In-hospital mortality in the emergency department: clinical and etiological differences between early and late deaths among patients awaiting admission

Objective Given that there are no studies on diseases that occur by waiting for hospitalization, we aimed to evaluate the main causes of death in the emergency room (ER) and their relationship with overcrowding.Methods Patients who died in the ER in the past 2 years (pediatrics and trauma victims excluded) were divided into two groups: patients who died within 6 hours of arrival (emergency department [ED] group) and patients who died later (LD group). We compared the causes of death, total vital signs, diagnostic tests performed, and therapy between the groups. We assessed for possible correlation between the number of monthly deaths per group and four variables of overcrowding: number of patients treated per month, waiting time before medical visit (W-Time), mean intervention time (I-Time), and number of patients admitted to the ward per month (NPA).Results During the two years, 175 patients had died in our ER (52% in ED group and 48% in LD group). The total time spent in the ER was, respectively, 2.9±0.2 hours for ED group and 17.9± 1.5 hours for LD group. The more frequent cause of death was cardiovascular syndrome (30%) in ED group and sepsis (27%) and acute respiratory failure (27%) in LD group. Positive correlations between number of monthly deaths and W-Time (R2 0.51, P<0.001), I-Time (R2 0.73, P< 0.0001), and NPA (R2 0.37, P<0.01) were found only in LD group.Conclusion Patients with sepsis and acute respiratory failure die after a long stay in the ER, and the risk increases with overcrowding. A fast-track pathway should be considered for hospital admission of critical patients.

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Excess Patient Visits for Cough and Pulmonary Disease at a Large US Health System in the Months Prior to the COVID-19 Pandemic: Time-Series Analysis

Journal of Medical Internet Research ◽

10.2196/21562 ◽

2020 ◽

Vol 22 (9) ◽

pp. e21562 ◽

Cited By ~ 3

Author(s):

Joann G Elmore ◽

Pin-Chieh Wang ◽

Kathleen F Kerr ◽

David L Schriger ◽

Douglas E Morrison ◽

...

Keyword(s):

Emergency Department ◽

Time Series ◽

Respiratory Failure ◽

Acute Respiratory Failure ◽

Health System ◽

Prediction Interval ◽

Emergency Department Visits ◽

Current Season ◽

Number Of Patients ◽

Clinical Awareness

Background Accurately assessing the regional activity of diseases such as COVID-19 is important in guiding public health interventions. Leveraging electronic health records (EHRs) to monitor outpatient clinical encounters may lead to the identification of emerging outbreaks. Objective The aim of this study is to investigate whether excess visits where the word “cough” was present in the EHR reason for visit, and hospitalizations with acute respiratory failure were more frequent from December 2019 to February 2020 compared with the preceding 5 years. Methods A retrospective observational cohort was identified from a large US health system with 3 hospitals, over 180 clinics, and 2.5 million patient encounters annually. Data from patient encounters from July 1, 2014, to February 29, 2020, were included. Seasonal autoregressive integrated moving average (SARIMA) time-series models were used to evaluate if the observed winter 2019/2020 rates were higher than the forecast 95% prediction intervals. The estimated excess number of visits and hospitalizations in winter 2019/2020 were calculated compared to previous seasons. Results The percentage of patients presenting with an EHR reason for visit containing the word “cough” to clinics exceeded the 95% prediction interval the week of December 22, 2019, and was consistently above the 95% prediction interval all 10 weeks through the end of February 2020. Similar trends were noted for emergency department visits and hospitalizations starting December 22, 2019, where observed data exceeded the 95% prediction interval in 6 and 7 of the 10 weeks, respectively. The estimated excess over the 3-month 2019/2020 winter season, obtained by either subtracting the maximum or subtracting the average of the five previous seasons from the current season, was 1.6 or 2.0 excess visits for cough per 1000 outpatient visits, 11.0 or 19.2 excess visits for cough per 1000 emergency department visits, and 21.4 or 39.1 excess visits per 1000 hospitalizations with acute respiratory failure, respectively. The total numbers of excess cases above the 95% predicted forecast interval were 168 cases in the outpatient clinics, 56 cases for the emergency department, and 18 hospitalized with acute respiratory failure. Conclusions A significantly higher number of patients with respiratory complaints and diseases starting in late December 2019 and continuing through February 2020 suggests community spread of SARS-CoV-2 prior to established clinical awareness and testing capabilities. This provides a case example of how health system analytics combined with EHR data can provide powerful and agile tools for identifying when future trends in patient populations are outside of the expected ranges.

