Nonspecific Symptoms Lack Diagnostic Accuracy for Infection in Older Patients in the Emergency Department

Consciousness consists of two components: arousal and awareness of the environment and self. Arousal refers to the behavioral continuum that occurs between sleep and wakefulness, while awareness to the content of consciousness (Laureys, 2014). In normal physiological states, with the exception of REM sleep, the level of arousal is positively correlated with awareness (Laureys, 2014) such that arousal is graded and measured by the degree to which it is diminished. This conceptualization appears to have led experts, including the DSM-5, to consider delirium as a condition to not associated with impairments in arousal (Schiff and Plum, 2000, American Psychiatric Association, 2013). However, arousal can be both diminished and heightened, not unlike the performance of an old-fashioned incandescent bulb at different voltages, giving barely sufficient light at low voltages and brightening up unbearably at high voltages (MacIsaac et al., 1999). Delirium is associated with both hypo-arousal and hyper-arousal (Han et al., 2017). A small but significant proportion of delirious older patients (10%; n = 155) in the emergency department in this study had normal arousal at the time of the short arousal assessment (Han et al., 2014).

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Diagnostic Accuracy of Lung Point-Of-Care Ultrasonography for Acute Heart Failure Compared With Chest X-Ray Study Among Dyspneic Older Patients in the Emergency Department

Journal of Emergency Medicine ◽

10.1016/j.jemermed.2021.02.019 ◽

2021 ◽

Author(s):

Shunichiro Nakao ◽

Christian Vaillancourt ◽

Monica Taljaard ◽

Marie-Joe Nemnom ◽

Michael Y. Woo ◽

...

Keyword(s):

Heart Failure ◽

Emergency Department ◽

Diagnostic Accuracy ◽

Acute Heart Failure ◽

Older Patients ◽

Point Of Care ◽

X Ray ◽

Chest X Ray ◽

Point Of Care Ultrasonography ◽

Lung Point

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Development and Performance Assessment of a Digital Serious Game to Assess Multi-Patient Care Skills in a Simulated Pediatric Emergency Department

Simulation & Gaming ◽

10.1177/1046878120904984 ◽

2020 ◽

Vol 51 (4) ◽

pp. 550-570

Author(s):

Cindy Luu ◽

Thomas B. Talbot ◽

Cha Chi Fung ◽

Eyal Ben-Isaac ◽

Juan Espinoza ◽

...

Keyword(s):

Emergency Department ◽

Diagnostic Accuracy ◽

Patient Care ◽

Skill Acquisition ◽

Video Game ◽

Rank Correlation ◽

Fixed Time ◽

Serious Game ◽

Cross Sectional ◽

Number Of Patients

Objective. Multi-patient care is important among medical trainees in an emergency department (ED). While resident efficiency is a typically measured metric, multi-patient care involves both efficiency and diagnostic / treatment accuracy. Multi-patient care ability is difficult to assess, though simulation is a potential alternative. Our objective was to generate validity evidence for a serious game in assessing multi-patient care skills among a variety of learners. Methods. This was a cross-sectional validation study using a digital serious game VitalSignsTM simulating multi-patient care within a pediatric ED. Subjects completed 5 virtual “shifts,” triaging, stabilizing, and discharging or admitting patients within a fixed time period; patients arrived at cascading intervals with pre-programmed deterioration if neglected. Predictor variables included generic multi-tasking ability, video game experience, medical knowledge, and clinical efficiency with real patients. Outcome metrics in 3 domains measured diagnostic accuracy (i.e. critical orders, diagnoses), efficiency (i.e. number of patients, time-to-order) and critical thinking (number of differential diagnoses); MANOVA determined differences between novice learners and expected expert physicians. Spearman Rank correlation determined associations between levels of expertise. Results. Ninety-five subjects’ gameplays were analyzed. Diagnostic accuracy and efficiency distinguished skill level between residency trained (residents, fellows and attendings) and pre-residency trained (medical students and undergraduate) subjects, particularly for critical orders, patients seen, and correct diagnoses (p < 0.003). There were moderate to strong correlations between the game’s diagnostic accuracy and efficiency metrics compared to level of training, including patients seen (rho = 0.47, p < 0.001); critical orders (rho = 0.80, p < 0.001); time-to-order (rho = −0.24, p = 0.025); and correct diagnoses (rho = 0.69, p < 0.001). Video game experience also correlated with patients seen (rho = 0.24, p = 0.003). Conclusion. A digital serious game depicting a busy virtual ED can distinguish between expected experts in multi-patient care at the pre- vs. post-residency level. Further study can focus on whether the game appropriately assesses skill acquisition during residency.

