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To validate a previously described hospital emergency department risk model to predict mortality in patients with COVID-19.Prospective observational noninterventional study. Patients aged over 18 years diagnosed with COVID-19 were included between December 1, 2020, and February 28, 2021. We calculated a risk score for each patient based on age 50 years (2 points) plus 1 point each for the presence of the following predictors: Barthel index 90 points, altered level of consciousness, ratio of arterial oxygen saturation to fraction of inspired oxygen 400, abnormal breath sounds, platelet concentration 100 × 109/L, C reactive protein level 5 mg/dL, and glomerular filtration rate 45 mL/min. The dependent variable was 30-day mortality. We assessed the score's performance with the area under the receiver operating characteristic curve (AUC).The validation cohort included 1223 patients. After a median follow-up of 80 days, 143 patients had died; 901 patients were classified as having low risk (score, 4 points), 270 as intermediate risk (5-6 points), and 52 as high risk ( 7 points). Thirty-day mortality rates at each risk level were 2.8%, 22.5%, and 65.4%, respectively. The AUC for the score was 0.883; for risk categorization, the AUC was 0.818.The risk score described is useful for stratifying risk for mortality in patients with COVID-19 who come to a tertiary-care hospital emergency department.Validación de un indicador de mortalidad previamente descrito en pacientes con COVID-19 en un servicio de urgencias hospitalario (SUH).Estudio observacional prospectivo no intervencionista. Se incluyeron pacientes 18 años diagnosticados de COVID-19 (1 de diciembre de 2020 hasta 28 de febrero de 2021). Se calculó el indicador para cada paciente: edad 50 años (2 puntos), índice de Barthel 90 puntos (1 punto), alteración de consciencia (1 punto), índice de SaO2/ FIO2 400 (1 punto), auscultación respiratoria patológica (1 punto), plaquetas 100 x 109/L (1 punto), proteína C reactiva 5 mg/dL (1 punto) y filtrado glomerular 45 mL/min (1 punto). La variable dependiente fue la mortalidad observada a 30 días. El rendimiento del indicador se valoró con el análisis del área bajo la curva de la característica operativa del receptor (ABC-COR).La validación del indicador se realizó sobre una cohorte de 1.223 pacientes. Tras una mediana de seguimiento de 80 días, 143 pacientes habían fallecido. Un total de 901 pacientes fueron catalogados como riesgo bajo (indicador 4 puntos), 270 lo fueron como riesgo intermedio (5-6 puntos) y 52 como riesgo alto ( 7 puntos). La mortalidad a 30 días observada en cada categoría fue de 2,8%, 22,5% y 65,4%, respectivamente. El ABC-COR fue de 0,883 para el indicador utilizado cuantitativamente y de 0,818 cuando se usó cualitativamente en forma de categorías de riesgo.El indicador descrito es una herramienta útil para estratificar el riesgo de mortalidad de los pacientes con COVID-19 que consultan a un SUH de un centro de tercer nivel.

espanolObjetivo. Analizar la adecuacion de las prescripciones de antibioticos de categoria especial (ATB de CE) en el Servicio de Urgencias Hospitalario (SUH) de un centro urbano de tercer nivel. Material y metodos. Se selecciono una muestra aleatoria de 100 pacientes diferentes a los que se les inicio un ATB de CE en Urgencias durante el ano 2018. El equipo investigador reviso la historia clinica del episodio de urgencias y de ingreso. Se determino mediante regresion logistica los factores independientes asociados con el grado de adecuacion del tratamiento. Resultados. Se analizaron 97 prescripciones de las cuales 66 (68%) cumplian los criterios de prescripcion adecuada. El grado de adecuacion fue del 70% si la infeccion estaba relacionada con la asistencia sanitaria y del 75% si el paciente tenia factores de riesgo de infeccion por microorganismos multirresistentes (MMR). El porcentaje de adecuacion fue mayor en los casos en los que se especifico el foco de la infeccion (72%) y la gravedad del episodio (73%). Las variables independientes que se asociaron a una prescripcion adecuada fueron: la presencia de factores de riesgo de infeccion por MMR (OR: 2,35 IC 95%: 1,65 – 3,17 p: 0,01), el especificar el foco de la infeccion (OR: 3,79 IC 95%: 1,72 – 4,22 p: 0,02) y senalar la gravedad del episodio (OR: 3,09 IC 95%: 1,12 – 3,09 p: 0,03). Conclusiones. La prescripcion de los ATB de CE en el SUH es adecuada en la medida que se tenga en cuenta el ambito de adquisicion de la infeccion, los factores de riesgo de MMR, el