A Comparrison of Two Emergency Departments

Time Frame ◽

Urine Specimen ◽

Urine Collection ◽

Initial Care ◽

Administration Time ◽

Developed World

Urosepsis accounts for approximately 25% of all cases of sepsis in the developed world. The mortality from urosepsis is high and the financial burden is exorbitant. Research has established that a patient’s survivability from sepsis is inversely proportional to time to antibiotic administration. The initial care of patients with urosepsis often occurs in the chaotic setting of the Emergency Department and obtaining a urine specimen is a key element of patient care. The purpose of the project was to compare two emergency departments door-to-urine time with a focus on urine procurement technique. Urine procurement may occur by straight catheterization, Quik ®catheterization, indwelling urinary catheterization, or mid stream clean catch collection. One department has access to Quik ®catheterization technology that is unavailable to the other department. Exclusion criteria are patients already diagnosed with UTI and patients taking antibiotics on arrival to the emergency room. A retrospective chart review was conducted on 60 records. Data collected included gender, age, chief concern, method of urine procurement, door-to-urine collection time, door-to antibiotic administration time and urinalysis results. Results showed that catheterization was not always faster than midstream clean catch collection. There were an insufficient number of Quik ®catheterizations performed during the time frame of the study to establish a link between the technology and expedited urine collection or antibiotic administration. The study does suggest that greater awareness and more research is needed concerning care of the uroseptic patient in the ED.

752. Timing of Antibiotics Administration in Emergency Department and Mortality in Sepsis by Sepsis-3 Definition

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.820 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S335-S336

Author(s):

Hyeri Seok ◽

Ju-Hyun Song ◽

Ji Hoon Jeon ◽

Hee Kyoung Choi ◽

Won Suk Choi ◽

...

Keyword(s):

Emergency Department ◽

Sofa Score ◽

Lactate Level ◽

P Value ◽

Risk Of Mortality ◽

Administration Time ◽

Comorbidity Index ◽

Time To Antibiotics ◽

The Mean

Abstract Background Even after the introduction of the Sepsis-3 definition, there is still debate on the ideal antibiotic administration time in patients with sepsis. This study was performed to evaluate the association between the timing of antibiotic administration and mortality in sepsis patients who visited the emergency room. Methods A prospective cohort study was conducted on patients who were diagnosed as sepsis with Sepsis-3 definition among patients who visited the emergency department (ED) of Korea University Ansan Hospital from September 2017 to January 2019. The timing of antibiotic administration was defined as the time in hours from ED arrival until the first antibiotic administration. Cox logistic regression analysis was used to estimate the association between time to antibiotics and 7-, 14-, and 28-day mortality. Results During the study period, a total of 251 patients were enrolled with a 7-, 14-, and 28-day mortality of 16.7%, 36.3%, and 57.4%, respectively. The median time to antibiotic administration was 247 minutes (interquartile range 72 – 202 minutes). The mean age was 72 ± 15 years old and 122 patients (48.6%) were female. The most common site of infection was respiratory infection. The timing of antibiotic administration were not associated with 7-, 14-, and 28-day mortality. Female (adjusted hazard ratio [HR] 2.06 [95% confidence interval (CI) 1.21 – 3.53]; P value = 0.008), SOFA score (aHR 1.17 [95% CI 1.05 - 1.31]; P = 0.005), and initial lactate level (aHR 1.13 [95% CI 1.05 - 1.22]; P = 0.001) increased the risk of 7-day mortality. Female (aHR 2.07 [95% CI 1.48 – 2.89]; P ≤ 0.001), Charlson comorbidity index (aHR 1.12 [95% CI 1.02 - 1.24]; P = 0.025), and initial lactate level (aHR 1.19 [95% CI 1.02 - 1.16]; P = 0.011) increased the risk of 14-day mortality. Female (aHR 1.95 [95% CI 1.50 – 2.54]; P = 0.001) increased the risk of 28-day mortality in patients with sepsis. Conclusion The timing of antibiotic administration did not increase the risk of mortality in the treatment of sepsis patients who visited ED. Rather, the SOFA score, lactate, female, and comorbidity increased the mortality associated with sepsis. Disclosures All authors: No reported disclosures.

