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Importantly, protocols should also be implemented to minimize potential COVID-19 spread during aerosol-generating procedures.An incredible amount of information has been published regarding inpatient management of patients with COVID-19. Although this is vitally important, critical interventions that occur in the emergency department (ED) can have a profound impact on the individual patient and the healthcare system as a whole. Much has been written regarding care in large centers, but there has been little discussion regarding similar patients in community settings. Prior to the pandemic, large centers were able to accept patients that outstripped the resources in community hospital settings, but currently we foresee that many community centers will begin to manage more complex cases without referral. As physicians in a medium-sized community academic center, we aim to enumerate community-hospital-relevant guidance for ED care that focuses on adherence to available evidence-based medicine, including early aggressive supplemental oxygenation, awake proning, and methods to improve oxygenation and ultimately delay intubation as long as safely possible. Equally importantly, it was recognized early that adjustments to medication regimens (eg, sedation) and personal protective equipment (PPE) use must be made in the ED to conserve those same resources for long-term use in inpatient units and improve the functionality of the hospital system as a whole. It is our hope that this article may serve as a framework for similar community-based hospitals to create their own protocols to optimize resource utilization, staff safety, and patient care.

The circumstances of the coronavirus disease 2019 pandemic necessitated an alternate operations strategy for efficient patient management. Alternate care sites were a viable option for managing emergency department (ED) surge in previous epidemics and disasters.

This study describes the development of an alternate care site and evaluates efficiency by comparing key performance indicators between an ad hoc nested respiratory evaluation unit (NRU) within the ED and an alternate care site outside the ED.

This was a cohort study of 2 care models in the same ED during 2 different time periods. As coronavirus disease 2019 surged in March 2020, potential treat-and-release patients with fever or respiratory symptoms were triaged to a dedicated ED area (NRU). As ED volume grew, these low-acuity patients were triaged to an ACS. We compared ED length of stay, elopement, and left without being evaluated rates and ED recidivism between the 2 care models NRU patients presented to the ED from March 16, 2020, to March 31, 2020, and ACS patients presented from April 1, 2020, to April 15, 2020. Continuous variables were compared using independent

test or Mann-Whitney test. Categorical variables were compared using χ

test.

There were 414 NRU patients and 146 alternate care site patients with no significant differences in sex or age. The mean ED length of stay was shorter for alternate care site patients 155versus 45 minutes (

<0.01). Elopement and left without being evaluated rates were higher in the NRU. There was no significant difference in ED recidivism between groups 10%versus 6% (

=0.15).

An alternate care site provided an efficient resource for the evaluation of patients with fever or respiratory symptoms during the coronavirus disease 2019 pandemic.

An alternate care site provided an efficient resource for the evaluation of patients with fever or respiratory symptoms during the coronavirus disease 2019 pandemic.This paper summarizes the methodology for the registry of suspected COVID-19 in emergency care (RECOVER), a large clinical registry of patients from 155 United States (US) emergency departments (EDs) in 27 states tested for SARS-CoV-2 from March-September 2020. The initial goals are to derive and test (1) a pretest probability instrument for prediction of SARS-CoV-2 test results, and from this instrument, a set of simple criteria to exclude COVID-19 (the COVID-19 Rule-Out Criteria-the CORC rule), and (2) a prognostic instrument for those with COVID-19. Patient eligibility included any ED patient tested for SARS-CoV-2 with a nasal or oropharyngeal swab. Abstracted clinical data included 204 variables representing the earliest manifestation of infection, including week of testing, demographics, symptoms, exposure risk, past medical history, test results, admission status, and outcomes 30 days later. In addition to the primary goals, the registry will provide a vital platform for characterizing the course, epidemiology, clinical features, and prognosis of patients tested for COVID-19 in the ED setting.

Cholesterol may be protective in sepsis. Patients with early sepsis may have critically low cholesterol levels that are associated with poor outcomes. The study objective was to test the safety of a fish oil-containing lipid injectable emulsion for stabilizing early cholesterol levels in sepsis.

Phase I Bayesian optimal interval design trial of adult patients with septic shock (Sequential Organ Failure Assessment score ≥4 or vasopressor dependence). Using sequential dose escalation, participants received 2 doses of 1.0 to 1.6g/kg of lipid emulsion (Smoflipid 20% lipid emulsion) within 48hours of enrollment. Cholesterol levels, function, and organ failure were assessed serially during the first 7 days of hospital admission.

A total of 10 patients with septic shock were enrolled. One patient withdrew for social reasons. Another patient had an unrelated medical complication and received 1 drug dose. Of 9 patients, mean age was 58 years (SD 16), median Sequential Organ Failure Assessment was 8, and 28-day mortality was 30%. find more No serious adverse events related to lipid infusion occurred. The six occurrences of non-serious adverse events possibly related to lipid infusion included hyperglycemia (1), elevated triglycerides (3), anemia (1), and vascular access redness/pain (1) for all doses. The mean change in total cholesterol levels from enrollment was -7 (SD 16.6) at 48hours and 14 (SD 25.2) at 7 days.

