Artificial Intelligence: its Future and Impact on Acute Medicine.

This commentary explores the potential impact of artificial intelligence (AI) in acute medicine, considering its possibilities and challenges. With its ability to simulate human intelligence, AI holds the promise for supporting timely decision-making and interventions in acute care. While AI has significantly contributed to improvements in various sectors, its implementation in healthcare remains limited. The development of AI tools tailored to acute medicine can improve clinical decision-making, and AI's role in streamlining administrative tasks, exemplified by ChatGPT, may offer immediate benefits. However, challenges include uniform data collection, privacy, bias, and preserving the doctor-patient relationship. Collaboration among AI researchers, healthcare professionals, and policymakers is crucial to harness the potential of AI in acute medicine and create a future where advanced technologies synergistically enhance human expertise.

Real-world characteristics and outcomes of patients with intermediate high risk acute pulmonary embolism.

BACKGROUND: Exact benefits of currently recommended close monitoring in intermediate high risk acute pulmonary embolism (PE) patients are unknown. METHODS: This prospective observational cohort study determined clinical characteristics, and disease course of intermediate high risk acute PE patients in an academic hospital setting . Frequency of hemodynamic deterioration, use of rescue reperfusion therapy and PE related mortality, were outcomes of interest. RESULTS: Of 98 intermediate high risk PE patients included for analysis, 81 patients (83%) were closely monitored. Two deteriorated hemodynamically and were treated with rescue reperfusion therapy. One patient survived after this. CONCLUSIONS: In these 98 intermediate high risk PE patients, hemodynamic deterioration occurred in three patients and rescue reperfusion therapy of two closely monitored patients led to survival of one. Underlining the need for better recognition of patients benefitting from and research in the optimal way of close monitoring.

Emergency department crowding and older patients: a nationwide retrospective cohort study.

OBJECTIVE: Emergency department (ED) crowding is a worldwide problem and one of the main causes internationally is an increase in presentations by older patients with complex and chronic care needs. Although there has been a 4,3% reduction in total ED visits from 2016-2019 in the Netherlands, the EDs still experience crowding. National crowding research has not focused on the older group in detail, hence their possible role remains ill defined. The primary aim of this study was to map the trend in ED visits by older patients in the Netherlands. The secondary aim was to identify healthcare utilization 30 days before/after ED visit. METHODS: We conducted a nationwide retrospective cohort study, using longitudinal health insurance claims data (2016-2019). The data encompasses all Dutch patients of 70 years or older who visited the ED. RESULTS: The number of older patients who visited the ED followed by admission, increased from 231,223 patients (2016), to 234,817 (2019). The number without admission also increased from 244,814 patients, to 274,984. There were 696,005 total visits by older patients (2016) increasing to 730,358 visits (2019). CONCLUSION: The slight rise in older patients at the ED is consistent with overall population growth of older people in the Netherlands. These results indicate that Dutch ED crowding cannot be explained by mere numbers of older patients. More research is needed with data on patient level, to study other contributing factors, such as complexity of care needs within the ageing population.

How to improve inpatient sleep in regular care wards: a systematic review and meta-analysis of sleep disturbers and non-pharmacological interventions.

OBJECTIVE: To determine factors affecting inpatient sleep and assess the range and effectiveness of non-pharmacological interventions aimed at improving the sleep of patients admitted to regular care wards. METHODS: A systematic literature search was conducted in five scientific databases, including articles published from inception to June 23rd, 2023. Eligible studies evaluated sleep disturbing factors or the effect of non-pharmacological intervention(s). Meta-analyses on intervention studies were conducted using a random effects model. Certainty of evidence was assessed using the GRADE approach. RESULTS: Out of 591 potentially eligible studies, 229 were included in this review. Sleep disturbers were identified in 153 studies, and 102 studies were eligible for meta-analysis. Common factors contributing to poor sleep included noise, light, care-related interruptions, pain, and anxiety. The meta-analyses revealed large pooled effects in favor of sleep for the use of eye masks and earplugs, headphones and white noise, aromatherapy, massage, muscle relaxation and breathing exercises, and advanced nursing strategies. However, the certainty of the evidence ranged from moderate to very low. CONCLUSION: Inpatient sleep is often disturbed by patient-related, care-related, and environmental factors. While there are promising non-pharmacological interventions, the overall quality of studies, heterogeneity in study populations, and differences in outcome measures present challenges for drawing definitive conclusions.

