No abstract

Key Points Question What is the ability of a host gene expression test to accurately discriminate bacterial from viral infection among patients with acute respiratory illness? Findings In this diagnostic study involving analysis of 616 children and adults with febrile acute respiratory illness of 7 or fewer days’ duration, the host response bacterial/viral test had up to 90% sensitivity, 82% specificity, and 98% negative predictive value for bacterial infection, which was significantly better than procalcitonin measurement. Meaning The study’s findings suggest that an accurate point-of-need host response test with high negative predictive value may identify patients unlikely to have bacterial infection, offering a better antibiotic stewardship strategy than is currently available.

OBJECTIVES: Evaluate the impact of an emergency department (ED)–based critical care consultation service, hypothesizing early consultation results in shorter hospital length of stay (LOS). DESIGN: Retrospective observational study from February 2018 to 2020. SETTING: An urban academic quaternary referral center. PATIENTS: Adult patients greater than or equal to 18 years admitted to the ICU from the ED. Exclusion criteria included age less than 18 years, do not resuscitate/do not intubate documented prior to arrival, advanced directives outlining limitations of care, and inability to calculate baseline modified Sequential Organ Failure Assessment (mSOFA) score. INTERVENTIONS: ED-based critical care consultation by an early intervention team (EIT) initiated by the primary emergency medicine physician compared with usual practice. MEASUREMENTS: The primary outcome was hospital LOS, and secondary outcomes were hospital mortality, ICU LOS, ventilator-free days, and change in the mSOFA. MAIN RESULTS: A total 1,764 patients met inclusion criteria, of which 492 (27.9%) were evaluated by EIT. Final analysis, excluding those without baseline mSOFA score, limited to 1,699 patients, 476 in EIT consultation group, and 1,223 in usual care group. Baseline mSOFA scores (± sd ) were higher in the EIT consultation group at 3.6 (±2.4) versus 2.6 (±2.0) in the usual care group. After propensity score matching, there was no difference in the primary outcome: EIT consultation group had a median (interquartile range [IQR]) LOS of 7.0 days (4.0–13.0 d) compared with the usual care group median (IQR) LOS of 7.0 days (4.0–13.0 d), p = 0.64. The median (IQR) boarding time was twice as long subjects in the EIT consultation group at 8.0 (5.0–15.0) compared with 4.0 (3.0–7.0) usual care, p < 0.001. CONCLUSIONS: An ED-based critical care consultation model did not impact hospital LOS. This model was used in the ED and the EIT cared for critically ill patients with higher severity of illness and longer ED boarding times.

Study Objectives: Out-of-hospital cardiac arrest is associated with higher survival rates when treated with early defibrillation. In cases of refractory ventricular fibrillation (v-fib), double sequential defibrillation (DSD) has been proposed as an effective alternative treatment. We aimed to track the outcomes after DSD for refractory v-fib in the field.Methods: Our county EMS system is one of the largest in our state. This analysis is a subset of our county EMS out-of-hospital IRB approved research registry that tracks all adult cardiac arrests. This dataset encompasses all patients in a 24-month period who underwent double sequential defibrillation after refractory v-fib. Refractory v-fib was defined as v-fib that did not convert after 3 full shocks.Results: A total of 31 cases met the criteria for refractory v-fib. The additional set of pads were placed in the antero-postero direction. The energy applied was 200J, and the shock-to-shock cycle time was less than 20 seconds. Seven patients achieved return of spontaneous circulation (ROSC) and six patients made it to hospital discharge (fig 1).Conclusion: Double sequential defibrillation is a viable option for patients in refractory v-fib in patients who would be otherwise dead. Our data demonstrates that DSD is feasible in the field and is associated with ROSC in 1 / 4 of cases, and with survival to hospital discharge in 1 out of every 5 cases.

Disclaimer: Due to the rapidly evolving nature of this outbreak, and in the interests of rapid dissemination of reliable, actionable information, this paper went through expedited peer review. Additionally, information should be considered current only at the time of publication and may evolve as the science develops.