Reasons for acute referrals to hospital from general practitioners and out-of-hours doctors in Norway: a registry-based observational study

Background General practitioners (GPs) and out-of-hours (OOH) doctors are gatekeepers to acute hospital admissions in many healthcare systems. The aim of the present study was to investigate the whole range of reasons for acute referrals to somatic hospitals from GPs and OOH doctors and referral rates for the most common reasons. We wanted to explore the relationship between some common referral diagnoses and the discharge diagnosis, and associations with patient’s gender, age, and GP or OOH doctor referral. Methods A registry-based study was performed by linking national data from primary care in the physicians’ claims database with hospital services data in the Norwegian Patient Registry (NPR). The referring GP or OOH doctor was defined as the physician who had sent a claim for the patient within 24 h prior to an acute hospital stay. The reason for referral was defined as the ICPC-2 diagnosis used in the claim; the discharge diagnoses (ICD-10) came from NPR. Results Of all 265,518 acute hospital referrals from GPs or OOH doctors in 2017, GPs accounted for 43% and OOH doctors 57%. The overall referral rate per contact was 0.01 from GPs and 0.11 from OOH doctors, with large variations by referral diagnosis. Abdominal pain (D01) (8%) and chest pain (A11) (5%) were the most frequent referral diagnoses. For abdominal pain and chest pain referrals the most frequent discharge diagnosis was the corresponding ICD-10 symptom diagnosis, whereas for pneumonia-, appendicitis-, acute myocardial infarction- and stroke referrals the corresponding disease diagnosis was most frequent. Women referred with chest pain were less likely to be discharged with ischemic heart disease than men. Conclusions The reasons for acute referral to somatic hospitals from GPs and OOH doctors comprise a wide range of reasons, and the referral rates vary according to the severity of the condition and the different nature between GP and OOH services. Referral rates for OOH contacts were much higher than for GP contacts. Patient age, gender and referring service influence the relationship between referral and discharge diagnosis.

193 Epidemiological trend of amyloidosis and its association with cardiovascular conditions: a single-center report

Aims Despite improved awareness and advances in cardiac imaging, cardiac amyloidosis (CA) is a substantially underdiagnosed disease. ATTRwt amyloidosis may be responsible for as many as 30% of HF with preserved ejection fraction in patients >75 years old. Contemporary estimates of its epidemiology in Italy are poorly provided. The aim of this study is to retrospectively analyse yearly inpatient claims consistent with amyloidosis in a single centre of Veneto region (Azienda Ospedaliera—Università di Padova). Methods Inpatient claims were counted in the series in each year if they had at least 1 principal or secondary International Classification of Diseases, Ninth revision—clinical modification (ICD-9, CM) code for amyloidosis (27730-27739), from January 2009 to February 2021. Primary outcome was to clarify if an increase in claims went hand in hand with novel and wider awareness of the disease. Secondary outcome was to identify major comorbidities determining or accompanying acute conditions leading to hospitalization. Results During the study period, there was a total of 328 claims containing ICD9-CM code for amyloidosis; 139 of them (42%) registered before 2015, 189 (58%) after 2015. Mean number of hospitalizations increased during time, starting from 20 claims per year between 2009 and 2015, to 36.8 from 2015 to 2020 (excluded current year). Considering main discharge diagnosis, 84 (25.6%) was related to cardiological condition, of them 56 (66%) was about acute or acute on chronic heart failure, 9 (10.7%) to arrhythmias, both brady- and tachyarrhythmia, 6 (7.1%) to coronary disease, 4 (4.8%) to aortic stenosis. The other most frequent discharge diagnoses, 36 (10.9%) were due to neurological condition, mostly neurovascular disease, 26 (7.9%) were due to haematological disease, mostly multiple myeloma, 14 (4.2%) were about nephrological condition, mostly related to advanced or pre-dialysis renal disease. Regarding related discharge diagnoses, the most frequent were cardiological conditions, appearing in 205 (62.5%) claims. 128 (62.4%) of them were due to acute or chronic heart failure, 10 (4.1%) to brady-tachyarrhythmias, 9 (4.4%) to ischaemic heart disease, and 6 (2.9%) to aortic valve disease. About other associated conditions reported in ICD9-CM codes used 84 (25.6%) were related to haematological diseases, 68 (20.7%) to neurological disease, 52 (15.8%) to renal disease, 23 (7%) to gastroenterological diagnoses (mostly GI bleeding). Conclusions Over the last years, there have been a substantial increase in amyloidosis diagnosis in our centre. This appears to go hand in hand with an increase in clinicians’ CA awareness, as confirmed by the fact that main discharge diagnosis is related to cardiac condition, and more specifically heart failure. Heart is again the most important comorbidity in patients hospitalized for other conditions, mostly related to nephrological, neurological, haematological affections confirming its role as main prognostic determinant in a complex disease, and the necessity to search for it, find it and quickly cure it.

