision making, improved guideline adherence, and better guideline applicability from the previously published 1994 and 2004 guidelines.

scholarly journals Utility and Acceptability of Influenza Surveillance amongst Emergency Providers

2015 ◽  
Vol 7 (1) ◽  
Author(s):  
Andrea F. Dugas ◽  
Howard Burkom ◽  
Anna L. DuVal ◽  
Richard Rothman
Keyword(s):  
Decision Making ◽  
Emergency Department ◽  
Real Time ◽  
Clinical Decision Making ◽  
Clinical Decision ◽  
Surveillance Data ◽  
Influenza Surveillance ◽  
Additional Information ◽  
Provider Surveys

We provided emergency department providers with a real-time laboratory-based influenza surveillance tool, and evaluated the utility and acceptability of the surveillance information using provider surveys. The majority of emergency department providers found the surveillance data useful and indicated the additional information impacted their clinical decision making regarding influenza testing and treatment.

scholarly journals Recovery from profound acidosis (pH 6.685) in multi-organ dysfunction syndrome

2019 ◽  
pp. 175114371987010
Author(s):  
Eryl A Davies ◽  
Christopher Saleh ◽  
Jonathan Bannard-Smith
Keyword(s):  
Decision Making ◽  
Emergency Department ◽  
Cardiac Arrest ◽  
Critical Care ◽  
Organ Dysfunction ◽  
Clinical Decision Making ◽  
Clinical Decision ◽  
Circulatory Shock ◽  
Arterial Ph ◽  
Multi Organ Dysfunction Syndrome

Acidosis is a common feature of patients referred to critical care from the emergency department. We present the case of a 49-year-old female with multi-organ dysfunction syndrome (MODS) and an arterial pH of 6.685 on arrival to the emergency department. This case is unique as the patient was in circulatory shock with MODS from rhabdomyolysis on arrival and had not suffered a cardiac arrest. We believe this to be the first reported case of full recovery from such an extreme metabolic disturbance in this context, and discuss the relevance of profound acidosis to early clinical decision-making.

scholarly journals Emotionally evocative patients in the emergency department: a mixed methods investigation of providers’ reported emotions and implications for patient safety

2020 ◽  
Vol 29 (10) ◽  
pp. 1.3-2 ◽  
Author(s):  
Linda M Isbell ◽  
Julia Tager ◽  
Kendall Beals ◽  
Guanyu Liu
Keyword(s):  
Mental Health ◽  
Decision Making ◽  
Emergency Department ◽  
Patient Safety ◽  
Qualitative Data ◽  
Clinical Decision Making ◽  
Quality Care ◽  
Clinical Decision ◽  
Safety Risks ◽  
Recent Patient

BackgroundEmergency department (ED) physicians and nurses frequently interact with emotionally evocative patients, which can impact clinical decision-making and behaviour. This study introduces well-established methods from social psychology to investigate ED providers’ reported emotional experiences and engagement in their own recent patient encounters, as well as perceived effects of emotion on patient care.MethodsNinety-four experienced ED providers (50 physicians and 44 nurses) vividly recalled and wrote about three recent patient encounters (qualitative data): one that elicited anger/frustration/irritation (angry encounter), one that elicited happiness/satisfaction/appreciation (positive encounter), and one with a patient with a mental health condition (mental health encounter). Providers rated their emotions and engagement in each encounter (quantitative data), and reported their perception of whether and how their emotions impacted their clinical decision-making and behaviour (qualitative data).ResultsProviders generated 282 encounter descriptions. Emotions reported in angry and mental health encounters were remarkably similar, highly negative, and associated with reports of low provider engagement compared with positive encounters. Providers reported their emotions influenced their clinical decision-making and behaviour most frequently in angry encounters, followed by mental health and then positive encounters. Emotions in angry and mental health encounters were associated with increased perceptions of patient safety risks; emotions in positive encounters were associated with perceptions of higher quality care.ConclusionsPositive and negative emotions can influence clinical decision-making and impact patient safety. Findings underscore the need for (1) education and training initiatives to promote awareness of emotional influences and to consider strategies for managing these influences, and (2) a comprehensive research agenda to facilitate discovery of evidence-based interventions to mitigate emotion-induced patient safety risks. The current work lays the foundation for testing novel interventions.

