Prevalence of Erectile Dysfunction and Associated Factors in Korean Older Adults With Coronary Artery Disease.

PubMed

Son, Youn-Jung; Jang, Miyoun; Jun, Eun-Young

2016-10-01

The current study aimed to identify the prevalence and associated factors of erectile dysfunction (ED) among 161 Korean adults 60 and older with coronary artery disease (CAD). ED was diagnosed in 72.2% of patients-the prevalence of which was significantly associated with age, education, employment, monthly income, frequency of sexual intercourse, body mass index, and low-density lipoprotein. Health-related quality of life (HRQoL) was lower in patients with ED than in those without ED (p < 0.001). Hierarchical multiple regression analysis revealed that ED significantly influenced HRQoL in patients with CAD after adjusting for sociodemographic and disease-related characteristic variables (p < 0.001). Interventions and training courses for health care providers should focus on improving caregivers' knowledge and communication skills with patients and spouses regarding sexual health. Furthermore, guidelines to improve HRQoL in patients with CAD should consider incorporating sexual counseling. [Journal of Gerontological Nursing, 42(10), 32-41.]. Copyright 2016, SLACK Incorporated.

RSV in adult ED patients: Do emergency providers consider RSV as an admission diagnosis?

PubMed

Binder, William; Thorsen, Jill; Borczuk, Pierre

2017-08-01

Respiratory Syncytial Virus (RSV) has been recognized for over half a century as a cause of morbidity in infants and children. Over the past 20years, data has emerged linking RSV as a cause of illness in adults resulting in 177,000 annual hospitalizations and up to 14,000 deaths among older adults. Characterize clinical variables in a cohort of adult RSV patients. We hypothesize that emergency physicians do not routinely consider RSV in the differential diagnosis (DDx) of influenza like illness. Observational study of all adult inpatients, age≥19, with a positive RSV swab ordered within 48h of their hospital visit, including their emergency department (ED) visit, and who initially presented to a university affiliated urban 100,000 annual visit emergency department from 2007 to 2014. A data collection form was created, and a single trained clinical research assistant abstracted demographic, clinical variables. ED providers were given credit for RSV DDx if an RSV swab was ordered as part of the diagnostic ED workup. 295 consecutive inpatients (mean age=66.5years, range, 19-97, 53% male) were RSV positive during the 7-year study period. 207 cases (70%) were age≥60. 76 (26%) had fever, 86 (29%) had O2sat <92% and 145 (49%) had wheezing. 279 patients required admission, 30 needed ICU stay and overall mortality was 12 patients (4%). Age≥60 was associated with overall mortality (p=0.09). There were 106 (36%) immunocompromised patients (23% transplant, 40% cancer, 33% steroid use) in the cohort. A diagnosis of RSV was considered in the ED in 105 (36%) of patients. Being immunocompromised, having COPD/asthma, O2sat <92, or wheezing did not alert the ED provider to order an RSV test. Adults can harbor RSV as this can lead to significant mobility and mortality, especially in individuals who are over the age of 60. RSV is not being considered in the DDx diagnosis, and this was especially surprising in the transplant/immunocompromised subgroups. Given antiviral treatment options, educational efforts should be undertaken to raise awareness of RSV in adults. Copyright © 2017 Elsevier Inc. All rights reserved.

Atypical presentations of dengue disease in the elderly visiting the ED.

PubMed

Lee, Ching-Chi; Hsu, Hsiang-Chin; Chang, Chia-Ming; Hong, Ming-Yuan; Ko, Wen-Chien

