Flushing of an intravenous catheter: a cause for unreliable laboratory results

Introduction: Phlebotomy is an error-prone process in which mistakes are difficult to reveal. This case report describes the effect on laboratory results originating from a blood sample collected in close proximity to an intravenous catheter. Materials and methods: A 69-year-old male patient was referred to the Emergency department where pneumonia was suspected. Phlebotomy was performed to collect blood samples to assess electrolytes, renal function, liver function, infection and haematological parameters. Results: The laboratory analysis showed reduced potassium and calcium concentrations. To prevent life-threatening cardiac failure the clinician decided to correct those electrolytes. Remarkably, the electrocardiogram showed no abnormalities corresponding to hypokalaemia and hypocalcaemia. This observation, in combination with an overall increase in laboratory parameters with the exception of sodium and chloride, led to the suspicion of a preanalytical error. Retrospectively, an intravenous catheter was inserted in close proximity of the puncture place but no continuous infusion was started prior to phlebotomy. However, the intravenous catheter was flushed with sodium chloride. Since potential other causes were excluded, the flushing of the intravenous catheter with sodium chloride prior to phlebotomy was the most probable cause for the deviating laboratory results and subsequently for the unnecessary potassium and calcium suppletion. Conclusion: This case underlines the importance of caution in the interpretation of laboratory results obtained from specimens that are collected in the proximity of an intravenous catheter, even in the absence of continuous infusion

Recognition of Critically Ill Patients by Acute Healthcare Providers: A Multicenter Observational Study∗

OBJECTIVES: Although the Modified Early Warning Score (MEWS) is increasingly being used in the acute care chain to recognize disease severity, its superiority compared with clinical gestalt remains unproven. Therefore, the aim of this study was to compare the accuracy of medical caregivers and MEWS in predicting the development of critical illness. DESIGN: This was a multicenter observational prospective study. SETTING: It was performed in a level-1 trauma center with two different sites and emergency departments (EDs) with a combined capacity of about 50.000 patients annually. PATIENTS: It included all adult patients presented to the ED by Emergency Medical Services (EMS). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: For all patients, the acute caregivers were asked several standardized questions regarding clinical predicted outcome (clinical gestalt), and the MEWS was calculated. The primary outcome was the occurrence of critical illness, defined as ICU admission, serious adverse events, and mortality within 72 hours. The sensitivity, specificity, and discriminative power of both clinical gestalt and MEWS for the occurrence of critical illness were calculated as the area under the receiver operating characteristic curve (AUROC). Among the total of 800 included patients, 113 patients (14.1%) suffered from critical illness. The specificity for predicting three-day critical illness for all caregivers (for EMS nurses, ED nurses, and physicians) was 93.2%; 97.3%, and 96.8%, respectively, and was significantly (p < 0.01) better than an MEWS score of 3 or higher (70.4%). The sensitivity was significantly lower for EMS and ED nurses, but not significantly different for physicians compared with MEWS. The AUROCs for prediction of 3-day critical illness by both the ED nurses (AUROC = 0.809) and the physicians (AUROC = 0.848) were significantly higher (p = 0.032 and p = 0.010, respectively) compared with MEWS (AUROC = 0.731). CONCLUSIONS: For patients admitted to the ED by EMS, medical professionals can predict the development of critical illness within 3 days significantly better than the MEWS. Although MEWS is able to correctly predict those patients that become critically ill, its use leads to overestimation due to a substantial number of false positives

Comparing complaint-based triage scales and early warning scores for emergency department triage

Background: Emergency triage systems are used globally to prioritise care based on patients' needs. These systems are commonly based on patient complaints, while the need for timely interventions on regular hospital wards is usually assessed with early warning scores (EWS). We aim to directly compare the ability of currently used triage scales and EWS scores to recognise patients in need of urgent care in the ED. Methods: We performed a retrospective, single-centre study on all patients who presented to the ED of a Dutch Level 1 trauma centre, between 1 September 2018 and 24 June 2020 and for whom a Netherlands Triage System (NTS) score as well as a Modified Early Warning Score (MEWS) was recorded. The performance of these scores was assessed using surrogate markers for true urgency and presented using bar charts, cross tables and a paired area under the curve (AUC). Results: We identified 12 317 unique patient visits where NTS and MEWS scores were documented during triage. A paired comparison of the AUC of these scores showed that the MEWS score had a significantly better AUC than the NTS for predicting the need for hospital admission (0.65 vs 0.60; p<0.001) or 30-day all-cause mortality (0.70 vs 0.60; p<0.001). Furthermore, when non-urgent MEWS scores co-occur with urgent NTS scores, the MEWS score seems to more accurately capture the urgency level that is warranted. Conclusions: The results of this study suggest that EWSs could potentially be used to replace the current emergency triage systems

A pre-hospital risk score predicts critical illness in non-trauma patients transported by ambulance to a Dutch tertiary referral hospital