503 Clinical Frailty Score (CFS) Vs Antibiotics, Time to Surgery and Time to Computerised Tomography (CT) Scan in An Emergency Surgical Population

British Journal of Surgery ◽

10.1093/bjs/znab134.193 ◽

2021 ◽

Vol 108 (Supplement_2) ◽

Author(s):

S Palaniappan ◽

R Soiza ◽

S Moug ◽

P Myint

Keyword(s):

Ct Scan ◽

Emergency Laparotomy ◽

Process Measures ◽

Time To Surgery ◽

Performance Time ◽

Frail Patients ◽

Management Plans ◽

Administration Time ◽

Frailty Score

Abstract Introduction Frail patients have increased mortality after surgery. However, it is not known if pre-operative process measures such as antibiotic administration, time to CT and time to surgery are influenced by patient frailty. Method The Emergency Laparotomy and Laparoscopy Scottish Audit (ELLSA) assessed outcome after emergency surgery across Scottish hospitals (November 2017 – October 2018). Frailty was measured using the 7-point Clinical Frailty Score (CFS). Outcome measures were antibiotic provision for sepsis, admission to CT time, admission to surgery time, CT request to performance time and CT request to surgery time. Results 1302 patients (median age 63 years [IQR 49-74]; 49% male) with complete data were included. Median time from admission to CT and surgery increased between those with CFS 1 to 6/7 from 597 to 1724 minutes (p < 0.0001) and 1556 to 4120 minutes (p < 0.0001) respectively. Time from CT request to surgery also significantly increased with CFS (p < 0.042). There was no significant association between CFS and antibiotic administration or CT request to performance. Conclusions Frail patients have to wait longer for CT scan requests and surgery, but frailty was not associated with antibiotic administration or delays in CT request to performance time. Possible explanations include frailty-related challenges making correct diagnoses and optimal management plans.

2011. Reaction of Clinicians to Positive Respiratory Viral Panels in Non-critically Ill Patients Without Bacterial Infection

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.1691 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S675-S675

Author(s):

Jason C Gallagher ◽

Sara Lee ◽

Leah Rodriguez ◽

Jacqueline Emily Von Bulow ◽

Kaede Ota Sullivan

Keyword(s):

Linear Regression ◽

Bacterial Infection ◽

Linear Regression Analysis ◽

Solid Organ Transplantation ◽

Multivariate Linear Regression ◽

Antibiotic Prescribing ◽

Multivariate Linear Regression Analysis ◽

Solid Organ

Abstract Background Respiratory viral panels (RVPs) can detect multiple viral pathogens and give clinicians diagnostic confidence to discontinue antibiotics. However, relatively little is known about how these tests influence antibiotic prescribing in hospital settings. Methods This was a 26-month retrospective chart review of patients with positive RVPs. Hospitalized adults receiving antibiotics at the time of the RVP were included. Exclusion criteria were: ICU care, solid-organ transplantation (SOT), positive RVP for influenza, positive bacterial cultures, and antibiotic administration for bacterial infection (e.g., cellulitis). A multivariate linear regression model was created to investigate associations with longer antibiotic use after a positive RVP. Results 1,346 patients were screened and 242 met inclusion criteria. Primary reasons for exclusion were SOT, ICU, and influenza diagnosis. Patients were a median age of 60.5 years [IQR 51,70] and 35.5% were men. The median length of stay (LOS) was 4 days [IQR 3.6]. 233 patients (6.3%) had chest radiology performed, of which 71 (30.4%) had possible pneumonia noted. 50 (20.7%) were immunocompromised (IC). 199 (82.2%) had a history of pulmonary disease, most commonly COPD. Rhinovirus was isolated in 156 patients (64.5%), followed by metapneumovirus (35, 14.9%) and RSV (32, 13.3%). Antibiotics were given for a median total of 3 days [IQR 3.6]; they were discontinued within 24 hours of the RVP result in 107 patients (44.2%). Conclusion In this population of patients with viral infection and no discernable bacterial infection, 44.2% of patients had antibiotics discontinued within 24 hours of RVP results. On multivariate linear regression analysis, younger age, longer LOS, and IC status were associated with longer antibiotic duration after a positive RVP. A comparison with patients with negative RVP results could reveal if the test prompted discontinuation. Disclosures All authors: No reported disclosures.

