What is the risk of returning to the emergency department within 30 days for patients diagnosed with substance-induced psychosis?

OBJECTIVES: The primary objective of this study was to measure the risk of return Emergency Department (ED) visits in patients presenting to the ED with a diagnosis of substance-induced psychosis. Secondary objectives included: (1) describing the characteristics of patients returning within 30 days to the ED with substance-induced psychosis, and (2) identifying risk factors associated with such ED return. METHODS: At two urban sites from January 1, 2018 to December 31, 2019, we included consecutive patients presenting to the ED with substance-induced psychosis defined by their ED discharge diagnosis of psychosis and clinical evidence of substance use. We described ED resources utilized by this patient population including ED time and disposition then subsequently described return visits within 30 days and characteristics among those patients who returned. RESULTS: We identified 611 unique patients presenting with substance-induced psychosis, with 813 total ED visits. The median age was 35 years (IQR 28-45), 71.4% (n = 436) were male, and 44.8% (n = 274) were homeless. The median ED length of stay was 619 min (IQR 313-898), and 48.4% (n = 296) were admitted to hospital. Forty percent of patients (n = 237) returned to the ED within 30 days of the index substance-induced psychosis visit, 116 (18.9%) returning more than once. Of these return visits, 74 (31.2%) were for recurrent substance-induced psychosis. Younger age, female gender, no opioid use, and no prior history of bipolar disorder were identified as common characteristics among those returning to the ED with substance-induced psychosis. CONCLUSIONS: In ED patients with substance-induced psychosis, nearly half of all patients were admitted to hospital, 40% had a 30 days return ED visit, and one-third of those were for substance-induced psychosis. We identified clinically relevant factors common to those returning with recurrent substance-induced psychosis.

RéSUMé: OBJECTIFS: L'objectif principal de cette étude était de mesurer le risque de retour aux urgences chez les patients se présentant aux urgences avec un diagnostic de psychose induite par une substance. Les objectifs secondaires comprenaient : 1) décrire les caractéristiques des patients qui retournent aux urgences dans les 30 jours avec une psychose induite par la substance, et 2) déterminer les facteurs de risque associés à ce retour aux urgences. MéTHODES: Dans deux sites urbains, du 1er janvier 2018 au 31 décembre 2019, nous avons inclus des patients consécutifs se présentant aux urgences avec une psychose induite par une substance, définie par leur diagnostic de psychose à la sortie des urgences et des preuves cliniques de consommation de substances. Nous avons décrit les ressources des urgences utilisées par cette population de patients, notamment le temps passé aux urgences et les dispositions prises, puis nous avons décrit les visites de retour dans les 30 jours et les caractéristiques des patients qui sont revenus. RéSULTATS: Nous avons identifié 611 patients uniques présentant une psychose induite par une substance, avec un total de 813 visites aux urgences. L'âge médian était de 35 ans (IQR 28-45), 71,4 % (n = 436) étaient des hommes et 44,8 % (n = 274) étaient sans domicile fixe. La durée médiane du séjour aux urgences était de 619 minutes (IQR 313-898), et 48,4 % (n = 296) ont été hospitalisés. Quarante pour cent des patients (n = 237) sont retournés aux urgences dans les 30 jours suivant la visite de référence pour une psychose due à une substance, 116 (18,9 %) y étant retournés plus d'une fois. Parmi ces visites de retour, 74 (31,2 %) concernaient une psychose récurrente induite par une substance. Un âge plus jeune, le sexe féminin, l'absence de consommation d'opioïdes et d'antécédents de troubles bipolaires ont été identifiés comme des caractéristiques communes chez les personnes revenant aux urgences pour une psychose induite par une substance. CONCLUSIONS: Chez les patients des urgences souffrant de psychose due à une substance, près de la moitié des patients ont été hospitalisés, 40 % sont revenus aux urgences dans les 30 jours, dont un tiers pour une psychose due à une substance. Nous avons identifié des facteurs cliniquement pertinents communs à ceux qui reviennent avec une psychose récurrente induite par une substance.

Effect of specialist consultation on emergency department revisits among patients with uncomplicated recent-onset atrial fibrillation or flutter.

