Impact of ED Organization with a Holding Area and a Dedicated Team on the Adherence to International Guidelines for Patients with Acute Pulmonary Embolism: Experience of an Emergency Department Organized in Areas of Intensity of Care

Abstract

Background and Objectives: Adherence to guidelines by physicians of an emergency department (ED) depends on many factors: guideline and environmental factors; patient and practitioner characteristics; the social-political context. We focused on the impact of the environmental influence and of the patients’ characteristics on adherence to the guidelines. It is our intention to demonstrate how environmental factors such as ED organization more affect adherence to guidelines than the patient’s clinical presentation, even in a clinically insidious disease such as pulmonary embolism (PE). Materials and Methods: A single-center observational study was carried out on all patients who were seen at our Department of Emergency and Acceptance from 1 January to 31 December 2017 for PE. For the assessment of adherence to guidelines, we used the European guidelines 2014 and analyzed adherence to the correct use of clinical decision rule (CDR as Wells, Geneva, and YEARS); the correct initiation of heparin therapy; and the management of patients at high risk for short-term mortality. The primary endpoint of our study was to determine whether adherence to the guidelines as a whole depends on patients’ management in a holding area. The secondary objective was to determine whether adherence to the guidelines depended on patient characteristics such as the presence of typical symptoms or severe clinical features (massive pulmonary embolism; organ damage). Results: There were significant differences between patients who passed through OBI and those who did not, in terms of both administration of heparin therapy alone (p = 0.007) and the composite endpoints of heparin therapy initiation and observation/monitoring (p = 0.004), as indicated by the guidelines. For the subgroups of patients with massive PE, organ damage, and typical symptoms, there was no greater adherence to the decision making, administration of heparin therapy alone, and the endpoints of heparin therapy initiation and guideline-based observation/monitoring. Conclusion: Patients managed in an ED holding area were managed more in accordance with the guidelines than those who were managed only in the visiting ED rooms and directly hospitalized from there.

Trauma-Induced Coagulopathy: Overview of an Emerging Medical Problem from Pathophysiology to Outcomes

“…We can therefore observe that these patients have worse clinical outcomes and require more hospital and pre-hospital resources. As demonstrated with other pathologies as well, the lack of early recognition and treatment aggravates the outcome [129][130][131][132][133][134].…”

Mild Head Trauma: Is Antiplatelet Therapy a Risk Factor for Hemorrhagic Complications?

“…The literature contains much debate as to whether APT predisposes to bleeding in the event of mild head trauma [ 1 , 12 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 ]. Our study indicates that APT is not related to a higher risk of bleeding, but it is related to a more severe clinical condition when bleeding does occur.…”

“…In patients receiving APT, unfavorable conditions related to MHI, particularly the need for neurosurgery and hospitalization, are predictable. Patients receiving APT also need a longer stay in the ED, and longer lengths of stay are correlated with worse outcomes [ 57 , 65 , 66 ]. These patients, therefore, have complex problems, and during triage, it seems appropriate that they are classified as patients at greater risk.…”

How the coronavirus disease 2019 pandemic changed the patterns of healthcare utilization by geriatric patients and the crowding: a call to action for effective solutions to the access block

“…Several past researchers and research communities have developed measures to prevent ED crowding and provide appropriate care for patients receiving emergency care. Interventions were categorized into input, throughput, and output controls [7,[11][12][13][14]. In particular, the American College of Physicians (ACEP) recently identified ED boarding and access block as "the primary [causes] of ED crowding" [31].…”

“…ED crowding has been extensively discussed for several decades, with various suggestions about interventions to reduce the ED crowding [ 11 – 13 ]. Presently, the most frequent cause of overcrowding is access block.…”