Reciprocal Abstracts November 22

Editor’s note:

The Hong Kong Journal of Emergency Medicine has partnered with a small group of selected journals of international emergency medicine societies to share from each a highlighted research study, as selected monthly by their editors. Our goals are to increase awareness of our readership to research developments in the international emergency medicine literature, promote collaboration among the selected international emergency medicine journals and support the improvement of emergency medicine world-wide, as described in the WAME statement at http://www.wame.org/about/policy-statements#Promoting%20Global%20Health. Abstracts are reproduced as published in the respective participating journals and are not peer reviewed or edited by the Hong Kong Journal of Emergency Medicine.

Annals of Emergency Medicine

(The print version of this article has been scheduled for November 2022)

The prognostic accuracy of clinical judgment versus a validated frailty screening instrument in older patients at the emergency department: findings of the AmsterGEM study

Carmen S van Dam, Marijke C Trappenburg, Marieke M ter Wee, Emiel O Hoogendijk, Riekie de Vet, Yvo M Smulders, Prabath B Nanayakkara, Majon Muller and Mike L Peters

Study objective: To compare the prognostic accuracy of clinical judgment for frailty in older patients at the emergency department (ED) with a validated screening instrument and patient-perceived frailty.

Methods: A prospective cohort study in patients 70 years of age and older in two Dutch EDs with a follow-up of 3 months. A dichotomous question was asked to the physician and patient: “Do you consider the patient/yourself to be frail?” The Identification of Seniors At Risk–Hospitalized Patients (ISAR-HP) was used as a validated screening instrument. The primary composite outcome consisted of either functional decline, institutionalization, or mortality.

Results: A total of 736 patients were included. The physician identified 59% as frail, compared with 49% by ISAR-HP and 43% by patients themselves. The level of agreement was fair (Fleiss Kappa = 0.31). After 3 months, 31% of the patients experienced at least one adverse health outcome. The sensitivity was 79% for the physician, 72% for ISAR-HP, 61% for the patient, and 48% for all three combined. The specificity was 50% for the physician, 63% for ISAR-HP, 66% for the patient, and 85% for all three positive. The highest positive likelihood ratio was 3.03 (physician, ISAR-HP, patient combined), and the lowest negative likelihood ratio was 0.42 (physician). The areas under the receiver operating curves were all poor: 0.68 at best for ISAR-HP.

Conclusion: Clinical judgment for frailty showed fair agreement with a validated screening instrument and patient-perceived frailty. All three instruments have poor prognostic accuracy, which does not improve when combined. These findings illustrate the limited prognostic value of clinical judgment as a frailty screener in older patients at the ED.

How to cite this article:

van Dam CS, Trappenburg MC, ter Wee MM, et al. The prognostic accuracy of clinical judgment versus a validated frailty screening instrument in older patients at the emergency department: findings of the AmsterGEM study. Ann Emerg Med 2022. DOI: 10.1016/j.annemergmed.2022.04.039.

(The print version of this article has been scheduled for December 2022)

Emergency department adverse events detected using the emergency department trigger tool

Richard T Griffey, Ryan M Schneider and Alexandre A Todorov

Study objective: The Emergency Department Trigger Tool (EDTT) is a novel approach to adverse event detection in the emergency department (ED). We previously described the derivation, validation, and high-level performance of this tool. Here, we further detail adverse events detected to demonstrate the utility of the EDTT and how it might be used for quality improvement.

Methods: This is a secondary analysis of data from a retrospective observational study. We ran the EDTT (a computerized query for triggers) on 13 months of ED visit data, reviewing 5582 selected records using a typical two-tiered trigger tool approach. The adverse events detected were categorized by place of occurrence (in the ED vs present on arrival), severity, omission/commission, and type using a taxonomy with categories, subcategories, and up to three cross-cutting modifiers. We present adverse event data in detail, focusing, in turn, on each of these descriptors (severity, event types, and cross-cutting themes) and highlight opportunities identified for targeted improvement.