OBJECTIVES: To examine the association between specialist consultation and risk of 30-day ED revisit in emergency department (ED) patients with recent-onset uncomplicated atrial fibrillation or flutter (AF/AFL). METHODS: As a secondary analysis of a previously published trial, clinical experts identified predictors of consultation including age and sex, ED sinus conversion, thromboembolic risk, heart rate, rate control medication use, coronary artery disease and anti-platelet use, and chronic obstructive pulmonary disease. These were included in a propensity-matched hierarchical Bayesian model accounting for hospital site as a random effect, with 30-day ED revisit as the primary outcome. We also measured ED length of stay for consulted and non-consulted patients. RESULTS: We analyzed data from 11 sites for 829 ED patients with AF/AFL, of whom 364 (44%) had specialist consultation. A total of 128 patients (15.4%) had an ED revisit, 78 (16.8%) from the no consult group and 50 (13.7%) from the consult group. Consultation rates ranged from 8.8 to 71% between sites. Median length of stay was 591 min (interquartile range [IQR] 359-1024) for consulted patients and 300 min (IQR 212-409) for patients without consultation. After propensity-matching, consulted patients had a 0.6% (IQR - 4 to 3%) lower risk of 30-day revisits than non-consulted patients (probability of lower risk 55%). CONCLUSIONS: In ED patients with uncomplicated AF/AFL, there was substantial between-site variation in specialist consultations; such consultation was unlikely to influence revisits within 30 days while ED length of stay was nearly double. ED specialist consultations may not be necessary for uncomplicated patients.

RéSUMé: OBJECTIFS: Examiner l'association entre la consultation d'un spécialiste et le risque d'une nouvelle visite aux urgences à 30 jours chez les patients des urgences souffrant de fibrillation auriculaire ou de flutter non compliqué d'apparition récente (FA/AFL). MéTHODES: Dans le cadre d'une analyse secondaire d'un essai précédemment publié, des experts cliniques ont identifié les facteurs prédictifs de la consultation, notamment l'âge et le sexe, la conversion sinusale des urgences, le risque thromboembolique, la fréquence cardiaque, l'utilisation de médicaments pour contrôler la fréquence cardiaque, la maladie coronarienne et l'utilisation d'antiplaquettaires, et la maladie pulmonaire obstructive chronique. Ceux-ci ont été inclus dans un modèle bayésien hiérarchique apparié en fonction de la propension, qui tient compte du site de l'hôpital comme effet aléatoire, le critère principal étant le retour aux urgences à 30 jours. Nous avons également mesuré la durée de séjour aux urgences des patients consultés et non consultés. RéSULTATS: Nous avons analysé les données de 11 sites pour 829 patients du service d'urgence atteints de FA/AFL, dont 364 (44 %) avaient consulté un spécialiste. Un total de 128 patients (15,4 %) ont eu une nouvelle visite à l'urgence, 78 (16,8 %) du groupe sans consultation et 50 (13,7 %) du groupe de consultation. Les taux de consultation variaient de 8,8 % à 71 % selon les sites. La durée médiane du séjour était de 591 minutes (intervalle interquartile [IQR] 359-1024) pour les patients consultés et de 300 min (IQR 212-409) pour les patients sans consultation. Après appariement par propension, les patients consultés avaient un risque inférieur de 0,6 % (IQR -4 % à 3 %) de revisites à 30 jours par rapport aux patients non consultés (probabilité de risque inférieur de 55 %). CONCLUSIONS: Chez les patients des urgences atteints de FA/AFL non compliquée, il y avait une variation substantielle entre les sites dans les consultations de spécialistes ; il était peu probable qu'une telle consultation influence les visites dans les 30 jours alors que la durée du séjour aux urgences était presque le double. Les consultations de spécialistes des urgences peuvent ne pas être nécessaires pour les patients sans complication.

Bayesian analysis of amiodarone or lidocaine versus placebo for out-of-hospital cardiac arrest.

OBJECTIVE: Clinical trials for patients with shock-refractory out-of-hospital cardiac arrest (OHCA), including the Amiodarone, Lidocaine or Placebo (ALPS) trial, have been unable to demonstrate definitive benefit after treatment with antiarrhythmic drugs. A Bayesian approach, combining the available evidence, may yield additional insights. METHODS: We conducted a reanalysis of the ALPS trial comparing treatment with amiodarone or lidocaine with placebo in patients with OHCA following shock-refractory ventricular fibrillation or ventricular tachycardia (VF/VT). We used Bayesian regression to assess the probability of improved survival or improved neurological outcome on the 7-point modified Rankin Scale. We derived weak, moderate and strong priors from a previous clinical trial. RESULTS: The original ALPS trial randomised 3026 adult patients with OHCA to amiodarone (n=974, survival to hospital discharge 24.4%), lidocaine, (n=993, survival 23.7%) or placebo (n=1059, survival 21.0%). In our reanalysis the probability of improved survival from amiodarone ranged from 83% (strong prior) to 95% (weak prior) compared with placebo and from 78% (strong) to 90% (weak) for lidocaine-an estimated improvement in survival of 2.9% (IQR 1.4%-3.8%) for amiodarone and 1.7% (IQR 0.84%-3.2%) for lidocaine over placebo (moderate prior). The probability of improved neurological outcome from amiodarone ranged from 96% (weak) to 99% (strong) compared with placebo and from 88% (weak) to 96% (strong) for lidocaine. CONCLUSIONS: In a Bayesian reanalysis of patients with shock-resistant VF/VT OHCA, treatment with amiodarone had high probabilities of improved survival and neurological outcome, while treatment with lidocaine had a more modest benefit.

