The impact of emergency department crowding on outcomes, other aspects should not be ignored
Correspondence
Contents lists available at ScienceDirect
American Journal of Emergency Medicine
journal homepage:
Treatment of ED patients with bacteriuria/
pyuria of clinically undetermined significance?
To the Editor:
In the study by Jorgensen et al. of patients with emergency depart- ment (ED) visits for supposed urinary tract infection, who did or did not have a return visit within 30 days, a strikingly high proportion of pa- tients presented initially with only non-specific (40.3%) or no (14.6%) symptoms [1]. It would be of interest to know what proportion of such patients had abnormal physical findings or laboratory results sug- gesting infection, vs. lacked all suggestive indicators of infection. The lat- ter group would qualify for the newly coined designation “bacteriuria/ pyuria of clinically undetermined significance” (BPCUS), for which opti- mal management is undefined, given the absence of relevant epidemio- logical studies and clinical trials [2]. Whereas Jorgensen et al. advocate for use of an ED-specific, urine-only antibiogram to guide antibiotic choice in the ED as a way to reduce drug-bug mismatch, an equally or possibly even more fruitful response to these findings might be (i) to find ways to reduce unnecessary antimicrobial therapy for non-infec- tions and (ii) to determine whether patients with BPCUS derive net ben- efit or harm from antimicrobial therapy.
James R. Johnson, MD
VA Medical Center and Department of Medicine, University of Minnesota,
Minneapolis, MN, United States Corresponding author at: Infectious Diseases (111F), VA Medical Center, 1 Veterans Drive, Minneapolis, MN 55417, United States
E-mail address: [email protected].
30 June 2017
http://dx.doi.org/10.1016/j.ajem.2017.07.057
Jorgensen S, Zurayk M, Yeung S, et al. Risk factors for early return visits to the emer- gency department in patientswith urinary tract infection. Am J Emerg Med 2017. http://dx.doi.org/10.1016/j.ajem.2017.06.041.
? This work was supported in part by Office of research and development, Department of Veterans Affairs (2I01CX000920-04). The opinions expressed are strictly those of the author and not those of his institution or the Department of Veterans Affairs.
Clinically significant bacteria/pyuria-the author responds
To the Editor,
We thank Dr. Johnson for bringing attention to the syndrome he has coined as “bacteriuria/pyuria of clinically undetermined significance (BPCUS)” [1]. We agree that patients with bacteriuria/pyuria and non-specific signs and symptoms should be considered in a different category as those with localized urinary tract specific signs and symptoms and hence we grouped patients accordingly in our analysis. Although over 40% of our cohort appear to meet the definition of BPCUS, our study was not designed to deter- mine its prevalence nor management. It is possible that an equal proportion was not given a diagnosis of urinary tract infection and was followed up closely without antibiotic treatment; however, these patients were not cap- tured in our analysis since we used ICD coding to identify study patients. In addition, some of those patients may have a dampened host immune re- sponse to infection that contributed to the nonspecific nature of their UTI pre- sentation. Nonetheless, to address the concerns expressed for under or over treatment in patients with BPCUS, we agree that this syndrome deserves to be studied further in prospective randomized trials to understand the epide- miology, differences in the underlying host immune response based on mea- surable immune biomarkers, treatment approach, and outcomes.
S. Jorgensen
A. Wong-Beringer*
Department of Pharmacy, Huntington Hospital, 100 W California Blvd,
Pasadena, CA 91105, United States University of Southern California, School of Pharmacy, 1985 Zonal Ave, Los
Angeles, CA 90089, United States
*Corresponding author at: University of Southern California, School of
Pharmacy, United States.
E-mail address: [email protected] (A. Wong-Beringer).
14 July 2017
http://dx.doi.org/10.1016/j.ajem.2017.07.060
[1] Johnson JR. Treatment of ED patients with bacteriuria/pyuria of clinically undetermined significance. Am J Emerg Med 2017. http://dx.doi.org/10.1016/j.ajem.2017.07.057. Pub- lished online July 17, 2017.
