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Heart Failure (HF) is a primary diagnosis for hospital admission from the Emergency Department (ED), although not all patients require hospitalization. The Emergency Heart Failure Mortality Risk Grade (EHMRG) estimates 7-day mortality in patients with acute HF in ED settings, but further validation is needed in the United States (US).To validate EHMRG scores by risk-stratifying patients with acute HF in a large tertiary healthcare center in the US and analyze outcome measures to determine if EHMRG risk scores safely identify low-risk groups that may be discharged or managed in ED observation units (EDOUs).A retrospective cohort analysis of 304 patients with acute HF presenting to an ED at a large, tertiary healthcare center was completed. EHMRG scores were calculated to stratify patients according to published thresholds. Mortality and major adverse cardiac event (MACE) rates were analyzed.No deaths occurred in very low and low-risk EHMRG groups at 7 days post discharge. 30-day mortality was significantly less in the lower risk groups (3.1%) when compared to all other patients (11.1%). MACE rates at 30 days in the very low risk group (15%) were significantly less when compared to all other patients (31.3%). Hospitalizations occurred in 23.4% of patients in lower risk groups.ED risk stratification with EHMRG differentiates high-risk patients requiring hospitalization from lower risk patients who can be safely managed in alternative settings with good outcomes. Data supports improved pathways for patients with acute HF during a time of high hospital volumes.

Objective To identify the diagnoses and outcomes associated with elevated high sensitivity cardiac troponin T (hs-cTnT) compared with the 4th-generation troponin T and to validate the Mayo Clinic hs-cTnT myocardial infarction algorithm cutoff values. Patients and Methods Consecutive blood samples of patients presenting to the emergency department between July 2017 and August 2017, who had 4th-generation troponin T, were also analyzed using the hs-cTnT assay. Troponin T values, discharge diagnoses, comorbidities, and outcomes were assessed. In addition, analyses of sex-specific and hs-cTnT cutoff values were assessed. Results Of 830 patients, 32% had an elevated 4th-generation troponin T, whereas 64% had elevated hs-cTnT. With serial sampling, 4th-generation troponin missed a chronic myocardial injury pattern and acute myocardial injury pattern in 64% and 16% of patients identified with hs-cTnT, respectively. Many of these “missed” patients had discharge diagnoses associated with cardiovascular disease, infection, or were postoperative. Five of the 6 patients with unstable angina ruled in for myocardial infarction. Conclusion There were many increases in hs-cTnT that were missed by the 4th-generation cTnT assay. Most new increases are not related to acute cardiac causes. They were more consistent with chronic myocardial injury. High-sensitivity cTnT did reclassify most patients with unstable angina as having non–ST-elevation myocardial infarction. Older age, more comorbidities, and lower hemoglobin were associated with elevated hs-cTnT. Our data also support the use of our sex-specific cutoff values.

Violence in the emergency department (ED) remains underreported. Patient factors are often cited as a source of confusion in determining the culpability of perpetrators and whether to proceed with incident reporting. This study’s objective was to determine how ED staff at one academic medical center perceive certain clinical scenarios and how this compares to local law enforcement officers (LEO). An anonymous survey with 4 scenarios was sent to multidisciplinary ED staff at our academic medical center, as well as local LEO and inquired whether respondents considered any of the scenarios to be reportable as a crime. Chi-square analysis was used for comparison. The study was deemed exempt by the Institutional Review Board. A total of 261 ED staff and 77 LEO completed the survey. Both groups were equally likely to believe that a reportable crime occurred in Scenario 1, where a patient with dementia punches a nurse (LEO: 26.0% vs. ED: 31.4%, p = 0.44), and in Scenario 2, where an intoxicated patient spits at a phlebotomist (LEO: 97.4% vs. ED: 95.0%, p = 0.56). However, the two groups differed in Scenario 3, in which a patient with delirium makes verbal threats to a doctor (LEO: 20.8% vs. ED: 42.9%, p < 0.001), and Scenario 4, in which a patient’s parent throws a chair at a medical student (LEO: 66.2% vs. ED: 81.2%, p = 0.009). As health systems seek to improve workplace safety, it is important to consider the barriers to reporting violent incidents, including staff’s understanding of what acts may constitute reportable violence, as well as LEO understanding of the unique ED environment and patient responsibilities.

