Using the Reverse Shock Index at the Injury Scene and in the Emergency Department to Identify High-Risk Patients: A Cross-Sectional Retrospective Study

Abstract Background Surgical options for patients vary with age and comorbidities, advances in medical technology and patients’ wishes. This complexity can make it difficult for surgeons to determine appropriate treatment plans independently. At our institution, final decisions regarding treatment for patients are made at multidisciplinary meetings, termed High-Risk Conferences, led by the Patient Safety Committee. Methods In this retrospective study, we assessed the reasons for convening High-Risk Conferences, the final decisions made and treatment outcomes using conference records and patient medical records for conferences conducted at our institution from April 2010 to March 2018. Results A total of 410 High-Risk Conferences were conducted for 406 patients during the study period. The department with the most conferences was cardiovascular surgery (24%), and the reasons for convening conferences included the presence of severe comorbidities (51%), highly difficult surgeries (41%) and nonmedical/personal issues (8%). Treatment changes were made for 49 patients (12%), including surgical modifications for 20 patients and surgery cancellation for 29. The most common surgical modification was procedure reduction (16 patients); 4 deaths were reported. Follow-up was available for 21 patients for whom surgery was cancelled, with 11 deaths reported. Conclusions Given that some change to the treatment plan was made for 12% of the patients discussed at the High-Risk Conferences, we conclude that participants of these conferences did not always agree with the original surgical plan and that the multidisciplinary decision-making process of the conferences served to allow for modifications. Many of the modifications involved reductions in procedures to reflect a more conservative approach, which might have decreased perioperative mortality and the incidence of complications as well as unnecessary surgeries. High-risk patients have complex issues, and it is difficult to verify statistically whether outcomes are associated with changes in course of treatment. Nevertheless, these conferences might be useful from a patient safety perspective and minimize the potential for legal disputes.

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

Zeitschrift für Gerontologie und Geriatrie ◽

10.1007/s00391-020-01837-9 ◽

2021 ◽

Author(s):

Laura C. Blomaard ◽

Bas de Groot ◽

Jacinta A. Lucke ◽

Jelle de Gelder ◽

Anja M. Booijen ◽

...

Keyword(s):

Emergency Department ◽

High Risk ◽

Older Patients ◽

Screening Program ◽

Admission Rate ◽

Older Patient ◽

Hospital Admission Rate ◽

High Risk Patients ◽

Risk Patients

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

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Preventing acute kidney injury in high-risk patients by temporarily discontinuing medication – an observational study in general practice

10.21203/rs.2.10114/v3 ◽

2019 ◽

Author(s):

Suzanne J Faber ◽

Nynke Scherpbier ◽

Hans Peters ◽

Annemarie Uijen

Keyword(s):

Heart Failure ◽

Acute Kidney Injury ◽

High Risk ◽

Kidney Injury ◽

Cross Sectional Study ◽

Fluid Loss ◽

Cross Sectional ◽

High Risk Patients ◽

Risk Patients ◽

Raas Inhibitors

Abstract Background Elderly, patients with chronic kidney disease (CKD) and patients with heart failure who continue using renin-angiotensin-aldosterone-system (RAAS) inhibitors, diuretics, or non-steroidal-anti-inflammatory drugs (NSAIDs) during times of fluid loss have a high risk of developing complications like acute kidney injury (AKI). The aim of this study was to assess how often advice to discontinue high-risk medication was offered to high-risk patients consulting the general practitioner (GP) with increased fluid loss. Furthermore, we assessed the number and nature of the complications that occurred after GP consultation. Methods We performed a cross-sectional study with patients from seven Dutch general practices participating in the Family Medicine Network between 1-6-2013 and 1-7-2018. We included patients who used RAAS-inhibitors, diuretics, or NSAIDs, and had at least one of the following risk factors: age ≥70 years, CKD, or heart failure. From this population, we selected patients with a ‘dehydration-risk’ episode (vomiting, diarrhoea, fever, chills, or gastrointestinal infection). We manually checked their electronic patient files and assessed the percentage of episodes in which advice to discontinue the high-risk medication was offered and whether a complication occurred in three months after the ‘dehydration-risk’ episode. Results We included 3607 high-risk patients from a total of 44.675 patients (8.1%). We found that patients were advised to discontinue the high-risk medication in 38 (4.6%) of 816 ‘dehydration-risk’ episodes. In 59 of 816 episodes (7.1%) complications (mainly AKI) occurred. Conclusions Dutch GPs do not frequently advise high-risk patients to discontinue high-risk medication during ‘dehydration-risk’ episodes. Complications occur frequently. Timely discontinuation of high-risk medication needs attention.