2013-05-01

The objective was to compare the clinical characteristics of elderly and young adult patients with dengue in the emergency department (ED). Demographic characteristics, clinical presentation, disease severity, laboratory characteristics, and outcomes were analyzed prospectively as a case-control study. Of the 193 adults with serologically confirmed dengue disease in 2007, 31 (16.1%) were elderly patients (aged ≥65) and 162 were young adults (aged <65). More dengue hemorrhagic fever (12.9% vs 2.5%, P = .02), a longer ED stay (13.3 vs 8.6 hours, P = .004), a longer hospital stay (7.4 vs 3.4 days, P < .001), a higher Simplified Acute Physiology Score II in the ED (29.7 vs 17.4, P < .001), and a higher rate of at least 1 comorbidity (61.8 vs 22.8%, P < .001) were found in the elderly. However, the length of the intensive care unit stay (elderly 0.7 vs young adults 0.3 day, P = .47) and the 14-day mortality rate (0% vs 0.6%, P = 1.00) were similar. Of note, in terms of clinical presentations of dengue in the ED, there were more elderly patients with isolated fever (41.9% vs 17.9%, P = .003) and fewer with typical presentation (41.9% vs 75.9%, P = <.001) than there were young adults. The present study found a higher number of atypical presentations, a longer hospitalization, and a higher degree of clinical illness in elderly patients with dengue. Copyright © 2013 Elsevier Inc. All rights reserved.

A multicenter observational study of US adults with acute asthma: who are the frequent users of the emergency department?

PubMed

Hasegawa, Kohei; Sullivan, Ashley F; Tovar Hirashima, Eva; Gaeta, Theodore J; Fee, Christopher; Turner, Stuart J; Massaro, Susan; Camargo, Carlos A

2014-01-01

Despite the substantial burden of asthma-related emergency department (ED) visits, there have been no recent multicenter efforts to characterize this high-risk population. We aimed to characterize patients with asthma according to their frequency of ED visits and to identify factors associated with frequent ED visits. A multicenter chart review study of 48 EDs across 23 US states. We identified ED patients ages 18 to 54 years with acute asthma during 2011 and 2012. Primary outcome was frequency of ED visits for acute asthma in the past year, excluding the index ED visit. Of the 1890 enrolled patients, 863 patients (46%) had 1 or more (frequent) ED visits in the past year. Specifically, 28% had 1 to 2 visits, 11% had 3 to 5 visits, and 7% had 6 or more visits. Among frequent ED users, guideline-recommended management was suboptimal. For example, of patients with 6 or more ED visits, 85% lacked evidence of prior evaluation by an asthma specialist, and 43% were not treated with inhaled corticosteroids. In a multivariable model, significant predictors of frequent ED visits were public insurance, no insurance, and markers for chronic asthma severity (all P < .05). Stronger associations were found among those with a higher frequency of asthma-related ED visits (eg, 6 or more ED visits). This multicenter study of US adults with acute asthma demonstrated many frequent ED users and suboptimal preventive management in this high-risk population. Future reductions in asthma morbidity and associated health care utilization will require continued efforts to bridge these major gaps in asthma care. Copyright © 2014 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.

Adolescent presentations to an adult hospital emergency department.

PubMed

Noori, Omar; Batra, Shweta; Shetty, Amith; Steinbeck, Katharine

2017-10-01

Age-related policies allow adolescents to access paediatric and adult EDs. Anecdotally, paediatric and adult EDs report challenges when caring for older and younger adolescents, respectively. Our aim was to describe the characteristics of an adolescent population attending an adult ED, co-located with a tertiary paediatric ED. The Westmead Hospital ED database was accessed for 14.5-17.9 years old presentations between January 2010 and December 2012. Patient diagnosis coding (SNOMED) was converted to ICD-10. De-identified data were transferred into Microsoft Excel with analysis performed using spss V22. There were 5718 presentations made to the Westmead Hospital, Sydney, Australia ED by 4450 patients, representing 3.3% (95% CI 3.2-3.4) of total visits from all patients 14.5 years and above. The mean age of the sample was 16.6 years (male 51.8%). Presentations triaged as level 4 or 5 represented 61.0% (95% CI 58.7-61.3) of visits. The proportion of patients who did not wait to receive care was 13.8% (95% CI 12.9-14.7), which was significantly higher than adult rates (P < 0.01). There were 279 unscheduled return visits (visits made <72 h of discharge) representing 4.9% (95% CI 4.4-5.8) of all presentations. Injury was the most common diagnosis (30.2%, 95% CI 28.8-31.6). Chronic physical illness and alcohol-related visits comprised 2.1% (95% CI 1.7-2.5) and 0.8% (95% CI 0.6-1.0) of adolescent presentations, respectively. Contrary to reported staff perceptions, adolescent chronic physical illness presentations were not a major burden. Alcohol was likely under-recorded as a contributing factor to presentations. © 2017 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

National study of health insurance type and reasons for emergency department use.