Optimizing Urine Collection Represents an Important Stewardship Opportunity in Primary Care

Antimicrobial Stewardship & Healthcare Epidemiology ◽

10.1017/ash.2021.26 ◽

2021 ◽

Vol 1 (S1) ◽

pp. s14-s15

Author(s):

Larissa Grigoryan ◽

Jennifer Matas ◽

Michael Hansen ◽

Samuel Willis ◽

Lisa Danek ◽

...

Keyword(s):

Primary Care ◽

Urine Culture ◽

Multinomial Logistic Regression ◽

Improve Patient Care ◽

Safety Net ◽

National Institutes Of Health ◽

Urine Collection ◽

High Count ◽

Tract Infections

Background: Urine cultures are the most common microbiological tests in the outpatient setting and heavily influence treatment of suspected urinary tract infections (UTIs). Antibiotics for UTI are usually prescribed on an empiric basis in primary care before the urine culture results are available. However, culture results may be needed to confirm a UTI diagnosis and to verify that the correct antibiotic was prescribed. Although urine cultures are considered as the gold standard for diagnosis of UTI, cultures can easily become contaminated during collection. We determined the prevalence, predictors, and antibiotic use associated with contaminated urine cultures in 2 adult safety net primary care clinics. Methods: We conducted a retrospective chart review of visits with provider-suspected UTI in which a urine culture was ordered (November 2018–March 2020). Patient demographics, culture results, and prescription orders were captured for each visit. Culture results were defined as no culture growth, contaminated (ie, mixed flora, non-uropathogens, or ≥3 bacteria isolated on culture), low-count positive (growth between 100 and 100,000 CFU/mL), and high-count positive (>100,000 CFU/mL). A multivariable multinomial logistic regression model was used to identify factors associated with contaminated culture results. Results: There were 1,265 visits with urine cultures: 264 (20.9%) had no growth, 694 (54.9%) were contaminated, 159 (12.6%) were low counts, and 148 (11.7%) were high counts. Encounter-level factors are presented in Table 1. Female gender (adjusted odds ratio [aOR], 15.8; 95% confidence interval [CI], 10.21–23.46; P < .001), pregnancy (aOR, 13.98; 95% CI, 7.93–4.67; P < .001), and obesity (aOR, 1.9; 95% CI 1.31–2.77; P < .001) were independently associated with contaminated cultures. Of 264 patients whose urine cultures showed no growth, 36 (14%) were prescribed an antibiotic. Of 694 patients with contaminated cultures, 153 (22%) were prescribed an antibiotic (Figure 1). Conclusions: More than half of urine cultures were contaminated, and 1 in 5 patients were treated with antibiotics. Reduction of contamination should improve patient care by providing a more accurate record of the organism in the urine (if any) and its susceptibilities, which are relevant to managing future episodes of UTI in that patient. Optimizing urine collection represents a diagnostic stewardship opportunity in primary care.Funding: This study was supported by the National Institute of Allergy and Infectious Diseases of the National Institutes of Health (grant no. UM1AI104681). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.Disclosures: None

Head CT overuse in children with a mild traumatic brain injury within two Canadian emergency departments

Paediatrics & Child Health ◽

10.1093/pch/pxy180 ◽

2019 ◽

Vol 25 (1) ◽

pp. 26-32

Author(s):

Martin Gariepy ◽

Jocelyn Gravel ◽

France Légaré ◽

Edward R Melnick ◽

Erik P Hess ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Mild Traumatic Brain Injury ◽

