Associations between presence of diabetes, mortality and fracture type in individuals with a hip fracture.

AIMS: An overlooked aspect of diabetes is an increased risk of hip fractures, with associated mortality. We investigated whether fracture type and/or burden of comorbidities explains the increased risk of mortality in diabetes after hip fracture. METHODS: For this cohort study, we used a de-identified data set of hip fracture patients registered in a quality-of-care registry (2017/2018) included in Maastricht University Medical Centre. RESULTS: Among 594 hip fracture patients, 90 (15.2 %) had diabetes. Median (IQR) age was 82 (71-87) years and 63.8 % were women. Compared to patients without, patients with diabetes had higher median Charlson Comorbidity Index [1 (0-2) vs 0 (0-2), P < 0.001)] and were more likely to sustain intertrochanteric/subtrochanteric fractures [54.4 vs 38.7 %, P = 0.02]. Over a median follow-up of 2.7 (1.6-3.3) years, crude mortality rate was 30.8 % in patients without and 50.0 % in patients with diabetes. This association remained unaltered after adjustment for age, sex, BMI, fracture type or burden of co-morbidities. CONCLUSION: Individuals with diabetes display a greatly increased absolute mortality risk after hip fracture. This association was not attenuated after adjustment for fracture type or non-diabetes associated co-morbidity. These findings have important implications for diabetes care in hip fracture patients, and underline the importance of fracture prevention.

Comparison of SIRS criteria and qSOFA score for identifying culture-positive sepsis in the emergency department: a prospective cross-sectional multicentre study.

OBJECTIVE: To compare the daily practice of two emergency departments (ED) in the Netherlands, where systemic inflammatory response syndrome (SIRS) criteria and quick Sequential Organ Failure Assessment (qSOFA) score are used differently as screening tools for culture-positive sepsis. DESIGN: A prospective cross-sectional multicentre study. SETTING: Two EDs at two European clinical teaching hospitals in the Netherlands. PARTICIPANTS: 760 patients with suspected infection who met SIRS criteria or had a qualifying qSOFA score who were treated at two EDs in the Netherlands from 1 January to 1 March 2018 were included. METHODS: SIRS criteria and qSOFA score were calculated for each patient. The first hospital treated the patients who met SIRS criteria following the worldwide Surviving Sepsis Campaign protocol. At the second hospital, only patients who met the qualifying qSOFA score received this treatment. Therefore, patients could be divided into five groups: (1) SIRS+, qSOFA-, not treated according to protocol (reference group); (2) SIRS+, qSOFA-, treated according to protocol; (3) SIRS+, qSOFA+, treated according to protocol; (4) SIRS-, qSOFA+, not treated according to protocol; (5) SIRS-, qSOFA+, treated according to protocol. PRIMARY AND SECONDARY OUTCOME MEASURES: To prove culture-positive sepsis was present, cultures were used as the primary outcome. Secondary outcomes were in-hospital mortality and intensive care unit (ICU) admission. RESULTS: 98.9% met SIRS criteria and 11.7% met qSOFA score. Positive predictive values of SIRS criteria and qSOFA score were 41.2% (95% CI 37.4% to 45.2%) and 48.1% (95% CI 37.4% to 58.9%), respectively. HRs were 0.79 (95% CI 0.40 to 1.56, p=0.500), 3.42 (95% CI 1.82 to 6.44, p<0.001), 18.94 (95% CI 2.48 to 144.89, p=0.005) and 4.97 (95% CI 1.44 to 17.16, p=0.011) for groups 2-5, respectively. CONCLUSION: qSOFA score performed as well as SIRS criteria for identifying culture-positive sepsis and performed significantly better for predicting in-hospital mortality and ICU admission. This study shows that SIRS criteria are no longer necessary and recommends qSOFA score as the standard for identifying culture-positive sepsis in the ED. TRIAL REGISTRATION NUMBER: NL8315.

The prevalence of pulmonary embolism in patients with COVID-19 and respiratory decline: A three-setting comparison.