Fish oil-containing lipid emulsion administration during early septic shock was safe. Further studies are needed to assess effects on cholesterol levels, function, and organ failure.

NCT03405870.

NCT03405870.Rapid adoption and widespread use of point-of-care ultrasound (POCUS) has impacted diagnostic testing and clinical care across medical disciplines. The benefits of POCUS must be weighed against certain pitfalls, such as the risk of misdiagnosis and false assurance. Beyond technical error in image acquisition and interpretation, an important pitfall is reliance on POCUS results without considering pre-test patient characteristics or the diagnostic accuracy of POCUS in varying clinical contexts. In this article, we introduce the concept of POCUS stewardship that emphasizes critical evaluation of clinical indications prior to performing POCUS as well as the individual patient and test characteristics of POCUS when integrating results into clinical decisionmaking. Adherence to these principles can lead to optimized POCUS application and improved patient care.Few studies evaluate the use of handheld ultrasound devices for point-of-care ultrasonography in the emergency department. link2 We hypothesized that image acquisition time and image quality are similar between a handheld device and a traditional device. We compared these 2 types of devices in healthy, non-pregnant adults with using a crossover non-inferiority design while acquiring Rapid Ultrasound for Shock and Hypotension (RUSH) view. We excluded those with a history of surgical intervention or known abnormality to the lungs, abdomen, or pelvis. Images were compiled into a de-identified video clip reviewed for image quality by 2 blinded reviewers. Cohen's Kappa was used to determine interrater agreement. Disagreements were adjudicated by an independent physician. Imaging time was compared using a paired Student's t test. Of 59 screened participants, 9 were excluded. Most subjects (N = 30, 60%) were female with a mean age of 39 (Range 19-67) years. The median time to complete the RUSH exam did not differ (handheld 249.4, interquartile range 33.5 seconds); traditional 251.4, interquartile range 66.3 seconds); [P = 0.81]). Agreement between ultrasound reviewers was good (agreement 83%; k = 0.69; 95% CI, 0.49-0.88). Images were determined to be of adequate quality for interpretation in 41/50 (82%) and 43/50 (86%) in the handheld and traditional devices, respectively (P = 0.786). Neither time to image acquisition nor image quality differed between the handheld and traditional devices. The handheld device may be an alternative for use in RUSH exams.

Emergency department (ED) crowding is a major problem across the world. Studies investigating the association between crowding and mortality are many, but the quality is inconsistent and there are very few large, high-quality multicenter studies that are properly designed to deal with confounding due to case mix. The aim of this study is to investigate the association between ED crowding and 30-day mortality.

We conducted an observational cohort study at all 7 EDs in Stockholm Region, Sweden 2012-2016. link3 The crowding exposure was defined as the mean hourly ED census during the shift that the exposed patient arrived, divided with the expected ED census for this shift. The expected ED census was estimated using a separate linear model for each hospital with year and shift as predictors. The exposure was categorized in 3 groups reference (lowest 75% of observations), moderate (75%-95% of observations), and high (highest 5% of observations). Hazard ratios (HR) for all-cause mortality within 30 days were estimated with a Cox proportional hazards model. The model was adjusted for age, sex, triage priority, arrival hour, weekend, arrival mode, chief complaint, number of prior hospital admissions, and comorbidities.

884,228 patients who visited the ED 2,252,656 times were included in the analysis. The estimated HR (95% confidence interval) for death within 30-days was 1.00 (0.97-1.03) in crowding category 75%-95% and 1.08 (1.03-1.14) in the 95%-100% category.

In a large cohort study including 7 EDs in Stockholm Region, Sweden we identified a significant association between high levels of ED crowding and increased 30-day mortality.

In a large cohort study including 7 EDs in Stockholm Region, Sweden we identified a significant association between high levels of ED crowding and increased 30-day mortality.

Telemedicine is used by emergency departments (EDs) to connect patients with specialty consultation and resources not available locally. Despite its utility, uptake of telemedicine in EDs has varied. We studied characteristics associated with telemedicine adoption during a 4-year period.

We analyzed data from the 2014 National Emergency Department Inventory (NEDI)-New England survey and follow-up data from 2016 and 2017 NEDI-USA and 2018 NEDI-New England surveys, with data from the Center for Connected Health Policy. Among EDs not using telemedicine in 2014, we examined characteristics associated with adoption by 2018.

Of the 159 New England EDs with available data, 80 (50%) and 125 (79%) reported telemedicine receipt in 2014 and 2018, respectively. Among the 79 EDs without telemedicine in 2014, academic EDs were less likely to adopt by 2018 (odds ratio, 0.12; 95% confidence interval, 0.03-0.46). State policy environment was not associated with likelihood of adoption. In 2018, all 7 freestanding EDs received telemedicine, whereas only 1 of 9 academic EDs (11%) did.