Abstract WP409: Impact of Nursing Expertise and Staffing Ratio on Compliance with Post-tPA/Endovascular Patient Monitoring

Introduction: In 2014, the Post-tPA/Endovascular nursing monitoring flow sheet was revised to harmonize with the NIHSS exam. The challenges to performance and documentation compliance posed by the intensity and frequency of assessments have been the focus of an ongoing quality improvement initiative. Methods: All Post-tPA/Endovascular monitoring flow sheets from June 2014- June 2016 at University Hospitals Case Medical Center were reviewed for presence of neurologic assessments, vital signs, and management of hypertension per protocol. Stroke staff conducted in-services on the enhanced assessments and modified NIHSS training and house staff mentored bedside RNs in performing the NIHSS. A tip sheet was developed for staff on the modified NIHSS and real time feedback was given on all outliers. Results: Of 459 patients, compliance with all of the 684 monitoring data points ranged from 67-100% in the Neuroscience ICU (Patient: RN ratio 2:1), 75-100% in the Neuro-Intermediate Unit (Patient: RN ratio 3:1) and 40-100% in the Emergency Department (Patient: RN ratio 4:1). Overall compliance to > 95% of data points was seen in all but 5 patients with missing flow sheets. Symptomatic hemorrhagic complications after IVtPA decreased from 6.5% to 2.7%. Root-cause analysis of missing data points revealed seven areas of opportunity: Interference by diagnostic testing (29%), during patient transportation (22%), and following endovascular treatment (15%) or due to travelling RNs (8%). Missing documentation was most frequent during the q15 minute phase due to the intensity of monitoring (11%)- with the Emergency Department the most vulnerable location- and less during the q30 minute (4%) or q1 hour (3%) assessments. Units with dedicated neuroscience nursing adjusted more rapidly to the revision compared to units that do not routinely perform such assessments. Conclusions: Optimum compliance with nursing assessments and monitoring occur when there is no interference with diagnostic testing or procedures, the patient needs were a high priority and the patient acuity was well matched to the RN staffing ratio. This data supports a care model where a neuroscience trained RN nurse transitions with the patient during the first 24 hours after tPA/Endovascular therapy.

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Clinical physiological parameters for the prediction of gram-negative bacterial infection in the emergency department

BMC Infectious Diseases ◽

10.1186/s12879-020-05758-1 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Chan-Peng Hsu ◽

Hsin-Yu Chen ◽

Wei-Lung Chen ◽

Jiann-Hwa Chen ◽

Chien-Cheng Huang ◽

...

Keyword(s):

Emergency Department ◽

Bacterial Infection ◽

Bacterial Culture ◽

Medical Center ◽

Laboratory Data ◽

Vital Signs ◽

Area Under The Curve ◽

Physiological Parameters ◽

Roc Curve Analysis ◽

Gram Negative

Abstract Background Early detection and treatment of Gram-negative bacteria (GNB), major causative pathogens of sepsis (a potentially fatal condition caused by the body’s response to an infection), may benefit a patient’s outcome, since the mortality rate increases by 5–10% for each hour of delayed therapy. Unfortunately, GNB diagnosis is based on bacterial culture, which is time consuming. Therefore, an economic and effective GNB (defined as a positive blood, sputum, or urine culture) infection detection tool in the emergency department (ED) is warranted. Methods We conducted a retrospective cohort study in the ED of a university-affiliated medical center between January 01, 2014 and December 31, 2017. The inclusion criteria were as follows: (1) age ≥ 18; (2) clinical suspicion of bacterial infection; (3) bacterial culture from blood, sputum, or urine ordered and obtained in the ED. Descriptive statistics was performed on patient demographic characteristics, vital signs, laboratory data, infection sites, cultured microorganisms, and clinical outcomes. The accuracy of vital signs to predict GNB infection was identified via univariate logistic regression and receiver operating characteristic (ROC) curve analysis. Results A total of 797 patients were included in this study; the mean age was 71.8 years and 51.3% were male. The odds ratios of patients with body temperature ≥ 38.5 °C, heart rate ≥ 110 beats per minute, respiratory rate ≥ 20 breaths per minute, and Glasgow coma scale (GCS) < 14, in predicting GNB infection were found to be 2.3, 1.4, 1.9, and 1.6, respectively. The area under the curve values for ROC analysis of these measures were 0.70, 0.68, 0.69, and 0.67, respectively. Conclusion The four physiological parameters were rapid and reliable independent predictors for detection of GNB infection.

