Mapa de la situación actual de la atención a la sepsis en los servicios de urgencias españoles / Current situation of sepsis care in Spanish emergency departments

Objetivo. Describir el abordaje que se realiza a los pacientescon sospecha de sepsis en los servicios de urgencias hospitalarios (SUH) españoles y analizar si existen diferencias atendiendoal tamaño del hospital y la afluencia a urgencias en el territorio.Método. Encuesta estructurada a los responsables de los282 SUH públicos que atienden adultos 24 horas/día, 365 días/año. Se preguntó sobre asistencia y manejo en urgencias en laatención a pacientes con sospecha de sepsis. Los resultados secomparan según tamaño del hospital (grande ≥ 500 camas vsmedio-pequeño < 500) y afluencia en urgencias (alta ≥ 200visitas/día vs media-baja < 200).Resultados. Respondieron 250 SUH españoles (89%). En163 (65%) SUH se dispone de protocolos de sepsis. La medianade sepsis semanales atendidas variaban desde 0-5 por semana en 39 (71%) SUH, 6-10 por semana en 10 (18%), 11-15por semana en 4 (7%), y más de 15 activaciones por semanaen 3 centros (3,6%). Los criterios utilizados para la activacióndel código sepsis (CS) fueron el qSOFA/SOFA en 105 (63,6%) delos hospitales, SIRS en 6 (3,6%), mientras que en 49 (29,7%)utilizaban ambos criterios de forma simultanea. En 79 centrosel CS estaba informatizado y en 56 existían herramientas deayuda a la toma de decisiones. Un 48% (79 de 163) de los SUHdisponían de datos de cumplimiento de medidas. En el 61%(99 de 163) de SUH existía formación en sepsis y en el 56% (55de 99) ésta era periódica. Atendiendo al tamaño del hospital,los hospitales grandes participaban más frecuentemente comoreceptores de enfermos con CS y disponían de servicio/unidadde infecciosas, de sepsis y de corta estancia, microbiólogo einfectólogo de guardia.Conclusión. la mayoría de los SUH disponen de protocolos de CS, pero existe margen de mejora. La informatización ydesarrollo de alertas para el diagnóstico y tratamiento tienenaún un gran recorrido en los SUH. (AU)

Objective. To describe the approach to the patients withsuspected sepsis in the Spanish emergency department hospitals (ED) and analyze whether there are differences according to the size of the hospital and the number of visits to theemergency room.Method. Structured survey of those responsible for the282 public EDs that serve adults 24 hours a day, 365 days ayear. It was asked about assistance and management in theemergency room in the care of patients with suspected sepsis.The results are compared according to hospital size (large ≥500 beds vs medium-small <500) and influx to the emergencyroom (discharge ≥ 200 visits / day vs medium-low <200).Results. A total of 250 Spanish EDs responded (89%).Sepsis protocols are available in 163 (65%) EDs median weekly sepsis treated ranged from 0-5 per week in 39 (71%) ED,6-10 per week in 10 (18%), 11-15 per week in 4 (7%), andmore than 15 activations per week in 3 centers (3.6%). Thecriteria used for sepsis diagnosis were the qSOFA/SOFA in 105(63.6%) of the hospitals, SIRS in 6 (3.6%), while in 49 (29.7%)they used both criteria simultaneously. In 79 centers, the sepsis diagnosis was computerized, and in 56 there were tools tohelp decision-making. 48% (79 of 163) of the EDs had dataon bundles compliance. In 61% (99 of 163) of EDs there wastraining in sepsis and in 56% (55 of 99) it was periodic. Considering the size of the hospital, large hospitals participated more frequently as recipients of patients with sepsis and hadan infectious, sepsis and short-stay unit, a microbiologist andinfectious disease specialist on duty.Conclusion. Most EDs have sepsis protocols, but there isroom for improvement. The computerization and developmentof alerts for diagnosis and treatment still have a long way togo in EDs (AU)

Incidence, Clinical Characteristics, Risk Factors, and Outcomes of Upper Gastrointestinal Bleeding in Patients With COVID-19: Results of the UMC-19-S12.