PubMed

Capp, Roberta; Rooks, Sean P; Wiler, Jennifer L; Zane, Richard D; Ginde, Adit A

2014-04-01

The rates of emergency department (ED) utilization vary substantially by type of health insurance, but the association between health insurance type and patient-reported reasons for seeking ED care is unknown. We evaluated the association between health insurance type and self-perceived acuity or access issues among individuals discharged from the ED. This was a cross-sectional analysis of the 2011 National Health Interview Survey. Adults whose last ED visit did not result in hospitalization (n = 4,606) were asked structured questions about reasons for seeking ED care. We classified responses as 1) perceived need for immediate evaluation (acuity issues), or 2) barriers to accessing outpatient services (access issues). We analyzed survey-weighted data using multivariable logistic regression models to test the association between health insurance type and reasons for ED visits, while adjusting for sociodemographic characteristics. Overall, 65.0% (95% CI 63.0-66.9) of adults reported ≥ 1 acuity issue and 78.9% (95% CI 77.3-80.5) reported ≥ 1 access issue. Among those who reported no acuity issue leading to the most recent ED visit, 84.2% reported ≥ 1 access issue. Relative to those with private insurance, adults with Medicaid (OR 1.05; 95% CI 0.79-1.40) and those with Medicare (OR 0.98; 95% CI 0.66-1.47) were similarly likely to seek ED care due to an acuity issue. Adults with Medicaid (OR 1.50; 95% CI 1.06-2.13) and Medicaid + Medicare (dual eligible) (OR 1.94; 95% CI 1.18-3.19) were more likely than those with private insurance to seek ED care for access issues. Variability in reasons for seeking ED care among discharged patients by health insurance type may be driven more by lack of access to alternate care, rather than by differences in patient-perceived acuity. Policymakers should focus on increasing access to alternate sites of care, particularly for Medicaid beneficiaries, as well as strategies to increase care coordination that involve ED patients and providers.

Exploring Older Adult ED Fall Patients' Understanding of Their Fall: A Qualitative Study.

PubMed

Shankar, Kalpana N; Taylor, Devon; Rizzo, Caroline T; Liu, Shan W

2017-12-01

We sought to understand older patients' perspectives about their fall, fall risk factors, and attitude toward emergency department (ED) fall-prevention interventions. We conducted semistructured interviews between July 2015 and January 2016 of community-dwelling, nondemented patients in the ED, who presented with a fall to an urban, teaching hospital. Interviews were halted once we achieve thematic saturation with the data coded and categorized into themes. Of the 63 patients interviewed, patients blamed falls on the environment, accidents, a medical condition, or themselves. Three major themes were generated: (1) patients blamed falls on a multitude of things but never acknowledged a possible multifactorial rationale, (2) patients have variable level of concerns regarding their current fall and future fall risk, and (3) patients demonstrated a range of receptiveness to ED interventions aimed at preventing falls but provided little input as to what those interventions should be. Many older patients who fall do not understand their fall risk. However, based on the responses provided, older adults tend to be more receptive to intervention and more concerned about their future fall risk, making the ED an appropriate setting for intervention.

Poor outcome and death among youth, young adults, and midlife adults with eating disorders: an investigation of risk factors by age at assessment.

