Algorithms for Individual Prediction of COVID-19 infection and Hospitalization among Symptomatic patients based on health data (Preprint)

BACKGROUND The coronavirus disease 2019 (COVID-19) pandemic has generated a huge strain on the health care system worldwide. The metropolitan area of Milan, Italy was one of the most hit area in the world. OBJECTIVE Robust risk prediction models are needed to stratify individual patient risk for public health purposes METHODS Two predictive algorithms were implemented in order to foresee the probability of being a COVID-19 patient and the risk of being hospitalized. The predictive model for COVID-19 positivity was developed in 61.956 symptomatic patients, whereas the model for COVID-19 hospitalization was developed in 36.834 COVID-19 positive patients. Exposures considered were age, gender, comorbidities and symptoms associated with COVID-19 (vomiting, cough, fever, diarrhoea, myalgia, asthenia, headache, anosmia, ageusia, and dyspnoea). RESULTS The predictive models showed a good fit for predicting COVID-19 disease [AUC 72.6% (95% CI 71.6%-73.5%)] and hospitalization [AUC 79.8% (95% CI 78.6%-81%)]. Using these results, 118,804 patients with COVID-19 from October 25 to December 11, 2020 were stratified into low, medium and high risk for COVID-19 severity. Among the overall population, 67.030 (56%) were classified as low-risk, 43.886 (37%) medium-risk, and 7.888 (7%) high-risk, with 89% of the overall population being assisted at home, 9% hospitalized, and 2% dead. Among those assisted at home, most people (60%) were classified as low risk, whereas only 4% were classified at high risk. According to ordinal logistic regression, the OR of being hospitalised or dead was 5.0 (95% CI 4.6-5.4) in high-risk patients and 2.7 (95% CI 2.6-2.9) in medium-risk patients, as compared to low-risk patients. CONCLUSIONS A simple monitoring system, based on primary care datasets with linkage to COVID-19 testing results, hospital admissions data and death records may assist in proper planning and allocation of patients and resources during the ongoing COVID-19 pandemic.

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Kidney Failure Risk Equation and Cost of Care in Patients with Chronic Kidney Disease

Clinical Journal of the American Society of Nephrology ◽

10.2215/cjn.06770521 ◽

2021 ◽

pp. CJN.06770521 ◽

Cited By ~ 1

Author(s):

Bhanu Prasad ◽

Meric Osman ◽

Maryam Jafari ◽

Lexis Gordon ◽

Navdeep Tangri ◽

...

Keyword(s):

High Risk ◽

Prescription Drugs ◽

Kidney Failure ◽

Hospital Admissions ◽

Low Risk ◽

Content Type ◽

Physician Visits ◽

Risk Equation ◽

Risk Of Progression ◽

Risk Patients

Background and objectivesPatients with CKD exhibit heterogeneity in their rates of progression to kidney failure. The kidney failure risk equation (KFRE) has been shown to accurately estimate progression to kidney failure in adults with CKD. Our objective was to determine health care utilization patterns of patients on the basis of their risk of progression.Design, setting, participants, & measurementsWe conducted a retrospective cohort study of adults with CKD and eGFR of 15–59 ml/min per 1.73 m2 enrolled in multidisciplinary CKD clinics in the province of Saskatchewan, Canada. Data were collected from January 1, 2004 to December 31, 2012 and followed for 5 years (December 31, 2017). We stratified patients by eGFR and risk of progression and compared the number and cost of hospital admissions, physician visits, and prescription drugs.ResultsIn total, 1003 adults were included in the study. Within the eGFR of 15–29 ml/min per 1.73 m2 group, the costs of hospital admissions, physician visits, and drug dispensations over the 5-year study period comparing high-risk patients with low-risk patients were (Canadian dollars) $89,265 versus $48,374 (P=0.008), $23,423 versus $11,231 (P<0.001), and $21,853 versus $16,757 (P=0.01), respectively. Within the eGFR of 30–59 ml/min per 1.73 m2 group, the costs of hospital admissions, physician visits, and prescription drugs were $55,944 versus $36,740 (P=0.10), $13,414 versus $10,370 (P=0.08), and $20,394 versus $14,902 (P=0.02) in high-risk patients in comparison with low-risk patients, respectively, for progression to kidney failure.ConclusionsIn patients with CKD and eGFR of 15–59 ml/min per 1.73 m2 followed in multidisciplinary clinics, the costs of hospital admissions, physician visits, and drugs were higher for patients at higher risk of progression to kidney failure by the KFRE compared with patients in the low-risk category. The high-risk group of patients with CKD and eGFR of 15–29 ml/min per 1.73 m2 had stronger association with hospitalizations costs, physician visits, and drug utilizations.