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Electronic Medical Record-Based Liver Fibrosis Staging: Identification of High-Risk Patients at Time of Hepatitis C Diagnosis in the Emergency Department

Open Forum Infectious Diseases ◽

10.1093/ofid/ofw172.299 ◽

2016 ◽

Vol 3 (suppl_1) ◽

Author(s):

Julie Schexnayder ◽

Ricardo Franco ◽

Joshua Richman ◽

James Galbraith ◽

Deanne Guthrie ◽

...

Keyword(s):

Emergency Department ◽

Hepatitis C ◽

High Risk ◽

Liver Fibrosis ◽

Medical Record ◽

Electronic Medical Record ◽

High Risk Patients ◽

Risk Patients ◽

Fibrosis Staging

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Selected High-Risk Patients With Upper Tract Urothelial Carcinoma Treated With Radical Nephroureterectomy for Adjuvant Chemotherapy: A Multi-Institutional Retrospective Study

Clinical Genitourinary Cancer ◽

10.1016/j.clgc.2017.10.014 ◽

2018 ◽

Vol 16 (3) ◽

pp. e669-e675 ◽

Cited By ~ 5

Author(s):

Masaomi Ikeda ◽

Kazumasa Matsumoto ◽

Takahiro Hirayama ◽

Dai Koguchi ◽

Yasukiyo Murakami ◽

...

Keyword(s):

Retrospective Study ◽

High Risk ◽

Adjuvant Chemotherapy ◽

Urothelial Carcinoma ◽

Upper Tract Urothelial Carcinoma ◽

Radical Nephroureterectomy ◽

Upper Tract ◽

High Risk Patients ◽

Risk Patients

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Coronary Heart Disease and Dyslipidemia: A Cross-Sectional Evaluation of Prevalence, Current Treatment, and Clinical Control in a Large Cohort of Spanish High-Risk Patients: The PRINCEPS Study

Preventive Cardiology ◽

10.1111/j.1751-7141.2008.00022.x ◽

2009 ◽

Vol 12 (2) ◽

pp. 65-71 ◽

Cited By ~ 7

Author(s):

Francisco Díaz de Rojas ◽

Trinidad De Frutos ◽

Ana Ponte ◽

Joaquin Mateos Chacón ◽

Gustavo C. Vitale ◽

...

Keyword(s):

Coronary Heart Disease ◽

Heart Disease ◽

High Risk ◽

Current Treatment ◽

Large Cohort ◽

Cross Sectional ◽

High Risk Patients ◽

Clinical Control ◽

Risk Patients

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Hepatitis C Virus Screening of High-Risk Patients in a Canadian Emergency Department

Canadian Journal of Gastroenterology and Hepatology ◽

10.1155/2020/5258289 ◽

2020 ◽

Vol 2020 ◽

pp. 1-6

Author(s):

Kelsey Ragan ◽

Anjali Pandya ◽

Tristan Holotnak ◽

Katrina Koger ◽

Neil Collins ◽

...

Keyword(s):