PubMed

Ackard, Diann M; Richter, Sara; Egan, Amber; Cronemeyer, Catherine

2014-11-01

Eating disorders (EDs) present across a broad age range, yet little is known about the characteristics and outcome of midlife patients compared to younger patients. Among patients seeking ED treatment who were stratified by age at initial assessment (IA), this study aimed to (1) discern sociodemographic and clinical differences, (2) determine outcome rates, and (3) identify predictors of poor outcome including death. Participants [219 females (12 years or older, 94.1% Caucasian) who completed outcome assessment and 31 known decedents] were stratified by age at IA (<18 as youth, 18-39 as young adult, and ≥40 years as midlife adult). Analyses of variance and chi-square tests identified group differences; ordered logistic regression with stepwise selection identified factors predicting outcome. Midlife adults were more significantly compromised at follow-up compared to youths and young adults, including psychological and physical quality of life, ineffectiveness, interpersonal concerns, and general psychological maladjustment. Midlife adults had the highest rates of poor outcome or death; good outcome was achieved by only 5.9% of midlife adult compared to 14.0% of young adult and 27.5% of youth patients. Older age at IA, alcohol and/or drug misuse, endocrine concerns, and absence of family ED history predicted poor outcome or death. Midlife adults seeking ED treatment have more complex medical and psychological concerns and poorer outcomes than youths and young adults; further exploration is needed to improve treatment outcome. Specialized treatment focusing on quality of life, comorbid medical concerns, interpersonal connection, and emotion regulation is encouraged. © 2014 Wiley Periodicals, Inc.

Nonurgent Emergency Department Visits by Insured and Uninsured Adults.

PubMed

Searing, Lisabeth M; Cantlin, Kelly A

2016-01-01

To compare nonurgent emergency department (ED) visits by insured and uninsured adults in a Midwest community. Records for this secondary data analysis included 84,877 nonurgent visits to a Midwest ED from September 2004 to January 2012. Insured versus uninsured visits were analyzed using t tests for continuous variables and chi-squared tests for categorical variables. Standardized residuals were compared to determine if changes over time were statistically significant. Variables included demographic characteristics of patients, payment source, patients' access to primary care, acuity rating, time of visit, and the stated reason for the visit. Of all nonurgent visits, 77.9% were made by insured adults. Insured nonurgent visits were more often made by adults who were female, older, White, and had a primary care provider (PCP). Nonurgent visits on weekdays between the hours of 09:00 and 18:00 were more likely to be uninsured visits. Dental issues were the fourth most common issue for uninsured visits. Nonurgent ED visits occur when more appropriate options for prompt care are available in the community. Interventions should target both patients and PCPs. While patients should contact their PCP when in need of prompt care, PCPs should refer patients to facilities other than the ED when medically appropriate. © 2015 Wiley Periodicals, Inc.

Jejunostomy feeding tube

MedlinePlus

... in adult hospitalized patients. In: Goldman L, Schafer AI, eds. Goldman-Cecil Medicine . 25th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap 217. Read More Cerebral palsy Cystic fibrosis Esophageal cancer Failure to thrive HIV/AIDS Patient Instructions Crohn ...

Utilization of the emergency department by older residents in Kuala Lumpur, Malaysia.

PubMed

Mohd Mokhtar, Mohd Amin; Pin, Tan Maw; Zakaria, Mohd Idzwan; Hairi, Noran Naqiah; Kamaruzzaman, Shahrul Bahiyah; Vyrn, Chin Ai; Hua, Philip Poi Jun

2015-08-01

To determine the pattern of utilization of emergency department (ED) services by older patients in Kuala Lumpur, Malaysia, compared with younger patients in the same setting. The sociodemographics, clinical characteristics and resource utilization of consecutive patients attending the adult ED at the University Malaya Medical Center were recorded during a typical week. A total of 1649 patients were included in the study; 422/1649 (25.6%) were aged ≥60 years and 1077 (74.4%) were aged <60 years. Older adult patients were more likely to be diagnosed with ischemic heart disease (12.6% vs 2.5%, P < 0.001), and more likely to require investigations such as electrocardiogram (68.1% vs 16.6%, P < 0.001) or chest X-rays (67.6% vs 24.0%, P < 0.001) than their younger counterparts. Logistic regression methods showed that older adults remained an independent predictor of hospital admission (OR 2.75, 95% CI 2.11-3.57). The ratio of older adult patients attending our ED over the proportion of older people in the general population was 26:6, which is far higher than reported in previous published studies carried out in other countries. Older ED attenders are also more likely to require investigations, procedures and hospital admissions. With the rapidly aging population in Malaysia, reconfiguration of resources will need to occur at a compatible rate in order to ensure that the healthcare needs of our older adults are met. © 2014 Japan Geriatrics Society.