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P136: A quality improvement initiative to optimize appropriate testing for venous thromboembolism in the emergency department

CJEM ◽

10.1017/cem.2016.310 ◽

2016 ◽

Vol 18 (S1) ◽

pp. S123-S123

Author(s):

S. Vaillancourt ◽

X.Y. Wang ◽

B. Leontowicz ◽

M. Sholzberg ◽

K. McIntyre

Keyword(s):

Emergency Department ◽

Quality Improvement ◽

Venous Thromboembolism ◽

Decision Aids ◽

Diagnostic Testing ◽

Turnaround Time ◽

Quality Improvement Initiative ◽

Online Portal ◽

Pulmonary Angiogram ◽

Physician Order Entry

Introduction: Venous thromboembolism (VTE) is a common diagnostic consideration among patients presenting to the emergency department (ED) and often requires the use of diagnostic testing. A normal d-dimer (DD) blood test can exclude VTE and eliminate the need for costly imaging and the associated contrast medium and radiation exposure. The purpose of this quality improvement initiative was to increase the use of DD testing for patients with a low and intermediate clinical pretest probability of VTE, increase the use of ventilation perfusion scans (VQ) as an alternative to CT pulmonary angiogram (CTPA) and decrease the use of CTPA and venous doppler ultrasound (VDUS) at St. Michael’s hospital. Methods: A multispecialty team developed an ED specific algorithm set for appropriate VTE testing that were posted on the ED online portal along with a poster in each zone of the ED after an ED launch campaign with request for feedback. A run chart was used to track DD, CTPA, VQ and VDUS utilization. Two-sided T-test comparison was conducted to compare pre- and post-implementation utilization. Results: Physician feedback was positive regarding the use of: DD in VTE intermediate risk patients and the VTE algorithm set. Feedback was negative for DD turnaround time. We found a significant increase in DD use (77 tests per month to 93; p=0.013), but no significant change in the use of CTPA (27.3 per month to 30; p=0.38), VDUS, or VQ. Number of monthly ED visits remained constant. Conclusion: This intervention increased DD utilization, but measuring appropriateness will require prospective collection of clinical pre-test probability. Integrated risk stratification and decision aids into computer physician order entry may be necessary to track and improve appropriateness.

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Real-world evaluation of AI driven COVID-19 triage for emergency admissions: External validation & operational assessment of lab-free and high-throughput screening solutions

10.1101/2021.08.24.21262376 ◽

2021 ◽

Author(s):

Andrew AS Soltan ◽

Jenny Yang ◽

Ravi Pattanshetty ◽

Alex Novak ◽

Omid Rohanian ◽

...

Keyword(s):