Emergency Department ◽

Hepatitis C Virus ◽

Hepatitis C ◽

High Risk ◽

Drug Use ◽

Hcv Rna ◽

High Risk Patients ◽

Risk Patients ◽

History Of ◽

Hcv Screening

Background. Approximately 0.7% of the Canadian population is infected with hepatitis C virus (HCV), and many individuals are unaware of their infection. Our objectives were to utilize an emergency department (ED) based point-of-care (POC) HCV screening test to describe our local population and estimate the proportion of high-risk patients in our population with undiagnosed HCV. Methods. A convenience sample of medically stable patients (≥18 years) presenting to a community ED in Calgary, AB, between April and July 2018 underwent rapid clinical screening for HCV risk factors, including history of injection drug use, healthcare in endemic countries, and other recognized criteria. High-risk patients were offered POC HCV testing. Antibody-positive patients underwent HCV-RNA testing and were linked to hepatology care. The primary outcome was the proportion of new HCV diagnoses in the high-risk population. Results. Of the 999 patients screened by survey, 247 patients (24.7%) were high-risk and eligible for testing. Of these, 123 (49.8%) were from HCV-endemic countries, while 63 (25.5%) and 31 (12.6%) patients endorsed a history of incarceration and intravenous drug use (IVDU), respectively. A total of 144 (58.3%) eligible patients agreed to testing. Of these, 6 patients were POC-positive (4.2%, CI 0.9–7.4%); all 6 had antibodies detected on confirmatory lab testing and 4 had detectable HCV-RNA viral loads in follow-up. Notably, 103 (41.7%) patients declined POC testing. Interpretation. Among 144 high-risk patients who agreed to testing, the rate of undiagnosed HCV infection was 4.2%, and the rate of undiagnosed HCV infection with detectable viral load was 2.8%. Many patients with high-risk clinical criteria refused POC testing. It is unknown if tested and untested groups have the same disease prevalence. This study shows that ED HCV screening is feasible and that a small number of previously undiagnosed patients can be identified and linked to potentially life-changing care.

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LO89: A multi-disciplinary quality improvement project to improve adherence to best practice guidelines for emergency department patients with transient ischemic attack

CJEM ◽

10.1017/cem.2019.131 ◽

2019 ◽

Vol 21 (S1) ◽

pp. S40

Author(s):

A. Verma ◽

A. Kapoor ◽

J. Kim ◽

N. Kujbid ◽

K. Si ◽

...

Keyword(s):

Emergency Department ◽

High Risk ◽

Transient Ischemic Attack ◽

Retrospective Chart Review ◽

Stroke Recurrence ◽

Improvement Project ◽

Support Tool ◽

High Risk Patients ◽

Risk Patients ◽

Ischemic Attack

Background: Canadian Stroke Guidelines recommend that Transient Ischemic Attack (TIA) patients at highest risk of stroke recurrence should undergo immediate vascular imaging. Computed tomography angiography (CTA) of the head and neck is recommended over carotid doppler because it allows for enhanced visualization of the intracranial and posterior circulation vasculature. Imaging while patients are in the emergency department (ED) is optimal for high-risk patients because the risk of stroke recurrence is highest in the first 48 hours. Aim Statement: At our hospital, a designated stroke centre, less than 5% of TIA patients meet national recommendations by undergoing CTA in the ED. We sought to increase the rate of CTA in high risk ED TIA patients from less than 5% to at least 80% in 10 months. Measures & Design: We used a multi-faceted approach to improve our adherence to guidelines including: 1) education for staff ED physicians; 2) agreements between ED and radiology to facilitate rapid access to CTA; 3) agreements between ED and neurology for consultations regarding patients with abnormal CTA; and 4) the creation of an electronic decision support tool to guide ED physicians as to which patients require CTA. We measured the rate of CTA in high risk patients biweekly using retrospective chart review of patients referred to the TIA clinic from the ED on a biweekly basis. As a balancing measure, we also measured the rate of CTA in non-high risk patients. Evaluation/Results: Data collection is ongoing. An interim run chart at 19 weeks shows a complete shift above the median after implementation, with CTA rates between 70 and 100%. At the time of submission, we had no downward trends below 80%, showing sustained improvement. The CTA rate in non-high risk patients did also increase. Disucssion/Impact: After 19 weeks of our intervention, 112 (78.9%) of high risk TIA patients had a CTA, compared to 10 (9.8%) in the 19 weeks prior to our intervention. On average, 10-15% of high risk patients will have an identifiable lesion on CTA, leading to immediate change in management (at minimum, an inpatient consultation with neurology). Our multi-faceted approach could be replicated in any ED with the engagement and availability of the same multi-disciplinary team (ED, radiology, and neurology), access to CTA, and electronic orders.

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