OBJECTIVE: The authors investigated the incidence, risk factors, clinical characteristics, and outcomes of upper gastrointestinal bleeding (UGB) in patients with coronavirus disease 2019 (COVID-19), who were attending the emergency department (ED), before hospitalization. METHODS: We retrospectively reviewed all COVID-19 patients diagnosed with UGB in 62 Spanish EDs (20% of Spanish EDs, case group) during the first 2 months of the COVID-19 outbreak. We formed 2 control groups: COVID-19 patients without UGB (control group A) and non-COVID-19 patients with UGB (control group B). Fifty-three independent variables and 4 outcomes were compared between cases and controls. RESULTS: We identified 83 UGB in 74,814 patients with COVID-19 who were attending EDs (1.11%, 95% CI=0.88-1.38). This incidence was lower compared with non-COVID-19 patients [2474/1,388,879, 1.78%, 95% confidence interval (CI)=1.71-1.85; odds ratio (OR)=0.62; 95% CI=0.50-0.77]. Clinical characteristics associated with a higher risk of COVID-19 patients presenting with UGB were abdominal pain, vomiting, hematemesis, dyspnea, expectoration, melena, fever, cough, chest pain, and dysgeusia. Compared with non-COVID-19 patients with UGB, COVID-19 patients with UGB more frequently had fever, cough, expectoration, dyspnea, abdominal pain, diarrhea, interstitial lung infiltrates, and ground-glass lung opacities. They underwent fewer endoscopies in the ED (although diagnoses did not differ between cases and control group B) and less endoscopic treatment. After adjustment for age and sex, cases showed a higher in-hospital all-cause mortality than control group B (OR=2.05, 95% CI=1.09-3.86) but not control group A (OR=1.14, 95% CI=0.59-2.19) patients. CONCLUSIONS: The incidence of UGB in COVID-19 patients attending EDs was lower compared with non-COVID-19 patients. Digestive symptoms predominated over respiratory symptoms, and COVID-19 patients with UGB underwent fewer gastroscopies and endoscopic treatments than the general population with UGB. In-hospital mortality in COVID-19 patients with UGB was increased compared with non-COVID patients with UGB, but not compared with the remaining COVID-19 patients.

Socio-Demographic Health Determinants Are Associated with Poor Prognosis in Spanish Patients Hospitalized with COVID-19.

INTRODUCTION: Social vulnerability is a known determinant of health in respiratory diseases. Our aim was to identify whether there are socio-demographic factors among COVID-19 patients hospitalized in Spain and their potential impact on health outcomes during the hospitalization. METHODS: A multicentric retrospective case series study based on administrative databases that included all COVID-19 cases admitted in 19 Spanish hospitals from 1 March to 15 April 2020. Socio-demographic data were collected. Outcomes were critical care admission and in-hospital mortality. RESULTS: We included 10,110 COVID-19 patients admitted to 18 Spanish hospitals (median age 68 (IQR 54-80) years old; 44.5% female; 14.8% were not born in Spain). Among these, 779 (7.7%) cases were admitted to critical care units and 1678 (16.6%) patients died during the hospitalization. Age, male gender, being immigrant, and low hospital saturation were independently associated with being admitted to an intensive care unit. Age, male gender, being immigrant, percentile of average per capita income, and hospital experience were independently associated with in-hospital mortality. CONCLUSIONS: Social determinants such as residence in low-income areas and being born in Latin American countries were associated with increased odds of being admitted to an intensive care unit and of in-hospital mortality. There was considerable variation in outcomes between different Spanish centers.

A case-control emergency department-based analysis of acute pancreatitis in Covid-19: Results of the UMC-19-S6.

