Prognostic Role of Serum Albumin in Predicting 30-Day Mortality in Patients with Infections in Emergency Department: A Prospective Study.

BACKGROUND: Infections in emergency departments (EDs) are insidious clinical conditions characterised by high rates of hospitalisation and mortality in the short-to-medium term. The serum albumin, recently demonstrated as a prognostic biomarker in septic patients in intensive care units, could be an early marker of severity upon arrival of infected patients in the ED. AIM: To confirm the possible prognostic role of the albumin concentration recorded upon arrival of patients with infection. METHODS: A prospective single-centre study was performed in the ED of the General Hospital of Merano, Italy, between 1 January 2021 and 31 December 2021. All enrolled patients with infection were tested for serum albumin concentration. The primary outcome measure was 30-day mortality. The predictive role of albumin was assessed by logistic regression and decision tree analysis adjusted for Charlson comorbidity index, national early warning score, and sequential organ failure assessment (SOFA) score. RESULTS: 962 patients with confirmed infection were enrolled. The median SOFA score was 1 (0-3) and the mean serum albumin level was 3.7 g/dL (SD 0.6). Moreover, 8.9% (86/962) of patients died within 30 days. Albumin was an independent risk factor for 30-day mortality with an adjusted hazard ratio of 3.767 (95% CI 2.192-6.437), p < 0.001. Decision tree analysis indicated that at low SOFA scores, albumin had a good predictive ability, indicating a progressive mortality risk reduction in concentrations above 2.75 g/dL (5.2%) and 3.52 g/dL (2%). CONCLUSIONS: Serum albumin levels at ED admission are predictive of 30-day mortality in infected patients, showing better predictive abilities in patients with low-to-medium SOFA scores.

Electrocardiogram interpretation during nurse triage improves the performance of the triage system in patients with cardiovascular symptoms - A prospective observational study.

BACKGROUND: An immediate ECG on arrival of a patient with cardiovascular symptoms in the ED may anticipate the need for life-saving intervention. The aim was to evaluate whether ECG interpretation during nurse triage can improve triage system performance in patients with cardiovascular symptoms. METHODS: All patients who required an assessment for cardiovascular symptoms were considered for this observational study. During triage assessment, the nurses assessed the patient's level of urgency applying the MTS, then again after this evaluation (confirming or modifying the level of urgency based on personal clinical experience) and after interpretation of the patient's ECG. The main study outcome was the diagnosis of an acute cardiovascular event. RESULTS: Of the 1211 patients in the study, 10.5% presented the main study outcome. ECG interpretation in triage exhibited a nurse-physician agreement of 92.9% (p<0.001). increased patient priority in 7.5% of cases and reduced it in 39.6%. The discriminatory ability of the triage system had an area under the ROC of 0.712and 0.845 after ECG interpretation. ECG interpretation improved the baseline assessment of priority, with an NRI of 60.1% (p<0.001). CONCLUSIONS: ECG interpretation in triage can be a simple and safe tool that improves the assessment of patient priority.

Impact of tourists on emergency department in a high-tourism alpin area: An observational study.

BACKGROUND: The exponential growth of tourism worldwide could have consequences for healthcare services in tourist locations. The impact of the tourist population on access to emergency departments (EDs) is currently unknown. AIM: To describe the characteristics of tourist access in an ED of an alpine tourist area in a period prior to the COVID-19 pandemic. METHODS: All patients evaluated at the ED of the Merano Hospital from January 1, 2017, to December 31, 2019, were considered and divided into two study groups: locals and tourists. Analyses were conducted to assess the impact of tourists in terms of weighted ED admissions and differences in admission characteristics. Finally, for tourist patients only, an analysis of severity according to their type of healthcare system of provenance was performed. RESULTS: A total of 208,875 ED presentations were considered, of which 90.7% (189,406) were by local patients and 9.3% (19,469) were by tourists. The median ED admission rate was 1.65 admissions per 1000 overnight stays for locals versus 0.90 admissions per 1000 overnight stays for tourists. The time series analysis revealed a greater seasonal variation in accesses by tourists than by resident patients. A higher proportion of accesses with a severe code was found among tourist patients, while the local population exhibited a higher proportion of patients with a non-urgent code. In the tourist population, patients from a country with a free-market healthcare system had a higher number of ED presentations for severe conditions or that required hospitalisation than tourists from countries with Bismarck or Beveridge healthcare systems. CONCLUSIONS: The tourist population can have an important impact on EDs in high-impact tourist areas. The seasonality of the tourist population indicates the need for health policies that focus on educating the tourist population on the correct use of the ED.

Nurse triage accuracy in the evaluation of syncope according to European Society of Cardiology guidelines.