Emergency Department ◽

High Throughput ◽

Clinical Pathway ◽

High Throughput Screening ◽

Standard Care ◽

Point Of Care ◽

Vital Signs ◽

Routine Care ◽

Service Improvement ◽

University Hospitals

Background Uncertainty in patients' COVID-19 status contributes to treatment delays, nosocomial transmission, and operational pressures in hospitals. However, typical turnaround times for batch-processed laboratory PCR tests remain 12-24h. Although rapid antigen lateral flow testing (LFD) has been widely adopted in UK emergency care settings, sensitivity is limited. We recently demonstrated that AI-driven triage (CURIAL-1.0) allows high-throughput COVID-19 screening using clinical data routinely available within 1h of arrival to hospital. Here we aimed to determine operational and safety improvements over standard-care, performing external/prospective evaluation across four NHS trusts with updated algorithms optimised for generalisability and speed, and deploying a novel lab-free screening pathway in a UK emergency department. Methods We rationalised predictors in CURIAL-1.0 to optimise separately for generalisability and speed, developing CURIAL-Lab with vital signs and routine laboratory blood predictors (FBC, U&E, LFT, CRP) and CURIAL-Rapide with vital signs and FBC alone. Models were calibrated during training to 90% sensitivity and validated externally for unscheduled admissions to Portsmouth University Hospitals, University Hospitals Birmingham and Bedfordshire Hospitals NHS trusts, and prospectively during the second-wave of the UK COVID-19 epidemic at Oxford University Hospitals (OUH). Predictions were generated using first-performed blood tests and vital signs and compared against confirmatory viral nucleic acid testing. Next, we retrospectively evaluated a novel clinical pathway triaging patients to COVID-19-suspected clinical areas where either model prediction or LFD results were positive, comparing sensitivity and NPV with LFD results alone. Lastly, we deployed CURIAL-Rapide alongside an approved point-of-care FBC analyser (OLO; SightDiagnostics, Israel) to provide lab-free COVID-19 screening in the John Radcliffe Hospital's Emergency Department (Oxford, UK), as trust-approved service improvement. Our primary improvement outcome was time-to-result availability; secondary outcomes were sensitivity, specificity, PPV, and NPV assessed against a PCR reference standard. We compared CURIAL-Rapide's performance with clinician triage and LFD results within standard-care. Results 72,223 patients met eligibility criteria across external and prospective validation sites. Model performance was consistent across trusts (CURIAL-Lab: AUROCs range 0.858-0.881; CURIAL-Rapide 0.836-0.854), with highest sensitivity achieved at Portsmouth University Hospitals (CURIAL-Lab:84.1% [95% Wilson's score CIs 82.5-85.7]; CURIAL-Rapide:83.5% [81.8 - 85.1]) at specificities of 71.3% (95% Wilson's score CIs: 70.9 - 71.8) and 63.6% (63.1 - 64.1). For 3,207 patients receiving LFD-triage within routine care for OUH admissions between December 23, 2021 and March 6, 2021, a combined clinical pathway increased sensitivity from 56.9% for LFDs alone (95% CI 51.7-62.0) to 88.2% with CURIAL-Rapide (84.4-91.1; AUROC 0.919) and 85.6% with CURIAL-Lab (81.6-88.9; AUROC 0.925). 520 patients were prospectively enrolled for point-of-care FBC analysis between February 18, 2021 and May 10, 2021, of whom 436 received confirmatory PCR testing within routine care and 10 (2.3%) tested positive. Median time from patient arrival to availability of CURIAL-Rapide result was 45:00 min (32-64), 16 minutes (26.3%) sooner than LFD results (61:00 min, 37-99; log-rank p<0.0001), and 6:52 h (90.2%) sooner than PCR results (7:37 h, 6:05-15:39; p<0.0001). Sensitivity and specificity of CURIAL-Rapide were 87.5% (52.9-97.8) and 85.4% (81.3-88.7), therefore achieving high NPV (99.7%, 98.2-99.9). CURIAL-Rapide correctly excluded COVID-19 for 58.5% of negative patients who were triaged by a clinician to COVID-19-suspected (amber) areas. Impact CURIAL-Lab & CURIAL-Rapide are generalisable, high-throughput screening tests for COVID-19, rapidly excluding the illness with higher NPV than LFDs. CURIAL-Rapide can be used in combination with near-patient FBC analysis for rapid, lab-free screening, and may reduce the number of COVID-19-negative patients triaged to enhanced precautions (amber) clinical areas.

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Clinical physiological parameters for the prediction of gram-negative bacterial infection in the emergency department

10.21203/rs.3.rs-27796/v1 ◽

2020 ◽

Author(s):

Chan-Peng Hsu ◽

Hsin-Yu Chen ◽

Wei-Lung Chen ◽

Jiann-Hwa Chen ◽

Chien-Cheng Huang ◽

...

Keyword(s):