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Harnessing the Chaplain’s Capacity to Identify Unmet Palliative Needs of Vulnerable Older Adults in the Emergency Department

Journal of Palliative Care ◽

10.1177/08258597211003359 ◽

2021 ◽

pp. 082585972110033

Author(s):

Elizabeth Hamill Howard ◽

Rachel Schwartz ◽

Bruce Feldstein ◽

Marita Grudzen ◽

Lori Klein ◽

...

Keyword(s):

Emergency Department ◽

Palliative Care ◽

End Of Life Care ◽

Older Patients ◽

Chart Review ◽

Retrospective Chart Review ◽

Life Care ◽

Emergency Medicine Physician ◽

Medicine Physician ◽

One Year

Objective: To explore chaplains’ ability to identify unmet palliative care (PC) needs in older emergency department (ED) patients. Methods: A palliative chaplain-fellow conducted a retrospective chart review evaluating 580 ED patients, age ≥80 using the Palliative Care and Rapid Emergency Screening (P-CaRES) tool. An emergency medicine physician and chaplain-fellow screened 10% of these charts to provide a clinical assessment. One year post-study, charts were re-examined to identify which patients received PC consultation (PCC) or died, providing an objective metric for comparing predicted needs with services received. Results: Within one year of ED presentation, 31% of the patient sub-sample received PCC; 17% died. Forty percent of deceased patients did not receive PCC. Of this 40%, chaplain screening for P-CaRES eligibility correctly identified 75% of the deceased as needing PCC. Conclusion: Establishing chaplain-led PC screenings as standard practice in the ED setting may improve end-of-life care for older patients.

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Dysphagia Prevalence, Time Course, and Association with Probable Sarcopenia, Inactivity, Malnutrition, and Disease Status in Older Patients Admitted to an Emergency Department: A Secondary Analysis of Cohort Study Data

Geriatrics ◽

10.3390/geriatrics6020046 ◽

2021 ◽

Vol 6 (2) ◽

pp. 46

Author(s):

Tina Hansen ◽

Rikke Lundsgaard Nielsen ◽

Morten Baltzer Houlind ◽

Juliette Tavenier ◽

Line Jee Hartmann Rasmussen ◽

...

Keyword(s):

Health Care ◽

Emergency Department ◽

Cohort Study ◽

Systemic Inflammation ◽

Older Patients ◽

Time Course ◽

Assessment Tool ◽

Handgrip Strength ◽

Secondary Analysis ◽

Disease Status

There is evolving evidence for an association between dysphagia and sarcopenia in older adults. For optimizing the acute health care initiative across health care settings, this study investigated prevalence and time-course of dysphagia in older patients admitted to an emergency department (ED) as well as its association with parameters for probable sarcopenia, inactivity, malnutrition, disease status, and systemic inflammation. A secondary analysis of data from the FAM-CPH cohort study on acutely admitted older medical patients (n = 125). Data were collected upon ED admission as well as four and 56 weeks after discharge. Using the Eating Assessment Tool cut-off score ≥ 2, signs of dysphagia were present in 34% of the patients at ED admission and persisted in 25% of the patients 56 weeks after discharge. Signs of dysphagia at 56-week follow-up were significantly (p < 0.05) associated with probable sarcopenia (low handgrip strength (OR = 3.79), low leg muscle strength (OR = 8.14), and low physical performance (OR = 5.68)) and with baseline swallowing inactivity (OR = 5.61), malnutrition (OR = 4.35), and systemic inflammation (OR = 1.33). Signs of dysphagia in older patients admitted to an ED was prevalent, persisted 56 weeks after discharge, and was associated with probable sarcopenia and related conditions; all modifiable targets for management of dysphagia in older patients.

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Independent Validation of Sepsis Index for Sepsis Screening in the Emergency Department

Diagnostics ◽

10.3390/diagnostics11071292 ◽

2021 ◽

Vol 11 (7) ◽

pp. 1292

Author(s):

Luisa Agnello ◽

Alessandro Iacona ◽

Salvatore Maestri ◽

Bruna Lo Sasso ◽

Rosaria Vincenza Giglio ◽

...