People with diabetes have been profoundly impacted by the COVID-pandemic. Diabetes and its comorbidities are strong risk factors for severe, including fatal, COVID-disease. People with diabetes may also have limited or delayed routine and non-emergent medical services, potentially increasing their risk of death from causes unrelated to COVID-19. Granular population-level data on rates, causes, and places (i.e. home vs. hospital) of death among people with diabetes during the COVID-pandemic is scarce. We examined Minnesota death certificates from 2020 (COVID-year) and 2018-20 (comparator years) among people with diabetes to compare changes in population-adjusted rates of diabetes-specific mortality (diabetes as a primary cause of death) , and all-cause and other disease-specific mortality (other primary causes with diabetes as a contributing cause of death) . We also assessed COVID-mortality (COVID-as a primary cause and diabetes as a contributing cause) . Analyses were adjusted for multiple comparisons using the false discovery rate correction. COVID-accounted for 246 deaths per 100,000 people with diabetes. There was no significant change in diabetes-specific mortality from 2018-20to 2020 (328 to 353 per 100,000; 2020 vs. 2018-20IRR 1.[95% CI 1.01-1.15]; p=0.08) . All-cause mortality among people with diabetes increased from 1,484 to 1,922 per 100,000 (IRR 1.30 [95% CI 1.26-1.33]; p Disclosure R.G.Mccoy: Consultant; Emmi. A.F.Mullan: None. M.M.Jeffery: Stock/Shareholder; Goodness Growth Holdings. C.M.Bucks: None. C.M.Clements: Consultant; Vail Scientific LLC. R.Campbell: Consultant; Bryn Pharma. Funding National Institute of Diabetes and Digestive and Kidney Diseases (K23DK114497)

Introduction: Opioid prescribing occurs within almost every healthcare setting. Implementation of safe, effective opioid stewardship programs represents a critical but daunting challenge for medical leaders. This study sought to understand the barriers and aids to the routine use of clinical guidelines for opioid prescribing among healthcare professionals and to identify areas in need of additional education for prescribing providers, pharmacists, and nurses. Methods: Data collection and analysis in 2018-2019 employed a team of two trained facilitators who conducted 20 focus groups using a structured facilitation guide to explore operational, interpersonal, and patient care-related barriers to best practice adherence. Each professional group was interviewed separately, with similar care settings assigned together. Invitation to participate was based on a sampling methodology representing emergency, medical specialty, primary care, and surgical practice settings. Results: Key concerns among all groups reflected the inadequacy of available tools for staff to appropriately assess and treat patients’ pain. Tools and technology to support safe opioid prescribing were also cited as a barrier by all three professional groups. All groups noted that prescribers tend to rely upon default settings within the electronic medical record when issuing prescriptions. Both pharmacists and prescribers cited time and scheduling as a barrier to adherence. Conclusions: In spite of significant regulatory and public policy efforts to address the opioid crisis, healthcare organizations face significant challenges to improve adherence to best practice prescribing guidelines. These findings highlight several facilitators for change which could boost opioid stewardship initiatives to focus on critical systems’ factors for improvement.

Background Urinary tract infection (UTI) is the second most common infection requiring intensive care unit (ICU) admission in emergency department (ED) patients. Optimal empiric management for health care-associated (HCA) UTI is unclear, particularly in the critically ill. Objective To compare clinical failure of broad vs. narrow antibiotic selection in the ED for patients presenting with HCA UTI admitted to the ICU. Methods Observational cohort of patients started on empiric antibiotic for UTI with at least one HCA risk factor (recurrent UTI, chronic urinary catheter or dialysis, urologic procedures, previous antibiotic exposure, hospitalization, or group facility residence). Broad antibiotics covered Pseudomonas spp. and extended-spectrum beta-lactamase. Clinical failure was a composite of multiorgan dysfunction (MODS) by day 2 and in-hospital mortality. Secondary outcomes were length of stay (LOS), readmission, recurrent infection, development of multidrug-resistant organisms, and Clostridium difficile infection. Associations were reported with odds ratios (OR) and 95% confidence intervals (CI). Results There were 272 patients included; 196 (72.1%) received broad and 76 (27.9%) received narrow therapy. There was no association between antibiotic selection and clinical failure (OR 1.05, 95% CI 0.5–2.25, p = 0.89) or between antibiotic selection and number of HCA risk factors (OR 0.98, 95% CI 0.73–1.31, p = 0.87). There was an association between clinical failure and MODS on ICU admission (OR 9.14, 95% CI 4.70–17.78, p Conclusion Initial empiric broad or narrow antibiotic coverage in HCA UTI patients who presented to the ED and required ICU admission had similar clinical outcomes.