foco de infeccion y la gravedad del cuadro clinico. EnglishObjective. The aim of the study was to analyze the adequacy of the special category antibiotics prescriptions in the Emergency Department (ED) of a third level urban Hospital. Material and methods. A random sample of 100 different patients who were started with a special category antibiotic along 2018 in the ED was selected. The research team reviewed the medical history of the emergency and admission episode. The independent factors associated with the degree of adequacy of the treatment were determined by logistic regression. Results. A total of 97 prescriptions were analyzed of which 66 (68%) met the criteria of adequate prescription, 23 (24%) adequate prescription, but with equally recommended alternatives and 8 (8%) were inappropriate prescriptions. The degree of adequacy was 70% if the infection was related to healthcare and 75% if the patient had risk factors for multiresistant (MR) microorganisms’ infection. The percentage of adequacy was higher in the cases in which the focus of the infection (72%) and the severity of the episode (73%) were specified. The independent variables that were associated with an adequate prescription were: the presence of risk factors for MR microorganisms’ infection (OR: 2.35 95% CI: 1.65 - 3.17 p: 0.01), if the focus of the infection (OR: 3.79 95% CI: 1.72 - 4.22 p: 0.02) and the severity of the episode (OR: 3.09 95% CI: 1.12 - 3.09 p: 0.03) were specified. Conclusions. The prescription of special category antibiotics in ED is appropriate if the clinical guidelines are followed and if the setting of infection acquisition, the risk factors of MR microorganisms, the focus and the severity of infection are taken into account in clinical picture.

To develop a risk model to predict 30-day mortality after emergency department treatment for COVID-19.Observational retrospective cohort study including 2511 patients with COVID-19 who came to our emergency department between March 1 and April 30, 2020. We analyzed variables with Kaplan Meier survival and Cox regression analyses.All-cause mortality was 8% at 30 days. Independent variables associated with higher risk of mortality were age over 50 years, a Barthel index score less than 90, altered mental status, the ratio of arterial oxygen saturation to the fraction of inspired oxygen (SaO2/FIO2), abnormal lung sounds, platelet concentration less than 100 000/mm3, a C-reactive protein concentration of 5 mg/dL or higher, and a glomerular filtration rate less than 45 mL/min. Each independent predictor was assigned 1 point in the score except age, which was assigned 2 points. Risk was distributed in 3 levels: low risk (score of 4 points or less), intermediate risk (5 to 6 points), and high risk (7 points or above). Thirty-day risk of mortality was 1.7% for patients who scored in the low-risk category, 28.2% for patients with an intermediate risk score, and 67.3% for those with a high risk score.This mortality risk stratification tool for patients with COVID-19 could be useful for managing the course of disease and assigning health care resources in the emergency department.Derivar un modelo de riesgo para estimar la probabilidad de mortalidad a los 30 días de la visita a urgencias de pacientes con COVID-19.Estudio observacional de cohortes retrospectivo de 2.511 pacientes con COVID-19 atendidos en el servicio de urgencias hospitalario (SUH) del 1 de marzo al 30 de abril de 2020. Se realizó análisis de supervivencia mediante Kaplan Meier y regresión de Cox.La mortalidad por cualquier causa a los 30 días fue de un 8%. Los factores asociados de forma independiente a mayor mortalidad fueron: edad 50 años, índice de Barthel 90 puntos, alteración del nivel de consciencia, índice de SaO2/FIO2 400, auscultación respiratoria anómala, cifra de plaquetas 100.000/mm3, PCR 5 mg/dL y filtrado glomerular 45 mL/min. A estos factores se les asignó una puntuación de 1, excepto a la edad, que se le asignó un valor de 2 puntos. Se dividió el modelo de riesgo en 3 categorías: riesgo bajo (menor o igual a 4 puntos), riesgo intermedio (5-6 puntos) y riesgo alto (igual o superior a 7 puntos). Para los pacientes clasificados como de bajo riesgo la probabilidad de mortalidad a los 30 días fue del 1,7%, en los casos de riesgo intermedio fue del 28,2% y para los de alto riesgo fue del 67,3%.Disponer de una herramienta para estratificar el riesgo de mortalidad de los pacientes con COVID-19 que consultan a un SUH podría ser de utilidad para la gestión de los recursos sanitarios disponibles.