Older adult falls prevention behaviors 60 days post-discharge from an urban emergency department after treatment for a fall.

PubMed

Shankar, Kalpana Narayan; Treadway, Nicole J; Taylor, Alyssa A; Breaud, Alan H; Peterson, Elizabeth W; Howland, Jonathan

2017-12-01

Falls are a common and debilitating health problem for older adults. Older adults are often treated and discharged home by emergency department (ED)-based providers with the hope they will receive falls prevention resources and referrals from their primary care provider. This descriptive study investigated falls prevention activities, including interactions with primary care providers, among community-dwelling older adults who were discharged home after presenting to an ED with a fall-related injury. We enrolled English speaking patients, aged ≥ 65 years, who presented to the ED of an urban level one trauma center with a fall or fall related injury and discharged home. During subjects' initial visits to the ED, we screened and enrolled patients, gathered patient demographics and provided them with a flyer for a Matter of Balance course. Sixty-days post enrollment, we conducted a phone follow-up interview to collect information on post-fall behaviors including information regarding the efforts to engage family and the primary care provider, enroll in a falls prevention program, assess patients' attitudes towards falling and experiences with any subsequent falls. Eighty-seven community-dwelling people between the ages of 65 and 90 were recruited, the majority (76%) being women. Seventy-one percent of subjects reported talking to their provider regarding the fall; 37% reported engaging in falls prevention activities. No subjects reported enrolling in a fall prevention program although two reported contacting falls program staff. Fourteen percent of subjects (n=12) reported a recurrent fall and 8% (7) reported returning to the ED after a recurrent fall. Findings indicate a low rate of initiating fall prevention behaviors following an ED visit for a fall-related injury among community-dwelling older adults, and highlight the ED visit as an important, but underutilized, opportunity to mobilize health care resources for people at high risk for subsequent falls.

The association between crowding and mortality in admitted pediatric patients from mixed adult-pediatric emergency departments in Korea.

PubMed

Cha, Won Chul; Shin, Sang Do; Cho, Jin Sung; Song, Kyoung Jun; Singer, Adam J; Kwak, Young Ho

2011-12-01

We aimed to investigate the effect of crowding on the hospital mortality of pediatric patients from adult-pediatric mixed emergency departments (EDs). We used the National Emergency Department Information System database, which included demographic, clinical, diagnostic, and procedural information with all emergency patients visiting to 116 EDs from Korea since 2004. We enrolled EDs with mean length of stay of more than 6 hours. Study period was from January 2006 to December 2008. Pediatric patients younger than 15 years admitted from these EDs were study targets. We calculated the mean patient volume (mean number of patients in the ED) over 8-hour shift for each hospital. When the volume reached the highest quartile, the period was considered as crowded. Patients who came during the overcrowded period were defined as the crowded group. We performed a Kaplan-Meier analysis, and hazard ratio and 95% confidence intervals (95% CIs) were calculated using a Cox proportional hazards regression model. A total of 34 EDs and 125,031 admitted pediatric patients were included; 74,152 (59.3%) were male, and the mean age was 3.84 (95% CI, 3.82-3.86) years; 35,924 (28.7%) were determined as the crowded group. The 30-day mortality rates were 0.4% and 0.3% (P = 0.063) for the crowded group and for the noncrowded group, respectively. The hazard ratio for hospital mortality of the crowded group was 1.230 (95% CI, 1.019-1.558). The ED crowding was associated with increased hazard for hospital mortality for pediatric patients in mixed EDs.