Infection by severe acute respiratory syndrome coronavirus 2 has led to cardiac complications including an increasing incidence of cardiac arrest. The resuscitation of these patients requires a conscious effort to minimize the spread of the virus. We present a best-practice model based in four guiding principles: (1) reduce the risk of exposure to the entire health care team; (2) decrease the number of aerosol generating procedures; (3) use a small resuscitation team to limit potential exposure; and (4) consider early termination of resuscitative efforts.

The opioid crisis is a major concern of most health care institutions, including our large academic center. In this article, an organized approach to managing the epidemic institutionally is discussed. An Opioid Stewardship Program was instituted at our tertiary-care center with multiple sites and states of practice, which included diverse membership and expertise. Charges of the program included reviewing current practice, workflows, and external and internal guidelines and evaluating and standardizing prescribing practices. The development of an Opioid Stewardship Program resulted in: (1) an understanding of our diverse prescribing practices and the formation of patient- and procedure-specific guidelines to manage them, (2) education tools for our patients and providers, and (3) workflows and practice advisories within the electronic health record to support appropriate prescribing and monitoring of patients. This ongoing work continues to evolve in response to the needs of our patients, changing regulatory environments, and our improved understanding of our practices.

Author(s): McGuire, Sarayna S.; Mullan, Aidan F.; Clements, Casey M. | Abstract: Introduction: Workplace violence in the emergency department (ED) is a serious threat to staff and is likely to go unreported. We sought to identify the incidence of violence among staff at our academic ED over a six-month period.Methods: An anonymous survey was sent to all ED staff, asking whether respondents had experienced verbal abuse or physical assault over the prior six months and whether they had reported it. Those working in the department l6 months were excluded from analysis. We used chi-squared comparison to analyze the results.n Results: We analyzed 242 responses. Overall, 208 (86%) respondents indicated being verbally abused in the preceding six months, and 90 (37%) indicated being physically assaulted. Security officers had the highest incidence of verbal abuse (98%), followed by nursing (95%), patient care assistants (PCA) (90%) and clinicians (90%), phlebotomists (75%), care team assistants (73%), registration staff (50%) and electrocardiogram (ECG)/radiology technicians (50%). Security also had the highest incidence of physical assault (73%), followed by nursing (49%), PCAs (30%), clinicians (24%), phlebotomists (17%), and ECG/radiology technicians (13%). A total of 140 (69%) non-security personnel indicated that they never report incidents of violence.Conclusion: Our results indicate that violence in the ED affects more than just nurses and doctors. As health systems seek to improve the safety of their employees in violence-prone areas, it is imperative that they direct initiatives to the entire healthcare team as no one group is immune.

Background Despite broad awareness of the opioid epidemic and the understanding that patients require much fewer opioids than traditionally prescribed, improvement efforts to decrease prescribing have only produced modest advances in recent years. Methods and findings By using a collaborative model for shared expertise and accountability, nine diverse health care systems completed quality improvement projects together over the course of one year to reduce opioid prescriptions for acute pain. The collaborative approach was flexible to each individual system’s goals, and seven of the nine participant institutions definitively achieved their desired results. Conclusions This report demonstrates the utility of a collaborative model of improvement to bring about real change in opioid prescribing practices and may inform quality improvement efforts at other institutions.

Objective To report the Mayo Clinic experience with coronavirus disease 2019 (COVID-19) related to patient outcomes. Methods We conducted a retrospective chart review of patients with COVID-19 diagnosed between March 1, 2020, and July 31, 2020, at any of the Mayo Clinic sites. We abstracted pertinent comorbid conditions such as age, sex, body mass index, Charlson Comorbidity Index variables, and treatments received. Factors associated with hospitalization and mortality were assessed in univariate and multivariate models. Results A total of 7891 patients with confirmed COVID-19 infection with research authorization on file received care across the Mayo Clinic sites during the study period. Of these, 7217 patients were adults 18 years or older who were analyzed further. A total of 897 (11.4%) patients required hospitalization, and 354 (4.9%) received care in the intensive care unit (ICU). All hospitalized patients were reviewed by a COVID-19 Treatment Review Panel, and 77.5% (695 of 897) of inpatients received a COVID-19–directed therapy. Overall mortality was 1.2% (94 of 7891), with 7.1% (64 of 897) mortality in hospitalized patients and 11.3% (40 of 354) in patients requiring ICU care. Conclusion Mayo Clinic outcomes of patients with COVID-19 infection in the ICU, hospital, and community compare favorably with those reported nationally. This likely reflects the impact of interprofessional multidisciplinary team evaluation, effective leveraging of clinical trials and available treatments, deployment of remote monitoring tools, and maintenance of adequate operating capacity to not require surge adjustments. These best practices can help guide other health care systems with the continuing response to the COVID-19 pandemic.