Emergency Department ◽

Early Detection ◽

Bacterial Infection ◽

Roc Analysis ◽

Medical Center ◽

Laboratory Data ◽

Vital Signs ◽

Physiological Parameters ◽

Gram Negative ◽

Positive Bacterial Culture

Abstract Background: Early detection and treatment of Gram-negative bacteria (GNB), major causative pathogens of sepsis, may benefit a patient’s outcome, since the mortality rate increases by 5–10% for each hour of delayed therapy. Unfortunately, GNB diagnosis is based on blood culture, which is time consuming. Therefore, an economic and effective GNB infection detection tool in the emergency department (ED) is warranted.Methods: We conducted a retrospective case control-study in the ED of a university-affiliated medical center between January 01, 2014 and December 31, 2017. The inclusion criteria were as follows: (1) age ≥ 18; (2) clinical suspicion of bacterial infection; (3) positive bacterial culture of blood or sputum or urine. Descriptive statistics was performed on patient demographic characteristics, vital signs, laboratory data, infection sites, cultured microorganisms, and clinical outcomes. The accuracy of vital signs to predict GNB infection was identified via logistic regression and receiver operating characteristic (ROC) analysis.Results: A total of 797 patients were included in this study; the mean age was 71.8 years and 51.3% were male. The results revealed that patients with body temperature ≥ 38.5°C, heart rate ≥ 110 beats per minute, respiratory rate ≥ 20 breaths per minute, and Glasgow coma scale (GCS) < 14, had a 2.3-, 1.4-, 1.9-, and 1.6-fold greater risk of GNB infection, respectively. The area under the curve values for ROC analysis of these measures were 0.70, 0.68, 0.69, and 0.67, respectively.Conclusion: The four physiological parameters were rapid and reliable independent predictors for early detection of GNB infection.

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A Model for Syphilis Screening in the Emergency Department

Public Health Reports ◽

10.1177/0033354920967302 ◽

2020 ◽

pp. 003335492096730

Author(s):

Justin A. Yax ◽

Joshua D. Niforatos ◽

Daniel L. Summers ◽

Margaret H. Bigach ◽

Christine Schmotzer ◽

...

Keyword(s):

Emergency Department ◽

African American Men ◽

Medical Center ◽

The United States ◽

University Hospitals ◽

Syphilis Screening ◽

Sex With Men ◽

Testing Algorithm ◽

The University

The incidence of syphilis infections is on the rise, particularly among African American men and men who have sex with men, and it is reaching epidemic levels in these communities throughout the United States. Although syphilis is relatively inexpensive to treat and cure and is a predictor for HIV incidence among men and transgender women who have sex with men, rates of co-screening for syphilis are low in the emergency department setting, with a dearth of literature on this topic since the 1990s and early 2000s. In this case study, we describe an operational model for routine syphilis screening implemented in June 2017 at the University Hospitals Cleveland Medical Center in Cleveland, Ohio. We describe the advantages of screening using a reverse testing algorithm rather than the traditional method and the necessity of partnering with the Cleveland Department of Public Health for both diagnostic and follow-up logistics.

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Clinical physiological parameters for the prediction of gram-negative bacterial infection in the emergency department

10.21203/rs.3.rs-27796/v2 ◽

2020 ◽

Author(s):

Chan-Peng Hsu ◽

Hsin-Yu Chen ◽

Wei-Lung Chen ◽

Jiann-Hwa Chen ◽

Chien-Cheng Huang ◽

...

Keyword(s):

Emergency Department ◽

Early Detection ◽

Bacterial Infection ◽

Roc Analysis ◽

Medical Center ◽

Laboratory Data ◽

Vital Signs ◽

Physiological Parameters ◽

Gram Negative ◽

Positive Bacterial Culture

Abstract Background Early detection and treatment of Gram-negative bacteria (GNB), major causative pathogens of sepsis, may benefit a patient’s outcome, since the mortality rate increases by 5–10% for each hour of delayed therapy. Unfortunately, GNB diagnosis is based on blood culture, which is time consuming. Therefore, an economic and effective GNB infection detection tool in the emergency department (ED) is warranted. Methods We conducted a retrospective case control-study in the ED of a university-affiliated medical center between January 01, 2014 and December 31, 2017. The inclusion criteria were as follows: (1) age ≥ 18; (2) clinical suspicion of bacterial infection; (3) positive bacterial culture of blood or sputum or urine. Descriptive statistics was performed on patient demographic characteristics, vital signs, laboratory data, infection sites, cultured microorganisms, and clinical outcomes. The accuracy of vital signs to predict GNB infection was identified via logistic regression and receiver operating characteristic (ROC) analysis. Results A total of 797 patients were included in this study; the mean age was 71.8 years and 51.3% were male. The results revealed that patients with body temperature ≥ 38.5°C, heart rate ≥ 110 beats per minute, respiratory rate ≥ 20 breaths per minute, and Glasgow coma scale (GCS) < 14, had a 2.3-, 1.4-, 1.9-, and 1.6-fold greater risk of GNB infection, respectively. The area under the curve values for ROC analysis of these measures were 0.70, 0.68, 0.69, and 0.67, respectively. Conclusion The four physiological parameters were rapid and reliable independent predictors for early detection of GNB infection.

