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ObjectiveThe aim of this study was to evaluate the diagnostic accuracy of bedside lung ultrasound and chest radiography (CXR) in patients with suspected pneumonia compared with CT scan and final diagnosis at discharge.DesignA prospective clinical study.MethodsLung ultrasound and CXR were performed in sequence in adult patients admitted to the emergency department (ED) for suspected pneumonia. A chest CT scan was performed during hospital stay when clinically indicated.Results120 patients entered the study. A discharge diagnosis of pneumonia was confirmed in 81 (67.5%). The first CXR was positive in 54/81 patients (sensitivity 67%; 95% CI 56.4% to 76.9%) and negative in 33/39 (specificity 85%; 95% CI 73.3% to 95.9%), whereas lung ultrasound was positive in 80/81 (sensitivity 98%; 95% CI 93.3% to 99.9%) and negative in 37/39 (specificity 95%; 95% CI 82.7% to 99.4%). A CT scan was performed in 30 patients (26 of which were positive for pneumonia); in this subgroup the first CXR was diagnostic for pneumonia in 18/26 cases (sensitivity 69%), whereas ultrasound was positive in 25/26 (sensitivity 96%). The feasibility of ultrasound was 100% and the examination was always performed in less than 5 min.ConclusionsBedside chest ultrasound is a reliable tool for the diagnosis of pneumonia in the ED, probably being superior to CXR in this setting. It is likely that its wider use will allow a faster diagnosis, conducive to a more appropriate and timely therapy.

During the COVID-19 pandemic, the number of individuals needing hospital admission has sometimes exceeded the availability of hospital beds. Since hospitalization can have detrimental effects on older individuals, preference has been given to younger patients. The aim of this study was to assess the utility of hospitalization for elderly affected by COVID-19. We hypothesized that their mortality decreases when there is greater access to hospitals. This study examined 1902 COVID-19 patients consecutively admitted to three large hospitals in Milan, Italy. Overall mortality data for Milan from the same period was retrieved. Based on emergency department (ED) data, both peak and off-peak phases were identified. The percentage of elderly patients admitted to EDs during these two phases were compared by calculating the standardized mortality ratio (SMR) of the individuals younger than, versus older than, 80 years. The median age of the patients hospitalized during the peak phase was lower than the median age during the off-peak phase (64 vs. 75 years, respectively; p <0.001). However, while the SMR for the younger patients was lower during the off-peak phase (1.98, 95% CI: 1.72-2.29 versus 1.40, 95% CI: 1.25-1.58, respectively), the SMR was similar between both phases for the elderly patients (2.28, 95% CI: 2.07-2.52 versus 2.48, 95% CI: 2.32-2.65, respectively). Greater access to hospitals during an off-peak phase did not affect the mortality rate of COVID-19-positive elderly patients in Milan. This finding, if confirmed in other settings, should influence future decisions regarding resource management of health care organizations.

The diffusion of the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) worldwide prompted the World Health Organization to declare the status of pandemic. The molecular diagnosis of SARS-CoV-2 infection is based on the detection of viral RNA on different biological specimens. Unfortunately, the test may require several hours to be performed. In the present study, we evaluated the diagnostic accuracy of lung point-of-care ultrasound (POCUS) for SARS-CoV-2 pneumonia in a cohort of symptomatic patients admitted to one emergency department (ED) in a high-prevalence setting. This retrospective study enrolled all patients who visited one ED with suspected respiratory infection in March 2020. All the patients were tested (usually twice if the first was negative) for SARS-CoV-2 on ED admission. The reference standard was considered positive if at least one specimen was positive. If all the specimens tested negative, the reference was considered negative. Diagnostic accuracy was evaluated using sensitivity, specificity, and positive and negative predictive value. Of the 444 symptomatic patients who were admitted to the ED in the study period, the result of the lung POCUS test was available for 384 (86.5%). The sensitivity of the test was 92.0% (95% CI 88.2–94.9%), and the specificity was 64.9% (95% CI 54.6–74.4%). We observed a prevalence of SARS-CoV-2 infection of 74.7%. In this setting, the positive and negative predicted values were 88.6% (95% CI 84.4–92.0) and 73.3% (95% CI 62.6–82.2%), respectively. Lung POCUS is a sensitive first-line screening tool for ED patients presenting with symptoms suggestive of SARS-CoV-2 infection.