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Excess Patient Visits for Cough and Pulmonary Disease at a Large US Health System in the Months Prior to the COVID-19 Pandemic: Time-Series Analysis (Preprint)

10.2196/preprints.21562 ◽

2020 ◽

Author(s):

Joann G Elmore ◽

Pin-Chieh Wang ◽

Kathleen F Kerr ◽

David L Schriger ◽

Douglas E Morrison ◽

...

Keyword(s):

Emergency Department ◽

Time Series ◽

Respiratory Failure ◽

Acute Respiratory Failure ◽

Health System ◽

Prediction Interval ◽

Emergency Department Visits ◽

Current Season ◽

Number Of Patients ◽

Clinical Awareness

BACKGROUND Accurately assessing the regional activity of diseases such as COVID-19 is important in guiding public health interventions. Leveraging electronic health records (EHRs) to monitor outpatient clinical encounters may lead to the identification of emerging outbreaks. OBJECTIVE The aim of this study is to investigate whether excess visits where the word “cough” was present in the EHR reason for visit, and hospitalizations with acute respiratory failure were more frequent from December 2019 to February 2020 compared with the preceding 5 years. METHODS A retrospective observational cohort was identified from a large US health system with 3 hospitals, over 180 clinics, and 2.5 million patient encounters annually. Data from patient encounters from July 1, 2014, to February 29, 2020, were included. Seasonal autoregressive integrated moving average (SARIMA) time-series models were used to evaluate if the observed winter 2019/2020 rates were higher than the forecast 95% prediction intervals. The estimated excess number of visits and hospitalizations in winter 2019/2020 were calculated compared to previous seasons. RESULTS The percentage of patients presenting with an EHR reason for visit containing the word “cough” to clinics exceeded the 95% prediction interval the week of December 22, 2019, and was consistently above the 95% prediction interval all 10 weeks through the end of February 2020. Similar trends were noted for emergency department visits and hospitalizations starting December 22, 2019, where observed data exceeded the 95% prediction interval in 6 and 7 of the 10 weeks, respectively. The estimated excess over the 3-month 2019/2020 winter season, obtained by either subtracting the maximum or subtracting the average of the five previous seasons from the current season, was 1.6 or 2.0 excess visits for cough per 1000 outpatient visits, 11.0 or 19.2 excess visits for cough per 1000 emergency department visits, and 21.4 or 39.1 excess visits per 1000 hospitalizations with acute respiratory failure, respectively. The total numbers of excess cases above the 95% predicted forecast interval were 168 cases in the outpatient clinics, 56 cases for the emergency department, and 18 hospitalized with acute respiratory failure. CONCLUSIONS A significantly higher number of patients with respiratory complaints and diseases starting in late December 2019 and continuing through February 2020 suggests community spread of SARS-CoV-2 prior to established clinical awareness and testing capabilities. This provides a case example of how health system analytics combined with EHR data can provide powerful and agile tools for identifying when future trends in patient populations are outside of the expected ranges.

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Value of Diaphragmatic Motion Measurement at Ultrasonography to Predict Poor Prognosis in Emergency Department Patients With Acute Respiratory Failure

Case Medical Research ◽

10.31525/ct1-nct04119505 ◽

2019 ◽

Author(s):

Keyword(s):

Emergency Department ◽

Respiratory Failure ◽

Acute Respiratory Failure ◽

Poor Prognosis ◽

Motion Measurement ◽

Diaphragmatic Motion ◽

Emergency Department Patients

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Randomized clinical trial comparing helmet continuous positive airway pressure (hCPAP) to facemask continuous positive airway pressure (fCPAP) for the treatment of acute respiratory failure in the emergency department

The American Journal of Emergency Medicine ◽

10.1016/j.ajem.2021.06.031 ◽

2021 ◽

Author(s):

Adi Osman ◽

Gabriele Via ◽

Siti Hafsah Salleh ◽

Tan Wan Chuan ◽

Jamalludin Ab Rahman ◽

...

Keyword(s):

Clinical Trial ◽

Emergency Department ◽

Respiratory Failure ◽

Continuous Positive Airway Pressure ◽

Acute Respiratory Failure ◽

Randomized Clinical Trial ◽

Airway Pressure ◽

Positive Airway Pressure

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The Use of Dexmedetomidine in the Emergency Department: A Cohort Study

Western Journal of Emergency Medicine ◽

10.5811/westjem.2021.4.50917 ◽

2021 ◽

Vol 22 (5) ◽

pp. 1202-1209

Author(s):

Joseph Sinnott ◽

Christopher Holthaus ◽

Enyo Ablordeppey ◽

Brian Wessman ◽

Brian Roberts ◽

...