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2100. A Retrospective Chart Review of Emergent Antibiotic Use

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.1780 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S710-S710

Author(s):

Michelle Blyth ◽

James McNary ◽

Arnold Decano ◽

Audrey Renson ◽

Jeanne Carey

Keyword(s):

Emergency Department ◽

Antibiotic Stewardship ◽

Chart Review ◽

Vital Signs ◽

Retrospective Chart Review ◽

Antibiotic Use ◽

Academic Community ◽

Suspected Sepsis ◽

Empiric Antibiotics ◽

Data Points

Abstract Background The need for responsible antibiotic stewardship can be difficult to reconcile with the clinician’s task of quickly recognizing and treating sepsis. Empiric antibiotics are often given in patients with any suspicion of infection, yet antibiotics carry non-trivial risks including antibiotic resistance and susceptibility to other infections, such as Clostridium difficile. Methods This retrospective chart review includes 200 patients who were admitted to the hospital and administered antibiotics while in the Emergency Department (ED). From clinical documentation several clinical data points were gathered such as: changes to (including discontinuation of) antibiotics by the admitting team, final culture data, discharge diagnosis, vital signs and routine laboratory values. Results Our study finds that the majority of patients administered antibiotics in the ED of our academic community hospital were not diagnosed with sepsis (67%) and did not meet SIRS (62.5%) nor qSOFA (88%) criteria prior to administration of antibiotics. Vancomycin (39.7%) and piperacillin–tazobactam (22.2%) were the most frequent empiric antibiotics started. Antibiotics were stopped completely on admission by the admitting team in 22.2% of included patients. A wide variety of sources of infection were suspected, pneumonia (33%), cellulitis (15%), and cystitis (18%) being the most common. The overall mortality rate for this group during the admission was 4.5%, which was comparable to all-cause hospital mortality during the same time period. Infection was ruled out by discharge in 91 of the included 200 patients (45.5%). At least 37.5% of all included patients had received antibiotics within the last 3 months. Intriguingly, recent exposure was nearly twice as common (47.8%) among infected patients than in those without infections (24.7%), with a relative risk of 1.48 (CI 1.0993–2.0014). Conclusion These findings suggest that an opportunity exists for increased antibiotic stewardship in the emergency department in the management of suspected sepsis and/or infection. Stable patients in whom infection cannot be definitively ruled out may benefit more from prompt, thorough evaluation by an admitting team prior to the initiation of empiric antibiotics. Disclosures All authors: No reported disclosures.

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Characteristics and Outcomes of Clinic Visits Immediately Preceding Sepsis Hospitalization

American Journal of Critical Care ◽

10.4037/ajcc2021456 ◽

2021 ◽

Vol 30 (2) ◽

pp. 135-139

Author(s):

H. Catherine Miller ◽

Vincent X. Liu ◽

Hallie C. Prescott

Keyword(s):

Emergency Department ◽

Medical Center ◽

Academic Medical Center ◽

Vital Signs ◽

Time Lapse ◽

Clinic Visit ◽

Illness Severity ◽

Multiple Parameters ◽

Qsofa Score ◽

Clinic Visits

Background Existing sepsis quality improvement initiatives focus on recognition and treatment of sepsis upon hospital admission. Yet many patients are evaluated in the clinic within 1 day of sepsis hospitalization. Objectives To determine the circumstances of clinic visits that precede sepsis hospitalization, including illness severity, whether patients are referred to the hospital, and time lapse and change in illness severity between clinic and hospital evaluation. Methods In a retrospective cohort study at a tertiary academic medical center, data from electronic medical records were collected for all adult patients evaluated in an outpatient clinic within 1 day of sepsis hospitalization in 2017. Results Of 1450 patients hospitalized with sepsis, 118 had an established outpatient provider and a clinic visit within 1 day of admission and thus were included. During the clinic visit, 47 patients (39.8%) had a quick Sequential Organ Failure Assessment (qSOFA) score ≥1, and 59 (50.0%) had vital sign abnormalities. Most (74, 62.7%) were sent directly to the emergency department or hospital. Upon emergency department/hospital presentation, 62 patients (52.5%) had a worsening qSOFA score and/ or vital signs and 27 (22.9%) had worsening of multiple parameters. Median time lapse from clinic to emergency department/hospital evaluation was 3.2 hours. Conclusions One in 10 patients hospitalized for sepsis had been evaluated in a clinic within 1 day of admission. At that clinic visit, most patients had an elevated qSOFA score or abnormal vital signs and a majority were sent directly to the emergency department/hospital. Half experienced clinical deterioration between the clinic visit and arrival in the emergency department/hospital.