BACKGROUND: The risk of pulmonary embolism (PE) in patients with Coronavirus Disease 2019 (COVID-19) is recognized. The prevalence of PE in patients with respiratory deterioration at the Emergency Department (ED), the regular ward, and the Intensive Care Unit (ICU) are not well-established. OBJECTIVES: We aimed to investigate how often PE was present in individuals with COVID-19 and respiratory deterioration in different settings, and whether or not disease severity as measured by CT-severity score (CTSS) was related to the occurrence of PE. PATIENTS/METHODS: Between April 6th and May 3rd, we enrolled 60 consecutive adult patients with confirmed COVID-19 from the ED, regular ward and ICU who met the pre-specified criteria for respiratory deterioration. RESULTS: A total of 24 (24/60: 40% (95% CI: 28-54%)) patients were diagnosed with PE, of whom 6 were in the ED (6/23: 26% (95% CI: 10-46%)), 8 in the regular ward (8/24: 33% (95% CI: 16-55%)), and 10 in the ICU (10/13: 77% (95% CI: 46-95%)). CTSS (per unit) was not associated with the occurrence of PE (age and sex-adjusted OR 1.06 (95%CI 0.98-1.15)). CONCLUSION: The number of PE diagnosis among patients with COVID-19 and respiratory deterioration was high; 26% in the ED, 33% in the regular ward and 77% in the ICU respectively. In our cohort CTSS was not associated with the occurrence of PE. Based on the high number of patients diagnosed with PE among those scanned we recommend a low threshold for performing computed tomography angiography in patients with COVID-19 and respiratory deterioration.

Mortality and the Use of Antithrombotic Therapies Among Nursing Home Residents with COVID-19.

BACKGROUND/OBJECTIVES: Nursing home (NH) residents are a vulnerable population, susceptible to respiratory disease outbreaks such as coronavirus disease 2019 (COVID-19). Poor outcome in COVID-19 is at least partly attributed to hypercoagulability, resulting in a high incidence of thromboembolic complications. It is unknown whether commonly used antithrombotic therapies may protect the vulnerable NH population with COVID-19 against mortality. This study aimed to investigate whether the use of oral antithrombotic therapy (OAT) was associated with a lower mortality in NH residents with COVID-19. DESIGN: A retrospective case series. SETTING: Fourteen NH facilities from the NH organization Envida, Maastricht, the Netherlands PARTICIPANTS: A total of 101 NH residents with COVID-19 were enrolled. MEASUREMENTS: The primary outcome was all-cause mortality. The association between age, sex, comorbidity, OAT, and mortality was assessed using logistic regression analysis. RESULTS: Overall mortality was 47.5% in NH residents from 14 NH facilities. Age, comorbidity, and medication use were comparable among NH residents who survived and who died. OAT was associated with a lower mortality in NH residents with COVID-19 in the univariable analysis (odds ratio (OR) = 0.89; 95% confidence interval (CI) = 0.41-1.95). However, additional adjustments for sex, age, and comorbidity attenuated this difference. Mortality in males was higher compared with female residents (OR = 3.96; 95% CI = 1.62-9.65). Male residents who died were younger compared with female residents (82.2 (standard deviation (SD) = 6.3) vs 89.1 (SD = 6.8) years; P < .001). CONCLUSION: NH residents in the 14 facilities we studied were severely affected by the COVID-19 pandemic, with a mortality of 47.5%. Male NH residents with COVID-19 had worse outcomes than females. We did not find evidence for any protection against mortality by OAT, necessitating further research into strategies to mitigate poor outcome of COVID-19 in vulnerable NH populations. J Am Geriatr Soc 68:1647-1652, 2020.

No age thresholds in the emergency department: A retrospective cohort study on age differences.

