The COVID-19 impact on STEMI disparities.

ST-segment elevation myocardial infarction (STEMI) is a significant source of morbidity and mortality. Despite guideline-driven management and increased awareness of social determinants of health, there are persistent disparities in diagnosis, management, and outcomes. The coronavirus disease 2019 (COVID-19) pandemic has greatly affected emergency department visitation, conditions and throughput. The aim of this study was to find any potential health disparities in patients who presented with STEMI during the COVID-19 pandemic by reviewing STEMI care data from April to September 2019 (pre-pandemic) and April to September 2020 (during the pandemic) for our hospital system. Patients with STEMI within 12 h of presentation were included in this study, and subdivided by age, gender, and race/ethnicity. We compared the turnaround times between emergency department arrival to intervention (electrocardiogram or catheterization) within the patient subgroups to find any notable differences. No statistically significant changes in turnaround times during either study period were found based on age, gender, or race/ethnicity for the STEMI interventions despite shifts in emergency department resources during the pandemic. This study helped assess the status quo in STEMI intervention for our health system and serves as a baseline for us to monitor gaps in care or areas of improvement. As healthcare systems institute new measures to promote equitable care, such as improving the accuracy of demographic data capture, establishing a baseline is an essential first step in evaluating the impact of these measures.

Refining the definition of the avian pathogenic Escherichia coli (APEC) pathotype through inclusion of high-risk clonal groups.

Colibacillosis in poultry is a unique disease manifestation of Escherichia coli in the animal world, as one of the primary routes of entry is via the respiratory tract of birds. Because of this, a novel extraintestinal pathogenic E. coli (ExPEC) subpathotype coined avian pathogenic E. coli (or APEC) has been described. Like other ExPEC, this pathotype has been challenging to clearly define, and in the case of APEC, its role as an opportunistic pathogen has further complicated these challenges. Using 3,479 temporally matched genomes of poultry-source isolates, we show that the APEC plasmid, previously considered a defining trait of APEC, is highly prevalent in clinical isolates from diseased turkeys. However, the plasmid is also quite prevalent among cecal E. coli isolates from healthy birds, including both turkeys and broilers. In contrast, we identify distinct differences in clonal backgrounds of turkey clinical versus cecal strains, with a subset of sequence types (STs) dominating the clinical landscape (ST23, ST117, ST131, ST355, and ST428), which are rare within the cecal landscape. Because the same clinical STs have also dominated the broiler landscape, we performed lethality assays using strains from dominant STs from clinical or cecal landscapes in embryonated turkey and chicken eggs. We show that, irrespective of plasmid carriage, dominant clinical STs are significantly more virulent than dominant cecal STs. We present a revised APEC screening tool that incorporates APEC plasmid carriage plus markers for dominant clinical STs. This revised APEC pathotyping tool improves the ability to identify high-risk APEC clones within poultry production systems, and identifies STs of interest for mitigation targets.

Emergency department bounceback characteristics for patients diagnosed with COVID-19.

BACKGROUND: The global healthcare burden of COVID-19 continues to rise. There is currently limited information regarding the disease progression and the need for hospitalizations in patients who present to the Emergency Department (ED) with minimal or no symptoms. OBJECTIVES: This study identifies bounceback rates and timeframes for patients who return to the ED due to COVID-19 after initial discharge on the date of testing. METHODS: Using the NorthShore University Health System's (NSUHS) Enterprise Data Warehouse (EDW), we conducted a retrospective cohort analysis of patients who were tested positive for COVID-19 and were discharged home on the date of testing. A one-month follow-up period was included to ensure the capture of disease progression. RESULTS: Of 1883 positive cases with initially mild symptoms, 14.6% returned to the ED for complaints related to COVID-19. 56.9% of the mildly symptomatic bounceback patients were discharged on the return visit while 39.5% were admitted to the floor and 3.6% to the ICU. Of the 1120 positive cases with no initial symptoms, only four returned to the ED (0.26%) and only one patient was admitted. Median initial testing occurred on day 3 (2-5.6) of illness, and median ED bounceback occurred on day 9 (6.3-12.7). Our statistical model was unable to identify risk factors for ED bouncebacks. CONCLUSION: COVID-19 patients diagnosed with mild symptoms on initial presentation have a 14.6% rate of bounceback due to progression of illness.

Decreased Time to Antibiotic Prophylaxis for Open Fractures at a Level One Trauma Center.

OBJECTIVE: To determine whether time to administration of antibiotics decreased after the implementation of an open fracture working group and antibiotic prophylaxis protocol. DESIGN: Retrospective cohort study. SETTING: One Level 1 Trauma Center. PATIENTS: Patients 18 years of age and older who sustained an open fracture and presented directly to our emergency department. INTERVENTION: Prompt irrigation and debridement in the operating room and fracture stabilization dictated by the treating surgeon. Fifty patients were reviewed as the preintervention group, comprising the period before conception and before intervention. Fifty patients were included after the initiation of our protocol during the same time period 1 year later. MAIN OUTCOME MEASUREMENTS: Time from entrance to the emergency department to ordering of antibiotics, time from ordering to administration of antibiotics, and time from entrance to the emergency department to administration of antibiotics. RESULTS: After protocol implementation, time from admission to antibiotic administration decreased significantly from 123.1 to 35.7 minutes (P = 0.0003). Each component decreased significantly: admission to order decreased from 94.1 to 26.1 minutes, and order to administration decreased from 29.0 to 9.5 minutes (P = 0.0046 and P = 0.0003). CONCLUSION: Our study demonstrates a significantly reduced time to antibiotic prophylaxis for patients with open fractures after the implementation of a multidisciplinary working group. We hope that this provides a model for institutions to improve care and outcomes of these injuries. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Diagnostic accuracy of a rapid checklist to identify delirium in older patients transported by EMS.

BACKGROUND: The presence of delirium in elderly patients is common and has been identified as an independent marker for increased mortality and hospital-acquired complications, yet it is poorly recognized by health care providers. Early recognition of delirium in the prehospital setting has the potential to improve outcomes, but is not feasible without valid assessment tools. OBJECTIVE: To determine whether use of a rapid delirium checklist by prehospital providers is a valid way to identify cases of delirium compared with a criterion standard and whether the checklist is better at identifying delirium than the Glasgow Coma Score (GCS). METHODS: We conducted a prospective study at two academic, tertiary-care emergency departments (EDs) where a convenience sample of matched dyads of emergency medical services providers and elderly patients (age ≥65 years) were enrolled. Prehospital providers reported limited demographics and work history about themselves. They also reported vital signs and GCS for each patient and completed the checklist asking about presence of the four features of delirium. The patient then underwent a cognitive assessment using the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) by a trained investigator, which was used as the criterion standard. Criterion validity and concurrent validity of the delirium checklist and abnormal GCS were evaluated using sensitivity and specificity. RESULTS: Two hundred fifty-nine matched dyads were studied. Delirium occurred in 24 (9%) of the elderly patients sampled. Prehospital providers' recognition of any delirium symptom resulted in a sensitivity of 0.63 (95% confidence interval [CI] 0.43-0.79) and a specificity of 0.74 (95% CI 0.73-0.84). Prehospital report of a GCS <15 has a sensitivity of 0.67 (95% CI 0.47-0.82) and a specificity of 0.85 (95% CI 0.80-0.89). CONCLUSIONS: A rapid delirium checklist can identify 63% of patients with delirium, but performed no better than the GCS. Future research should determine whether a rapid test of cognition improves early identification of elderly patients with delirium.