The impact of emergency department crowding on outcomes, other aspects should not be ignored
Keywords:
Sepsis Severe sepsis
Emergency department(ED) Crowding
early interventions, Mortality
0735-6757/
To the Editor,
We read with interest the study by Gaieski and colleagues [1]. The authors concluded that as emergency department (ED) crowding in- creased, the time to administer critical severe sepsis therapies signifi- cantly increased and protocolised care initiation decreased. Although the study sounds scientific, in our opinion, some issues in the report de- serve to be discussed and clarified.
First, the authors claimed that they defined the protocolised resuscita-
tion strategy based on 6 referred studies in their report. However, in the re- ferred ProCESS study [2], 2 different protocol-based therapies (protocol- based EGDT and protocol-based Standard therapy) were applied, and in an- other study [3] which was a review, different components and forms of EGDT (protocol-based therapies) were discussed. This leads to the ques- tion: Which protocol-based therapy did the authors really administer in their study? They should better clarify this critically important point.
Second, there was some discordance between the content of the text and a table in the paper. In line 4 of paragraph 1 on page 4, the value 50.2% should be 50.5% according to Table 2. Similarly, in line 6 of para- graph 1 on page 6, the value should be 20.8% (calculated by subtracting 50.5% from 71.3%) rather than 21.3%.
Third, the study found an interesting phenomenon that the delivery of protocolised care increased as ED occupancy (one index of ED crowding) increased. This seemed to be contradictory, as we usually surmise that the more crowded an ED is, the more unlikely that time-consuming protocolised therapies will be delivered. The authors tried to interpret this abnormal phenomenon by the statement: “During times of decreased ED occupancy, patients may move directly to the ICU to receive protocolised care.” We do not agree with this point, as the ratio of critical care patients who satisfy the criterion for ICU admission will not significantly change in a given time period. ED occupancy that contributed to greater delivery of protocolised care might be due to the fact that the total number of patients who accessed the ED increased as ED occupancy increased, even though the ratio of ED patients who received protocolised therapies might decrease.
Fourth, the authors chose four parameters (occupancy, waiting patients, admitted patients, and patient-hours) to measure ED crowding; however, ED crowding not only depends on the conditions of the patients, but also on the available medical resources. ED crowding could be acceptably defined as “the need for emergency services ex- ceeds available resources for patient care in the ED, hospital, or both” or “inadequate resources to meet patient demands lead to a reduction in the quality of care.” [4] Thus, factors such as the capacity of physi- cians, Triage nurses, and laboratories; [5] additional medical personnel; Observation Units; hospital bed access; non-urgent referrals; and ambu- lance diversion [6] should also be considered and analysed in this study. The last, we appreciate Gaieski et al. for their innovative and mean- ingful study on the impact of ED crowding on early interventions and mortality in patients with severe sepsis though some minor issues need to be discussed and improved. Therefore, further more rigorous
studies are still warranted.
Abbreviations
ED emergency department EGDT Early Goal Directed Therapy ICU Intensive Care Unit
Declarations
Ethical approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Availability of supporting data
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Funding
YY was supported by a grant from Guangdong Provincial Depart- ment of Science and Technology (Grant number: 2015A020210093). JL was funded by a grant from the Traditional Chinese Medicine (TCM) Guideline for Preventing and Treating Sepsis group: (fund number: SATCM-2014-BZ (182)), which was supported by the State Administra- tion of Traditional Chinese Medicine of the P.R.C (SATCM). The funding sources had no role in the preparation, drafting, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Acknowledgements
None.
Xianshi Zhou, MD* Zhongde Zhang, MD
Jun Li, MD Ye Ye, MD
Guanghua Tang, PhD Banghan Ding, PhD
Emergency Department, Guangdong Provincial Hospital of Chinese Medicine, affiliated to Guangzhou University of Chinese Medicine,
Guangzhou 510120, China
?Corresponding author at: Department of Emergency, Guangdong Provincial Hospital of Chinese Medicine, 111 Dade Road, Yuexiu District,
Guangzhou 510120, China. Email addresses: [email protected] (X. Zhou) [email protected] (Z. Zhang), [email protected] (G. Tang)
[email protected] (B. Ding)
6 May 2017
http://dx.doi.org/10.1016/j.ajem.2017.07.010
References
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