Emergency Departments ◽

Trauma Centre ◽

Diagnostic Tools ◽

General Level ◽

Head Ct ◽

Significant Difference

Abstract Background The validated Pediatric Emergency Care Applied Network (PECARN) rule helps determine the relevance of a head computerized tomography (CT) for children with mild traumatic brain injury (mTBI). We sought to estimate the potential overuse of head CT within two Canadian emergency departments (EDs). Methods We conducted a retrospective chart review of children seen in 2016 in a paediatric Level I (site 1) and a general Level II (site 2) trauma centre. We reviewed charts to determine the appropriateness of head CT use according to the PECARN rule in a random subset of children presenting with head trauma. Simple descriptive statistics were applied. Results One thousand five hundred and forty-six eligible patients younger than 17 years consulted during the study period. Of the 203 randomly selected cases per setting, 16 (7.9%) and 24 (12%), respectively from sites 1 and 2 had a head CT performed. Based on the PECARN rule, we estimated the overuse for the younger group (<2 years) to be below 3% for both hospitals without significant difference between them. For the older group (≥2 years), the overuse rate was higher at site 2 (9.3%, 95% confidence interval [CI]: 4.8 to 17% versus 1.2%, 95% CI: 0.2 to 6.5%, P=0.03). Conclusion Both EDs demonstrated overuse rates below 10% although it was higher for the older group at site 2. Such low rates can potentially be explained by the university affiliation of both hospitals and by two Canadian organizations working to raise awareness among physicians about the overuse of diagnostic tools and dangers inherent to radiation.

Sensitivity of High-Resolution Computed Tomography in Otosclerosis Patients undergoing Primary Stapedotomy

Annals of Otology Rhinology & Laryngology ◽

10.1177/0003489420921420 ◽

2020 ◽

Vol 129 (9) ◽

pp. 918-923

Author(s):

Anne K. Maxwell ◽

Mohamed Hosameldeen Shokry ◽

Adam Master ◽

William H. Slattery

Keyword(s):

Computed Tomography ◽

High Resolution ◽

Demographic Data ◽

Time Frame ◽

High Resolution Computed Tomography ◽

Acoustic Reflexes ◽

Negative Report ◽

Unexplained Symptoms ◽

Rule Out

Objective: To determine the incidence of abnormal otospongiotic or otosclerotic findings on high-resolution computed tomography (HRCT) as read by local radiologists in patients with surgically-confirmed otosclerosis. Study design: Retrospective chart review. Setting: Tertiary-referral private otology-neurotology practice. Patients: Adults (>18 years old) with surgically-confirmed otosclerosis between 2012 and 2017 with a HRCT performed preoperatively. Intervention: Preoperative HRCT then stapedotomy. Main outcome measures: Positive identification and location of radiographic otosclerosis as reported by the local radiologist. We then correlated the CT with surgical location as documented at time of surgery. Audiometry, demographic data, intraoperative findings, and surgical technique were secondarily reviewed. Results: Of the 708 stapes surgeries were performed during the study time frame. Preoperative HRCT scans were available for 68 primary stapedotomy surgeries performed in 54 patients. Otosclerosis was reported in 20/68 (29.4%). Following a negative report by the local radiologist, a re-review by the surgeon and/or collaborating neuroradiologist confirmed otosclerosis in 12/48 additional cases (25.0%). There was an overall sensitivity of 47.1%. Intraoperatively, cases with negative reads tended to have more limited localization at the ligament (8.7%) or anterior crus (39.1%), compared with positive reads, which demonstrated more extensive involvement, with bipolar foci (30.0%) or diffuse footplate manifestations (20.0%) more common. Acoustic reflexes were characteristically absent. Conclusions: While HRCT may aid in the diagnosis of otosclerosis and rule out concomitant pathology in certain cases of clinical uncertainty or unexplained symptoms, its sensitivity for otosclerosis remains low. HRCT should not be relied upon to diagnose routine fenestral otosclerosis.