Results: We identified 458 adverse events occurring in the ED for a 13-month period, 10% of which required urgent intervention. Nearly all (90%) were acts of commission. Events resulting in harm were most often related to medications administered and patient care. Common cross-cutting event types included adverse events related to bleeding, opioids, and the use of propofol. Most adverse events (80%) led to temporary harm.

Conclusion: The EDTT identifies a broad spectrum of adverse event types, allowing a review by severity, frequency, and type to better understand existing levels of harm in the ED and identify targets for quality improvement. A multicenter study of the EDTT is currently underway, which will contribute additional power and assess generalizability.

How to cite this article:

Griffey, RT, Schneider, RM, Todorov, AA. Emergency department adverse events detected using the emergency department trigger tool. Ann Emerg Med 2022. DOI: 10.1016/j.annemergmed.2022.05.037.

Canadian Journal of Emergency Medicine

http://caep.ca/resources/cjem/

NOVEMBER 2022

Out-of-hospital management of unresponsive, apneic, witnessed opioid overdoses: a case series from a supervised consumption site

Adrianna Rowe, Andrew Chang, Emily Lostchuck, Kathleen Lin, Frank Scheuermeyer, Victoria McCann, Jane Buxton, Jessica Moe, Raymond Cho, Paul Clerc, Connor McSweeney, Andy Jiang and Roy Purssell

Rowe A, Chang A, Lostchuck E, et al. Out-of-hospital management of unresponsive, apneic, witnessed opioid overdoses: a case series from a supervised consumption site. Can J Emerg Med 2022. DOI: 10.1007/s43678-022-00326-9.

Objectives: There are conflicting recommendations for lay rescuer management of patients who are unresponsive and apneic due to opioid overdose. We evaluated the management of such patients at an urban supervised consumption site.

Methods: At a single urban supervised consumption site in Vancouver, BC, we conducted a retrospective chart review and administrative database linkage of consecutive patients who were unresponsive and apneic following witnessed opioid overdose between 1 January 2012 and 31 December 2017. We linked these visits with regional hospital records to define the entire care episode, which concluded when the patient was discharged from the supervised consumption site, emergency department (ED), or hospital, or died. The primary outcome was successful resuscitation, defined as alive and neurologically intact (ambulatory and speaking coherently, or alert and oriented, or Glasgow Coma Scale 15) at the conclusion of the care episode. Secondary outcomes included mortality and predefined complications of resuscitation.

Results: We collected 767 patients, with a median age of 43 years and 81.6% male, with complete follow-up on 763 patients (99.5%). All patients were managed with oxygen and ventilation (100%, 95% confidence interval (CI) = 0.995–1.0); 715 (93.2%, 95% CI = 0.911–0.949) received naloxone; no patients underwent chest compressions (0%, 95% CI = 0–0.005). All patients with complete follow-up were alive and neurologically intact at the end of their care episode (100%, 95% CI = 0.994–1.0). Overall, 191 (24.9%) patients were transported to hospital, and 15 (2.0%) patients required additional naloxone after leaving the supervised consumption site; 16 (2.1%) developed complications; 1 patient was admitted to hospital.

Conclusion: At an urban supervised consumption site, all unresponsive, apneic patients with witnessed opioid overdose were successfully resuscitated with oxygen and/or naloxone. No patients required chest compressions.

Keywords: Opiate overdose, harm reduction, ventilation, cardiopulmonary resuscitation

Emergencias

NOVEMBER 2022

Model to predict risk for hospital admission and indicate the safety of reverse triage in a hospital emergency department: a prospective validation study

Connie Leey-Echavarría, José Zorrilla-Riveiro, Anna Arnau, Mireia Fernàndez-Puigbó, Ester Sala-Barcons and Emili Gené

Cited: Leey-Echavarría C, Zorrilla-Riveiro J, Arnau A, et al. Model to predict risk for hospital admission and indicate the safety of reverse triage in a hospital emergency department: a prospective validation study. Emergencias. 2022; 34: 165–173.

http://emergencias.portalsemes.org/descargar/validacin-prospectiva-de-un-modelo-predictivo-de-ingreso-y-orientar-la-seguridad-de-la-derivacin-inversa-desde-el-triaje-de-los-servicios-de-urgencias-hospitalarios/

Objectives: To prospectively validate a model to predict hospital admission of patients given a low-priority classification on emergency department triage and to indicate the safety of reverse triage.