To analyze emergency department (ED) revisits from patients discharged with possible coronavirus disease 2019 (COVID-19).Retrospective observational study of consecutive patients who came to the ED over a period of 2 months and were diagnosed with possible COVID-19. We analyzed clinical and epidemiologic variables, treatments given in the ED, discharge destination, need to revisit, and reasons for revisits. Patients who did or did not revisit were compared, and factors associated with revisits were explored.The 2378 patients included had a mean age of 57 years; 49% were women. Of the 925 patients (39%) discharged, 170 (20.5%) revisited the ED, mainly for persistence or progression of symptoms. Sixty-six (38.8%) were hospitalized. Odds ratios (ORs) for the following factors showed an association with revisits: history of rheumatologic disease (OR, 2.97; 95% CI, 1.10-7.99; P = .03), digestive symptoms (OR, 1.73; 95% CI, 1.14-2.63; P = .01), respiratory rate over 20 breaths per minute (OR, 1.03; 95% CI, 1.0-1.06; P = .05), and corticosteroid therapy given in the ED (OR, 7.78; 95% CI, 1.77-14.21, P = .01). Factors associated with hospitalization after revisits were age over 48 years (OR, 2.57; 95% CI, 1 42-4.67; P = .002) and fever (OR, 4.73; 95% CI, 1.99-11.27; P = .001).Patients under the age of 48 years without comorbidity and with normal vitals can be discharged from the ED without fear of complications. A history of rheumatologic disease, fever, digestive symptoms, and a respiratory rate over 20 breaths per minute, or a need for corticosteroid therapy were independently associated with revisits. Fever and age over 48 years were associated with a need for hospitalization.Analizar las revisitas y los factores asociados a la misma en pacientes con diagnóstico de posible COVID-19 dados de alta de un servicio de urgencias hospitalario (SUH).Estudio observacional, retrospectivo que incluyó pacientes consecutivos que consultaron al SUH en un periodo de 2 meses y fueron diagnosticados de posible de COVID-19. Se analizaron variables clínico-epidemiológicas, tratamiento administrado en urgencias, destino final, revisita al SUH y motivo de esta. Se hizo un análisis comparativo entre ambos grupos (revisita sí/no) y se identificaron factores asociados a la revisita.Se incluyeron 2.378 pacientes (edad media 57 años; 49% mujeres). De los pacientes dados de alta (39% del total; n = 925), 170 (20,5%) reconsultaron al SUH, principalmente por persistencia o progresión de síntomas, y 66 (38,8%) precisaron ingreso. Los factores relacionados con la revisita fueron: antecedentes de enfermedad reumatológica [OR: 2,97 (IC 95%: 1,10-7,99, p = 0,03)], síntomas digestivos [OR: 1,73 (IC 95%: 1,14-2,63, p = 0,01)], frecuencia respiratoria $ 20 [OR: 1,03 (IC 95%: 1,0-1,06, p = 0,05)] y haber recibido tratamiento con esteroides en urgencias [OR: 7,78 (IC 95%: 1,77-14,21, p = 0,01)]. Los factores asociados al ingreso en la revisita fueron la edad $ 48 años [OR: 2,57 (IC 95%: 1,42-4,67, p = 0,002)] y presentar fiebre [OR: 4,73 (IC 95%: 1,99-11,27, p = 0,001)].Los pacientes con posible COVID-19 menores de 48 años, sin comorbilidad y con signos vitales normales podrían ser dados de alta desde urgencias sin temor a sufrir complicaciones. Los antecedentes de enfermedad reumatológica, fiebre, sintomas digestivos, frecuencia respiratoria $ 20/min o necesidad de tratamiento con esteroides fueron factores independientes de revisita, y la fiebre y edad $ 48 años de necesidad de ingreso.