The use of chloride-rich crystalloids for resuscitation is associated with acute kidney injury (AKI). We aimed to explore the impact of resuscitation with chloride-rich crystalloids compared to balanced crystalloids on kidney function recovery in patients presenting with sepsis-associated community-acquired AKI (SACA-AKI). This is a single-center, historical cohort study of the adult intensive care unit (ICU) patients who presented to the emergency department (ED) with sepsis-associated community-acquired-AKI at the Mayo Clinic, Rochester, MN, from January 2011 to April 2018. We divided the cohort into two groups based on the primary type of crystalloids they received in the ED and the first 48-h of ICU. The first group received primarily normal saline with

Background The Institute of Medicine, the National Patient Safety Foundation, and The Joint Commission have advocated for increased systematic care review to inform future quality improvement. Developing a system to efficiently gather meaningful feedback, review care, and identify areas for improvement can take years to construct. Yet, these systems are vital to reducing future medical error. Context, History, and Development In this article, the authors present a refined intradepartmental system of retrospective care review. The team created and iteratively improved this model for more than 10 years. Herein, key aspects and benefits of the system are described. Care Review System A successful care review system should include a broad catchment for cases to review, direct input from multidisciplinary staff involved in each case, a standardized evaluation and feedback process, a system to translate identified gaps into practice improvement, and development of a psychologically safe space for discussions to occur. Resources required to build this system include a quality specialist, a panel of physician and nurse reviewers, and administrative assistance. Blinding cases and electronic blinded polling technology can enhance participation and reduce bias in case assessment. Conclusion The authors believe that this process for care review can help hospital systems of varying resource levels produce high-quality case review and thereby activate practice improvement to prevent downstream medical errors.

STUDY OBJECTIVES: COVID-19 brought unique challenges; however, it remains unclear what effect the pandemic had on violence in healthcare. The objective of this study was to identify the impact of the pandemic on workplace violence at an academic emergency department (ED). METHODS: This mixed-methods study involved a prospective descriptive survey study and electronic medical record review. Within our hospital referral region (HRR), the first COVID-19 case was documented on 3/11/2020 and cases peaked in mid-November 2020. We compared the monthly HRR COVID-19 case rate per 100,000 people to the rate of violent incidents per 1000 ED visits. Multidisciplinary ED staff were surveyed both pre/early-pandemic (April 2020) and mid/late-pandemic (December 2020) regarding workplace violence experienced over the prior 6-months. The study was deemed exempt by the Mayo Clinic Institutional Review Board. RESULTS: There was a positive association between the monthly HRR COVID-19 case rate and rate of violent ED incidents (r = 0.24). Violent incidents increased overall during the pandemic (2.53 incidents per 1000 visits) compared to the 3 months prior (1.13 incidents per 1000 visits, p

Study Objectives: Violence in the emergency department (ED) is a common and longstanding threat to staff. The COVID-19 pandemic brought unique challenges;however, it remains unclear what effect the pandemic had on violence in health care. The objective of this study was to identify the impact of the pandemic on workplace violence at an academic emergency department in the Midwest. Methods: The hospital referral region (HRR) COVID-19 case rate per 100,000 people was obtained from March through December 2020. Monthly incidents of ED violence were obtained from the Office of Security and included both physical assault and verbal threats where security officers were notified to respond. These incidents were combined with monthly reports of violent flags added to patient charts within the electronic medical record. Overlapping data from both sources were counted only once. Monthly ED patient volume was obtained to calculate a rate of violent incidents per 1,000 ED visits. Two anonymous surveys were sent to all multidisciplinary ED staff both pre/early-pandemic (April 2020) and mid/late-pandemic (December 2020) and surveyed respondents regarding the incidence of verbal abuse and physical assault experienced over the prior 6-months (November 2019-April 2020 and July 2020-December 2020). Chi-squared tests and Fisher’s exact tests were used for comparison. The study was deemed exempt by the Mayo Clinic Institutional Review Board. Results: There was a positive association between the HRR rate and rate of violent ED incidents (r = 0.24;Figure 1). There was also an increase in overall violent workplace incidents per ED volume during the pandemic compared to the months leading up to it. A total of 259 responses were received for the initial pre/early-pandemic survey and 259 responses received for the mid/late-pandemic survey. The reported level of safety perceived by staff remained the same, as did the overall percentage of respondents indicating any verbal abuse or physical assault in the prior 6-months. The frequency of verbal abuse experienced by staff did increase during the pandemic, with 6.2% of respondents pre/early-pandemic indicating verbal abuse by patients or their visitors every day or two, compared to 10.8% mid/late-pandemic (p =.029). Conclusion: Despite our findings of a positive association between the COVID-19 case rate and rate of violent ED incidents, the percentage of our survey respondents indicating verbal abuse or physical assault experienced in a 6-month time period remained unchanged between the pre/early-pandemic and mid/late-pandemic periods, as did staff perception of workplace safety. This difference in documented and self-reported/perceived violence may be attributable to staff prioritizing other personal safety concerns throughout the pandemic. This positive association could be due to significant fear and stress experienced by the general public, or worsening substance abuse or mental health state during the pandemic. [Formula presented]