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P0687DO ALL PATIENTS BENEFIT FROM MULTIDISCIPLINARY CHRONIC KIDNEY DISEASE CLINICS?

Nephrology Dialysis Transplantation ◽

10.1093/ndt/gfaa142.p0687 ◽

2020 ◽

Vol 35 (Supplement_3) ◽

Author(s):

Bhanu Prasad ◽

Maryam Jafari ◽

Lexis Gordon ◽

Navdeep Tangri ◽

Joanne Kappel

Keyword(s):

Health Care ◽

High Risk ◽

Health Care Utilization ◽

Kidney Failure ◽

Low Risk ◽

Care Utilization ◽

Medium Risk ◽

Risk Of Progression ◽

Risk Patients ◽

The Cost

Abstract Background and Aims: Multidisciplinary clinics (MDC’s) were established in Canada to offer a variety of support systems (diabetes care, social support, easy access to pharmacists, dietitians, specialty trained nurses), to monitor and delay progression through timed lab investigations and visits in conjunction with the Nephrologist. The reasons for better outcomes have been identified as better education, focus on self-care, dietary interventions, timely transplant referrals, modality education, lower hospitalizations and mortality. Treating all patients with chronic kidney disease (CKD) as part of a multidisciplinary care team runs the risk of adding unwarranted labs, interventions, polypharmacy and costs. Kidney Failure Risk Equation (KFRE) uses routine laboratory and clinical data, to stratify patients into three risk categories (low, medium, and high risk) of progression. KFRE has been shown to accurately estimate progression to kidney failure in adults with CKD. The objectives of the study were to i) validate the KFRE in our CKD patients, ii) evaluate health care utilization of patients based on the risk of progression in our province, Saskatchewan. iii) identify the subgroup of patients that benefit most from follow up in MDC. Methods: We conducted a retrospective study on 1007 patients with CKD stages G3 and G4 in two CKD multidisciplinary clinics in the province of Saskatchewan, Canada (January 2004-December 2012). The predicted risk of kidney failure (low, medium high) for each patient was calculated using the 8-variable KFRE. Patients were followed for five years to validate the KFRE; data on initiation of dialysis or death was collected. Cost of delivery of care per patient per year in the CKD clinic was determined. Health care utilization was evaluated by measuring the number/cost of hospital admissions, cardiovascular and thoracic (CVT) surgery, non-nephrology specialist appointments, and medications. Results: There were more patients in G 3 (n= 533) than in G 4 (n=474). 313 (59%), 150 (28%), and 70 (13%) were in low, medium and high-risk categories for G 3 CKD. 275 (58%), 86 (18%), and 113 (24%) were in similar categories for G 4. The mean age (SD) was 71 (12.8) years. The number of patients > 65 years of age was 75%. 57% were men, mean GFR (mls/min/1.73m2) for G3 was 40 (7.8) and 23 (4) for G4. Of the G3 patients, 4% of low risk, 11% of the medium risk and 26% of the high risk progressed to dialysis by 5 years. In G 4 patients, 7% of low risk, 17% of medium risk and 48% of high risk progressed to dialysis over 2 years. These results validate the KFRE in our population. The cost of care per patient in MDC was $ 3800 (CAD) per year. There was a difference in the cost of medications, number and cost of (inpatient hospitalizations, cardiovascular surgeries, non-Nephrology specialist visits, and day surgeries) between low risk patients vs high risk patients in G4 patients. Conclusion: We performed a cost-effectiveness analysis of our MDC’s and show that very few patients at low-risk of progression advance to ESRD. They are also unlikely to benefit from intensive care management and better managed in primary care with advice from tertiary centres. Individual programs have significant opportunity to improve health care delivery by identifying the sub- groups that benefit the most from MDC based on the risk of progression to allow optimal utilization of resources. At $ 3800 (CAD) per patient, we suggest that MDC’s are best utilized by patients with medium and high risk of progression. Further, we show that patients that the low-risk patients were older, had fewer inpatient visits, had lesser drug costs, underwent fewer cardiovascular surgeries, had fewer day surgery visits, and fewer non-nephrology specialist visits. This is the first study to our knowledge that focuses on health care utilization based on the risk of disease progression rather than the stage of CKD.