Emergency care in elderly patients has gained attention by researchers due to high utilization rate and the importance of emergency services in elderly care. We examine if there is a clear age threshold between young and old patients at which there is a need for extra care and facilities in the emergency department. This retrospective cohort study uses emergency department (ED) data collected over the course of a year, containing information about 31,491 patient visits. The measured variables are treatment time, waiting time, number of tests, number of medical procedures, number of specialties involved and the patient's length of stay on the ED. To examine the multivariate differences between different patient groups, the data set is split into eighteen age groups and a MANOVA analysis is conducted to compare group means. The results show that older patients tend to have a longer stay on the ED. They also require more medical tests, have higher resource utilization and admission rates to the hospital. When the patients are grouped according to life stages (<18, 18-39, 40-64 and ≥65), each life stage shows significantly different characteristics across all variables. To understand where these differences start, age bins of five years are analyzed and almost none of the consecutive groups are significantly different in any variable. A significant difference between all groups is observed when age interval of the bins is increased to 10 years. This indicates that although age has an effect on the patient's treatment, a clear age threshold that identifies the group of elderly patients is not observable from emergency room variables. The results of this study show no clear age boundary between young and old patients. In other words, we could not find support for favoring the often-used age boundary of 65 over other boundaries (e.g. 60 or 70) to distinguish the group of elderly patients on the ED.

Performance of the Manchester triage system in older emergency department patients: a retrospective cohort study.

BACKGROUND: Studies on the reliability of the MTS and its predictive power for hospitalisation and mortality in the older population have demonstrated mixed results. The objective is to evaluate the performance of the Manchester Triage System (MTS) in older patients (≥65 years) by assessing the predictive ability of the MTS for emergency department resource utilisation, emergency department length of stay (ED-LOS), hospitalisation, and in-hospital mortality rate. The secondary goal was to evaluate the performance of the MTS in older surgical versus medical patients. METHODS: A retrospective cohort study was conducted of all emergency department visits by patients ≥65 years between 01 and 09-2011 and 31-08-2012. Performance of the MTS was assessed by comparing the association of the MTS with emergency department resource utilisation, ED-LOS, hospital admission, and in-hospital mortality in older patients and the reference group (18-64 years), and by estimating the area under the receiver operating characteristics curves. RESULTS: Data on 7108 emergency department visits by older patients and 13,767 emergency department visits by patients aged 18-64 years were included. In both patient groups, a higher emergency department resource utilisation was associated with a higher MTS urgency. The AUC for the MTS and hospitalisation was 0.74 (95%CI 0.73-0.75) in older patients and 0.76 (95%CI 0.76-0.77) in patients aged 18-64 years. Comparison of the predictive ability of the MTS for in-hospital mortality in older patients with patients aged 18-64 years revealed an AUC of 0.71 (95%CI 0.68-0.74) versus 0.79 (95%CI 0.72-0.85). The majority of older patients (54.8%) were evaluated by a medical specialty and 45.2% by a surgical specialty. The predictive ability of the MTS for hospitalisation and in-hospital mortality was higher in older surgical patients than in medical patients (AUC 0.74, 95%CI 0.72-0.76 and 0.74, 95%CI 0.68-0.81 versus 0.69, 95%CI 0.67-0.71 and 0.66, 95%CI 0.62-0.69). CONCLUSION: The performance of the MTS appeared inferior in older patients than younger patients, illustrated by a worse predictive ability of the MTS for in-hospital mortality in older patients. The MTS demonstrated a better performance in older surgical patients than older medical patients regarding hospitalisation and in-hospital mortality.

Outcome of elderly emergency department patients hospitalised on weekends - a retrospective cohort study.

BACKGROUND: Studies investigating different medical conditions and settings have demonstrated mixed results regarding the weekend effect. However, data on the outcome of elderly patients hospitalised on weekends is scarce. The objective was to compare in-hospital and two-day mortality rates between elderly emergency department (ED) patients (≥65 years) admitted on weekends versus weekdays. METHODS: A retrospective cohort study of emergency department visits of internal medicine patients ≥65 years presenting to the emergency department between 01 and 09-2010 and 31-08-2012 was conducted. The weekend was defined as the period from midnight on Friday to midnight on Sunday. RESULTS: Data on 3697 emergency department visits by elderly internal medicine patients (mean age 78.6 years old) were included. In total, 2743 emergency department visits (74.2%) resulted in hospitalisation, of which 22.9% occurred on weekends. Comorbidity and urgency levels were higher in patients admitted on weekends. In-hospital mortality was 11.4% for patients admitted on weekends compared with 8.9% on weekdays (OR 1.3, 95%CI 0.99-1.8). Two-day mortality was 3.2% in patients hospitalised on weekends versus 1.9% on weekdays (OR 1.7, 95%CI 0.99-2.9). Multivariable adjustment for age, comorbidity and triage level demonstrated comparable in-hospital and two-day mortality for weekend and week admission (ORadj 1.2, 95%CI 0.9-1.7 and ORadj 1.5, 95%CI 0.8-2.6, resp.). CONCLUSION: A small weekend effect was observed in elderly internal medicine patients, which was not statistically significant. This effect was partly explained by a higher comorbidity and urgency level in elderly patients hospitalised on weekends than during weekdays. Emergency care for the elderly is not compromised by adjusted logistics during the weekend.