To identify the diagnoses and outcomes associated with elevated high sensitivity cardiac troponin T (hs-cTnT) compared with the 4th-generation troponin T and to validate the Mayo Clinic hs-cTnT myocardial infarction algorithm cutoff values.Consecutive blood samples of patients presenting to the emergency department between July 2017 and August 2017, who had 4th-generation troponin T, were also analyzed using the hs-cTnT assay. Troponin T values, discharge diagnoses, comorbidities, and outcomes were assessed. In addition, analyses of sex-specific and hs-cTnT cutoff values were assessed.Of 830 patients, 32% had an elevated 4th-generation troponin T, whereas 64% had elevated hs-cTnT. With serial sampling, 4th-generation troponin missed a chronic myocardial injury pattern and acute myocardial injury pattern in 64% and 16% of patients identified with hs-cTnT, respectively. Many of these "missed" patients had discharge diagnoses associated with cardiovascular disease, infection, or were postoperative. Five of the 6 patients with unstable angina ruled in for myocardial infarction.There were many increases in hs-cTnT that were missed by the 4th-generation cTnT assay. Most new increases are not related to acute cardiac causes. They were more consistent with chronic myocardial injury. High-sensitivity cTnT did reclassify most patients with unstable angina as having non-ST-elevation myocardial infarction. Older age, more comorbidities, and lower hemoglobin were associated with elevated hs-cTnT. Our data also support the use of our sex-specific cutoff values.

Highlights • Contact tracing is an essential step in infectious disease control and prevention. • Using Electronic medical record (EMR) is challenging and misses a number of potential exposures. • Real time location system (RTLS) doubled the potential exposures list for pertussis disease beyond the conventional method of EMR-based contact identification • RTLS is more efficient and timely in the process of contact tracing. • Further studies with larger sample size are needed to confirm the findings., Background Contact tracing is the systematic method of identifying individuals potentially exposed to infectious diseases. Electronic medical record (EMR) use for contact tracing is time-consuming and may miss exposed individuals. Real-time location systems (RTLSs) may improve contact identification. Therefore, the relative effectiveness of these 2 contact tracing methodologies were evaluated. Methods During a pertussis outbreak in the United States, a retrospective case study was conducted between June 14 and August 31, 2016, to identify the contacts of confirmed pertussis cases, using EMR and RTLS data in the emergency department of a tertiary care medical center. Descriptive statistics and a paired t test (α = 0.05) were performed to compare contacts identified by EMR versus RTLS, as was correlation between pertussis patient length of stay and the number of potential contacts. Results Nine cases of pertussis presented to the emergency department during the identified time period. RTLS doubled the potential exposure list (P