A prospective, observational study of the performance of MEWS, NEWS, SIRS and qSOFA for early risk stratification for adverse outcomes in patients with suspected infections at the emergency department.

BACKGROUND: Many patients with suspected infection are presented to the emergency Department. Several scoring systems have been proposed to identify patients at high risk of adverse outcomes. METHODS: We compared generic early warning scores (MEWS and NEWS) to the (SIRS) criteria and quick Sequential Organ Failure Assessement (qSOFA), for early risk stratification in 1400 patients with suspected infection in the ED. The primary study end point was 30-day mortality. RESULTS: The AUROC of the NEWS score for predicting 30-day mortality was 0.740 (95% Confidence Interval 0.682- 0.798), higher than qSOFA (AUROC of 0.689, 95% CI 0.615- 0.763), MEWS (AUROC 0.643 (95% CI 0.583-0.702) and SIRS (AUROC 0.586, 95%CI 0.521 - 0.651). The sensitivity was also highest for NEWS⋝ 5 (sensitivity 75,8% specificity of 67,4%). CONCLUSION: Among patients presenting to the ED with suspected infection, early risk stratification with NEWS (cut-off of ⋝5) is more sensitive for prediction of mortality than qSOFA, MEWS or SIRS, with adequate specificity.

Predicting poor outcome in patients with suspected COVID-19 presenting to the Emergency Department (COVERED) - Development, internal and external validation of a prediction model.

BACKGROUND: A recent systematic review recommends against the use of any of the current COVID-19 prediction models in clinical practice. To enable clinicians to appropriately profile and treat suspected COVID-19 patients at the emergency department (ED), externally validated models that predict poor outcome are desperately needed. OBJECTIVE: Our aims were to identify predictors of poor outcome, defined as mortality or ICU admission within 30 days, in patients presenting to the ED with a clinical suspicion of COVID-19, and to develop and externally validate a prediction model for poor outcome. METHODS: In this prospective, multi-center study, we enrolled suspected COVID-19 patients presenting at the EDs of two hospitals in the Netherlands. We used backward logistic regression to develop a prediction model. We used the area under the curve (AUC), Brier score and pseudo-R2 to assess model performance. The model was externally validated in an Italian cohort. RESULTS: We included 1193 patients between March 12 and May 27 2020, of whom 196 (16.4%) had a poor outcome. We identified 10 predictors of poor outcome: current malignancy (OR 2.774; 95%CI 1.682-4.576), systolic blood pressure (OR 0.981; 95%CI 0.964-0.998), heart rate (OR 1.001; 95%CI 0.97-1.028), respiratory rate (OR 1.078; 95%CI 1.046-1.111), oxygen saturation (OR 0.899; 95%CI 0.850-0.952), body temperature (OR 0.505; 95%CI 0.359-0.710), serum urea (OR 1.404; 95%CI 1.198-1.645), C-reactive protein (OR 1.013; 95%CI 1.001-1.024), lactate dehydrogenase (OR 1.007; 95%CI 1.002-1.013) and SARS-CoV-2 PCR result (OR 2.456; 95%CI 1.526-3.953). The AUC was 0.86 (95%CI 0.83-0.89), with a Brier score of 0.32 and, and R2 of 0.41. The AUC in the external validation in 500 patients was 0.70 (95%CI 0.65-0.75). CONCLUSION: The COVERED risk score showed excellent discriminatory ability, also in an external validation. It may aid clinical decision making, and improve triage at the ED in health care environments with high patient throughputs.