Elderly emergency patients presenting with non-specific complaints: Characteristics and outcomes.

BACKGROUND: Non-specific complaints (NSC) are common at the emergency department, but only a few studies have shown evidence that these complaints are associated with a poor prognosis in elderly emergency patients. OBJECTIVE: To describe patient characteristics and outcomes in a cohort of elderly emergency patients presenting with NSC. Outcomes were: patient characteristics, hospitalization, 90-day ED-return visits, and 30-day mortality. METHOD: A retrospective cohort study was conducted amongst elderly patients present to the Internal Medicine Emergency Department (ED) between 01-09-2010 and 31-08-2011. NSC were defined as indefinable complaints that lack a pre-differential diagnosis needed to initiate of a standardized patient evaluation. Cox regression was performed to calculate Hazard Ratios (HR) and corrected for confounders such as comorbidity. RESULTS: In total, 1784 patients were enrolled; 244 (13.7%) presented with NSC. Compared to those with SC, comorbidity was higher in the NSC-group (Charlson comorbidity index 3.0 vs. 2.4, p<0.001). The triage level did not differ, but ED-length of stay was longer in the NSC-group (188 vs. 178 minutes, p = 0.004). Hospitalization was more frequent (84.0 vs. 71.1%, p<0.001) and the length of hospital stay (9 vs. 6 days, p<0.001 was longer in the NSC- than in the SC-group. The number of ED-return visits were comparable between both groups (HR 0.8, 95%CI 0.6-1.1). Mortality within 30-days was higher in the NSC- (20.1%) than in the SC-group (11.0%, HR 1.7 95%CI 1.2-2.4). CONCLUSION: Elderly patients present with NSC at the ED regularly. These patients are more often hospitalized and have a substantially higher 30-day mortality than patients with SC.

Association of socioeconomic status with outcomes in older adult community-dwelling patients after visiting the emergency department: a retrospective cohort study.

OBJECTIVES: Older adults frequently visit the emergency department (ED). Socioeconomic status (SES) has an important impact on health and ED utilisation; however, the association between SES and ED utilisation in elderly remains unclear. The aim of this study was to investigate the association between SES in older adult patients visiting the ED on outcomes. DESIGN: A retrospective study. PARTICIPANTS: Older adults (≥65 years) visiting the ED, in the Netherlands. SES was stratified into tertiles based on average household income at zip code level: low (<€1800/month), intermediate (€1800-€2300/month) and high (>€2300/month). PRIMARY OUTCOMES: Hospitalisation, inhospital mortality and 30-day ED return visits. Effect of SES on outcomes for all groups were assessed by logistic regression and adjusted for confounders. RESULTS: In total, 4828 older adults visited the ED during the study period. Low SES was associated with a higher risk of hospitalisation among community-dwelling patients compared with high SES (adjusted OR 1.3, 95% CI 1.1 to 1.7). This association was not present for intermediate SES (adjusted OR 1.1, 95% CI 0.95 to 1.4). Inhospital mortality was comparable between the low and high SES group, even after adjustment for age, comorbidity and triage level (low OR 1.4, 95% CI 0.8 to 2.6, intermediate OR 1.3, 95% CI 0.8 to 2.2). Thirty-day ED revisits among community-dwelling patients were also equal between the SES groups (low: adjusted OR 1.0, 95% CI 0.7 to 1.4, and intermediate: adjusted OR 0.8, 95% CI 0.6 to 1.1). CONCLUSION: In older adult ED patients, low SES was associated with a higher risk of hospitalisation than high SES. However, SES had no impact on inhospital mortality and 30-day ED revisits after adjustment for confounders.