Keyword(s):

Emergency Department ◽

High Risk ◽

Early Detection ◽

Diagnostic Accuracy ◽

Positive Likelihood Ratio ◽

Curve Analysis ◽

Roc Curve Analysis ◽

Distribution Width ◽

Independent Validation ◽

Sepsis Screening

(1) Background: The early detection of sepsis is still challenging, and there is an urgent need for biomarkers that could identify patients at a high risk of developing it. We recently developed an index, namely the Sepsis Index (SI), based on the combination of two CBC parameters: monocyte distribution width (MDW) and mean monocyte volume (MMV). In this study, we sought to independently validate the performance of SI as a tool for the early detection of patients at a high risk of sepsis in the Emergency Department (ED). (2) Methods: We enrolled all consecutive patients attending the ED with a request of the CBC. MDW and MMV were measured on samples collected in K3-EDTA tubes on the UniCel DxH 900 haematology analyser. SI was calculated based on the MDW and MMV. (3) Results: We enrolled a total of 703 patients stratified into four subgroups according to the Sepsis-2 criteria: control (498), infection (105), SIRS (52) and sepsis (48). The sepsis subgroup displayed the highest MDW (median 27.5, IQR 24.6–32.9) and SI (median 1.15, IQR 1.05–1.29) values. The ROC curve analysis for the prediction of sepsis showed a good and comparable diagnostic accuracy of the MDW and SI. However, the SI displayed an increased specificity, positive predictive value and positive likelihood ratio in comparison to MDW alone. (4) Conclusions: SI improves the diagnostic accuracy of MDW for sepsis screening.

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Implementation of the acutely presenting older patient (APOP) screening program in routine emergency department care

Zeitschrift für Gerontologie und Geriatrie ◽

10.1007/s00391-020-01837-9 ◽

2021 ◽

Author(s):

Laura C. Blomaard ◽

Bas de Groot ◽

Jacinta A. Lucke ◽

Jelle de Gelder ◽

Anja M. Booijen ◽

...

Keyword(s):

Emergency Department ◽

High Risk ◽

Older Patients ◽

Screening Program ◽

Admission Rate ◽

Older Patient ◽

Hospital Admission Rate ◽

High Risk Patients ◽

Risk Patients

Abstract Objective The aim of this study was to evaluate the effects of implementation of the acutely presenting older patient (APOP) screening program for older patients in routine emergency department (ED) care shortly after implementation. Methods We conducted an implementation study with before-after design, using the plan-do-study-act (PDSA) model for quality improvement, in the ED of a Dutch academic hospital. All consecutive patients ≥ 70 years during 2 months before and after implementation were included. The APOP program comprises screening for risk of functional decline, mortality and cognitive impairment, targeted interventions for high-risk patients and education of professionals. Outcome measures were compliance with interventions and impact on ED process, length of stay (LOS) and hospital admission rate. Results Two comparable groups of patients (median age 77 years) were included before (n = 920) and after (n = 953) implementation. After implementation 560 (59%) patients were screened of which 190 (34%) were high-risk patients. Some of the program interventions for high-risk patients in the ED were adhered to, some were not. More hospitalized patients received comprehensive geriatric assessment (CGA) after implementation (21% before vs. 31% after; p = 0.002). In 89% of high-risk patients who were discharged to home, telephone follow-up was initiated. Implementation did not influence median ED LOS (202 min before vs. 196 min after; p = 0.152) or hospital admission rate (40% before vs. 39% after; p = 0.410). Conclusion Implementation of the APOP screening program in routine ED care did not negatively impact the ED process and resulted in an increase of CGA and telephone follow-up in older patients. Future studies should investigate whether sustainable changes in management and patient outcomes occur after more PDSA cycles.

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SPMSQ for risk stratification of older patients in the emergency department

Zeitschrift für Gerontologie und Geriatrie ◽

10.1007/s00391-019-01626-z ◽

2019 ◽

Vol 52 (S4) ◽

pp. 222-228 ◽

Cited By ~ 1

Author(s):

A. Schönstein ◽

H.-W. Wahl ◽

H. A. Katus ◽

A. Bahrmann

Keyword(s):