Background Several high-sensitivity cardiac troponin (cTn) assays have been cleared by the United States (US) Food and Drug Administration (FDA) for clinical use. Although some of them have been used outside the US for some time, there is limited experience thus far across US sites. Following FDA clearance of the Roche 5th Gen cTnT assay in January 2017, a multicenter US regional healthcare system introduced this more sensitive cTnT assay into clinical practice in September 2018. Purpose To examine cTn testing patterns, incidence of acute myocardial infarction (MI), and resource utilization before and after implementation of the 5th Gen cTnT assay across a large US healthcare system. Methods Using electronic-health records reporting software (Cogito SlicerDicer, EPIC), administrative data was examined to evaluate the transition (4-months before and after implementation) from the 4th to 5th Gen cTnT assays across 16 hospitals but not the major hub hospital of the system that transitioned at a separate time. Adult patient visits (emergency and hospital encounters), cTnT testing, incidence of chest discomfort and acute MI, and resource utilization, including hospital admissions, were examined during the transition period. Results 98,558 adult ED patient visits occurred during an 8-month period across 16 hospitals, including 50,485 and 48,073 patient visits before (5/12/18 – 9/11/18) and after (9/12/18 – 1/11/19) implementation of the 5th Gen cTnT assay respectively. cTnT testing occurred in 20% (range 8.9–34.8%) of all ED visits, with testing performed in the absence of chest pain in 54% (range 37–67%) of cases. Acute MI was diagnosed in 5.6% (n=561) of cases using the 4th Gen cTnT assay as compared to 6.6% (n=608) of cases using the 5th Gen cTnT assay (absolute difference 1.0%, 95% CI: 0.32–1.68, p=0.004). Much of the increase in MI diagnoses were in women (2.2% vs. 2.8%, p=0.008). The proportion of ED patients requiring hospital admission did not differ between pre- and post-implementation periods (24.1% vs. 23.6%, p=0.4); however, among the subset of patients with chest pain, fewer admissions occurred post-implementation (17.9% vs. 15.8%, p=0.006). There was no increase in echocardiography (9.3% vs. 8.4%), coronary angiography (2.9% vs. 3.1%), or cardiac consultations (7.3% vs. 7.3%) utilization post-implementation. Conclusions Cardiac troponin testing occurs in nearly 20% of ED visits in a large multicenter regional healthcare system. About half of all tests are ordered in the absence of chest pain, with a low MI rate observed among the patients undergoing testing. Following implementation of the 5th Gen cTnT assay, testing rates/patterns remained unchanged, with a small but significant increase in MI diagnoses, primarily due to more women being diagnosed with MI. Fewer ED patients with chest pain required admission. Despite using a more sensitive cTn assay, hospital admissions and resource utilization did not increase post-implementation.

Objective Chief complaint (CC) is among the earliest health information recorded at the beginning of a patient's visit to an emergency department (ED). We propose a heuristic methodology for automatically mapping the free-text data into a structured list of CCs. Methods A comprehensive structured list categorizing CCs was developed by experienced Emergency Medicine (EM) physicians. Using this list, we developed a natural language processing-based algorithm, referred to as Chief Complaint Mapper (CCMapper), for automatically mapping a CC into the most appropriate category (ies). We trained and validated CCMapper using free-text CC data from the Mayo Clinic ED in Rochester, MN. We developed a consensus-based validation approach to handle both indifferences and disagreements between the two EM physicians who manually mapped a random sample of free-text CCs into categories within the structured list. Results The kappa statistic demonstrated a high level of agreement (κ = 0.958) between the two physicians with less than 2% human error. CCMapper achieved a total sensitivity of 94.2% with a specificity of 99.8% and F-score of 94.7% on the validation set. The sensitivity of CCMapper when mapping free-text data with multiple CCs was 82.3% with a specificity of 99.1% and total F-score of 82.3%. Conclusion Due to its simplicity, high performance, and capability of incorporating new free-text CC data, CCMapper can be readily adopted by other EDs to support clinical decision making. CCMapper can facilitate the development of predictive models for the type and timing of important events in ED (e.g., ICU admission).

Lactate, white blood cell (WBC) and neutrophil count, procalcitonin and immature granulocyte (IG) count were compared for the prediction of sepsis, and severe sepsis or septic shock, in patients presenting to the emergency department (ED).We prospectively enrolled 501 ED patients with a sepsis panel ordered for suspicion of sepsis. WBC, neutrophil, and IG counts were measured on a Sysmex XT-2000i analyzer. Lactate was measured by i-STAT, and procalcitonin by Brahms Kryptor. We classified patients as having sepsis using a simplification of the 1992 consensus conference sepsis definitions. Patients with sepsis were further classified as having severe sepsis or septic shock using established criteria. Univariate receiver operating characteristic (ROC) analysis was performed to determine odds ratio (OR), area under the ROC curve (AUC), and sensitivity/specificity at optimal cut-off for prediction of sepsis (vs. no sepsis), and prediction of severe sepsis or septic shock (vs. no sepsis).There were 267 patients without sepsis; and 234 with sepsis, including 35 patients with severe sepsis or septic shock. Lactate had the highest OR (1.44, 95th% CI 1.20-1.73) for the prediction of sepsis; while WBC, neutrophil count and percent (neutrophil/WBC) had OR1.00 (p0.05). All biomarkers had AUC0.70 and sensitivity and specificity70% at the optimal cut-off. Initial lactate was the best biomarker for predicting severe sepsis or septic shock, with an odds ratio (95th% CI) of 2.70 (2.02-3.61) and AUC 0.89 (0.82-0.96).Traditional biomarkers (lactate, WBC, neutrophil count, procalcitonin, IG) have limited utility in the prediction of sepsis.