Background: Early pre-hospital identification of critically ill patients reduces morbidity and mortality. To identify critically ill non-traumatic and non-cardiac arrest patients, a pre-hospital risk stratification tool was previously developed in the United States. The aim of this study was to investigate the accuracy of this tool in a Dutch Emergency Department. Methods: This retrospective study included all patients of 18 years and older transported by ambulance to the Emergency Department of a tertiary referral hospital between January 1st 2017 and December 31st 2017. Documentation of pre-hospital vital parameters had to be available. The tool included a full set of vital parameters, which were categorized by predetermined thresholds. Study outcome was the accuracy of the tool in predicting critical illness, defined as admittance to the Intensive Care Unit for delivery of vital organ support or death within 28 days. Accuracy of the risk stratification tool was measured with the Area Under the Receiver Operating Characteristics (AUROC) curve. Results: Nearly 3000 patients were included in the study, of whom 356 patients (12.2%) developed critical illness. We observed moderate discrimination of the pre-hospital risk score with an AUROC of 0.74 (95%-CI 0.71–0.77). Using a threshold of 3 to identify critical illness, we observed a sensitivity of 45.0% (95%-CI 44.8–45.2) and a specificity of 86.0% (95%-CI 85.9–86.0). Conclusion: These data show that this pre-hospital risk stratification tool is a moderately effective tool to predict which patients are likely to become critically ill in a Dutch non-trauma and non-cardiac arrest population

A pre-hospital risk score predicts critical illness in non-trauma patients transported by ambulance to a Dutch tertiary referral hospital

Background: Early pre-hospital identification of critically ill patients reduces morbidity and mortality. To identify critically ill non-traumatic and non-cardiac arrest patients, a pre-hospital risk stratification tool was previously developed in the United States. The aim of this study was to investigate the accuracy of this tool in a Dutch Emergency Department. Methods: This retrospective study included all patients of 18 years and older transported by ambulance to the Emergency Department of a tertiary referral hospital between January 1st 2017 and December 31st 2017. Documentation of pre-hospital vital parameters had to be available. The tool included a full set of vital parameters, which were categorized by predetermined thresholds. Study outcome was the accuracy of the tool in predicting critical illness, defined as admittance to the Intensive Care Unit for delivery of vital organ support or death within 28 days. Accuracy of the risk stratification tool was measured with the Area Under the Receiver Operating Characteristics (AUROC) curve. Results: Nearly 3000 patients were included in the study, of whom 356 patients (12.2%) developed critical illness. We observed moderate discrimination of the pre-hospital risk score with an AUROC of 0.74 (95%-CI 0.71–0.77). Using a threshold of 3 to identify critical illness, we observed a sensitivity of 45.0% (95%-CI 44.8–45.2) and a specificity of 86.0% (95%-CI 85.9–86.0). Conclusion: These data show that this pre-hospital risk stratification tool is a moderately effective tool to predict which patients are likely to become critically ill in a Dutch non-trauma and non-cardiac arrest population

Older patients’ perspectives on factors contributing to frequent visits to the emergency department: a qualitative interview study

Background: Older patients are at high risk of unplanned revisits to the emergency department (ED) because of their medical complexity. To reduce the number of ED visits, we need more knowledge about the patient-level, environmental, and healthcare factors involved. The aim of this study was to describe older patients’ perspectives and experiences before and after an ED visit, and to identify factors that possibly contribute to frequent ED revisits. Methods: This was a qualitative description study. We performed semi-structured individual interviews with older patients who frequently visited the ED and were discharged home after an acute visit. Patients were enrolled in the ED of a university medical centre using purposive sampling. Interviews were recorded, transcribed, and coded independently by two researchers. Theoretical analysis was used to identify recurring patterns and themes in the data. Interviews were conducted until thematic saturation was reached. Results: In-depth interviews were completed with 13 older patients. Three main themes emerged: 1) medical events leading to feelings of crisis, 2) patients’ untreated health problems, and 3) persistent problems in health and daily functioning post discharge. Participants identified problems before and after their ED visit that possibly contributed to further ED visits. These problems included increasing symptoms leading to feelings of crisis, the relationship with the general practitioner, incomplete discharge information at the ED, and inadequate follow-up and lack of recovery after an ED visit. Conclusions: This qualitative study identified multiple factors that may contribute to frequent ED visits among older patients. Older patients in need of acute care might benefit from hospital-at-home interventions, or acute care provided by geriatric emergency teams in the primary care setting. Identifying frailty in the ED is needed to improve discharge communication and adequate follow-up is needed to improve recovery after an acute ED visit

Older patients’ perspectives on factors contributing to frequent visits to the emergency department: a qualitative interview study

Background: Older patients are at high risk of unplanned revisits to the emergency department (ED) because of their medical complexity. To reduce the number of ED visits, we need more knowledge about the patient-level, environmental, and healthcare factors involved. The aim of this study was to describe older patients’ perspectives and experiences before and after an ED visit, and to identify factors that possibly contribute to frequent ED revisits. Methods: This was a qualitative description study. We performed semi-structured individual interviews with older patients who frequently visited the ED and were discharged home after an acute visit. Patients were enrolled in the ED of a university medical centre using purposive sampling. Interviews were recorded, transcribed, and coded independently by two researchers. Theoretical analysis was used to identify recurring patterns and themes in the data. Interviews were conducted until thematic saturation was reached. Results: In-depth interviews were completed with 13 older patients. Three main themes emerged: 1) medical events leading to feelings of crisis, 2) patients’ untreated health problems, and 3) persistent problems in health and daily functioning post discharge. Participants identified problems before and after their ED visit that possibly contributed to further ED visits. These problems included increasing symptoms leading to feelings of crisis, the relationship with the general practitioner, incomplete discharge information at the ED, and inadequate follow-up and lack of recovery after an ED visit. Conclusions: This qualitative study identified multiple factors that may contribute to frequent ED visits among older patients. Older patients in need of acute care might benefit from hospital-at-home interventions, or acute care provided by geriatric emergency teams in the primary care setting. Identifying frailty in the ED is needed to improve discharge communication and adequate follow-up is needed to improve recovery after an acute ED visit