Association of emergency department boarding times on hospital length of stay for patients with psychiatric illness.

BACKGROUND: Extended periods awaiting an inpatient bed in the emergency department (ED) may exacerbate the state of patients with acute psychiatric illness, increasing the time it takes to stabilise their acute problem in hospital. Therefore, we assessed the association between boarding time and hospital length of stay for psychiatric patients. METHODS: ED clinical records were linked to inpatient administrative records for all patients with a primary psychiatric diagnosis admitted to a Calgary, Alberta hospital between April 2014 and March 2018. The primary exposure was boarding time (admission decision to inpatient bed transfer), and primary outcome was inpatient length of stay. Confounders for this relationship, including indicators of illness severity, were selected a priori then the association was assessed using hierarchical Bayesian Poisson regression, which accounts for repeat observations of the same patient and differences between hospital sites. Changes in length of stay were measured using a rate ratio (ie, expected change in length of stay for each 1 hour increase in boarding time). RESULTS: A total of 19 212 admissions (14 261 unique patients) were included in the analysis. The average boarding time was 14 hours (range: 0-186 hours). Patients who were boarded for greater than 14 hours more frequently required a high-observation bed (14% vs 3.5%), received an antipsychotic (44% vs 14%) or received sedation (55% vs 33%) while in the ED. The probability that boarding time increased hospital length of stay (rate ratio: >1) was 92%, with a median increase for a patient boarded for 24 hours of 0.01 days. CONCLUSION: Boarding in the ED was associated with a high probability of increasing the hospital length of stay for psychiatric patients; however, the absolute increase is minimal. Although slight, this signal for longer length of stay may be a sign of increased morbidity for psychiatric patients held in the ED.

Phytoextraction and recovery of rare earth elements using willow (Salix spp.).

Soil and water contaminations are caused by rare earth elements (REEs) due to mining and industrial activities, that threaten the ecosystem and human health. Therefore, phytoremediation methods need to be developed to overcome this problem. To date, little research has been conducted concerning the phytoremediation potential of Salix for REEs. In this study, two Salix species (Salix myrsinifolia and Salix schwerinii) and two Salix cultivars (Klara and Karin) were hydroponically exposed to different concentrations of six-REE for 4 weeks. The treatments were: T1 (Control: tap water), T2 (La: 50 mg/L) and T3 (La 11.50 + Y 11 + Nd 10.50 + Dy 10 + Ce 12 and Tb 11.50 in mg L-1). The effects of the REE on Salix growth indicators (height, biomass, shoot diameter and root length), concentrations of REE in the produced biomass, and accumulation of REE in different parts of the Salix (stem, root, and leaf) tissues, were determined. In addition, the retention of REE in ashes following Salix combustion (800 and 1000 °C) was determined. The result indicates that with La and REE exposure, the height growth, dry biomass, shoot diameter and root length of all Salix remained equivalent to the control treatment excluding Klara, which displayed relatively higher growth in all parameters. Further, among the REE studied, the highest La concentration (8404 µg g-1 DW) and La accumulation (10,548 µg plant-1) were observed in Karin and Klara root respectively. Translocations and bioconcentration factors were discovered at <1 for all Salix, which indicates their phytostabilization potential. The total REE concentrations in bottom ashes varied between 7 and 8% with retention rates between 85 and 89%. This study demonstrates that Salix are suitable candidates for REE phytostabilization and the remediation of wastewater sites to limit metals percolating to the water layers in the ecosystem.

Hydronephrosis severity clarifies prognosis and guides management for emergency department patients with acute ureteral colic.

