Impact of a qSOFA-based triage procedure on antibiotic timing in ED patients with sepsis: A prospective interventional study.

BACKGROUND: It has not been investigated whether the quick sepsis-related organ failure assessment score (qSOFA), a new bedside tool for early sepsis detection, may help accelerating antibiotic initiation in ED patients with sepsis. METHODS: In this prospective pre/post quasi-experimental single-ED study, patients admitted with a suspected bacterial infection were managed using standard triage procedures only (baseline) or in association with qSOFA (intervention, with prioritization of patients with a qSOFA ≥ 2). RESULTS: A total of 151/328 (46.0%) and 185/350 (52.8%) patients with definite bacterial infection met the criteria for sepsis in the baseline and intervention periods, respectively. The sensitivity and specificity of a qSOFA ≥ 2 for sepsis prediction were 17.3% (95% confidence interval [CI], 13.6%-21.7%) and 98.8% (95% CI, 97.0%-99.5%). Eleven (7.3%) and 28 (13.5%) patients with sepsis in the baseline and intervention periods received a first antibiotic dose within one hour following triage (primary endpoint, absolute difference 6.2%, 95% CI [-0.5%, 12.7%], P = 0.08). The proportions of patients with sepsis receiving a first antibiotic dose within three hours following triage (39.7% [50/151] versus 36.8% [68/185], absolute difference - 2.9%, 95% CI [-13.3%, 7.3%], P = 0.65), requiring ICU admission, or dying in the hospital were similar in both periods. The median ED occupation rate at triage was 104.3% (interquartile range [IQR], 80.4%-128.3%), with a median number of 157 ED visits per day (IQR, 147-169). CONCLUSIONS: A qSOFA-based triage procedure does not improve antibiotic timing and outcomes in patients with sepsis admitted to a high-volume ED. The qSOFA value at triage was poorly sensitive for early sepsis detection. Trial registration (ClinicalTrials.gov): NCT03299894.

Association between long boarding time in the emergency department and hospital mortality: a single-center propensity score-based analysis.

Once diagnostic work-up and first therapy are completed in patients visiting the emergency department (ED), boarding them within the ED until an in-hospital bed became available is a common practice in busy hospitals. Whether this practice may harm the patients remains a debate. We sought to determine whether an ED boarding time longer than 4 h places the patients at increased risk of in-hospital death. This retrospective, propensity score-matched analysis and propensity score-based inverse probability weighting analysis was conducted in an adult ED in a single, academic, 1136-bed hospital in France. All patients hospitalized via the adult ED from January 1, 2013 to March 31, 2018 were included. Hospital mortality (primary outcome) and hospital length of stay (LOS) were assessed in (1) a matched cohort (1:1 matching of ED visits with or without ED boarding time longer than 4 h but similar propensity score to experience an ED boarding time longer than 4 h); and (2) the whole study cohort. Sensitivity analysis to unmeasured confounding and analyses in pre-specified cohorts of patients were conducted. Among 68,632 included ED visits, 17,271 (25.2%) had an ED boarding time longer than 4 h. Conditional logistic regression performed on a 10,581 pair-matched cohort, and generalized estimating equations with adjustment on confounders and stabilized propensity score-based inverse probability weighting applied on the whole cohort showed a significantly increased risk of hospital death in patients experiencing an ED boarding time longer than 4 h: odds ratio (OR) of 1.13 (95% confidence interval [95% CI] 1.05-1.22), P = 0.001; and OR of 1.12 (95% CI 1.03-1.22), P = 0.007, respectively. Sensitivity analyses showed that these findings might be robust to unmeasured confounding. Hospital LOS was significantly longer in patients exposed to ED boarding time longer than 4 h: median difference 2 days (95% CI 1-2) (P < 0.001) in matched analysis and mean difference 1.15 days (95% CI 1.02-1.28) (P < 0.001) in multivariable unmatched analysis. In this single-center propensity score-based cohort analysis, patients experiencing an ED boarding time longer than 4 h before being transferred to an in-patient bed were at increased risk of hospital death.

Simultaneous identification of elastic properties, thickness, and diameter of arteries excited with ultrasound radiation force.

The elastic and geometric properties of arteries have been long recognized as important predictors of cardiovascular disease. This work presents a robust technique for the noninvasive characterization of anisotropic elastic properties as well as thickness and diameter in arterial vessels. In our approach, guided waves are excited along arteries using the radiation force of ultrasound. Group velocity is used as the quantity of interest to reconstruct elastic and geometric features of the vessels. One of the main contributions of this work is a systematic approach based on sparse-grid collocation interpolation to construct surrogate models of arteries. These surrogate models are in turn used with direct-search optimization techniques to produce fast and accurate estimates of elastic properties, diameter, and thickness. One of the attractive features of the proposed approach is that once a surrogate model is built, it can be used for near real-time identification across many different types of arteries. We demonstrate the feasibility of the method using simulated and in vitro laboratory experiments on a silicon rubber tube and a porcine carotid artery. Our results show that using our proposed method, we can reliably identify the longitudinal modulus, thickness, and diameter of arteries. The circumferential modulus was found to have little influence in the group velocity, which renders the former quantity unidentifiable using the current experimental setting. Future work will consider the measurement of circumferential waves with the objective of improving the identifiability of the circumferential modulus.

Stochastic and deterministic motion of a laminar-turbulent front in a spanwisely extended Couette flow.

We investigate numerically the dynamics of a laminar-turbulent interface in a spanwisely extended and streamwisely minimal plane Couette flow. The chosen geometry allows one to suppress the large-scale secondary flow and to focus on the nucleation of streaks near the interface. It is shown that the resulting spanwise motion of the interface is essentially stochastic and can be modeled as a continuous-time random walk. This model corresponds here to a Gaussian diffusion process. The average speed of the interface and the corresponding diffusion coefficient are determined as functions of the Reynolds number Re, as well as the threshold value above which turbulence contaminates the whole domain. For the lowest values of Re, the stochastic dynamics competes with another deterministic regime of growth of the localized perturbations. The latter is interpreted as a depinning process from the homoclinic snaking region of the system.