Recent studies have suggested different organisational strategies, modifying Emergency Departments (EDs) during the COVID-19 epidemic. However, real data on the practical application of these ...strategies are not yet available. The objective of this study is to evaluate the inclusion of pre-triage during the COVID-19 outbreak. In March 2020, the structure of the ED at Merano General Hospital (Italy) was modified, with the introduction of a pre-triage protocol to divide patients according to the risk of infection. The performance of pre-triage was evaluated for sensitivity, specificity and negative predictive value (NPV). From 4th to 31st March, 2,279 patients were successively evaluated at the pre-triage stage. Of these, 257 were discharged directly from pre-triage by triage out or home quarantine and none has subsequently been hospitalised. Of the 2022 patients admitted to ED, 182 were allocated to an infected area and 1840 to a clean area. The proportion of patients who tested COVID-19 positive was 5% and, of these, 91.1% were allocated to the infected area. The pre-triage protocol demonstrated sensitivity of 91.1%, specificity of 95.3% and NPV of 99.5%. In addition, none of the healthcare workers was infected during the study period. Pre-triage can be a useful tool that, if standardised and associated with a change in the structure of the ED, can limit the spread of infection within the ED, optimise ED resources and protect healthcare workers.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
BACKGROUND AND PURPOSE—Symptomatic intracerebral hemorrhage (sICH) is a rare but the most feared complication of intravenous thrombolysis for ischemic stroke. We aimed to develop and validate a ...nomogram for individualized prediction of sICH in intravenous thrombolysis–treated stroke patients included in the multicenter SITS-ISTR (Safe Implementation of Thrombolysis in Stroke-International Stroke Thrombolysis Register).
METHODS—All patients registered in the SITS-ISTR by 179 Italian centers between May 2001 and March 2016 were originally included. The main outcome measure was sICH per the European Cooperative Acute Stroke Study II definition (any type of intracerebral hemorrhage with increase of ≥4 National Institutes of Health Stroke Scale score points from baseline or death <7 days). On the basis of multivariate logistic model, the nomogram was generated. We assessed the discriminative performance by using the area under the receiver-operating characteristic curve and calibration of risk prediction model by using the Hosmer–Lemeshow test.
RESULTS—A total of 15 949 patients with complete data for generating the nomogram was randomly dichotomized into training (3/4; n=12 030) and test (1/4; n=3919) sets. After multivariate logistic regression, 10 variables remained independent predictors of sICH to compose the STARTING-SICH (systolic blood pressure, age, onset-to-treatment time for thrombolysis, National Institutes of Health Stroke Scale score, glucose, aspirin alone, aspirin plus clopidogrel, anticoagulant with INR ≤1.7, current infarction sign, hyperdense artery sign) nomogram. The area under the receiver-operating characteristic curve of STARTING-SICH was 0.739. Calibration was good (P=0.327 for the Hosmer–Lemeshow test).
CONCLUSIONS—The STARTING-SICH is the first nomogram developed and validated in a large SITS-ISTR cohort for individualized prediction of sICH in intravenous thrombolysis–treated stroke patients.
•The severity of SARS-CoV-2 patients is difficult to quickly assess in the ED.•The ABG test is a quick and easy tool that can help identify more severe patients.•CT cannot be used on all suspected ...SARS-CoV-2 infected patients admitted in ED.•The CT volumetry correlates well with the values of severity reported by the ABG test.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
The Sequential Organ Failure Assessment (SOFA) score is currently the primary prognostic tool used in patients with infections to predict sepsis and mortality, although its predictive role remains ...debated. Serum albumin values have been recently found to correlate with the severity of sepsis. The purpose of this study is to evaluate the clinical usefulness of albumin dosage on SOFA score prediction in infected patients.
This prospective single-centre observational study was performed in 2021. We used the net reclassification improvement (NRI) technique to evaluate the additional prognostic value of serum albumin used together with the SOFA score in infected patients. The discriminatory abilities of the SOFA score alone, of albumin levels alone, and of the albumin levels together with (but not incorporated into) the SOFA score was evaluated by comparing the area under the curve of the corresponding receiver operating characteristic (ROC) curves.
We included 949 patients with an infectious status; 8.9% (84/949) died within 30 days of ED admission. The AUROC for the SOFA score was 0.802 (95% CI: 0.756-0.849) and the albumin level was 0.813 (95% CI: 0.775-0.852). The NRI found that serum albumin improved SOFA score predictions of 30-day mortality by 24.3% (
< 0.001), yielding an AUROC of 0.881 (95% CI: 0.848-0.912;
< 0.001).
Using serum albumin values together with the SOFA score can improve prognostic prediction in patients with infections evaluated in the ED.
For patients with sepsis in the Emergency Department (ED), early risk stratification is important to improve prognosis. The study aimed to evaluate the predictive role of estimated plasma volume ...(ePVS) on admission to the ED. All sepsis patients who were admitted to our ED in 2021, were included in this prospective study. Multivariate models adjusted for patients' clinical characteristics were used to assess the contribution of ePVS to the independent prediction of death at 30 days. A total of 455 septic patients were enrolled and 16.9% of patients died. Patients who survived to 30 days had a mean ePVS of 5.19, while those who died at 30 days had a value of 5.74 (p=0.004). ePVS was an independent risk factor for 30-day mortality with an adjusted OR of 1.211 (95% CI 1.004–1.460, p=0.045). The AUROC of ePVS was 0.619 (95% CI 0.545–0.689). Decision tree analysis showed a predictive role for ePVS in less severe patients. In septic patients, ePVS is an independent predictor of 30-day mortality and may improve risk prediction in less severe patients.