Treatment of Snake Bites at a Regional Burn Center

Kansas Journal of Medicine ◽

10.17161/kjm.v6i2.11437 ◽

2013 ◽

Vol 6 (2) ◽

pp. 44-50

Author(s):

Gie N Yu ◽

Stephen D Helmer ◽

Anjay K Khandelwal

Keyword(s):

Chart Review ◽

Time Frame ◽

Morbidity And Mortality ◽

Significant Morbidity ◽

Wound Debridement ◽

Burn Center ◽

Snake Bites ◽

Anaphylactoid Reactions ◽

Complex Wounds

Background. Although uncommon, snakebites can cause significant morbidity and mortality. The objective of this study was to review the characteristics, treatment, and outcome of patients with a suspected or known snakebite who were treated at a regional verified burn center. Methods. A retrospective chart review of all snakebite victims was conducted for the time frame between January 1991 and June 2009. Results. During the study period, 12 patients were identified. One of the twelve patients was excluded because he had been admitted as an outpatient for wound debridement after being initially treated at another facility. Ten of the remaining 11 patients were male (90.9%). Rattlesnakes were responsible for the majority of bites. One of the eleven patients needed a fasciotomy. The majority of patients received antivenin (ACP/fabAV). No anaphylactoid reactions to either antivenin were recorded. There were no deaths. Conclusion. With burn centers evolving into centers for the care of complex wounds, patients with snakebite injuries can be managed safely in a burn center.

Effects of Delayed Antibiotic Therapy on Outcomes in Children with Streptococcus pneumoniae Sepsis

Antimicrobial Agents and Chemotherapy ◽

10.1128/aac.00623-19 ◽

2019 ◽

Vol 63 (9) ◽

Cited By ~ 1

Author(s):

Qinyuan Li ◽

Jie Cheng ◽

Yi Wu ◽

Zhili Wang ◽

Siying Luo ◽

...

Keyword(s):

Streptococcus Pneumoniae ◽

Antibiotic Therapy ◽

Time Window ◽

Classification And Regression Tree ◽

Content Type ◽

Cart Analysis ◽

Administration Time ◽

Appropriate Therapy ◽

Poor Outcomes

ABSTRACT Delayed antimicrobial therapy is associated with poor outcomes in sepsis, but the optimal antibiotic administration time remains unclear. We aimed to investigate the effects of the time of antimicrobial administration on outcomes and evaluate an optimal empirical antibiotic administration time window for children with Streptococcus pneumoniae sepsis. This retrospective study enrolled children with S. pneumoniae sepsis who presented to the Children’s Hospital of Chongqing Medical University from May 2011 to December 2018. Classification and regression tree (CART) analysis was used to determine the time-to-appropriate-therapy (TTAT) breakpoint. Outcomes were compared between patients receiving early or delayed therapy, defined by CART-derived TTAT breakpoint. During the study period, 172 patients were included. The CART-derived TTAT breakpoint was 13.6 h. After adjustment for confounding factors, a TTAT of ≥13.6 hours was found to be an independent predictor of sepsis-related in-hospital mortality (odds ratio [OR] = 39.26; 95% confidence interval [CI] = 6.10 to 252.60), septic shock (OR = 4.58; 95% CI = 1.89 to 11.14), and requiring mechanical ventilation (OR = 2.70; 95% CI = 1.01 to 7.35). A Pediatric Risk of Mortality (PRISM) III score of ≥10 was independently associated with delayed therapy. Delayed antibiotic therapy was associated with poor outcomes in children with S. pneumoniae sepsis. The optimal empirical antibiotic administration time window in children with S. pneumoniae sepsis was within 13.6 h. Efforts should be made to ensure timely and appropriate therapy.