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Impact of Stratification of Comorbidities on Nutrition Indices and Survival in Patients on Continuous Ambulatory Peritoneal Dialysis

Peritoneal Dialysis International ◽

10.1177/089686080902902s30 ◽

2009 ◽

Vol 29 (2_suppl) ◽

pp. 153-157 ◽

Cited By ~ 3

Author(s):

Narayan Prasad ◽

Amit Gupta ◽

Archana Sinha ◽

Anurag Singh ◽

Raj Kumar Sharma ◽

...

Keyword(s):

Peritoneal Dialysis ◽

High Risk ◽

Continuous Ambulatory Peritoneal Dialysis ◽

Risk Group ◽

Risk Groups ◽

High Risk Group ◽

Low Risk ◽

Comorbid Illness ◽

Medium Risk ◽

Risk Patients

Background Case-mix comorbidities and malnutrition influence outcome in continuous ambulatory peritoneal dialysis (CAPD) patients. In the present study, we analyzed the influence of stratified comorbidities on nutrition indices and survival in CAPD patients. Patients and Methods We categorized 373 CAPD patients (197 with and 176 without diabetes) into three risk groups: low—age under 70 years and no comorbid illness; medium—age 70 – 80 years, or any age with 1 comorbid illness, or age under 70 years with diabetes; high—age over 80 years, or any age with 2 comorbid illnesses. We then compared nutrition indices and malnutrition by subjective global assessment (SGA) between the three groups. Survival was compared using Kaplan–Meier survival analysis. Results Mean daily calorie and protein intakes in the low-risk group (21 ± 6.7 Kcal/kg, 0.85 ± 0.28 g/kg) were significantly higher than in the medium- (17.6 ± 5.2 Kcal/kg, 0.79 ± 0.25 g/kg) and high-risk (17.5 ± 6.1 Kcal/kg, 0.78 ± 0.26 g/kg) groups ( p = 0.001 and p = 0.04 respectively). Relative risk (RR) of malnutrition was less in the low-risk group (103/147, 70.06%) than in the medium-risk group [135/162, 83.3%; RR: 2.0; 95% confidence interval (CI): 2.1 to 3.4; p = 0.01] or the high-risk group (54/64, 84.4%; RR: 2.3; 95% CI: 2.1 to 4.9; p = 0.03). Mean survivals of patients in the low-, medium-, and high-risk groups were 51 patient–months (95% CI: 45.6 to 56.4 patient–months), 43.3 patient–months (95% CI: 37.8 to 48.7 patient–months), and 29.7 patient–months (95% CI: 23 to 36.4 patient–months) respectively (log-rank: 35.9 patient–months; p = 0.001). The 1-, 2-, 3-, 4-, and 5-year patient survivals in the low-, medium-, and high-risk groups were 96%, 87%, 79%, 65%, and 56%; 89%, 67%, 54%, 43%, and 34%; and 76%, 48%, 31%, 30%, and 30% respectively. Conclusions Intake of calories and protein was significantly lower in the medium-risk and high-risk groups than in the low-risk group. Survival was significantly better in low-risk patients than in medium- and high-risk patients.

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Impacts of remdesivir on dynamics and efficacy stratified by the severity of COVID- 19: a simulated two-arm controlled study

10.1101/2020.05.17.20104711 ◽

2020 ◽

Author(s):

Ting-Yu Lin ◽

Wei-Jung Chang ◽

Chen-Yang Hsu ◽

Chao-Chih Lai ◽

Amy Ming-Fang Yen ◽

...

Keyword(s):