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Clinical physiological parameters for the prediction of gram-negative bacterial infection in the emergency department

10.21203/rs.3.rs-27796/v3 ◽

2020 ◽

Author(s):

Chan-Peng Hsu ◽

Hsin-Yu Chen ◽

Wei-Lung Chen ◽

Jiann-Hwa Chen ◽

Chien-Cheng Huang ◽

...

Keyword(s):

Emergency Department ◽

Bacterial Infection ◽

Bacterial Culture ◽

Medical Center ◽

Laboratory Data ◽

Vital Signs ◽

Area Under The Curve ◽

Physiological Parameters ◽

Roc Curve Analysis ◽

Gram Negative

Abstract Background: Early detection and treatment of Gram-negative bacteria (GNB), major causative pathogens of sepsis (a potentially fatal condition caused by the body's response to an infection), may benefit a patient’s outcome, since the mortality rate increases by 5–10% for each hour of delayed therapy. Unfortunately, GNB diagnosis is based on bacterial culture, which is time consuming. Therefore, an economic and effective GNB (defined as a positive blood, sputum, or urine culture) infection detection tool in the emergency department (ED) is warranted.Methods: We conducted a retrospective cohort study in the ED of a university-affiliated medical center between January 01, 2014 and December 31, 2017. The inclusion criteria were as follows: (1) age ≥ 18; (2) clinical suspicion of bacterial infection; (3) bacterial culture from blood, sputum, or urine ordered and obtained in the ED. Descriptive statistics was performed on patient demographic characteristics, vital signs, laboratory data, infection sites, cultured microorganisms, and clinical outcomes. The accuracy of vital signs to predict GNB infection was identified via univariate logistic regression and receiver operating characteristic (ROC) curve analysis.Results: A total of 797 patients were included in this study; the mean age was 71.8 years and 51.3% were male. The odds ratios of patients with body temperature ≥ 38.5°C, heart rate ≥ 110 beats per minute, respiratory rate ≥ 20 breaths per minute, and Glasgow coma scale (GCS) < 14, in predicting GNB infection were found to be 2.3, 1.4, 1.9, and 1.6, respectively. The area under the curve values for ROC analysis of these measures were 0.70, 0.68, 0.69, and 0.67, respectively.Conclusion: The four physiological parameters were rapid and reliable independent predictors for detection of GNB infection.

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Pulmonary Hypertension Roundtable: COPD, IPF, and Pulmonary Hypertension: A Clinician's Dilemma

Advances in Pulmonary Hypertension ◽

10.21693/1933-088x-12.3.145 ◽

2013 ◽

Vol 12 (3) ◽

pp. 145-151

Keyword(s):

Pulmonary Hypertension ◽

Rhode Island ◽

Medical Center ◽

Puget Sound ◽

Health Science ◽

Pulmonary Vascular Disease ◽

University Hospitals ◽

Science Center ◽

University Of Texas ◽

Transplant Program

On October 9, 2013, a group of experts met by telephone to discuss PH in the setting of COPD and IPF. The group consisting of guest editor of this issue Jeffrey Edelman, MD, Head, Lung Transplant Program VA Puget Sound Health System, University of Washington; Deborah J. Levine, MD, Director, Pulmonary Hypertension Center, University of Texas Health Science Center at San Antonio; James Klinger, MD, Director, Rhode Island Hospital Pulmonary Hypertension Center; and Robert Schilz, DO, PhD, Director of Pulmonary Vascular Disease and Lung Transplantation, University Hospitals, Case Medical Center; provided perspective and insight into how clinicians can approach these patients most effectively.

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