Methods: Single-center observational study of a prospective cohort to validate a risk model incorporating demographic and emergency care process variables as well as vital signs. The cohort included emergency visits from patients over the age of 15 years with priority level classifications of IV and V according to the Andorran–Spanish triage system (Spanish acronym, MAT-SET) between October 2018 and June 2019. The area under the receiver operating characteristic curve (AUC) of the model was calculated to evaluate discrimination. Based on the model, we identified cut-off points to distinguish patients with low, intermediate, or high risk for hospital admission.

Results: A total of 2110 emergencies were included in the validation cohort; 109 patients (5.2%) were hospitalized. The median age was 43.5 years (interquartile range = 31–60.3 years); 55.5% were female. The AUC was 0.71 (95% confidence interval (CI) = 0.64–0.75). The model identified 357 patients (16.9%) at low risk of hospitalization and 240 (11.4%) at high risk. A total of 15.8% of the high-risk patients and 2.8% of the low-risk patients were hospitalized.

Conclusion: The validated model is able to identify risk for hospitalization among patients classified as low priority on triage. Patients identified as having high risk of hospitalization could be offered preferential treatment within the same level of priority at triage, while those at low risk of admission could be referred to a more appropriate care level on reverse triage.

Keywords: Emergency department triage, low priority, hospitalization

Emergency Medicine Journal

November 2022

Determination of potential risk characteristics for cauda equina compression in emergency department patients presenting with atraumatic back pain: a 4-year retrospective cohort analysis within a tertiary referral neurosciences centre

Angus M, Curtis-Lopez CM, Carrasco R, Currie V, Siddique I and Horner DE

Emergency Medicine Journal(12 October 2021)

Objective: Atraumatic back pain is an increasingly common presentation to the emergency department (ED). A minority of these cases will have significant structural pathology, resulting in acute cauda equina compression (CEC). Although clinicians often look for ‘red flags’ to identify potential CEC, the prognostic accuracy of these presenting symptoms and clinical examination findings is unclear. We sought to evaluate the accuracy of individual clinical features in a large cohort of ED patients with atraumatic back pain and reference standard imaging, for the diagnosis of CEC.

Methods: A retrospective case note review from 2014 to 2018 within an established ED atraumatic back pain pathway, undertaken at the largest tertiary spinal referral centre in the United Kingdom. We analysed routine data, collected prospectively by treating clinicians within a structured electronic health record clinical proforma. Data on signs and symptoms in 996 patients with suspected CEC referred for definitive magnetic resonance imaging (MRI) over a 4-year study period were extracted and compared against a final reference standard diagnosis.

Results: We identified 111 patients with radiological evidence of CEC within the cohort referred for definitive imaging (111/996, 11.1%), of whom 109 (98.2%) underwent operative intervention. Patients with CEC were more likely to present with bilateral leg pain (odds ratio (OR) = 2.2), dermatomal sensory loss (OR = 1.8), and bilateral absent ankle or ankle and knee jerks (OR = 2.9). Subjective weakness was found to be associated with CEC on univariate but not multivariate analysis. We found no relationship between digital rectal examination findings and the diagnosis of CEC.

Conclusion: In our cohort, factors independently associated with CEC diagnosis on MRI included bilateral leg pain, dermatomal sensory loss. Loss of lower limb reflexes was strongly suggestive of CES (likelihood ratio 3.4 on multivariate logistic regression). Our findings raise questions about the diagnostic utility of invasive digital rectal examination.