A 10-Year Review of Necrotizing Fasciitis in the Pediatric Population: Delays to Diagnosis and Management

Clinical Pediatrics ◽

10.1177/0009922816667314 ◽

2016 ◽

Vol 56 (7) ◽

pp. 627-633 ◽

Cited By ~ 6

Author(s):

Heather VanderMeulen ◽

Jeffrey M. Pernica ◽

Madan Roy ◽

April J. Kam

Keyword(s):

Necrotizing Fasciitis ◽

Chart Review ◽

Pediatric Population ◽

Care Center ◽

Tertiary Care ◽

Length Of Hospital Stay ◽

Causative Organism ◽

Large Variability

Objective. To assess the promptness and appropriateness of management in pediatric cases of necrotizing fasciitis (NF). Methods. A retrospective chart review examined cases of pediatric NF treated at a pediatric tertiary care center over a 10-year period. Results. Twelve patients were identified over the 10-year period. The median (25th to 75th centile) times to appropriate antibiotic administration, infectious disease consults, surgical consults and debridement surgeries were 2.6 (2.1-3.2), 7.7 (3.4-24.4), 4.6 (1.7-21.0), and 22.1 (10.3-28.4) hours following assessment at triage. The initial antibiotic(s) administered covered the causative organism in 9 of 12 cases. The median (25th to 75th centile) length of hospital stay was 21 (14.0-35.5) days. Conclusions. The large variability in the care of these patients speaks to the range of their presenting symptomatology. The lack of a standardized approach to the pediatric patient with suspected NF results in delays in management and suboptimal antibiotic choice.

The clinical utility of strict laboratory monitoring of CDK 4/6 inhibitors in metastatic breast cancer patients.

Journal of Clinical Oncology ◽

10.1200/jco.2019.37.15_suppl.1062 ◽

2019 ◽

Vol 37 (15_suppl) ◽

pp. 1062-1062

Author(s):

Urvi Patel ◽

Jane Lowe Meisel ◽

Meagan Spencer Barbee ◽

Kristina Frinzi ◽

Elizabeth Sakach ◽

...

Keyword(s):

Breast Cancer ◽

Quality Of Life ◽

Metastatic Breast Cancer ◽

Financial Burden ◽

Metastatic Breast ◽

Breast Cancer Patients ◽

Prior Therapy ◽

Grade 3

1062 Background: Cyclin-dependent kinase 4/6 inhibitors (CDK 4/6i) are widely used in the treatment of hormone receptor positive, metastatic breast cancer (MBC). CDK 4/6is are well-tolerated and highly effective, but can cause neutropenia. Therefore, the FDA mandates assessment of the absolute neutrophil count (ANC) every 2 weeks for the first 2 cycles of therapy and monthly thereafter. Strict ANC monitoring is optimal in theory, but presents a challenge in the real world, impacting quality of life for patients (pts) and adding financial burden to the healthcare system. This study aims to evaluate whether strict monitoring of ANC significantly impacts treatment decisions, pt safety, and disease outcomes. Methods: A retrospective chart review of 160 pts with MBC was conducted at the Winship Cancer Institute in pts prescribed CDK 4/6is from Feb 2015 to Jan 2019. The pt’s ANC at C1D1, C1D14, C2D1, C2D14 were recorded along with various pt outcomes. Pts were divided into strict monitoring (SM) or relaxed monitoring (RM) groups. SM is defined as pts who received ANC testing within 72h of C1D14, C2D1, and C2D14. RM was defined as not meeting those criteria. Results: Palbociclib was used in 152 pts; abemaciclib was used in 8. Average age was 58. Study population was 55% Caucasian; 38% African American; 6% Asian. Pts had an average of 3 lines of prior therapy and average of 9 cycles on a CDK 4/6i. 71% of pts suffered neutropenia (40% grade 3, 4% grade 4, 2.5% febrile neutropenia). PFS and OS did not statistically differ between groups (Table), but OS data is immature. Conclusions: This study analyzed a more diverse and heavily pre-treated MBC population than previous CDK 4/6 studies. The prevalence of neutropenia (grade 3/4) aligns with results described in the PALOMA trial. PFS was higher in the RM group than in the SM group, suggesting strict monitoring for neutropenia does not improve PFS. If ANC monitoring parameters could be safely relaxed for CDK 4/6i, it could improve quality of life and decrease financial toxicity across the system. This is a topic worthy of further study. [Table: see text]