OBJECTIVE: In emergency department patients with ureteral colic, the prognostic value of hydronephrosis is unclear. Our goal was to determine whether hydronephrosis can differentiate low-risk patients appropriate for trial of spontaneous passage from those with clinically important stones likely to experience passage failure. METHODS: We used administrative data and structured chart review to evaluate a consecutive cohort of patients with ureteral stones who had a CT at nine Canadian hospitals in two cities. We used CT, the gold standard for stone imaging, to assess hydronephrosis and stone size. We described classification accuracy of hydronephrosis severity for detecting large (≥ 5 mm) stones. In patients attempting spontaneous passage we used hierarchical Bayesian regression to determine the association of hydronephrosis with passage failure, defined by the need for rescue intervention within 60 days. To illustrate prognostic utility, we reported pre-test probability of passage failure among all eligible patients (without hydronephrosis guidance) to post-test probability of passage failure in each hydronephrosis group. RESULTS: Of 3251 patients, 70% male and mean age 51, 38% had a large stone, including 23%, 29%, 53% and 72% with absent, mild, moderate and severe hydronephrosis. Passage failure rates were 15%, 20%, 28% and 43% in the respective hydronephrosis categories, and 23% overall. "Absent or mild" hydronephrosis identified a large subset of patients (64%) with low passage failure rates. Moderate hydronephrosis predicted slightly higher, and severe hydronephrosis substantially higher passage failure risk. CONCLUSIONS: Absent and mild hydronephrosis identify low-risk patients unlikely to experience passage failure, who may be appropriate for trial of spontaneous passage without CT imaging. Moderate hydronephrosis is weakly associated with larger stones but not with significantly greater passage failure. Severe hydronephrosis is an important finding that warrants definitive imaging and referral. Differentiating "moderate-severe" from "absent-mild" hydronephrosis provides risk stratification value. More granular hydronephrosis grading is not prognostically helpful.

RéSUMé: OBJECTIF: Chez les patients des services d'urgence (SU) atteints de colique urétérale, la valeur pronostique de l'hydronéphrose n'est pas claire. Notre objectif était de déterminer si l'hydronéphrose peut différencier les patients à faible risque appropriés pour l'essai de passage spontané de ceux qui ont des calculs cliniquement importants susceptibles de subir un échec de passage. MéTHODES: Nous avons utilisé des données administratives et un examen structuré des dossiers pour évaluer une cohorte consécutive de patients atteints de calculs urétéraux qui avaient subi une tomodensitométrie dans neuf hôpitaux canadiens de deux villes. Nous avons utilisé la tomodensitométrie, l'étalon-or pour l'imagerie des calculs, pour évaluer l'hydronéphrose et la taille des calculs. Nous avons décrit la précision de la classification de la gravité de l'hydronéphrose pour la détection de gros calculs (> 5 mm). Chez les patients tentant un passage spontané, nous avons utilisé la régression bayésienne hiérarchique pour déterminer l'association de l'hydronéphrose avec l'échec du passage, défini par le besoin d'intervention de sauvetage dans les 60 jours. Pour illustrer l'utilité pronostique, nous avons signalé la probabilité d'échec de passage avant le test chez tous les patients admissibles (sans directives sur l'hydronéphrose) à la probabilité d'échec de passage post-test dans chaque groupe d'hydronéphrose. RéSULTATS: Sur 3251 patients, 70% d'hommes et d'âge moyen 51 ans, 38% avaient un gros calcul, dont 23%, 29%, 53% et 72% avec une hydronéphrose absente, légère, modérée et sévère. Les taux d'échec au passage étaient de 15%, 20%, 28% et 43% dans les catégories d'hydronéphrose respectives et de 23% dans l'ensemble. L'hydronéphrose « absente ou légère ¼ a permis d'identifier un sous-ensemble important de patients (64%) présentant de faibles taux d'échec au passage. Une hydronéphrose modérée prédisait un risque d'échec de passage légèrement plus élevé, et une hydronéphrose sévère un risque sensiblement plus élevé. CONCLUSIONS: L'absence d'hydronéphrose et une hydronéphrose légère permettent d'identifier les patients à faible risque, peu susceptibles d'avoir un échec de passage, qui peuvent être appropriés pour un essai de passage spontané sans imagerie CT. Une hydronéphrose modérée est faiblement associée à des calculs plus gros mais pas à un échec de passage significativement plus important. L'hydronéphrose sévère est une constatation importante qui justifie une imagerie définitive et une référence. Différencier l'hydronéphrose « modérée-sévère ¼ de l'« absence-légère ¼ fournit une valeur de stratification du risque. Un classement plus granulaire de l'hydronéphrose n'est pas utile sur le plan pronostique.

Changes in presentation, presenting severity and disposition among patients accessing emergency services during the first months of the COVID-19 pandemic in Calgary, Alberta: a descriptive study.

