Annals of emergency medicine最新文献

Study objective: Early prognostic stratification could optimize the management of patients with upper gastrointestinal bleeding and reduce unnecessary hospitalizations. The aim of this study was to assess and compare the performance of existing prognostic scores in predicting therapeutic intervention and death.

Methods: A systematic search of the literature identified existing prognostic scores. A multicenter retrospective cohort study included adult patients hospitalized for upper gastrointestinal bleeding from January 1, 2019, to December 31, 2020. The primary outcome was a composite including therapeutic intervention within 7 days (blood transfusion, endoscopic, surgical, or interventional radiology hemostasis) and/or 30-day death. Discrimination performance was estimated by the area under the curve (AUC). The ability to identify low-risk patients was analyzed using sensitivity and negative predictive value (NPV) for defined thresholds.

Results: The systematic search identified 39 prognostic scores, 12 of which could be analyzed. Among the 990 patients included, therapeutic intervention and/or death occurred in 755 (76.4%) patients. Scores with the highest discriminative performance to predict the primary composite outcome were Glasgow-Blatchford score (GBS) (AUC 0.869 [0.842 to 0.895]), modified GBS (AUC 0.872 [0.847 to 0.898]) and modified GBS 2 (AUC 0.855 [0.827 to 0.884]). The best performance to identify low-risk patients was for GBS≤1 (sensitivity 0.99 [0.99 to 1.00], NPV 0.89 [0.75 to 0.97]) and modified GBS=0 (sensitivity 0.99 [0.98 to 1.00], NPV 0.84 [0.71 to 0.94]).

Conclusions: The GBS and the modified GBS are the 2 best performing scores because they achieve both key objectives: stratifying patients based on their risk of therapeutic intervention and/or death and identifying low-risk patients who may qualify for outpatient management.

Study objective: Physician experiences with new care models like the virtual observation unit in emergency departments (EDs) can offer important insights. Virtual observation unit leverages telehealth, remote monitoring, and mobile integrated health to enable home-based ED-level care. We explored physicians' experience with delivering care in the virtual observation unit and perceived effect of this new model.

Methods: We conducted semistructured in-depth interviews with 10 emergency physicians who staffed the newly launched virtual observation unit in an academic hospital. We conducted a thematic analysis, which involved identifying and examining codes that describe important themes in the data.

Results: Three themes emerged in terms of emergency physicians' experience with the virtual observation unit: (1) forming a deeper connection with patients as the virtual observation unit allowed them to spend more time with patients and care for patients in the patients' home environment; (2) increased appreciation for interprofessional and interspecialty care as the virtual observation unit presented opportunities to work closely with nurses, paramedics, and primary care physicians; and (3) (surmountable) programmatic challenges related to dealing with multipronged technology and finding the right patient with an appropriate clinical condition and acceptance of home-based care. These experiences then contributed to positive perceptions of patient-physician interactions and increased job satisfaction among physicians who participated in the virtual observation unit.

Conclusion: Physicians who staffed the virtual observation unit in our context reported largely positive experiences. Policymakers and administrators should consider benefits to physician wellbeing and cultivating interprofessional and interspecialty care when making decisions about funding telehealth and care models like the virtual observation unit.