Evaluating quality in acute care using patient reported outcome measures: a scoping review.

The aim of this scoping review is to identify patient reported outcome measures (PROMs) in acute care settings, assess their psychometric properties and provide recommendations for their use in daily practice. We performed a search in the PubMed database to identify publications concerning PROMs in an acute care setting. The COSMIN checklist was used to assess the psychometric properties of the reported PROMs. We found 1407 publications and included 14 articles, describing 15 measures. Most publications provided limited information on psychometric properties. Three generic PROMs were deemed of adequate quality for use in acute care. We recommend future development and evaluation of PROMs focussing on acute care to further evaluate and improve the quality of acute care.

The utility of peripheral venous lactate in emergency department patients with normal and higher lactate levels: A prospective observational study.

OBJECTIVE: to assess the utility of peripheral venous lactate (PVL) in Emergency Department patients. METHODS: arteriovenous agreement was assessed in three subgroups: PVL <2 mmol/l, PVL ≥ 2 mmol/l to < 4 mmol/l and PVL ≥ 4 mmol/l. The predictive value of PVL to predict arterial lactate (AL) ≥2 mmol/l was assessed at different cut-off values. RESULTS: 74 samples were analysed. The venous-arterial mean difference and 95% limits of agreement for the subgroups were 0.25 mmol/l (-0.18 to 0.68), 0.37 mmol/l (-0.57 to 1.32) and -0.89 mmol/l (-3.75 to 1.97). PVL ≥2 mmol/l predicts AL ≥2 mmol/l with 100% sensitivity. CONCLUSION: PVL <2 mmol/l rules out arterial hyperlactatemia. As agreement declines in higher levels, arterial sampling should be considered.

Screening instruments for identification of vulnerable older adults at the emergency department: a critical appraisal.

BACKGROUND: Early detection of vulnerable older adults at the emergency department (ED) and implementation of targeted interventions to prevent functional decline may lead to better patient outcomes. OBJECTIVE: To assess the level of agreement between four frequently used screening instruments: ISAR-HP, VMS, InterRAI ED Screener and APOP. METHODS: Observational prospective cohort study in patients ≥ 70 years attending Dutch ED. RESULTS: The prevalence of vulnerability ranged from 19% (APOP) to 45% (ISAR-HP). Overall there was a moderate agreement between the screening instruments (Fleiss Kappa of 0.42 (p<0.001)). CONCLUSION: Depending on the screening instrument used, either only a small percentage or almost as many as half of the presenting patients will be eligible for targeted interventions, leading to large dissimilarities in working processes, resources and costs.

Are we able to predict who needs a bed the most?

In recent years we indeed have witnessed an increasing demand on healthcare services coupled with spiraling healthcare costs forcing us towards identifying factors and interventions leading to greater healthcare efficiency.

Results on patient flow of implementing an Acute Medical Unit.

BACKGROUND: There is an increased influx of patients needing admission. Introducing an acute medical unit (AMU) may increase the admission capacity without increasing the total number of beds. METHODS: Data collected during the first four years after implementation of an AMU in an academic tertiary care center in Amsterdam were analyzed. RESULTS: A 24 bed unit was realized. The total number of admissions increased in the first year with 977 (16%), with an additional 4.1% increase after 2 years with stabilization thereafter. The length of stay decreased, the absolute number of refusals declined, the number of readmissions remained unchanged. CONCLUSION: Introduction of AMUs in overcrowded services could be beneficial in improving the strain on the acute healthcare systems.

Exploring the value of routinely measured hematology parameters for identification of elderly patients at high risk of death at the Emergency Department.