BACKGROUND/PURPOSE: We investigated the incidence, risk factors, clinical characteristics and outcomes of acute pancreatitis (AP) in patients with COVID-19 attending the emergency department (ED), before hospitalization. METHODS: We retrospectively reviewed all COVID patients diagnosed with AP in 62 Spanish EDs (20% of Spanish EDs, COVID-AP) during the COVID outbreak. We formed two control groups: COVID patients without AP (COVID-non-AP) and non-COVID patients with AP (non-COVID-AP). Unadjusted comparisons between cases and controls were performed regarding 59 baseline and clinical characteristics and four outcomes. RESULTS: We identified 54 AP in 74 814 patients with COVID-19 attending the ED (frequency = 0.72‰, 95% CI = 0.54-0.94‰). This frequency was lower than in non-COVID patients (2231/1 388 879, 1.61‰, 95% CI = 1.54-1.67; OR = 0.44, 95% CI = 0.34-0.58). Etiology of AP was similar in both groups, being biliary origin in about 50%. Twenty-six clinical characteristics of COVID patients were associated with a higher risk of developing AP: abdominal pain (OR = 59.4, 95% CI = 23.7-149), raised blood amylase (OR = 31.8; 95% CI = 1.60-632) and vomiting (OR = 15.8, 95% CI = 6.69-37.2) being the strongest, and some inflammatory markers (C-reactive protein, procalcitonin, platelets, D-dimer) were more increased. Compared to non-COVID-AP, COVID-AP patients differed in 23 variables; the strongest ones related to COVID symptoms, but less abdominal pain was reported, pancreatic enzymes raise was lower, and severity (estimated by BISAP and SOFA score at ED arrival) was higher. The in-hospital mortality (adjusted for age and sex) of COVID-AP did not differ from COVID-non-AP (OR = 1.12, 95% CI = 0.45-245) but was higher than non-COVID-AP (OR = 2.46, 95% CI = 1.35-4.48). CONCLUSIONS: Acute pancreatitis as presenting form of COVID-19 in the ED is unusual (<1‰ cases). Some clinically distinctive characteristics are present compared to the remaining COVID patients and can help to identify this unusual manifestation. In-hospital mortality of COVID-AP does not differ from COVID-non-AP but is higher than non-COVID-AP, and the higher severity of AP in COVID patients could partially contribute to this increment.

GYM score: 30-day mortality predictive model in elderly patients attended in the emergency department with infection.

OBJECTIVE: To determine the validity of the classic sepsis criteria or systemic inflammatory response syndrome (heart rate, respiratory rate, temperature, and leukocyte count) and the modified sepsis criteria (systemic inflammatory response syndrome criteria plus glycemia and altered mental status), and the validity of each of these variables individually to predict 30-day mortality, as well as develop a predictive model of 30-day mortality in elderly patients attended for infection in emergency departments (ED). METHODS: A prospective cohort study including patients at least 75 years old attended in three Spanish university ED for infection during 2013 was carried out. Demographic variables and data on comorbidities, functional status, hemodynamic sepsis diagnosis variables, site of infection, and 30-day mortality were collected. RESULTS: A total of 293 patients were finally included, mean age 84.0 (SD 5.5) years, and 158 (53.9%) were men. Overall, 185 patients (64%) fulfilled the classic sepsis criteria and 224 patients (76.5%) fulfilled the modified sepsis criteria. The all-cause 30-day mortality was 13.0%. The area under the curve of the classic sepsis criteria was 0.585 [95% confidence interval (CI) 0.488-0.681; P=0.106], 0.594 for modified sepsis criteria (95% CI: 0.502-0.685; P=0.075), and 0.751 (95% CI: 0.660-0.841; P<0.001) for the GYM score (Glasgow <15; tachYpnea>20 bpm; Morbidity-Charlson index ≥3) to predict 30-day mortality, with statistically significant differences (P=0.004 and P<0.001, respectively). The GYM score showed good calibration after bootstrap correction, with an area under the curve of 0.710 (95% CI: 0.605-0.815). CONCLUSION: The GYM score showed better capacity than the classic and the modified sepsis criteria to predict 30-day mortality in elderly patients attended for infection in the ED.