Personality Traits Predict Emergency Department Utilization Over 3 Years in Older Patients

PubMed Central

Chapman, Benjamin P.; Shah, Manish; Friedman, Bruce; Drayer, Rebecca; Duberstein, Paul R.; Lyness, Jeffrey M.

2009-01-01

Background Emergency department (ED) utilization by older patients has major implications for morbidity, mortality, and health costs, yet its behavioral determinants remain poorly understood. Powerfully tied to health in older adults, the “Big Five” personality traits of neuroticism, extroversion, openness to experience, agreeableness, and conscientiousness may predict ED use. Objectives Investigate the role of personality in prospective ED use among older patients. Research Design Prospective cohort. Subjects Adults aged 65 and older. Measures Participants completed the NEO Five Factor Inventory of personality at baseline, and interviewers administered the Cornell Services Index assessing ED use at baseline and 3 yearly follow-ups. Results Controlling for income, education, gender, age, physician-assessed medical burden and physical functioning, and interviewer-assessed impairments in basic activities of daily living and physical self-maintenance, and depression, lower agreeableness and higher extroversion were each associated with increased odds of an ED visit over the follow-up period. A 1 sample deviation (SD) increase in extroversion (i.e., 50th versus 83rd population percentile) increased the odds of ED use by 51% (adjusted odds ratio [AOR] [95% CI] = 1.51 [1.03-2.21], z = 2.12, N = 923, p = 0.034). A 1-SD decrease in agreeableness (i.e., 50th versus 17th population percentile) increased odds of ED use by 54% (AOR [95% CI] = 1.54 [1.05-2.22], z = -2.25, N = 923, p = 0.034). Conclusion The greater assertiveness and social confidence signified by lower agreeableness and higher extroversion may help older adults overcome potential barriers to the ED. Overly introverted and agreeable older adults may require special encouragement to access the ED—particularly for time-sensitive conditions—to reduce morbidity and mortality. PMID:19461261

Management and educational status of adult anaphylaxis patients at emergency department.

PubMed

Kim, Mi-Yeong; Park, Chan Sun; Jeong, Jae-Won

2017-12-28

We evaluated the management and educational status of adult anaphylaxis patients at emergency departments (EDs). Anaphylaxis patients who visited ED from 2011 to 2013 were enrolled from three hospitals. We analyzed clinical features, prior history of anaphylaxis, management and provided education for etiology and/or prevention. For analyzing associated factors with epinephrine injection, Pearson chi-square test was used by SPSS version 21 (IBM Co.). A total of 194 anaphylaxis patients were enrolled. Ninety-nine patients (51%) visited ED by themselves. Time interval from symptom onset to ED visit was 62 ± 70.5 minutes. Drug (56.2%) was the most frequent cause of anaphylaxis. Forty-seven patients (24.2%) had prior history of anaphylaxis and 33 patients had same suspicious cause with current anaphylaxis. Cutaneous (88.7%) and respiratory (72.7%) symptoms were frequent. Hypotension was presented in 114 patients (58.8%). Mean observation time in ED was 12 ± 25.7 hours and epinephrine was injected in 114 patients (62%). In 68 patients, epinephrine was injected intramuscularly with mean dose of 0.3 ± 0.10 mg. Associated factor with epinephrine injection was hypotension (p = 0.000). Twenty-three patients (13%) were educated about avoidance of suspicious agent. Epinephrine auto-injectors were prescribed only in five patients. Only 34 (19%) and 72 (40%) patients were consulted to allergist at ED and outpatient allergy department respectively. We suggested that management and education of anaphylaxis were not fully carried out in ED. An education and promotion program on anaphylaxis is needed for medical staff.

Serious conditions for ED elderly fall patients: a secondary analysis of the Basel Non-Specific Complaints study.

