Odds of return: a prospective study using provider assessment to predict short-term patient return visits to the emergency department

ObjectivePrevious studies have assessed patient-level characteristics associated with emergency department (ED) return visits, but none have used provider assessment. We prospectively investigate whether clinical providers could accurately predict ED return visits.MethodsProspective cohort study.SettingSingle academically affiliated urban county hospital.ParticipantsDischarged ED patients over a 14-month period with a provider assessment of the likelihood of patient return within 7 days of ED discharge.Main outcome measuresThe primary outcome of interest was a return visit to the ED within 7 days. Additional outcome measures included a return visit within 72 hours and a return visit resulting in admission. We also measured the accuracy of provider gestalt, and provide measures of sensitivity, specificity, predictive values, and likelihood ratios.ResultsOf the 11 922 ED discharges included in this study, providers expected 2116 (17.7%) to result in a return visit within 7 days. Providers were much more likely to perceive a return visit if the patient left against medical advice (OR: 5.97, 95% CI: 4.67 to 7.62), or was homeless (OR: 5.69, 95% CI: 5.14 to 6.29). Patients who actually returned were also more likely to be homeless, English speaking and to have left the ED against medical advice on the initial encounter. The strongest predictor of a return visit at both 72 hours and 7 days in multivariable modelling was provider assessment (OR: 3.77, 95% CI: 3.25 to 4.37; OR: 3.72, 95% CI: 3.29 to 4.21, respectively). Overall sensitivity and specificity of provider gestalt as a measure of patient return within 7 days were 47% and 87%, respectively. The positive and negative likelihood ratios were 3.51 and 0.61, respectively.ConclusionsClinician assessment was the strongest predictor of a return visit in this dataset. Clinician assessment may be used as a way to screen patients during the index visit and enrol them in efforts to decrease return visits.

Comparison of clinician and model estimates of risk for hospitalization during systemic therapy for advanced cancer.

1530 Background: Patients receiving treatment for advanced cancer are at substantial risk for unplanned hospitalization. A validated two-variable risk model can identify patients at increased risk for hospitalization. However, little is known about how model-based estimates of hospitalization risk compare with assessments of treating clinicians. Methods: We identified patients initiating a new line of systemic therapy for advanced non-hematologic cancer. For each patient, we assigned three categorical estimates of 30-day hospitalization risk. The first risk estimate was generated by a validated two-variable risk prediction model with inputs of pretreatment plasma sodium and albumin (PMID: 30995122); continuous risk scores were converted to risk tertiles. We solicited a second risk estimate by real-time survey of a treating oncology clinician; clinicians were instructed to estimate hospitalization risk as low, intermediate, or high, as compared with other patients. A third hybrid risk estimate retained the highest risk category from either the clinician or model risk assessment. We describe the agreement of clinician and model-based estimates of 30-day hospitalization risk, and we compare the sensitivity and specificity of clinician, model, and hybrid high-risk assessments, using McNemar’s test. We compared discrimination of the three risk estimates via the area under the ROC curve (AUC). Results: We identified 104 patients with valid clinician and model hospitalization risk estimates and complete 30-day follow-up. The most common cancer type was lung cancer (27%), the median age was 68 years, and 62% of patients were male. 30-day hospitalization occurred in 21 patients (20.2%). There was moderate to poor agreement between clinician and model categorical estimates of hospitalization risk (weighted kappa = 0.245). The proportion of patients identified as high-risk by the clinician, model, and hybrid assessments was 15.4%, 26.0%, and 33.7%. Sensitivity and specificity of the high-risk categorization for 30-day hospitalization were 38% and 90% for the clinician assessment, 57% and 82% for the model assessment (NSS for comparison with clinician assessment), and 76% and 77% for the hybrid assessment (greater sensitivity [p = 0.008] and lesser specificity [p = 0.001] than clinician assessment). The AUC values for the clinician, model, and hybrid assessments were 0.674, 0.757, and 0.764, respectively. Conclusions: Compared with the estimate of a treating clinician, a two-variable risk model exhibited similar sensitivity and specificity for 30-day hospitalization risk. A hybrid risk assessment incorporating information from the risk model significantly improved on the sensitivity of the clinician risk assessment. Future research should test strategies to prevent hospitalizations by targeting interventions to high-risk patients.

Common reasons patients are being referred from primary to secondary care, their journey and its impact on patient flow in the Emergency Department

A longstanding issue common to all Emergency Departments (ED), worldwide, is that of crowding. In recent years, prior to the CoVid-19 pandemic this was a national problem with trolleys lined up in ED corridors and waiting rooms filled with acutely unwell patients who have only received basic triage and no other clinician assessment. Many solutions have been put forward such as the concept of “reverse queueing”, the use of urgent treatment centres [1-4] and the use of ambulatory areas, particularly for medical patients. A clearly recognized strategy in managing overcrowding in the emergency department is prehospital assessment and judicious use of secondary care by primary care colleagues. “Initial Assessment” and referral to the correct area of secondary care promotes good patient flow and directs the patient to an appropriate area of the hospital, avoiding the emergency department altogether. One of the busiest clinical specialty within most hospitals is General Medicine. This specialty generally receives twice (if not more) the referrals than any other specialties but often has the same level of staffing. We undertook an audit of a cohort of patient referred by their GPs to acute specialties over a 2-week period to see if there are lessons to be learnt in order ease pressure on the emergency department and acute medical take.