Background: he surge in the use of Pre-hospital Emergency Medical Systems (EMS) and Emergency Departments (ED) has become a pressing issue worldwide after the COVID-19 pandemic. To address this challenge, we developed an experimental and innovative care pathway supported by telemedicine. The aim of this study is to describe the activity of the Integrated Medical Center (CMI): a new telemedicine-based care model for patients referring to the Emergency Medical System. Methods: A prospective observational study was conducted from January 2022 to December 2022. The CMI was established to manage patients referring to the Emergency Medical System. Results: From January to December 2022, a total of 8680 calls were managed by CMI, with an average of 24 calls per day. 6243 patients (71.9%) were managed without ED access of whom 4884 patients (78.2%) were managed through telemedicine evaluation only, and 1359 (21.8%) with telemedicine evaluation and dispatch of the Home Rapid Response Team (HRRT). The population treated by the HRRT exhibited a higher age. The mean satisfaction score was 9.1/10. Conclusions: Telemedicine evaluation allowed for remote assessments, treatment prescriptions, and teleconsultation for HRRT and was associated with high patient satisfaction. This model could be useful in future pandemics for managing patients with non-urgent illnesses at home, preventing hospital admissions for potentially infectious patients, and thereby reducing in-hospital transmission.

Background The progressive aging of the population and the increasing complexity of health issues contribute to a growing number of older individuals seeking emergency care. This study aims to assess the state of the art of care provided to older people in the Emergency Departments of Lombardy, the most populous region in Italy, counting over 2 million people aged 65 years and older. Methods An online cross-sectional survey was developed and disseminated among emergency medicine physicians and physicians affiliated to the Lombardy section of the Italian Society of Geriatrics and Gerontology (SIGG), during June and July 2023. The questionnaire covered hospital profiles, geriatric consultation practices, risk assessment tools, discharge processes and perspectives on geriatric emergency care. Results In this mixed method research, 219 structured interviews were collected. The majority of physicians were employed in hospitals, with 54.7% being geriatricians. Critical gaps in older patient’s care were identified, including the absence of dedicated care pathways, insufficient awareness of screening tools, and a need for enhanced professional training. Conclusions Tailored protocols and geriatric educational programs are crucial for improving the quality of emergency care provided to older individuals. These measures might also help relieve the burden on the Emergency Departments, thereby potentially enhancing overall efficiency and ensuring better outcomes.

ObjectivesThe fragmentation of the response to the COVID-19 pandemic at national, regional and local levels is a possible source of variability in the impact of the pandemic on society. This study aims to assess how much of this variability affected the burden of COVID-19, measured in terms of all-cause 2020 excess mortality.DesignEcological retrospective study.SettingLombardy region of Italy, 2015–2020.Outcome measuresWe evaluated the relationship between the intensity of the epidemics and excess mortality, assessing the heterogeneity of this relationship across the 91 districts after adjusting for relevant confounders.ResultsThe epidemic intensity was quantified as the COVID-19 hospitalisations per 1000 inhabitants. Five confounders were identified through a directed acyclic graph: age distribution, population density, pro-capita gross domestic product, restriction policy and population mobility.Analyses were based on a negative binomial regression model with district-specific random effects. We found a strong, positive association between COVID-19 hospitalisations and 2020 excess mortality (p<0.001), estimating that an increase of one hospitalised COVID-19 patient per 1000 inhabitants resulted in a 15.5% increase in excess mortality. After adjusting for confounders, no district differed in terms of COVID-19-unrelated excess mortality from the average district. Minimal heterogeneity emerged in the district-specific relationships between COVID-19 hospitalisations and excess mortality (6 confidence intervals out of 91 did not cover the null value).ConclusionsThe homogeneous effect of the COVID-19 spread on the excess mortality in the Lombardy districts suggests that, despite the unprecedented conditions, the pandemic reactions did not result in health disparities in the region.

Background There is no ubiquitous definition of Emergency Department (ED) crowding and several indicators have been proposed to measure it. The National ED Overcrowding Study (NEDOCS) score is among the most popular, even though it has been severely criticised. We used the waiting time for the physician’s initial assessment to evaluate the performance of the NEDOCS and proposed a new crowding indicator based on this objective measure. Methods To evaluate the NEDOCS, we used the 2022 data of all the Lombardy EDs and compared the distribution of waiting times across the five levels of the NEDOCS at ED arrival. To construct the new indicator, we estimated the centre-specific relationship between the total number of ED patients and the waiting time of those with minor or deferrable urgency. We defined seven classes of waiting times and calculated how many patients corresponded to an average waiting time in the classes. These centre-specific cutoffs were used to define the 7-level crowding indicator. The indicator was then compared to the NEDOCS score and validated on the first six months of 2023 data. Results Patients’ waiting time did not increase at the increase of the NEDOCS score, suggesting the absence of a relationship between this score and the effect of ED crowding on the ED capacity of evaluating new patients. The indicator we propose is easy to estimate in real-time and based on centre-specific cutoffs, which depend on the volume of yearly accesses. We observed minimal agreement between the proposed indicator and the NEDOCS in most EDs, both in the development and validation datasets. Conclusions We proposed to quantify ED crowding using the waiting time for physician’s initial assessment of patients with minor or deferrable urgency, which increases in crowding situations due to the prioritization of urgent patients. The centre-specific cutoffs avoid the problem of the heterogeneity of the volume of accesses and organization among EDs, while enabling a fair comparison between centres.