Emergency Department ◽

Nursing Home ◽

Risk Stratification ◽

Predictive Validity ◽

Older Patients ◽

Area Under The Curve ◽

Composite Endpoint ◽

Adverse Outcomes ◽

Nursing Home Admission ◽

Initial Contact

Abstract Background Risk stratification of older patients in the emergency department (ED) is seen as a promising and efficient solution for handling the increase in demand for geriatric emergency medicine. Previously, the predictive validity of commonly used tools for risk stratification, such as the identification of seniors at risk (ISAR), have found only limited evidence in German geriatric patient samples. Given that the adverse outcomes in question, such as rehospitalization, nursing home admission and mortality, are substantially associated with cognitive impairment, the potential of the short portable mental status questionnaire (SPMSQ) as a tool for risk stratification of older ED patients was investigated. Objective To estimate the predictive validity of the SPMSQ for a composite endpoint of adverse events (e.g. rehospitalization, nursing home admission and mortality). Method This was a prospective cohort study with 260 patients aged 70 years and above, recruited in a cardiology ED. Patients with a likely life-expectancy below 24 h were excluded. Follow-up examinations were conducted at 1, 3, 6 and 12 month(s) after recruitment. Results The SPMSQ was found to be a significant predictor of adverse outcomes not at 1 month (area under the curve, AUC 0.55, 95% confidence interval, CI 0.46–0.63) but at 3 months (AUC 0.61, 95% CI 0.54–0.68), 6 months (AUC 0.63, 95% CI 0.56–0.70) and 12 months (AUC 0.63, 95% CI 0.56–0.70) after initial contact. Conclusion For longer periods of observation the SPMSQ can be a predictor of a composite endpoint of adverse outcomes even when controlled for a range of confounders. Its characteristics, specifically the low sensitivity, make it unsuitable as an accurate risk stratification tool on its own.

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The Effect of Frailty on 30‐day Mortality Risk in Older Patients With Acute Heart Failure Attended in the Emergency Department

Academic Emergency Medicine ◽

10.1111/acem.13124 ◽

2017 ◽

Vol 24 (3) ◽

pp. 298-307 ◽

Cited By ~ 27

Author(s):

Francisco Javier Martín‐Sánchez ◽

Esther Rodríguez‐Adrada ◽

Christian Mueller ◽

María Teresa Vidán ◽

Michael Christ ◽

...

Keyword(s):

Heart Failure ◽

Emergency Department ◽

Acute Heart Failure ◽

Mortality Risk ◽

Older Patients

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Machine-learning algorithm that can improve the diagnostic accuracy of septic arthritis of the knee

Knee Surgery Sports Traumatology Arthroscopy ◽

10.1007/s00167-020-06418-2 ◽

2021 ◽

Author(s):

Eun-Seok Choi ◽

Jae Ang Sim ◽

Young Gon Na ◽

Jong- Keun Seon ◽

Hyun Dae Shin

Keyword(s):

Machine Learning ◽

Emergency Department ◽

Confidence Interval ◽

Diagnostic Accuracy ◽

Septic Arthritis ◽

Inflammatory Arthritis ◽

Supervised Machine Learning ◽

Diagnostic Model ◽

Extreme Gradient Boosting ◽

Wbc Count

Abstract Purpose Prompt diagnosis and treatment of septic arthritis of the knee is crucial. Nevertheless, the quality of evidence for the diagnosis of septic arthritis is low. In this study, the authors developed a machine learning-based diagnostic algorithm for septic arthritis of the native knee using clinical data in an emergency department and validated its diagnostic accuracy. Methods Patients (n = 326) who underwent synovial fluid analysis at the emergency department for suspected septic arthritis of the knee were enrolled. Septic arthritis was diagnosed in 164 of the patients (50.3%) using modified Newman criteria. Clinical characteristics of septic and inflammatory arthritis were compared. Area under the receiver-operating characteristic (ROC) curve (AUC) statistics was applied to evaluate the efficacy of each variable for the diagnosis of septic arthritis. The dataset was divided into independent training and test sets (comprising 80% and 20%, respectively, of the data). Supervised machine-learning techniques (random forest and eXtreme Gradient Boosting: XGBoost) were applied to develop a diagnostic model using the training dataset. The test dataset was subsequently used to validate the developed model. The ROC curves of the machine-learning model and each variable were compared. Results Synovial white blood cell (WBC) count was significantly higher in septic arthritis than in inflammatory arthritis in the multivariate analysis (P = 0.001). In the ROC comparison analysis, synovial WBC count yielded a significantly higher AUC than all other single variables (P = 0.002). The diagnostic model using the XGBoost algorithm yielded a higher AUC (0.831, 95% confidence interval 0.751–0.923) than synovial WBC count (0.740, 95% confidence interval 0.684–0.791; P = 0.033). The developed algorithm was deployed as a free access web-based application (www.septicknee.com). Conclusion The diagnosis of septic arthritis of the knee might be improved using a machine learning-based prediction model. Level of evidence Diagnostic study Level III (Case–control study).

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