Evaluation of a novel approach to recognising community-acquired paediatric sepsis at ED triage by combining an electronic screening algorithm with clinician assessment

ObjectiveWe report the utilisation and impact of a novel triage-based electronic screening tool (eST) combined with clinical assessment to recognise sepsis in paediatric ED.MethodsAn electronic sepsis screening tool was implemented in the paediatric EDs of two large UK secondary care hospitals between June 2018 and January 2019. Patients eligible for screening were children < 16 years of ages excluding those with minor injuries or who were brought directly to resuscitation. Subsequently, a retrospective evaluation was performed to determine the performance of the tool alone and in combination with clinical assessment after triage, to identify septic patients, using sensitivity, specificity, positive, negative predictive values (PPV and NPV) and likelihood ratios.Results19 912 children were triaged during the study period, of whom 90 (0.45%) were classified as having sepsis. 99% of all eligible patients were screened. The eST alerted for 2651 (13.3%) patients. After immediate physician assessment, 151 were treated for sepsis in the ED, of whom 70 had a final diagnosis of sepsis. Eight patients who were not thought to be septic returned with sepsis within 24 hours. The eST showed a sensitivity of 86.7% (95% CI 77.5% to 92.6%), specificity 87.0% (95% CI 86.5% to 87.5%), PPV 2.94% (95% CI 2.35% to 3.68%), NPV 99.9% (95% CI 99.8% to 99.9%) which improved with combined clinical assessment to a sensitivity of 90.0% (95% CI 81.4% to 95.0%), specificity 99.4 (95% CI 99.3% to 99.5%), PPV 42.0 (95% CI 35.0% to 49.3%) and NPV 99.9% (95% CI 99.9% to 99.9%).ConclusionUtilisation of a novel triage-based eST allowed sepsis screening in over 99% of eligible patients. The screening tool showed good accuracy to recognise sepsis at triage in the ED, which was augmented further by combining it with clinician assessment. The screening tool requires further refinement through multicentre evaluation to avoid missing sepsis cases.

Application of the ‘5-2-1’ screening criteria in advanced Parkinson’s disease: interim analysis of DUOGLOBE

Aim: A Delphi expert consensus panel proposed that fulfilling ≥1 of the ‘5-2-1 criteria’ (≥five-times daily oral levodopa use, ≥two daily hours with ‘Off’ symptoms or ≥one daily hour with troublesome dyskinesia) suggests advanced Parkinson’s disease (PD). Patients & methods: DUOdopa/Duopa in Patients with Advanced PD – a GLobal OBservational Study Evaluating Long-Term Effectiveness (DUOGLOBE) – is a single-arm, postmarketing, observational, long-term effectiveness study of levodopa–carbidopa intestinal gel (LCIG) for advanced PD. Results: This 6-month interim analysis (n = 139) affirms that most (98%) enrolled patients fulfill ≥1 of the 5-2-1 criteria. These patients responded favorably to LCIG treatment. Safety was consistent with other LCIG studies. Conclusion: In advanced PD patients, the 5-2-1 criteria generally aligns with clinician assessment. Clinical Trial Registration: NCT02611713 ( ClinicalTrials.gov )

79 Acceptability and impact of psychosocial screening in the emergency department

Background Psychosocial concerns in youth are prevalent and undertreated. Early identification through screening may promote appropriate management before youth present in crisis. Objectives Our primary objective was to assess the acceptability of psychosocial screening in the pediatric emergency department (ED) setting. Secondarily, we report the prevalence of psychosocial issues among youth with non-psychiatric ED presentations, and the impact of screening on mental health resource-seeking behaviour. Design/Methods We conducted a prospective cohort study of youth aged 10-17 years at two pediatric EDs. Youth with a mental health-related reason for visiting the ED were excluded. Eligible and consenting youth (and their families) completed a comprehensive psychosocial self-assessment delivered on an electronic tablet, followed by standardized clinician assessment. Consent to participate in the study was used as a proxy measure for acceptability of screening. Participants with identified psychosocial resource needs were followed up at 30 days with a semi-structured telephone/email interview to assess whether they had sought recommended resources and to explore barriers to accessing care. Results Of the 1432 eligible youth given the opportunity to enrol, 795 consented. Among the 637 youth who declined enrolment, 467 specified that they declined for reasons other than not wanting to conduct a psychosocial self-assessment. This suggests that at least 55.5% (95% CI = 52.9%, 58.1%) and up to 88.1% (95% CI = 86.4%, 89.8%) find screening acceptable. Among the 760 participants who completed clinician assessment, 276 (36.3%) were identified as having a psychosocial resource need. Resources were already in place for 105 youth, leaving 171 (22.5%) with newly identified or unmet psychosocial needs. Only 41 (33.1%) of the 124 participants and/or their families who completed a 30-day follow up interview reported attempting to access the recommended resources, despite 92 (74.2%) stating they agreed with the original recommendations. The most common reason for not accessing care was the belief that the recommendations were not yet necessary or were not a priority. Of those who had attempted to access resources, 18 (43.9%) were unsuccessful at the time of interview, with the most common barrier being access delay (e.g. on a waitlist). Conclusion We found that previously unidentified/unmet psychosocial needs are prevalent among youth in the ED, and that screening is generally acceptable. However, a limited number of those who screened positive attempted to access resources, and when they did, access was often unsuccessful or delayed. More work is needed to address barriers to timely psychosocial care.