Pediatric eye emergency department activity during the first wave of Covid-19 pandemic

Background We investigated the volume and the characteristics of pediatric eye emergency department (PEED) consultations performed at our tertiary eye center during the early months of the COVID-19 pandemic and we compared them to those carried out in the same time interval of the previous three years. Methods Ophthalmic emergency examinations of patients aged ≤18 years old and done during the national COVID-19 lockdown (March 9th, 2020 – May 3rd, 2020) and in the corresponding date range of the previous three years (2017, 2018, and 2019) have been considered and reviewed. The following features were retrieved and analyzed: age, gender, duration and type of accused symptoms, traumatic etiology, and the discharge diagnosis. Results 136, 133, and 154 PEED visits have been performed respectively in 2017, 2018, and 2019, while 29 patients presented in 2020. Therefore, the volume of PEED activity decreased by 79.4% (p < 0.0001). Demographical and clinical characteristics were comparable to those of the pre-COVID period. Despite the absolute reduction in the number of traumas, urgent conditions increased significantly from 30.7 to 50.7% (p = 0.024). Conclusions PEED activity decreased consistently after the onset of the pandemic and it was mainly attended by those children whose conditions required prompt assistance, reducing the number of patients diagnosed with milder pathologies. At the end of the emergency, better use of PEED could avoid overcrowding and minimize waste, allowing resource optimization for the management of urgent cases.

1137. Effect of an Antibiotic Stewardship Program on Antibiotic Choice, Dosing, and Duration in Pediatric Urgent Care

Background Many studies have focused on decreasing inappropriate antibiotic prescriptions. In August 2018, our institution implemented an outpatient antibiotic stewardship program (ASP). We describe the impact of an outpatient ASP on the antibiotic choice, dose, and duration for common pediatric infections in a pediatric urgent care (PUC) setting. Methods We reviewed all encounters at 4 freestanding PUC centers within our organization of patients &gt;60 days and &lt; 18 years with a discharge diagnosis of acute otitis media (AOM), group A streptococcal (GAS) pharyngitis, community acquired pneumonia (CAP), urinary tract infection (UTI), cellulitis, abscess, and animal bite who received systemic antibiotics between July 2017 and December 2020. We excluded patients who were transferred, admitted, or had a concomitant diagnosis that required systemic antibiotics. We used established national guidelines to determine appropriateness of antibiotic choice, dose, and duration for each diagnosis (Table 1). Our outpatient ASP efforts included the development of an antibiotic handbook, data sharing, education, quality improvement projects, and commitment letters. Pearson’s chi-square test was used to compare appropriate prescribing (choice, dose, and duration) between pre-implementation (July 2017 – July 2018) and post-implementation (August 2018 -forward). Monthly run charts evaluated improvement over time. Results We included 35,915 encounters. Appropriate antibiotic agent improved in AOM (75.8% to 77.2%; p=0.03), UTI (74.9% to 89.5%; p&lt; 0.001), cellulitis (70.5% to 75.1%; p=0.02) and abscess (53.6% to 67.7%; p&lt; 0.001) following implementation of our ASP (Figure 1). Excluding GAS pharyngitis, all diagnoses had improvement in appropriate duration (p&lt; 0.001) (Figure 2). Appropriate dosing improved for AOM (75.7% to 81.6%; p&lt; 0.001), UTI (34.9% to 42.9%; p=0.01) animal bites (37.1% to 45.6%; p=0.048), and cellulitis (28.0% to 42.3%; p&lt; 0.001) (Figure 3). Figure 1. Appropriate Agent Run chart of percentage of encounters with antibiotic choice consistent with national guideline recommendations by discharge diagnosis. The vertical line indicates the start of outpatient antibiotic stewardship efforts in August 2018. Figure 2. Appropriate Duration Run chart of percentage of encounters with antibiotic duration consistent with national guideline recommendations. The vertical line indicates the start of outpatient antibiotic stewardship efforts in August 2018. Figure 3. Appropriate Dose Run chart of percentage of encounters with antibiotic dose consistent with national guideline recommendations. The vertical line indicates the start of outpatient antibiotic stewardship efforts in August 2018. Conclusion Our outpatient ASP improved prescribing patterns for agent, duration, and dose for many common pediatric infections in the PUC setting. Future work will focus on identifying opportunities to improve prescribing practices when antibiotics are indicated. Disclosures Brian R. Lee, PhD, MPH , Merck (Grant/Research Support)Pfizer (Grant/Research Support)