Abstract W MP61: Prevalence of Echocardiographic Abnormalities in Acute Ischemic Stroke

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Bryan Eckerle ◽  
Heidi Sucharew ◽  
Kathleen Alwell ◽  
Charles J Moomaw ◽  
Matthew Flaherty ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Clinical Decision Making ◽  
Retrospective Chart Review ◽  
Clinical Decision ◽  
Imaging Method ◽  
Chi Square ◽  
Exact Test ◽  
High Prevalence ◽  
Chi Square Test

Introduction: Non-invasive cardiac imaging is an important tool in evaluation of acute ischemic stroke, as a cardiac source can be implicated in approximately 20% of cases. However, the preferred imaging method is unclear due in part to the lack of consistent data regarding the yield of the two most commonly employed modalities, transthoracic and transesophageal echocardiography (TTE and TEE). Here we examine, in a large, biracial population, the prevalence of abnormalities detected by echocardiography during evaluation of acute ischemic stroke. Methods: Acute ischemic stroke cases were identified from a population of 1.3 million in the Greater Cincinnati area in 2005. Medical history and echocardiography results were determined by retrospective chart review. Echocardiographic abnormalities were pre-defined based on possibility of change in clinical decision making. All cases were abstracted by study nurses and subsequently verified by study physicians. Results were stratified by cardiac history and choice of echocardiographic technique; groups were compared using chi-square test or Fisher’s Exact test. Results: There were 2197 hospital-ascertained ischemic stroke cases in 2005. Median age was 73 (IQR 61-81), 22% were black, and 55% were female. TTE was performed in 68% of cases; TEE was performed in 7%. TEE revealed at least one abnormality in 55% of cases with cardiac history and 32% of cases without (Table). Yield of TTE was 20% in cases with cardiac history and 3% in cases without. Discussion: TEE is of considerable yield in selected patients, irrespective of cardiac history. This is in keeping with prior cost-effectiveness analyses recommending TEE alone for patients in whom suspicion of occult source of cardiac embolism is high. Prevalence of abnormalities on TTE in this population is similar to that of previously published series.

scholarly journals Inpatient Palliative Care Utilization for Patients with Brain Metastases

2021 ◽  
Author(s):  
Meghan Price ◽  
Elizabeth P Howell ◽  
Tara Dalton ◽  
Luis Ramirez ◽  
Claire Howell ◽  
...  
Keyword(s):  
Palliative Care ◽  
Brain Metastases ◽  
Clinical Decision Making ◽  
Symptom Burden ◽  
Retrospective Chart Review ◽  
Clinical Decision ◽  
Patient Specific ◽  
Care Utilization ◽  
Black African ◽  
Patient Race

Abstract Introduction Given the high symptom burden and complex clinical decision making associated with a diagnosis of brain metastases (BM), specialty Palliative Care (PC) can meaningfully improve patient quality of life. However, no prior study has formally evaluated patient-specific factors associated with PC consultation among BM patients. Methods We examined the rates of PC consults in a cohort of 1303 patients with brain metastases admitted to three tertiary medical centers from October 2015 to December 2018. Patient demographics, surgical status, 30-day readmission, and death data were collected via retrospective chart review. PC utilization was assessed by identifying encounters for which an inpatient consult to PC was placed. Statistical analyses were performed to compare characteristics and outcomes between patients who did and did not receive PC consults. Results We analyzed 1303 patients admitted to the hospital with brain metastases. The average overall rate of inpatient PC consultation was 19.6%. Rates of PC utilization differed significantly by patient race (17.5% in White/Caucasian vs. 26.0% in Black/African American patients, p = 0.0014). Patients who received surgery during their admission had significantly lower rates of PC consultation (3.9% vs 22.4%, p &lt; 0.0001). Patients who either died during their admission or were discharged to hospice had significantly higher rates of PC than those who were discharged home or to rehabilitation (p &lt; 0.0001). Conclusions In our dataset, PC consultation rates varied by patient demographic, surgical status, discharging service and practice setting. Further work is needed to identify the specific barriers to optimally utilizing specialty PC in this population.

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