Applicability of the modified Emergency Department Work Index (mEDWIN) at a Dutch emergency department.

BACKGROUND: Emergency department (ED) crowding leads to prolonged emergency department length of stay (ED-LOS) and adverse patient outcomes. No uniform definition of ED crowding exists. Several scores have been developed to quantify ED crowding; the best known is the Emergency Department Work Index (EDWIN). Research on the EDWIN is often applied to limited settings and conducted over a short period of time. OBJECTIVES: To explore whether the EDWIN as a measure can track occupancy at a Dutch ED over the course of one year and to identify fluctuations in ED occupancy per hour, day, and month. Secondary objective is to investigate the discriminatory value of the EDWIN in detecting crowding, as compared with the occupancy rate and prolonged ED-LOS. METHODS: A retrospective cohort study of all ED visits during the period from September 2010 to August 2011 was performed in one hospital in the Netherlands. The EDWIN incorporates the number of patients per triage level, physicians, treatment beds and admitted patients to quantify ED crowding. The EDWIN was adjusted to emergency care in the Netherlands: modified EDWIN (mEDWIN). ED crowding was defined as the 75th percentile of mEDWIN per hour, which was ≥0.28. RESULTS: In total, 28,220 ED visits were included in the analysis. The median mEDWIN per hour was 0.15 (Interquartile range (IQR) 0.05-0.28); median mEDWIN per patient was 0.25 (IQR 0.15-0.39). The EDWIN was higher on Wednesday (0.16) than on other days (0.14-0.16, p<0.001), and a peak in both mEDWIN (0.30-0.33) and ED crowding (52.9-63.4%) was found between 13:00-18:00 h. A comparison of the mEDWIN with the occupancy rate revealed an area under the curve (AUC) of 0.86 (95%CI 0.85-0.87). The AUC of mEDWIN compared with a prolonged ED-LOS (≥4 hours) was 0.50 (95%CI 0.40-0.60). CONCLUSION: The mEDWIN was applicable at a Dutch ED. The mEDWIN was able to identify fluctuations in ED occupancy. In addition, the mEDWIN had high discriminatory power for identification of a busy ED, when compared with the occupancy rate.

Organisational Factors Induce Prolonged Emergency Department Length of Stay in Elderly Patients--A Retrospective Cohort Study.

STUDY OBJECTIVE: To assess the association of patient and organisational factors with emergency department length of stay (ED-LOS) in elderly ED patients (226565 years old) and in younger patients (<65 years old). METHODS: A retrospective cohort study of internal medicine patients visiting the emergency department between September 1st 2010 and August 31st 2011 was performed. All emergency department visits by internal medicine patients 226565 years old and a random sample of internal medicine patients <65 years old were included. Organisational factors were defined as non-medical factors. ED-LOS is defined as the time between ED arrival and ED discharge or admission. Prolonged ED-LOS is defined as ≥75th percentile of ED-LOS in the study population, which was 208 minutes. RESULTS: Data on 1782 emergency department visits by elderly patients and 597 emergency department visits by younger patients were analysed. Prolonged ED-LOS in elderly patients was associated with three organisational factors: >1 consultation during the emergency department visit (odds ratio (OR) 3.2, 95% confidence interval (CI) 2.3-4.3), a higher number of diagnostic tests (OR 1.2, 95% CI 1.16-1.33) and evaluation by a medical student or non-trainee resident compared with a medical specialist (OR 4.2, 95% CI 2.0-8.8 and OR 2.3, 95% CI 1.4-3.9). In younger patients, prolonged ED-LOS was associated with >1 consultation (OR 2.6, 95% CI 1.4-4.6). Factors associated with shorter ED-LOS were arrival during nights or weekends as well as a high urgency level in elderly patients and self-referral in younger patients. CONCLUSION: Organisational factors, such as a higher number of consultations and tests in the emergency department and a lower seniority of the physician, were the main aspects associated with prolonged ED-LOS in elderly patients. Optimisation of the organisation and coordination of emergency care is important to accommodate the needs of the continuously growing number of elderly patients in a better way.