Keyword(s):

Emergency Department ◽

Adverse Event ◽

Cohort Study ◽

Respiratory Failure ◽

Adverse Events ◽

Acute Respiratory Failure ◽

Tertiary Care ◽

Multivariable Logistic Regression Model ◽

Non Invasive Ventilation ◽

Improved Outcomes

Introduction: Management of sedation, analgesia, and anxiolysis are cornerstone therapies in the emergency department (ED). Dexmedetomidine (DEX), a central alpha-2 agonist, is increasingly being used, and intensive care unit (ICU) data demonstrate improved outcomes in patients with respiratory failure. However, there is a lack of ED-based data. We therefore sought to: 1) characterize ED DEX use; 2) describe the incidence of adverse events; and 3) explore factors associated with adverse events among patients receiving DEX in the ED. Methods: This was a single-center, retrospective, cohort study of consecutive ED patients administered DEX (January 1, 2017–July 1, 2019) at an academic, tertiary care ED with an annual census of ~90,000 patient visits. All included patients (n= 103) were analyzed for characterization of DEX use in the ED. The primary outcome was a composite of adverse events, bradycardia and hypotension. Secondary clinical outcomes included ventilator-, ICU-, and hospital-free days, and hospital mortality. To examine for variables associated with adverse events, we used a multivariable logistic regression model. Results: We report on 103 patients. Dexmedetomidine was most commonly given for acute respiratory failure, including sedation for mechanical ventilation (28.9%) and facilitation of non-invasive ventilation (17.4%). Fifty-four (52.4%) patients experienced the composite adverse event, with hypotension occurring in 41 patients (39.8%) and bradycardia occurring in 18 patients (17.5%). Dexmedetomidine was stopped secondary to an adverse event in eight patients (7.8%). Duration of DEX use in the ED was associated with an increase adverse event risk (adjusted odds ratio, 1.004; 95% confidence interval, 1.001, 1.008). Conclusion: Dexmedetomidine is most commonly administered in the ED for patients with acute respiratory failure. Adverse events are relatively common, yet DEX is discontinued comparatively infrequently due to adverse events. Our results suggest that DEX could be a viable option for analgesia, anxiolysis, and sedation in ED patients.

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Abstract 131: Cardiac Arrest Due to Cardiac Etiology: A Progress Report on the Past 20 Years in an Emergency Department in Vienna

Circulation ◽

10.1161/circ.130.suppl_2.131 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

Patrick Sulzgruber ◽

Pia Hubner ◽

Andreas Schober ◽

Alexander Spiel ◽

Thomas Uray ◽

...

Keyword(s):

Emergency Department ◽

Cardiac Arrest ◽

Neurological Outcome ◽

Mortality Rates ◽

Western World ◽

The Past ◽

Initial Event ◽

Long Term Study ◽

Number Of Patients ◽

Favorable Neurological Outcome

Background: Based on demographic changes in the western world, the number of patients with cardiac arrest due to a cardiovascular event is continuously rising. A large variety of factors impacting on favorable neurological outcome (CPC 1-2) and the 6-month survival, are well established. The question whether the knowledge about these predictive factors result in improved outcome over the last 20 years, has not been proven within a long-term study so far. Methods: We prospectively identified 2670 patients (out-of hospital [OOH], n = 1822; in-hospital [IH], n = 848) with cardiac arrest of cardiac etiology and ventricular fibrillation as a first rhythm treated at our emergency department between January 1992 and December 2012. Chi-square test and Cochran-Mantel-Haenszel test have been used to assess differences in CPC and 6-month survival within the observation-period. Results: Within our total cohort, 2189 patients (82.0%) survived the initial event. After a follow-up period of 6 months, 1007 patients (46%) with ROSC deceased. A favorable CPC (1-2) after 6 months has been detected in 1197 patients (54.7%). Within the last 20 years there was an improvement of favorable neurological outcome (CPC 1-2) (p<0.001) and as well a reduction of 6-month mortality rates (p=0.004). Independently in patients with IH cardiac arrest, 78.5% (n=666) survived the initial event, but the 6-month survival rate (n=381, 57.2%) and the favorable CPC outcome (n=443, 66.5%) were approximately higher. Independently within IH cardiac arrest patients a reduction of 6-month mortality rates (p=0.048) was found. Still there were constantly high rates of favorable neurological outcome (CPC 1-2) after 6 months, but there was no improvement within the past 20 years (p=0.665). Conclusion: We were able to demonstrate, that outcome of patients with cardiac arrest of a cardiac etiology has improved significantly within the last 20 years. This gives the impression, that critical care medicine on a high level for patients with cardiac arrest even in the emergency department could be important for outcome. If such specific cardiac arrest centers merged with emergency departments prove to be valuable for ideal patient care has to be further evaluated in detail.

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