Triage systems, calibrated to discriminate acute conditions, seem unable to deal with minor non-urgent conditions. The aim of the present study to verify whether some level 4 priority codes can be ...safely declassified to level 5 priority codes. A prospective observational study was performed between 1° October 2022 to 31° March 2023. All patients with a code 5 according to the Manchester Triage System (MTS) were compared with patients with a priority level 4 code but with a general indicator that was downgraded to a code 5 after the triage nurse's assessment. Of the 2032 patients enrolled, 58.6% were part of the 'blue from MTS' group while 41.4% were part of the 'blue after re-evaluation' group. There was no statistical difference in the rate of hospitalisation and discharge between the two groups (p=0.928). There was also no difference between the two groups in the comparisons of short- and medium-term death. This study highlights the need to rethink strategies to declassify patients through MTS, especially given the continuous increase of non-urgent patients presenting in the ED.
Abstract
Background
Nomograms are easy-to-handle clinical tools which can help in estimating the risk of adverse outcome in certain population. This multi-center study aims to create and validate a ...simple and usable clinical prediction nomogram for individual risk of post-traumatic Intracranial Hemorrhage (ICH) after Mild Traumatic Brain Injury (MTBI) in patients treated with Direct Oral Anticoagulants (DOACs).
Methods
From January 1, 2016 to December 31, 2019, all patients on DOACs evaluated for an MTBI in five Italian Emergency Departments were enrolled. A training set to develop the nomogram and a test set for validation were identified. The predictive ability of the nomogram was assessed using AUROC, calibration plot, and decision curve analysis.
Results
Of the 1425 patients in DOACs in the study cohort, 934 (65.5%) were included in the training set and 491 (34.5%) in the test set. Overall, the rate of post-traumatic ICH was 6.9% (7.0% training and 6.9% test set). In a multivariate analysis, major trauma dynamic (OR: 2.73, p = 0.016), post-traumatic loss of consciousness (OR: 3.78, p = 0.001), post-traumatic amnesia (OR: 4.15, p < 0.001), GCS < 15 (OR: 3.00, p < 0.001), visible trauma above the clavicles (OR: 3. 44, p < 0.001), a post-traumatic headache (OR: 2.71, p = 0.032), a previous history of neurosurgery (OR: 7.40, p < 0.001), and post-traumatic vomiting (OR: 3.94, p = 0.008) were independent risk factors for ICH. The nomogram demonstrated a good ability to predict the risk of ICH (AUROC: 0.803; CI95% 0.721–0.884), and its clinical application showed a net clinical benefit always superior to performing CT on all patients.
Conclusion
The Hemorrhage Estimate Risk in Oral anticoagulation for Mild head trauma (HERO-M) nomogram was able to predict post-traumatic ICH and can be easily applied in the Emergency Department (ED).
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
Background and purpose
The nomogram is an important component of modern medical decision-making, which calculates the probability of an event entirely based on individual characteristics. We aimed to ...develop and validate a nomogram for individualized prediction of the probability of unfavorable outcome in intravenous thrombolysis-treated stroke patients included in the large multicenter Safe Implementation of Thrombolysis in Stroke-International Stroke Thrombolysis Register.
Methods
All patients registered in the Safe Implementation of Thrombolysis in Stroke-International Stroke Thrombolysis Register by 179 Italian centers between May 2001 and March 2016 were originally included. The main outcome measure was three-month unfavorable outcome (modified Rankin Scale 3–6). Four non-categorical predictors of unfavorable outcome (baseline National Institutes of Health (NIH) Stroke Scale score: 0–25, age ≥18 years, pre-stroke modified Rankin Scale score: 0–2, and onset-to-treatment time: 0–270 min) were identified a-priori by three neurologists with expertise in the management of stroke. To generate the NIHSS STroke Scale score, Age, pre-stroke mRS score, onset-to-treatment Time (START), the pre-established predictors were entered into a logistic regression model. The discriminative performance of the model was assessed using the area under the receiver operating characteristic curve.
Results
A total of 15,862 patients with complete data for generating the START was randomly dichotomized into training (2/3, n = 10,574) and test (1/3, n = 5288) sets. The area under the receiver operating characteristic curve of START was 0.800 (95% confidence interval: 0.792–0.809) in the training set and 0.815 (95% confidence interval: 0.804–0.822) in the test set.
Conclusions
By using a limited number of non-categorical predictors, the START is the first nomogram developed and validated in a large Safe Implementation of Thrombolysis in Stroke-International Stroke Thrombolysis Register cohort, which reliably calculates the probability of unfavorable outcome in intravenous thrombolysis-treated stroke patients.
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NUK, OILJ, SAZU, UKNU, UL, UM, UPUK
The effects of Oral Anticoagulation Therapy (OAT) in older patients who suffered a mild Traumatic Brain Injury (mTBI) are widely debated but still strong guidelines are lacking and clinical ...approaches and management are sometimes heterogeneous. Different predictors of adverse outcomes were identified in the literature but their use in the decision-making process is unclear. Moreover, there is no consensus on the appropriate length of stay in the Observation Unit nor on the continuation of OAT, even if the diagnosis of life-threatening delayed post-traumatic Intracranial Hemorrhage is rare. The recurrence of a control CT scan is often needless. This review aims to summarize recent scientific literature focusing on patients with mTBI taking OAT and to identify crucial questions on the topic to suggest a best clinical practice.
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