Regarding ultrasound evaluation of the tip position of the CVL in the intrathoracic vessels using B-mode, we can see the tip in the neck veins and only few centimeters before the entrance of superior vena cava (SVC) in right atrium (this means that the tip might be anywhere distal the brachiocephalic vein); in our study, CEUS could not differentiate the malpositioning of CVL in brachiocefalic vein as the delay of appearance compared with correct positioning in SVC is not detectable with visual extimation time of bubble appearance in right atrium (RA).

Sepsis is a rapidly evolving disease with a high mortality rate. The early identification of sepsis and the implementation of early evidence-based therapies have been recognized to improve outcome and decrease sepsis-related mortality. The aim of this study was to compare the accuracy of the standard diagnostic work-up of septic patients with an integrated approach using early point of care ultrasound (POCUS) to identify the source of infection and to speed up the time to diagnosis. We enrolled a consecutive sample of adult patients admitted to the ED who met the Surviving Sepsis Campaign (SSC) criteria for sepsis. For every patient, the emergency physician was asked to identify the septic source after the initial clinical assessment and after POCUS. Patients were then addressed to the standard predefined work-up. The impression at the initial clinical assessment and POCUS-implemented diagnosis was compared with the final diagnosis of the septic source, determined by independent review of the entire medical record after discharge. Two hundred consecutive patients entered the study. A final diagnosis of the septic source was obtained in 178 out of 200 patients (89 %). POCUS-implemented diagnosis had a sensitivity of 73 % (95 % CI 66–79 %), a specificity of 95 % (95 % CI 77–99 %), and an accuracy of 75 %. Clinical impression after the initial clinical assessment (T0) had a sensitivity of 48 % (CI 95 % 41–55 %) and a specificity of 86 % (CI 95 % 66–95 %). POCUS improved the sensitivity of the initial clinical impression by 25 %. POCUS-implemented diagnoses were always obtained within 10 min. Instead the septic source was identified within 1 h in only 21.9 % and within 3 h in 52.8 % with a standard work-up. POCUS-implemented diagnosis is an effective and reliable tool for the identification of septic source, and it is superior to the initial clinical evaluation alone. It is likely that a wider use of POCUS in an emergency setting will allow a faster diagnosis of the septic source, leading to more appropriate and prompt antimicrobial therapy and source control strategies.

Background/Objectives: Emergency department (ED) crowding has become a pressing global concern exacerbated by the COVID-19 pandemic. No studies have addressed this issue in Europe during the post-pandemic period so far. This study examined ED visit volumes, patient acuity, hospital admission rates, emergency vehicle arrivals, and crowding metrics before, during, and after the pandemic. Methods: We conducted a retrospective descriptive study including data on all ED visits in the Lombardy Region of Italy from January 2019 to December 2023. Furthermore, an inferential statistical analysis was performed to compare ED trends between 2019 and 2023. Results: During the analyzed period, there were 15,515,128 visits across all Lombardy EDs. ED visits dropped from 3,514,426 in 2019 to 2,380,005 in 2020, then rebounded to 3,464,756 in 2023. In 2019, triage code distribution was 9.9% white, 68.7% green, 19.0% yellow, and 1.9% red. During the pandemic, the proportion of white and green codes decreased. By 2023, these comprised 80.7% of the total. The percentage of admitted patients was 11.9% in 2019, rose to 16.2% in 2020, and returned to 11.4% in 2023. The median ED length of stay (EDLOS) for admitted patients in 2023 was 5.2 h (IQR [2.1–17.4]), compared to 3.8 h (IQR [1.6–8.6]) in 2019 (p-value < 0.01). The median EDLOS for discharged patients in 2023 was 2.7 h (IQR [1.4–4.9]), compared to 2.4 h (IQR [1.3–4.4]) in 2019 (p-value < 0.01). The rate of patients leaving before completing treatment was 5.0% in 2019 and peaked at 6.8% in 2023 (p-value < 0.01). Conclusions: In 2023, ED visits in Lombardy increased, compared to the pandemic period, but remained below 2019 levels. The proportion of high-acuity codes and hospital admissions was slightly lower than in 2019. However, ED crowding metrics worsened. The high levels of lower-acuity visits and the deterioration in crowding metrics highlight systemic challenges within the healthcare system.