High Risk ◽

Secondary Analysis ◽

Low Risk ◽

Controlled Study ◽

Significant Efficacy ◽

Medium Risk ◽

Risk Patients ◽

Discharge From Hospital ◽

The Impact ◽

Insight Into

Background: The impact of remdesivir on length of stay of hospitalization, high-risk state, and death stratified by the severity of COVID-19 at enrollment is controversial. Methods: We applied a simulated two-arm controlled study design to the data on compassionate use of remdesivir as a secondary analysis. Dynamics of risk states and death from COVID-19 patients defined by the six-point disease severity recommended by the WHO R&D and the time to discharge from hospital were used to evaluate the efficacy of remdesivir treatment compared with standard care. Results: Stratified by the risk state at enrollment, low-risk patients exhibited the highest efficacy of remdesivir in reducing subsequent progression to high-risk state by 67% (relative risk (RR)=0.33,95% CI: 0.30-0.35) and further to death by 55% (RR=0.45, 95%CI: 0.39-0.50). For the medium-risk patients, less but still statistically significant efficacy results were noted in reducing progression to high-risk state by 52% (RR=0.48, 95% CI: 0.45-0.51) and further to death by 40% (RR=0.60, 95% CI:0.54-0.66). High-risk state patients treated with remdesivir led to a 25% statistically significant reduction in death (RR=0.75, 95% CI: 0.69-0.82). Regarding the outcome of discharge, remdesivir treatment was most effective for medium-risk patients at enrollment (RR: 1.41, 95% CI: 1.35-1.47) followed by high- (RR=1.34, 95% CI: 1.27-1.42) and low-risk patients (RR=1.28, 95% CI: 1.25-1.31). Conclusion: Our results with a simulated two-arm controlled study have provided a new insight into the precision treatment of remdesivir for COVID-19 patients based on risk-stratified efficacy.

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Comparative Analysis of Obstetric Hemorrhage Risk Prediction Tools

American Journal of Perinatology ◽

10.1055/s-0041-1740013 ◽

2021 ◽

Author(s):

Francis M. Hacker ◽

Jaclyn M. Phillips ◽

Lara S. Lemon ◽

Hyagriv N. Simhan

Keyword(s):

Risk Factors ◽

High Risk ◽

Risk Prediction ◽

Scoring Systems ◽

Low Risk ◽

Individual Risk ◽

Medium Risk ◽

Risk Patients ◽

Hemorrhage Risk ◽

Individual Risk Factors

Objective Hemorrhage risk prediction tools were developed in response to rising rates of obstetric hemorrhage (OBH). The California Maternal Quality Care Collaborative (CMQCC) risk prediction tool classifies patients as low, medium, and high risk for OBH based on individual risk factors. At our institution, Magee-Womens Hospital (MWH), a unique OBH risk prediction tool was derived from the CMQCC tool that differs through its use of weighted risk factors and distinctive laboratory value cutoffs. Our objective is to compare this enhanced institution-specific tool to the CMQCC tool. Study Design This study was a retrospective cohort analysis of delivery admissions from a single health care network. Admission OBH risk scores were assigned to each patient using both the MWH and CMQCC scores. Cohen's kappa estimated agreement. Scoring systems and maternal outcomes were compared using chi-square test. Composite morbidity included transfusion, hysterectomy, uterine artery embolization, and intensive care unit admission. Results A total of 21,843 delivery admissions were included. A moderate association was observed between scoring systems (kappa 0.41, p < 0.001). The CMQCC tool categorized 16,184 (74%) patients as low risk, 4,664 (21%) as medium risk, and 995 (5%) as high risk. The MWH tool categorized 13,137 (60%) patients as low risk, 8,113 (37%) as medium risk, and 593 (3%) as high risk. The MWH score recategorized CMQCC low-risk patients to a higher stratum 26% of the time. CMQCC high-risk patients were recategorized to a lower stratum 82% of the time. Both the MWH and CMQCC tools were able to differentiate OBH-related morbidity across risk strata. The MWH tool independently predicted risk of composite morbidity within each stratum of the CMQCC score. Conclusion Both the MWH and CMQCC tools independently distinguish risk of composite morbidity. Adding weighted values to individual risk factors further discriminates risk of morbidity. This suggests it may be reasonable to adapt the CMQCC tool to reflect institutional populations and resources. Key Points

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P8 A single centre evaluation of risk prediction models and imaging modalities in acute appendicitis

BJS Open ◽

10.1093/bjsopen/zrab032.007 ◽

2021 ◽

Vol 5 (Supplement_1) ◽

Author(s):

James Ashcroft ◽

Aminder A Singh ◽

Siobhan Rooney ◽

John Bennett ◽

Richard Justin Davies ◽

...