Of the warning scores in use for recognition of high-risk patients at the Emergency Department (ED), few incorporate laboratory results. Although hematological characteristics have shown prognostic value in small studies, large studies in elderly ED populations are lacking. We studied the association between blood cell and platelet counts and characteristics as well as C-reactive protein (CRP) at ED presentation with mortality in non-multitrauma patients ≥ 65 years. Comparison between survivors and non-survivors showed small, significant differences with AUROCs ranging between 56.6% and 65.2% for 30-day mortality. Combining parameters yielded an evident improvement (AUROC of 70.4%). Efforts should be pursued to study the added value of hematological parameters on top of clinical data when assessing patient risk.

Research Protocol: Intravenous Access during Resuscitation: the IVAR trial.

OBJECTIVE: To compare the effects of central versus peripheral drug administration on the rate of return of organised electrical activity and/or spontaneous circulation during CPR. STUDY DESIGN: Randomized clinical trial. STUDY POPULATION: Hospitalized patients and patients presenting at the emergency department, older than 18 years, requiring CPR. INTERVENTION: Central venous access Main study parameters/endpoints: Combined primary endpoint: rate of appearance of organised electrical activity or return of spontaneous circulation. Nature and extent of the burden and risks associated with participation, benefit and group relatedness: All patients are treated according to the guidelines of the European Resuscitation Council, which are endorsed by the local VUMC CPR-committee. Central access will be obtained by cannulation of the external or internal jugular vein. To avoid interference with initial management, central venous access will be obtained after initiation of chest compressions, first attempt at defibrillation (if applicable), securing the airway and obtaining a peripheral access. All resuscitated patients require vascular access and almost all successfully resuscitated patients require central venous access. Obtaining central access during CPR may be associated with a slightly higher complication rate, such as arterial puncture and pneumothorax. Possible benefits for study subjects are a higher success rate of CPR.

Measurement of generic patient reported outcome measures (PROMs) in an acute admission unit: A feasibility study.

OBJECTIVE: Measuring patient-reported outcome measures (PROMs) is a challenge in Acute Admission Units (AAUs), where patients present with a variety of pathologies. Generic PROMs may be used to measure the quality of care in this population. The main objective of this study was to assess the feasibility of measuring generic PROMs in a Dutch AAU. DESIGN: Longitudinal cohort study Setting: An AAU of a tertiary hospital in Amsterdam, the Netherlands Participants: 123 patients admitted to the AAU during 5 weeks in May and June 2015 METHODS: Patients admitted to the AAU were asked to fill out a questionnaire relating to three time points: 7 days before, during, and within 2 weeks after admission. Additionally, patients were asked to report on their experienced level of safety on the AAU and the contribution of the AAU to their recovery. RESULTS: There were significant trends in generic PROMs for all three domains. Physical functioning decreased during hospital admission and almost fully returned to the previous level after discharge. Satisfaction with social role and anxiety significantly decreased over time. CONCLUSIONS: Measuring generic PROMs in the AAU is feasible. The analysis of the PROMs took little effort and results could be reported back to the healthcare workers on the AAU quickly. Patients appreciated being asked about their own perceived health and the quality of care. Given that this is the first study focusing on PROMs in AAU patients in the Netherlands, future studies with larger sample sizes, and from other nations are needed to further investigate PROMs in this patient group to establish International reference values.

Anomaly of the inferior vena cava causing recurrent deep vein thrombosis in a young male.

Anomaly of the inferior vena cava (IVC) as a cause of (recurrent) deep vein thrombosis (DVT) is uncommon. We report on a 33-year-old patient suffering from this unusual cause of DVT without the presence of known predisposing factors (immobilization, trauma, surgery, or underlying thrombophilia). Thus, in young patients with recurrent DVT, anomaly of the IVC should be regarded as an independent risk factor.

The skin is the clue.

A 67-year-old woman presented with aseptic osteomyelitis and palmoplantar pustular psoriasis. The diagnosis of SAPHO syndrome was made. Treatment with pamidronate led to symptomatic improvement.