Background Unexpected situations of workplace violence are occurring in the United States at increasing rates in health care environments, warranting increased attention to processes supporting safety for health care workers. At a large, academic hospital, two patient safety incidents had occurred in a two-year period in which a patient had become violent at the time of admission from the emergency department (ED) to the medical unit. Methods A multidisciplinary quality improvement (QI) team was formed to address the risk of violent patient events. Using two iterative Plan–Do–Study–Act (PDSA) cycles, the QI team designed and tested a huddle handoff communication tool, the Potentially Aggressive/Violent Huddle Form. An ED nurse would initiate the huddle process by informing the admitting unit that a patient at risk for violence was being admitted. The admitting care team would then call the ED team so that both teams participated in the handoff call together. The huddle process occurred for 21 transfers in the first PDSA cycle and for 18 transfers in the second. Results RNs from the ED and the six medical units reported feeling safe during the transfer process 100% of the time during both tests of change PDSAs (vs. 54.7% at baseline). In the ED, from the first test of change to the second test of change, satisfaction with the process improved from 53.3% to 75.0%. Conclusion The huddle handoff communication tool and other methods to facilitate the transfer of potentially violent patients have the potential to decrease the number and severity of violent incidents in the health care workplace.

Objectives Opioid treatment of chronic noncancer pain (CNCP) adds complexity and uncertainty to patient interactions. We sought to assess clinician attitudes, beliefs, practice styles, and concerns around opioid prescribing following the release of the US Centers for Disease Control and Prevention (CDC) guideline for prescribing opioids for chronic pain. Methods E-mailed electronic survey to clinicians at a large academic medical institution. Results A total of 961 clinicians responded to the survey (response rate = 40%), 720 of whom prescribed opioids and were not in training. Sixty-five percent were physicians, and 35% were nurse practitioners or physician assistants, with a mean age of 47 years (SD ± 11.4 years). Eighty-two percent were reluctant to prescribe opioids for CNCP, and only 47% expressed confidence in their care for CNCP patients. Sixty-seven percent were aware of the CDC guideline, 55% were enrolled in the state Prescription Drug Monitoring Program (PDMP), and 2% always or frequently prescribed naloxone to patients on opioids. Guideline awareness was associated with increased confidence in caring for CNCP patients. Clinicians having knowledge of a patient overdose were 31% more likely to be enrolled in the PDMP (relative rate= 1.31, 95% confidence interval = 1.14-1.52, chi-square = 11.00, P

Background Clinical care review is the process of retrospectively examining potential errors or gaps in medical care, aiming for future practice improvement. The objective of our systematic review is to identify the current state of care review reported in peer-reviewed publications and to identify domains that contribute to successful systems of care review. Methods A librarian designed and conducted a comprehensive literature search of eight electronic databases. We evaluated publications from January 1, 2000, through May 31, 2016, and identified common domains for care review. Sixteen domains were identified for further abstraction. Results We found that there were few publications that described a comprehensive care review system and more focus on individual pathways within the overall systems. There is inconsistent inclusion of the identified domains of care review. Conclusion While guidelines for some aspects of care review exist and have gained traction, there is no comprehensive standardized process for care review with widespread implementation. Electronic supplementary material The online version of this article (10.1186/s12245-018-0166-y) contains supplementary material, which is available to authorized users.

Cardiac arrest is the leading cause of death in Europe and the United States. Many patients who are initially resuscitated die in the hospital, and hospital survivors often have substantial neurologic dysfunction. Most cardiac arrests are caused by coronary artery disease; patients with coronary artery disease likely benefit from early coronary angiography and intervention. After resuscitation, cardiac arrest patients remain critically ill and frequently suffer cardiogenic shock and multiorgan failure. Early cardiopulmonary stabilization is important to prevent worsening organ injury. To achieve best patient outcomes, comprehensive critical care management is needed, with primary goals of stabilizing hemodynamics and preventing progressive brain injury. Targeted temperature management is frequently recommended for comatose survivors of cardiac arrest to mitigate the neurologic injury that drives outcomes. Accurate neurologic assessment is central to managing care of cardiac arrest survivors and should combine physical examination with objective neurologic testing, with the caveat that delaying neurologic prognosis is essential to avoid premature withdrawal of supportive care. A combination of clinical findings and diagnostic results should be used to estimate the likelihood of functional recovery. This review focuses on recent advances in care and specific cardiac intensive care strategies that may improve morbidity and mortality for patients after cardiac arrest.