Keyword(s):

High Risk ◽

Risk Prediction ◽

Prediction Models ◽

Ct Imaging ◽

Low Risk ◽

Imaging Modalities ◽

Risk Prediction Models ◽

Suspected Appendicitis ◽

High Risk Women ◽

Low Risk Women

Abstract Objective Patients with suspected appendicitis remain a diagnostic challenge. This study aims to validate risk prediction models and to investigate diagnostic accuracy of ultrasonography (US) and computed tomography (CT) in adults undergoing an appendicectomy. Materials and Methods A retrospective case review of patients aged 16-45 undergoing an appendicectomy between January 2019 to January 2020 at a tertiary referral centre was performed. Primary outcomes were the accuracy of a high-risk appendicitis risk score and US and CT imaging modalities when compared to histological reports following appendicectomy. Results A total of 206 patients (107/205, 51.9% women) were included. Removal of histologically normal appendix was equally likely in men and women (13.1 versus 11.2%, relative risk 1.17, 95% c.i. 0.56 to 2.44; P =0.67). A high-risk appendicitis score correctly identified 84.0% (79/94) of cases in men and 85.9% (67/78) of cases in women. US was reported as equivocal in 85.7% (18/21) of low-risk women and 59.0% (23/39) of high-risk women. CT in low-risk women resulted in 25.0% (2/8) equivocal results whilst correctly diagnosing (5/6) or excluding (1/2) appendicitis in 75.0% of the total cohort (6/8). In high-risk women CT resulted in 3.8% (1/26) equivocal results whilst correctly detecting (22/23) or excluding (1/3) appendicitis in 88.5% of total high-risk patients (23/26). Conclusions This study suggests that risk prediction models may be useful in both women and men to identify appendicitis. US imaging gave high rates of equivocal results and should not be relied upon for the diagnosis of appendicitis but may be useful to exclude other differential diagnoses. CT imaging is a highly accurate diagnostic tool and could be considered in those at low-risk where clinical suspicion remains to reduce negative appendicectomy rates.

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R package “QRISK3”: an unofficial research purposed implementation of ClinRisk’s QRISK3 algorithm into R

F1000Research ◽

10.12688/f1000research.21679.2 ◽

2020 ◽

Vol 8 ◽

pp. 2139

Author(s):

Yan Li ◽

Matthew Sperrin ◽

Tjeerd van Staa

Keyword(s):

Cardiovascular Disease ◽

High Risk ◽

Risk Prediction ◽

Prediction Models ◽

R Package ◽

Research Community ◽

Risk Prediction Models ◽

Risk Patients ◽

Future Risk ◽

The Uk

Cardiovascular disease has been the leading cause of death for decades. Risk prediction models are used to identify high risk patients; the most common model used in the UK is ClinRisk’s QRISK3. In this paper we describe the implementation of the QRISK3 algorithm into an R package. The package was successfully validated by the open sourced QRISK3 algorithm and QRISK3 SAS program. We provide detailed examples of the use of the package, including assigning QRISK3 scores for a large cohort of patients. This R package could help the research community to better understand risk prediction scores and improve future risk prediction models. The package is available from CRAN: https://cran.r-project.org/web/packages/QRISK3/index.html.

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R package “QRISK3”: an unofficial research purposed implementation of ClinRisk’s QRISK3 algorithm into R

F1000Research ◽

10.12688/f1000research.21679.1 ◽

2019 ◽

Vol 8 ◽

pp. 2139

Author(s):

Yan Li ◽

Matthew Sperrin ◽

Tjeerd van Staa

Keyword(s):

Cardiovascular Disease ◽

High Risk ◽

Risk Prediction ◽

Prediction Models ◽

R Package ◽

Research Community ◽

Risk Prediction Models ◽

Risk Patients ◽

Future Risk ◽

The Uk

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Feasibility of Withholding Antibiotics in Selected Febrile Neutropenic Cancer Patients

Journal of Clinical Oncology ◽

10.1200/jco.2004.00.5264 ◽

2005 ◽

Vol 23 (30) ◽

pp. 7437-7444 ◽

Cited By ~ 59

Author(s):

Claudi Oude Nijhuis ◽

Willem A. Kamps ◽

Simon M.G. Daenen ◽

Jourik A. Gietema ◽

Winette T.A. van der Graaf ◽

...