BACKGROUND: The COVID-19 pandemic has resulted in unique pressures on the emergency services system. This study describes changes in the presentation, presenting severity and disposition of patients accessing emergency services in Calgary, Alberta, during the first wave of the pandemic. METHODS: In this descriptive study, we constructed a population cohort of all patients who accessed emergency services by calling emergency medical services (EMS) (ambulance service that provides prehospital treatment and transport to medical facilities) or presenting directly to an emergency department (4 adult and 1 pediatric) or 2 urgent care centres in Calgary during the exposure period (December 2019 to June 2020) compared to 2 historical control periods (December to June, 2017-2018 and 2018-2019) combined. Outcomes included frequency of presentation, system flow indicators, patient severity, disposition and mortality. We used a locally estimated scatterplot smoothing function to visualize trends. We described differences at the maximum and minimum point of the exposure period compared to the control period. RESULTS: A total of 1 127 014 patient encounters were included. Compared to the control period, there was a 61% increase in the number of patients accessing EMS and a 35% decrease in the number of those presenting to an adult emergency department or urgent care centre in the COVID-19 period. The proportion of EMS calls for the highest-priority patients remained stable, whereas the proportion of patients presenting to an emergency department or urgent care centre with the highest-priority triage classification increased transiently by 0.9 percentage points (increase of 89%). A smaller proportion of patients were transported by EMS (decrease of 21%), and a greater proportion of emergency department patients were admitted to hospital (increase of 25%). After the first case was reported, the mortality rate among EMS patients increased by 265% (3.4 v. 12.4 per 1000 patient encounters). INTERPRETATION: The first wave of the COVID-19 pandemic was associated with substantial changes in the frequency and disposition of patients accessing emergency services. Further research examining the mechanism of these observations is important for mitigating the impact of future pandemics.

Detoxification of wood-combustion ashes containing Cr and Cd by thermal treatment.

This study assesses the potential of thermal processing for detoxification of wood-combustion ashes that contain high levels of Cr and Cd. Thermal treatment (1000 °C) of bottom ash and fly ash in an oxidising gas (air) atmosphere resulted in: low volatilisation of Cd and most other heavy metals, oxidation of Cr in the ashes to Cr (VI), and, in the case of the fly ash, significantly increased leaching of Cr and Mo. Thermal treatment in a nitrogen atmosphere resulted in local reducing conditions due to oxidation of ash-derived carbon to CO (g). Thermal treatments in this atmosphere and in a reducing atmosphere consisting of 10 % H2 and the balance N2 detoxified the ashes in at least two ways: (i) by substantially removing Cd, Pb, Bi, Tl, and, in the case of the fly ash, Zn from the ashes by volatilisation; and (ii) by thermal reduction of Cr (VI) in the ashes. There was at least a 100-fold reduction in the leaching of total Cr from both the bottom ash and the fly ash following the thermal treatments in reducing conditions. Chromium only leached from the detoxified bottom ash to a significant extent in acidic conditions (pH < 4).

Lorazepam Versus Diazepam in the Management of Emergency Department Patients With Alcohol Withdrawal.

STUDY OBJECTIVE: Alcohol withdrawal is a common emergency department (ED) presentation. Although benzodiazepines reduce symptoms of withdrawal, there is little ED-based evidence to assist clinicians in selecting appropriate pharmacotherapy. We compare lorazepam with diazepam for the management of alcohol withdrawal to assess 1-week ED and hospital-related outcomes. METHODS: From January 1, 2015, to December 31, 2018, at 3 urban EDs in Vancouver, Canada, we studied patients with a discharge diagnosis of alcohol withdrawal. We excluded individuals presenting with a seizure or an acute concurrent illness. We performed a structured chart review to ascertain demographics, ED treatments, and outcomes. Patients were stratified according to initial management with lorazepam versus diazepam. The primary outcome was hospital admission, and secondary outcomes included in-ED seizures and 1-week return visits for discharged patients. RESULTS: Of 1,055 patients who presented with acute alcohol withdrawal, 898 were treated with benzodiazepines. Median age was 47 years (interquartile range 37 to 56 years) and 73% were men. Baseline characteristics were similar in the 2 groups. Overall, 69 of 394 patients (17.5%) receiving lorazepam were admitted to the hospital compared with 94 of 504 patients receiving diazepam (18.7%), a difference of 1.2% (95% confidence interval -4.2% to 6.3%). Seven patients (0.7%; 95% confidence interval 0.3% to 1.4%) had an in-ED seizure, but all seizures occurred before receipt of benzodiazepines. Among patients discharged home, 1-week return visits occurred for 78 of 325 (24.0%) who received lorazepam and 94 of 410 (23.2%) who received diazepam, a difference of 0.8% (95% confidence interval -5.3% to 7.1%). CONCLUSION: In our sample of ED patients with acute alcohol withdrawal, patients receiving lorazepam had an admission rate similar to that of those receiving diazepam. The few in-ED seizures occurred before medication administration. For discharged patients, the 1-week ED return visit rate of nearly 25% could warrant enhanced follow-up and community support.

Correction to: Epidemiology and patient predictors of infection and sepsis in the prehospital setting.

The original version of this article unfortunately contained a mistake.

Thermal treatment of municipal solid waste incineration fly ash: Impact of gas atmosphere on the volatility of major, minor, and trace elements.