DJ-1/PARK7, a cancer- and Parkinson's disease (PD)-associated protein, protects cells from toxic stresses. However, the functional basis of this protection has remained elusive. We found that loss of DJ-1 leads to deficits in NQO1 [NAD(P)H quinone oxidoreductase 1], a detoxification enzyme. This deficit is attributed to a loss of Nrf2 (nuclear factor erythroid 2-related factor), a master regulator of antioxidant transcriptional responses. DJ-1 stabilizes Nrf2 by preventing association with its inhibitor protein, Keap1, and Nrf2's subsequent ubiquitination. Without intact DJ-1, Nrf2 protein is unstable, and transcriptional responses are thereby decreased both basally and after induction. This effect of DJ-1 on Nrf2 is present in both transformed lines and primary cells across human and mouse species. DJ-1's effect on Nrf2 and subsequent effects on antioxidant responses may explain how DJ-1 affects the etiology of both cancer and PD, which are seemingly disparate disorders. Furthermore, this DJ-1/Nrf2 functional axis presents a therapeutic target in cancer treatment and justifies DJ-1 as a tumor biomarker.

Biomarker discovery research has not focused on the emergency department (ED) due to perceived lack of access to ED patients for study, difficult patient identification, and preemption by time-critical clinical needs. The aim of this study was to use an automated process to accrue, within the ED, a biobank of patients presenting at risk for severe sepsis.

Heightened DJ-1 (Park7) expression is associated with a reduction in chemotherapeutic-induced cell death and poor prognosis in several cancers, whereas the loss of DJ-1 function is found in a subgroup of Parkinson disease associated with neuronal death. This study describes a novel pathway by which DJ-1 modulates cell survival. Mass spectrometry shows that DJ-1 interacts with BBS1, CLCF1, MTREF, and Cezanne/OTUD7B/Za20d1. Among these, Cezanne is a known deubiquitination enzyme that inhibits NF-κB activity. DJ-1/Cezanne interaction is confirmed by co-immunoprecipitation of overexpressed and endogenous proteins, maps to the amino-terminal 70 residues of DJ-1, and leads to the inhibition of the deubiquitinating activity of Cezanne. Microarray profiling of shRNA-transduced cells shows that DJ-1 and Cezanne regulate IL-8 and ICAM-1 expression in opposing directions. Similarly, DJ-1 enhances NF-κB nuclear translocation and cell survival, whereas Cezanne reduces these outcomes. Analysis of mouse Park7(-/-) primary cells confirms the regulation of ICAM-1 by DJ-1 and Cezanne. As NF-κB is important in cellular survival and transformation, IL-8 functions as an angiogenic factor and pro-survival signal, and ICAM-1 has been implicated in tumor progression, invasion, and metastasis; these data provide an additional modality by which DJ-1 controls cell survival and possibly tumor progression via interaction with Cezanne.

Fever predicts an infection cause of SIRS/sepsis more specifically than other commonly used hemodynamic criteria. Traditionally, a body temperature of 38.0°C has been used to define fever, but this cutoff is based on limited research. Furthermore, it has been proposed that fever responses are blunted in older adults, limiting the utility of fever in infection. This study determines the likelihood that a body temperature will predict diagnosis of infection in the emergency department (ED).

Macrophage inflammatory protein 1 alpha (MIP-1 alpha), a CC chemokine, is a chemoattractant for T cells and immature dendritic cells. Plasmacytoma cells expressing MIP-1 alpha generate a cytotoxic T cell response without affecting tumor growth. To understand this discrepancy, we compared a local tumor model with a metastatic one using MIP-1 alpha-transfected B16 F10 melanoma cells. Clonal idiosyncrasies were controlled by selecting three lipotransfected tumor clones and two pcDNA vector transfected control clones with equivalent in vitro proliferative capacities. No significant differences were seen between the MIP-1 alpha-producing and control melanoma cells after s.c. injection in the hind leg. All animals had a leg diameter of 10 cm in 18.5-21.5 days. However, after i.v. injection the number of pulmonary foci was significantly reduced in the MIP-1 alpha-producing clones. Injection of 10(6) control transfected cells resulted in a median of 98.5 tumor foci in 2 wk, whereas the injection of the MIP-1 alpha-producing clones resulted in 89.5, 26.5, and 0 foci. The number of metastatic foci was inversely proportional to the amount of MIP-1 alpha produced by the clone in vitro. Flow cytometry showed a significant increase in CD8(+) cells in lungs of mice with MIP-1 alpha-transfected tumors 3 days after injection. This increase was not maintained 10 days later despite continued production of MIP-1 alpha. The protection offered by transfection with MIP-1 alpha was significantly impaired in beta(2)-microglobulin(-/-) mice. Our findings suggest that MIP-1 alpha is effective in preventing the initiation of metastasis, but not at sustaining an effective antitumor response.