Keyword(s):

Risk Assessment ◽

High Risk ◽

Bacterial Infection ◽

Treatment Protocol ◽

Low Risk ◽

Assessment Model ◽

Risk Assessment Model ◽

Medium Risk ◽

Risk Patients ◽

Neutropenic Patients

Purpose To investigate the feasibility of withholding antibiotics and early discharge for patients with chemotherapy-induced neutropenia and fever at low risk of bacterial infection by a new risk assessment model. Patients and Methods Outpatients with febrile neutropenia were allocated to one of three groups by a risk assessment model combining objective clinical parameters and plasma interleukin 8 level. Patients with signs of a bacterial infection and/or abnormal vital signs indicating sepsis were considered high risk. Based on their interleukin-8 level, remaining patients were allocated to low or medium risk for bacterial infection. Medium-risk and high-risk patients received standard antibiotic therapy, whereas low-risk patients did not receive antibiotics and were discharged from hospital after 12 hours of a febrile observation. End points were the feasibility of the treatment protocol. Results Of 196 assessable episodes, 76 (39%) were classified as high risk, 84 (43%) as medium risk, and 36 (18%) as low risk. There were no treatment failures in the low-risk group (95% CI, 0% to 10%). Therefore, sensitivity of our risk assessment model was 100% (95% CI, 90% to 100%), the specificity, positive, and negative predictive values were 21%, 13%, and 100%, respectively. Median duration of hospitalization was 3 days in the low-risk group versus 7 days in the medium- and high-risk groups (P < .0001). The incremental costs of the experimental treatment protocol amounted to a saving of €471 (US $572) for every potentially low-risk patient. Conclusion This risk assessment model appears to identify febrile neutropenic patients at low risk for bacterial infection. Antibiotics can be withheld in well-defined neutropenic patients with fever.

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LO06: Development of practice recommendations for ED management of syncope by mixed methods

CJEM ◽

10.1017/cem.2020.62 ◽

2020 ◽

Vol 22 (S1) ◽

pp. S8-S9

Author(s):

V. Thiruganasambandamoorthy ◽

M. Taljaard ◽

N. Hudek ◽

J. Brehaut ◽

B. Ghaedi ◽

...

Keyword(s):

High Risk ◽

Low Risk ◽

Cardiac Monitoring ◽

Structured Interviews ◽

High Risk Patients ◽

Practice Recommendations ◽

Medium Risk ◽

Risk Patients ◽

Risk Categories

Introduction: Emergency department (ED) syncope management is extremely variable. We developed practice recommendations based on the validated Canadian Syncope Risk Score (CSRS) and outpatient cardiac monitoring strategy with physician input. Methods: We used a 2-step approach. Step-1: We pooled data from the derivation and validation prospective cohort studies (with adequate sample size) conducted at 11 Canadian sites (Sep 2010 to Apr 2018). Adults with syncope were enrolled excluding those with serious outcome identified during index ED evaluation. 30-day adjudicated serious outcomes were arrhythmic (arrhythmias, unknown cause of death) and non-arrhythmic (MI, structural heart disease, pulmonary embolism, hemorrhage)]. We compared the serious outcome proportion among risk categories using Cochran-Armitage test. Step-2: We conducted semi-structured interviews using observed risk to develop and refine the recommendations. We used purposive sampling of physicians involved in syncope care at 8 sites from Jun-Dec 2019 until theme saturation was reached. Two independent raters coded interviews using an inductive approach to identify themes; discrepancies were resolved by consensus. Results: Of the 8176 patients (mean age 54, 55% female), 293 (3.6%; 95%CI 3.2-4.0%) experienced 30-day serious outcomes; 0.4% deaths, 2.5% arrhythmic, 1.1% non-arrhythmic outcomes. The serious outcome proportion significantly increased from low to high-risk categories (p < 0.001; overall 0.6% to 27.7%; arrhythmic 0.2% to 17.3%; non-arrhythmic 0.4% to 5.9% respectively). C-statistic was 0.88 (95%CI0.86–0.90). Non-arrhythmia risk per day for the first 2 days was 0.5% for medium-risk, 2% for high-risk and very low thereafter. We recruited 31 physicians (14 ED, 7 cardiologists, 10 hospitalists/internists). 80% of physicians agreed that low risk patients can be discharged without specific follow-up with inconsistencies around length of ED observation. For cardiac monitoring of medium and high-risk, 64% indicated that they don't have access; 56% currently admit high-risk patients and an additional 20% agreed to this recommendation. A deeper exploration led to following refinement: discharge without specific follow-up for low-risk, a shared decision approach for medium-risk and short course of hospitalization for high-risk patients. Conclusion: The recommendations were developed (with online calculator) based on in-depth feedback from key stakeholders to improve uptake during implementation.

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