AIMS: The role of triage for patients admitted to the emergency department (ED) for a syncopal transitory loss of consciousness (TLOC) has not been debated, and no comparisons with the recent European Society of Cardiology (ESC) guidelines are currently available. To verify the ability of triage to correctly prioritize patients with syncopal TLOC. METHODS AND RESULTS: All patients who received a triage assessment at the ED of the Merano Hospital (Italy) between 1 January 2017 and 30 June 2019 for a syncope were considered. All syncope were reclassified according to the aetiology reported in the ESC guidelines. The baseline characteristics of the patients were recorded and divided according to the severity code provided during triage into two study groups: high priority (red/orange) and low priority (yellow/green/blue). The outcome of the study was the presence of a diagnosed cardiac cause within 30 days after the admission. A total of 2066 patients were enrolled (14.3% high priority vs. 85.7% low priority). Cardiac syncope was present in 7.5% of patients. Nurse triage showed a sensitivity for cardiac syncope of 44.8%, a specificity of 88.1%, and an accuracy of 84.9%. The observed discriminatory ability presented an area under the receiver operating characteristic curve of 0.685 (95% confidence interval 0.638-0.732). The possible identification of the aetiology of the syncopal TLOC by the nurse showed good agreement with the medical diagnosis (Cohen's kappa 0.857, P < 0.001). CONCLUSIONS: In cases of syncopal TLOC, nurse triage had a fair specificity but suboptimal sensitivity for cardiac causes. Specific nursing assessments following triage (e.g. precise scores or electrocardiogram) could improve the triage performance.

Effect of the Emergency Department Assessment of Chest Pain Score on the Triage Performance in Patients With Chest Pain.

The sensitivity of triage systems in identifying acute cardiovascular events in patients presented to the emergency department with chest pain is not optimal. Recently, a clinical score, the Emergency Department Assessment of Chest Pain Score (EDACS), has been proposed for a rapid assessment without additional instruments. To evaluate whether the integration of EDACS into triage evaluation of patients with chest pain can improve the triage's predictive validity for an acute cardiovascular event, a single-center prospective observational study was conducted. This study involved all patients who needed a triage admission for chest pain between January 1, 2020, and December 31, 2020. All enrolled patients first underwent a standard triage assessment and then the EDACS was calculated. The primary outcome of the study was the presence of an acute cardiovascular event. The discriminatory ability of EDACS in triage compared with standard triage assessment was evaluated by comparing the areas under the receiver operating characteristic curve, decision curve analysis, and net reclassification improvement. The study involved 1,596 patients, of that 7.3% presented the study outcome. The discriminatory ability of triage presented an area under the receiver operating characteristic curve of 0.688 that increased to 0.818 after the application of EDACS in the triage assessment. EDACS improved the baseline assessment of priority assigned in triage, with a net reclassification improvement of 33.6% (p <0.001), and the decision curve analyses demonstrated that EDACS in triage resulted in a clear net clinical benefit. In conclusion, the results of the study suggest that EDACS has a good discriminatory capacity for acute cardiovascular events and that its implementation in routine triage may improve triage performance in patients with chest pain.

Decision tree analysis to predict the risk of intracranial haemorrhage after mild traumatic brain injury in patients taking DOACs.

BACKGROUND: Although the preliminary evidence seems to confirm a lower incidence of post-traumatic bleeding in patients treated with direct oral anticoagulants (DOACs) compared to those on vitamin K antagonists (VKAs), the recommended management of mild traumatic brain injury (MTBI) in patients on DOACs is the same as those on the older VKAs, risking excessive use of CT in the emergency department (ED). AIM: To determine which easily identifiable clinical risk factors at the first medical evaluation in the ED may indicate an increased risk of post-traumatic intracranial haemorrhage (ICH) in patients on DOACs with MTBI. METHODS: Patients on DOACs who were evaluated in the ED for an MTBI from 2016 to 2020 at four centres in Northern Italy were considered. A decision tree analysis using the chi-square automatic interaction detection (CHAID) method was conducted to assess the risk of post-traumatic ICH after an MTBI. Known pre- and post-traumatic clinical risk factors that are easily identifiable at the first medical evaluation in the ED were used as input predictor variables. RESULTS: Among the 1146 patients on DOACs in this study, post-traumatic ICH was present in 6.5% (75/1146). Decision tree analysis using the CHAID method found post-traumatic TLOC, post-traumatic amnesia, major trauma dynamic, previous neurosurgery and evidence of trauma above the clavicles to be the strongest predictors associated with the presence of post-traumatic ICH in patients on DOACs. The absence of a concussion seems to indicate subgroups at very low risk of requiring neurosurgery. CONCLUSIONS: The machine-based CHAID model identified distinct prognostic groups of patients with distinct outcomes based on clinical factors. Decision trees can be useful as guides for patient selection and risk stratification.