Development of thermal processes for selective recovery of Zn and other valuable elements from municipal solid waste incineration (MSWI) fly ash requires comprehensive knowledge of the impact of gas atmosphere on the volatile behaviour of the element constituents of the ash at different reaction temperatures. This study assesses the partitioning of 18 elements (Al, As, Bi, C, Ca, Cd, Cl, Cu, K, Mg, Na, P, Pb, S, Sb, Sn, Ti, and Zn) between condensed and gaseous phases during thermal treatment of MSWI fly ash in both oxidising gas and reducing gas atmospheres, at different temperatures spanning the range 200-1050 °C. The operating atmosphere had major impacts on the partitioning of the following elements: As, Bi, C, Cd, Cu, Na, Pb, S, Sb, Sn, and Zn. The partitioning of these elements cannot be accurately predicted over the full range of investigated operating conditions with global thermodynamic equilibrium calculations alone, i.e. without also considering chemical kinetics and mass transfer. In oxidising conditions, the following elements were predominately retained in condensed phases, even at high temperatures: As, Bi, Sb, Sn, and Zn. All these elements, except As, were largely released to the gas phase (>70%) at high temperatures in reducing conditions. The impact of gas atmosphere on the volatility of Cd and Pb was greatest at low reaction temperatures (below ~750 °C). Results for volatile matrix elements, specifically C, Cl, K, Na, and S, are interpreted in terms of the mechanisms governing the release of these elements to the gas phase.

Epidemiology and patient predictors of infection and sepsis in the prehospital setting.

PURPOSE: Paramedics are often the first healthcare contact for patients with infection and sepsis and may identify them earlier with improved knowledge of the clinical signs and symptoms that identify patients at higher risk. METHODS: A 1-year (April 2015 and March 2016) cohort of all adult patients transported by EMS in the province of Alberta, Canada, was linked to hospital administrative databases. The main outcomes were infection, or sepsis diagnosis among patients with infection, in the Emergency Department. We estimated the probability of these outcomes, conditional on signs and symptoms that are commonly available to paramedics. RESULTS: Among 131,745 patients transported by EMS, the prevalence of infection was 9.7% and sepsis was 2.1%. The in-hospital mortality rate for patients with sepsis was 28%. The majority (62%) of patients with infections were classified by one of three dispatch categories ("breathing problems," "sick patient," or "inter-facility transfer"), and the probability of infection diagnosis was 17-20% for patients within these categories. Patients with elevated temperature measurements had the highest probability for infection diagnosis, but altered Glasgow Coma Scale (GCS), low blood pressure, or abnormal respiratory rate had the highest probability for sepsis diagnosis. CONCLUSION: Dispatch categories and elevated temperature identify patients with higher probability of infection, but abnormal GCS, low blood pressure, and abnormal respiratory rate identify patients with infection who have a higher probability of sepsis. These characteristics may be considered by paramedics to identify higher-risk patients prior to arrival at the hospital.

Screening strategies to identify sepsis in the prehospital setting: a validation study.

BACKGROUND: In the prehospital setting, differentiating patients who have sepsis from those who have infection but no organ dysfunction is important to initiate sepsis treatments appropriately. We aimed to identify which published screening strategies for paramedics to use in identifying patients with sepsis provide the most certainty for prehospital diagnosis. METHODS: We identified published strategies for screening by paramedics through a literature search. We then conducted a validation study in Alberta, Canada, from April 2015 to March 2016. For adult patients (≥ 18 yr) who were transferred by ambulance, we linked records to an administrative database and then restricted the search to patients with infection diagnosed in the emergency department. For each patient, the classification from each strategy was determined and compared with the diagnosis recorded in the emergency department. For all strategies that generated numeric scores, we constructed diagnostic prediction models to estimate the probability of sepsis being diagnosed in the emergency department. RESULTS: We identified 21 unique prehospital screening strategies, 14 of which had numeric scores. We linked a total of 131 745 eligible patients to hospital databases. No single strategy had both high sensitivity (overall range 0.02-0.85) and high specificity (overall range 0.38-0.99) for classifying sepsis. However, the Critical Illness Prediction (CIP) score, the National Early Warning Score (NEWS) and the Quick Sepsis-Related Organ Failure Assessment (qSOFA) score predicted a low to high probability of a sepsis diagnosis at different scores. The qSOFA identified patients with a 7% (lowest score) to 87% (highest score) probability of sepsis diagnosis. INTERPRETATION: The CIP, NEWS and qSOFA scores are tools with good predictive ability for sepsis diagnosis in the prehospital setting. The qSOFA score is simple to calculate and may be useful to paramedics in screening patients with possible sepsis.

Strategy to Identify Paramedic Transported Sepsis Cases in an Emergency Department Administrative Database.

