Amith Shetty

Senior Streaming Assessment Further Evaluation after Triage zone: A novel model of care encompassing various emergency department throughput measures

Objective: Access block (AB) and hospital overcrowding adversely affect ED functionality. ED throughput measures have been described in the literature with positive impacts on key performance indicators (KPIs) – time to first seen, did‐not‐wait rates, off‐stretcher times for ambulances and ED length of stay figures. In this study, we aimed to assess the impact of a new model of care, the Senior Streaming Assessment Further Evaluation after Triage (SAFE‐T) zone concept on ED performance indicators and statistical outcomes.

Point of Care D-Dimer Testing in the Emergency Department: A Bioequivalence Study

Background D-dimer is used widely as a diagnostic aid in low- and moderate-risk patients with suspected venous thromboembolism (VTE). While our laboratory utilizes VIDAS D-dimer analyzer (bioMérieux SA, France), our emergency department (ED) recently procured a D-dimer analyzer AQT90 FLEX (Radiometer Medical ApS, Denmark) for point of care testing (POCT) to facilitate patient management. We aimed to determine whether the time taken to receive D-dimer results using the 2 different analyzers differed significantly and to quantify the limits of agreement between the results of the 2 methods measured on the same patient. Methods Adult patients presenting to the ED and requiring diagnostic workup for suspected VTE were included in this prospective observational study. Patients underwent simultaneous D-dimer measurements using the 2 different analyzers. Results The paired results from 104 patients were analyzed. The median time for the D-dimer results from triage by VIDAS was 258 min (Inter-quartile range [IQR], 173-360) and by POCT was 146 min (IQR, 55-280.5); the median time difference was 101.5 min (IQR, 82-125.5). On an average, POCT D-dimer values were 15% lower on the same sample (limits of agreement, 34-213%). POCT predicted 83% of VIDAS positive results (sensitivity, 83.3% [95% confidence interval (CI), 70.4-91.3%]; specificity, 100% [95% CI, 93.6-100%]). All patients with positive imaging were identified correctly by both methods. Conclusions POCT delivers D-dimer results in significantly shorter turnaround times than pathology services; however, poor bioequivalence between VIDAS and POCT raises the issue of acceptability for use in the ED.

The emergency department prediction of disposition (EPOD) study

BACKGROUND Emergency departments (ED) continue to evolve models of care and streaming as interventions to tackle the effects of access block and overcrowding. Tertiary ED may be able to design patient-flow based on predicted dispositions in the department. Segregating discharge-stream patients may help develop patient-flows within the department, which is less affected by availability of beds in a hospital. We aim to determine if triage nurses and ED doctors can predict disposition outcomes early in the patient journey and thus lead to successful streaming of patients in the ED. METHODS During this study, triage nurses and ED doctors anonymously predicted disposition outcomes for patients presenting to triage after their brief assessments. Patient disposition at the 24-h post ED presentation was considered as the actual outcome and compared against predicted outcomes. RESULTS Triage nurses were able to predict actual discharges of 445 patients out of 490 patients with a positive predictive value (PPV) of 90.8% (95% CI 87.8-93.2%). ED registrars were able to predict actual discharges of 85 patients out of 93 patients with PPV of 91.4% (95% CI 83.3-95.9%). ED consultants were able to predict actual discharges of 111 patients out of 118 patients with PPV 94.1% (95% CI 87.7-97.4%). PPVs for admission among ED consultants, ED registrars and Triage nurses were 59.7%, 54.4% and 48.5% respectively. CONCLUSIONS Triage nurses, ED consultants and ED registrars are able to predict a patients discharge disposition at triage with high levels of confidence. Triage nurses, ED consultants, and ED registrars can predict patients who are likely to be admitted with equal ability. This data may be used to develop specific admission and discharge streams based on early decision-making in EDs by triage nurses, ED registrars or ED consultants.

Systemic inflammatory response syndrome-based severe sepsis screening algorithms in emergency department patients with suspected sepsis.

Systemic inflammatory response syndrome (SIRS)‐based severe sepsis screening algorithms have been utilised in stratification and initiation of early broad spectrum antibiotics for patients presenting to EDs with suspected sepsis. We aimed to investigate the performance of some of these algorithms on a cohort of suspected sepsis patients.

Accuracy of computed tomography of the kidneys, ureters and bladder interpretation by emergency physicians.

The study aims to determine the interpretation accuracy of computed tomography of the kidneys, ureters and bladder (CT‐KUB) by emergency physicians (EPs) compared with the formal radiology report, as the reference standard, in patients with suspected acute urinary tract calculous disease.

Impact of emergency department discharge stream short stay unit performance and hospital bed occupancy rates on access and patient flowmeasures: A single site study

The ED discharge stream short stay units (EDSSUs) aim to facilitate patient flows through EDs. We investigate the relationship between EDSSU census and hospital bed occupancy rates (BORs) on National Emergency Access Target (NEAT) performance and did‐not‐wait (DNW) rates at a tertiary metropolitan adult ED in Sydney, Australia.

Age and admission times as predictive factors for failure of admissions to discharge‐stream short‐stay units

Discharge‐stream emergency short‐stay units (ESSU) improve ED and hospital efficiency. Age of patients and time of hospital presentations have been shown to correlate with increasing complexity of care. We aim to determine whether an age and time cut‐off could be derived to subsequently improve short‐stay unit success rates.

The CO2 GAP Project – CO2 GAP as a prognostic tool in emergency departments

Objective:  To determine whether CO2 GAP [(a‐ET) PCO2] value differs consistently in patients presenting with shortness of breath to the ED requiring ventilatory support. To determine a cut‐off value of CO2 GAP, which is consistently associated with measured outcome and to compare its performance against other derived variables.

Review article: Sepsis in the emergency department – Part 1: Definitions and outcomes

Sepsis has recently been redefined as acute organ dysfunction due to infection. The ED plays a critical role in identifying patients with sepsis. This is challenging due to the heterogeneity of the syndrome, and the lack of an objective standard diagnostic test. While overall mortality rates from sepsis appear to be falling, there is an increasing burden of morbidity among survivors. This largely reflects the growing proportion of older patients with comorbid illnesses among those treated for sepsis.

Blood pressure cuffs as a vector for transmission of multi-resistant organisms: Colonisation rates and effects of disinfection

Blood pressure (BP) cuffs are potential vectors for transmission of multi‐resistant organisms (MROs). The present study aims to determine MRO colonisation rates in BP cuffs from areas of high patient flow as an assessment of the quality of disinfection and infection control practices.