Shedding Light Into The Black Box of Out-of-Hospital Respiratory Emergencies – A Retrospective Cohort Analysis of Discharge Diagnoses, Prehospital Diagnostic Accuracy, And Predictors of Mortality

Background: Respiratory distress is one of the most common complaints of patients requiring out-of-hospital emergency services. Determining the precise discharge diagnosis in these circumstances can be challenging due to the wide range of suspected diagnoses. Moreover, these patients appear to have particularly high mortality, but little is currently known about the exact mortality rates associated with specific discharge diagnoses. Our study, therefore, aimed to determine how accurately correct diagnoses are made by EMS physicians in the out-of-hospital setting, identify examination findings that correlate with discharge diagnoses, investigate hospital mortality, and identify mortality-associated predictors.Methods: This retrospective observational study examined emergency medical service (EMS) encounters between December 2015 and May 2016 in the city of Aachen, Germany, in which an EMS physician was present at the scene. Adult patients were included if the EMS physician initially detected dyspnea, low oxygen saturation, or pathological auscultation findings at the scene (n = 719). By linking out-of-hospital data to hospital records, including initial blood gas analysis, a discharge diagnosis was assigned to each EMS encounter, and the outcome was analyzed. Binary logistic regressions were used to search for associations between pathological findings and discharge diagnoses, as well as predictors of hospital mortality.Results: The overall diagnostic accuracy was 69.9% (485/694). The highest diagnostic accuracies were observed in asthma (15/15 ≙ 100%), hypertensive crisis (28/33 ≙ 84.4%), and COPD exacerbation (114/138 ≙ 82.6%), and the lowest accuracies were observed in urinary tract infection (14/35 ≙ 40%), pulmonary embolism (8/18 ≙ 44.4%), and pneumonia (70/142 ≙ 49.3%). The overall hospital mortality rate was 13.8% (99/719). The highest hospital mortality rates were seen in pneumonia (44/142 ≙ 31%) and urinary tract infection (7/35 ≙ 20%). Potential risk factors for hospital mortality identified in this study were reduced vigilance, low oxygen saturation, increasing age, blood gas analysis (BGA) results associated with metabolic acidosis, and an incorrect out-of-hospital diagnosis by the EMS physician.Conclusions: Our data highlight the diagnostic uncertainties and high mortality in out-of-hospital emergency patients presenting with respiratory distress. The identified predictors could help in early detection of patients at risk in the future.

A Retrospective Study on the Factors Associated with Long-Stay Hospitalization in a Child Neuropsychiatry Unit

The past twenty years have seen a rapid increase in acute psychiatric symptoms in children and adolescents, with a subsequent rise in the number of psychiatric hospitalizations. This paper aims to: (a) describe the epidemiology of hospitalizations and some of the clinical and sociodemographic characteristics of pediatric patients admitted to a regional referral Complex Operative Child Neuropsychiatry Hospital Unit in Northeast Italy and (b) identify potential factors correlated with the length of hospital stay. Methods: 318 (M = 12.8 years; SD = 3.11; 72% Female) patients hospitalized for mental health disorders from 2013 to 2019. Results: Around 60% of hospital admissions occurred via the emergency room, mostly due to suicidal ideation and/or suicide attempts (24%). Affective disorders were the most frequent discharge diagnosis (40%). As for factors correlated with length of hospital stay, we found significant links with chronological age, way of hospital admission, cause of admission, discharge diagnosis, presence of psychiatric comorbidity, family conflict, and psychiatric family history. Conclusions: These results provide information about global characteristics associated with the length of psychiatric hospital stays in pediatric patients and provide a basis on which specific precautions can be hypothesized with the aim of developing more focused treatments.

Evidence-Based Analysis on Observation for Nursing Care of Patients with Intra-Aortic Balloon Pumping

In this study, data analysis was performed on 52 patients. According to the different outcomes and discharge diagnosis of patients, data on sedative use, emotions, behavioral abnormalities, hearing loss, pain, total time on board the IABP (intra-aortic balloon pumping), and days of hospitalization of patients were collected. The data were subjected to frequency analysis, paired chi-square analysis, chi-square test, Poisson regression analysis, and stepwise regression analysis. Some findings of the analysis included the following: Between outcome and admission diagnosis, the analysis showed that significant differences existed between paired data. Patients with heart failure and acute myocardial infarction are in an unhealed state, and most patients with coronary atherosclerotic heart disease, myocarditis, and heart disease showed improvement. The samples taken by different sedatives showed no significant differences in the emotional and behavioral abnormalities, hearing loss, and pain. A total of 1 item of hospital stay had a significant negative impact on the total operation time of IABP. However, discharge diagnosis and admission diagnosis did not affect the total time on board the IABP. The dorsalis pedis artery pulse condition has a significant negative effect on the total time on board the IABP.