Background: To evaluate a new strategy for identifying sepsis in Emergency Department (ED) patients that combines administrative diagnosis codes with clinical information from the point of first contact. Methods: This study linked clinical data from adult patients transported by a provincial Emergency Medical Services (EMS) system to ED and inpatient administrative databases. Sepsis cases were identified by searching ED databases for diagnosis codes consistent with infection and organ dysfunction. Organ dysfunction was further assessed using a partial Sequential Organ Failure Assessment (SOFA) score derived from EMS clinical information. Reliability was evaluated by comparing patients' ED diagnosis codes (ICD-10CA) to their inpatient diagnosis codes; criterion validity by comparing cases classified by the new strategy to an existing inpatient administrative algorithm; and construct validity by assessing for clinical characteristics typically associated with sepsis (e.g., mortality). Results: A total of 43,297 patients were included. ED infection codes were more reliable for classifying patients with infection than using ED sepsis codes alone (proportion of agreement with inpatient codes 79% vs. 74%; p-value < 0.001). The novel strategy requiring the presence of an infection code and either an organ dysfunction code or 2 or more SOFA points from EMS clinical information identified 1,379 more ED patients as having sepsis than the inpatient algorithm. These patients had high mortality supporting construct validity. Conclusions: Incorporation of a broader range of diagnostic codes and linking to an electronic database to obtain initial clinical information for the assessment of organ dysfunction improves reliability, criterion, and construct validity for identifying sepsis in ED patients.

Classification versus Prediction of Mortality Risk using the SIRS and qSOFA Scores in Patients with Infection Transported by Paramedics.

Objective: Identifying patients with sepsis in the prehospital setting is an important opportunity to increase timely care. When assessing clinical tools designed for paramedic sepsis identification, predicted risk may provide more useful information to support decision-making, compared to traditional estimates of classification accuracy (i.e., sensitivity and specificity). We sought to contrast classification accuracy versus predicted risk of a modified version of the Systemic Inflammatory Response Syndrome score (i.e., excluding white blood cell measure which is often unavailable to paramedics; mSIRS) and quick Sepsis Related Organ Failure Assessment (qSOFA) for determining mortality risk among patients with infection transported by paramedics. Methods: A one-year cohort of patients with infections transported to the Emergency Department (ED) by paramedics was linked to in-hospital administrative databases. Scores were calculated using the first reported vital sign measure for each patient. We calculated sensitivity and specificity of mSIRS and qSOFA for classifying hospital mortality at different score thresholds, and estimated discrimination (using the C-statistic) and calibration (using calibration curves). Regression models for predicting hospital mortality were constructed using the mSIRS or qSOFA scores for each patient as the predictor. Results: A total of 10,409 patients with infection who were transported by paramedics were successfully linked, with an overall mortality rate of 9.2%. The mSIRS score had higher sensitivity estimates than qSOFA for classifying hospital mortality at all thresholds (mSIRS ≥ 1: 0.83 vs. qSOFA≥ 1: 0.80, mSIRS ≥ 3: 0.11 vs. qSOFA ≥ 3: 0.08), but the qSOFA score had better discrimination (C-statistic qSOFA: 0.72 vs. mSIRS: 0.63) and calibration. The risk of hospital mortality predicted by the mSIRS score ranged from 8.0 to 19% across score values, whereas the risk predicted by the qSOFA score ranged from 10 to 51%. Conclusion: Assessing the predicted risk for the mSIRS and qSOFA scores instead of classification accuracy reveals that the qSOFA score provides more information to clinicians about a patient's mortality risk, supporting its use in clinical decision-making.

Assessing Severity of Illness in Patients Transported to Hospital by Paramedics: External Validation of 3 Prognostic Scores.

Introduction: Emergency Medical Services (EMS) are the first healthcare contact for the majority of severely ill patients. Physiologic measures collected by EMS, when incorporated into a prognostic score, may provide important information on patient illness severity. This study compares the predictive ability of 3 common prognostic scores for predicting clinical outcomes in EMS patients. Methods: Discrimination and calibration for predicting the primary outcome of hospital mortality, and secondary outcomes of 2-day mortality and ED disposition, were assessed for each of the scores using a one-year cohort of patients transported to hospital by EMS in Alberta, Canada. For each score, binary logistic regression was used to predict hospital mortality and 2-day mortality and ordinal logistic regression was used to predict ED disposition. Discrimination for each outcome was assessed using C-statistics, and calibration was assessed using calibration curves comparing predicted versus observed outcomes. Results: The Critical Illness Prediction [CIP], Modified Early Warning Score [MEWS], and National Early Warning Score [NEWS] were compared using 121,837 adult patients who were transported by paramedics. All scores had good discrimination for hospital mortality (C-statistic CIP: 0.79, MEWS: 0.71, NEWS: 0.78) and 2-day mortality (CIP:0.85, MEWS: 0.80, NEWS:0.85) but only moderate discrimination for ED disposition (CIP: 0.68, MEWS: 0.61, NEWS: 0.66). Calibration was reliable for hospital mortality in all scores but over-predicted risk for 2-day mortality at higher scores. Overall, the CIP score had the best discrimination, good calibration, and the greatest range of predicted probabilities (0.01 at a CIP score of 0 to 0.92 at a CIP score of 8) for hospital mortality. Conclusions: Prognostic scores using physiologic measures assessed by paramedics have good predictive ability for hospital mortality. These scores, particularly the CIP score, may be considered as a tool for mortality risk stratification or as a general measure of illness severity for patients included in EMS studies.