To identify predictors of mortality after implementation of a treatment protocol in the first 3 hours for patients who come to our emergency department with sepsis scored 2 or 3 on the Quick Sequential Organ Failure Assessment (qSOFA) scale.Our team identified adult emergency department patients with a diagnosis of sepsis on starting the morning shift between September 2018 and March 2019. We selected patients whose qSOFA score on arrival was 2 or 3. Variables were explored statistically to identify factors associated with mortality.A total of 90 patients with a mean (SD) age of 72 (16) years were included. Thirty-three (37%) died. Univariate analysis detected that the only qSOFA indicator that was significantly associated with mortality was altered mentation (level of consciousness), which was noted in 79% of patients who died versus 54% of survivors (P=.02). Other variables associated with higher mortality were age 70 years or older, an order to limit therapeutic interventions in emergencies, and lactic acid levels on first and second extractions. The treatment protocol was completed in 42% of the cases and compliance was associated with a lower mortality rate of 21% versus 54% when the protocol was not fully implemented (P=.003). Multivariate Cox regression analysis showed that risk for death was higher when the full protocol was not implemented within 3 hours of arrival (hazard ratio, 2.67; 95% CI, 1.15-6.21; P=.02).Full implementation of the protocol within 3 hours of hospital arrival favors survival in patients with sepsis and qSOFA scores of 2 or 3 on arrival. We recommend that emergency departments organize ways to train staff in the use of a sepsis treatment protocol and improve compliance.Determinar los factores predictivos de mortalidad de los pacientes que acuden a urgencias con sepsis y tiene un qSOFA de 2 o 3 puntos tras la implementación de un paquete de medidas a cumplimentar en las primeras 3 horas.De septiembre de 2018 a marzo de 2019 el equipo investigador identificó a los pacientes adultos que se encontraban en urgencias en el inicio del turno de mañana con el diagnóstico de sepsis. De estos pacientes se seleccionaron los que en el momento de su llegada tenían un qSOFA de 2 o 3 puntos. Se realizó análisis estadístico para establecer los factores relacionados con mortalidad.Se incluyeron 90 pacientes con una edad media de 72 (DE 16) años. La mortalidad global fue de 33 pacientes (37%). En el análisis univariado de mortalidad, el único indicador del qSOFA con significación estadística fue el nivel de consciencia (79% vs 54%, p = 0,02). Otras variables relacionadas con mayor mortalidad fueron: edad igual o mayor de 70 años, orden de limitación del esfuerzo terapéutico en urgencias y valor de la primera y de la segunda determinación de lactato. El cumplimiento del paquete de medidas fue del 42% y se asoció a una menor mortalidad (21% vs 54%, p = 0,003). En el análisis multivariado mediante regresión de Cox, los pacientes en los que no se cumplimentó el paquete de medidas en las primeras 3 horas tuvieron mayor riesgo de mortalidad al final del episodio (HR = 2,67; IC95% = 1,15-6,21; p = 0,02).En los pacientes con sepsis y un qSOFA de 2-3 puntos a su llegada a urgencias el cumplimiento del paquete de medidas en las primeras 3 horas mejora la supervivencia. Es recomendable hacer los esfuerzos organizativos y docentes necesarios para mejorar el cumplimiento.

Objectives The incidence of infections caused by multidrug-resistant Pseudomonas aeruginosa (MDR-Pa) has become a concern of increasing relevance nowadays. Ceftolozane/tazobactam (C/T) is a novel fifth-generation cephalosporin/β-lactamase inhibitor combination with activity against MDR-Pa. Methods The clinical records of all patients diagnosed from May 2016 to May 2017 with an infection due to a MDR-Pa treated with C/T were retrospectively reviewed. Results A total of 23 patients with 24 episodes of infection due to MDR-Pa were included. The minimum inhibitory concentration (MIC) of C/T against MDR-Pa ranged from 0.75–8 μg/mL. In 14 cases (58%) the use of C/T was off-label, including 8 respiratory tract infections (RTIs) and 6 skin and soft-tissue infections, whilst in 10 cases the use was for approved indications, including 7 urinary tract infections and 3 intra-abdominal infections. C/T was the first-line therapy in only three cases with a mean ± standard deviation treatment duration of 9.3 ± 4 days, and it was associated with another active drug (aminoglycoside or colistin) in 16 cases. The global clinical cure rate was 88% (21/24 episodes), and the 6-week mortality rate was 22% (5/23 patients) being higher in RTIs (37%). In these infections, three patients received 2/1 g every 8 h (q8h) and were cured without mortality, whilst three (60%) of five patients receiving 1/0.5 g q8h died. Conclusion C/T had good clinical responses in different types of infection, including both FDA-accepted and off-label indications. The results support the use of higher doses in RTIs.