Volatilisation of major, minor, and trace elements during thermal processing of fly ashes from waste- and wood-fired power plants in oxidising and reducing gas atmospheres.

This study assesses the volatility of 15 elements (As, Bi, C, Cd, Cl, Cu, K, Mn, Na, P, Pb, S, Sb, Sn, and Zn) during thermal processing of fly ashes obtained from four waste-to-energy plants and one wood-combustion plant. Differences in volatility in oxidising and reducing atmospheres (air and 10% H2/90% N2) were assessed at two temperatures, 700 and 1000 °C. P and Mn were predominately retained in all ashes regardless of the operating atmosphere and temperature. Other elements showed significant variation in volatility depending on the type of fly ash, atmosphere, and temperature. Heat-treatment of the wood-combustion fly ash in the air atmosphere resulted in low release of K, Na, and all investigated heavy metals and metalloids. Several valuable elements, including Zn, Sb, Sn, and Bi, were significantly more volatile in the reducing atmosphere than in the oxidising atmosphere, particularly at 1000 °C. Other elements were either less volatile, equally volatile, or only marginally more volatile when the ashes were heated at 1000 °C in the reducing atmosphere. These elements include C, Cl, Cu, and, in the case of fly ashes derived from municipal solid waste, Cd and Pb. A two-step process, in which municipal solid waste incineration fly ash is first heated in an oxidising atmosphere and then in a reducing atmosphere, is proposed for production of a chloride-free zinc concentrate. Evaluation of the two-step process at 880 °C shows good potential for selective volatilisation of Zn with other valuable elements, including Sn, Sb, and Bi.

Association Between Early Intravenous Fluids Provided by Paramedics and Subsequent In-Hospital Mortality Among Patients With Sepsis.

Importance: Early administration of intravenous fluids is recommended for all patients with sepsis, but the association of this treatment with mortality may depend on the patient's initial blood pressure. Objective: To test the association between early administration of intravenous fluids by paramedics and in-hospital mortality among patients with sepsis, accounting for patients' initial blood pressure. Design, Setting, and Participants: Cohort study in which multiple analyses were conducted using a 1-year (from April 1, 2015, to March 31, 2016) cohort of 1871 patients with sepsis who were transported to the hospital by paramedics from a large emergency medical services system in Alberta, Canada. Multivariable logistic regression and a propensity-matched analysis adjusting for baseline patient characteristics were used to minimize confounding by indication and test the association between early administration of intravenous fluids by paramedics and in-hospital mortality. Nonparametric additive regression was used to assess the association of early administration of intravenous fluids with prehospital and in-hospital treatment times. Exposures: Intravenous fluids administered by paramedics at the point of first contact and during transportation to the hospital. Main Outcomes and Measures: The primary outcome was in-hospital mortality. Secondary outcomes included prehospital and emergency department treatment times. Results: A total of 1871 patients with sepsis were identified (955 women and 916 men; median age, 77 years [interquartile range, 64-85 years]), with an overall in-hospital mortality of 28.2% (n = 528). More than half of patients (1015 [54.2%]) received intravenous fluids from paramedics; the median volume provided was 400 mL (interquartile range, 250-500 mL). The association of intravenous fluids with mortality depended on the patient's initial systolic blood pressure (range, 42-222 mm Hg; P < .001 for interaction). For example, in a typical patient with an initial systolic blood pressure of 100 mm Hg, intravenous fluids were associated with decreased mortality (odds ratio, 0.73; 95% CI, 0.56-0.95), but for a typical patient with the median initial systolic blood pressure of 125 mm Hg, intravenous fluids were not associated with in-hospital mortality (odds ratio, 1.41; 95% CI, 0.81-2.44). Similar results were obtained in the propensity-matched analysis. The administration of intravenous fluids was associated with increased prehospital time compared with patients who did not receive intravenous fluids (median difference, 3.2 minutes; 95% CI, 1.7-4.7 minutes) but was not associated with time to assessment in the emergency department (median difference, 2.4 minutes; 95% CI, -2.4 to 7.3 minutes). Conclusions and Relevance: Intravenous fluids provided by paramedics were associated with reduced in-hospital mortality for patients with sepsis and hypotension but not for those with a higher initial systolic blood pressure.