PubMed

Liu, Shan W; Sri-On, Jiraporn; Tirrell, Gregory Philip; Nickel, Christian; Bingisser, Roland

2016-08-01

Falls among older adults are a public health problem and are multifactorial. We sought to determine whether falls predict more serious conditions in older adult patients presenting to the emergency department (ED) with a "nonspecific complaint" (NSC). A secondary objective was to examine what factors predicted serious conditions among older adult patients with a fall. This study was a secondary analysis of a prospective delayed-type cross-sectional diagnostic study that included a 30-day follow-up. We included patients 65 years and older who presented to the ED from May 2007 and July 2011 with a NSC and had an Emergency Severity Index score of 2 or 3. We then compared the serious conditions among older adults who presented to the ED with a fall with those who did not fall in a cohort of patients with NSC. We had 1111 patients enrolled in our study; 518 (47%) of them had fallen. We found that 310 (60%) of elderly fall patients vs 349 (59%) of nonfall patients had a 30-day serious condition (P=.74). In multiple logistic regression analysis, falls did not predict serious conditions or 30-day mortality among all NSC patients. Among fall patients, male sex, diuretic use, and generalized weakness predicted serious conditions. Fall patients share many features with nonfall NSC patient. However, falls did not increase the risk of serious conditions. Falls in the elderly could be considered under the broader entity of NSC. Copyright © 2016 Elsevier Inc. All rights reserved.

Code Help: Can This Unique State Regulatory Intervention Improve Emergency Department Crowding?

PubMed

Michael, Sean S; Broach, John P; Kotkowski, Kevin A; Brush, D Eric; Volturo, Gregory A; Reznek, Martin A

2018-05-01

Emergency department (ED) crowding adversely affects multiple facets of high-quality care. The Commonwealth of Massachusetts mandates specific, hospital action plans to reduce ED boarding via a mechanism termed "Code Help." Because implementation appears inconsistent even when hospital conditions should have triggered its activation, we hypothesized that compliance with the Code Help policy would be associated with reduction in ED boarding time and total ED length of stay (LOS) for admitted patients, compared to patients seen when the Code Help policy was not followed. This was a retrospective analysis of data collected from electronic, patient-care, timestamp events and from a prospective Code Help registry for consecutive adult patients admitted from the ED at a single academic center during a 15-month period. For each patient, we determined whether the concurrent hospital status complied with the Code Help policy or violated it at the time of admission decision. We then compared ED boarding time and overall ED LOS for patients cared for during periods of Code Help policy compliance and during periods of Code Help policy violation, both with reference to patients cared for during normal operations. Of 89,587 adult patients who presented to the ED during the study period, 24,017 (26.8%) were admitted to an acute care or critical care bed. Boarding time ranged from zero to 67 hours 30 minutes (median 4 hours 31 minutes). Total ED LOS for admitted patients ranged from 11 minutes to 85 hours 25 minutes (median nine hours). Patients admitted during periods of Code Help policy violation experienced significantly longer boarding times (median 20 minutes longer) and total ED LOS (median 46 minutes longer), compared to patients admitted under normal operations. However, patients admitted during Code Help policy compliance did not experience a significant increase in either metric, compared to normal operations. In this single-center experience, implementation of the Massachusetts Code Help regulation was associated with reduced ED boarding time and ED LOS when the policy was consistently followed, but there were adverse effects on both metrics during violations of the policy.

Frequency of alcohol use among injured adult patients presenting to a Ghanaian emergency department

PubMed Central

Forson, Paa Kobina; Gardner, Andrew; Oduro, George; Bonney, Joseph; Biney, Eno Akua; Oppong, Chris; Momade, Ezster; Maio, Ronald F.

2016-01-01

Objective Injuries are the cause of almost six million deaths annually worldwide, with 15–20% alcohol-associated. The frequency of alcohol-associated injury varies among countries, and is unknown in Ghana. We determined the frequency of positive alcohol tests among injured adults in a Ghanaian Emergency Department (ED). Methods This is a cross-sectional chart review of consecutive injured patients 18 years or older presenting to the Komfo Anokye Teaching Hospital ED for care within eight hours of injury. Patients were tested for alcohol using a breathalyzer or a saliva alcohol test. Patients were excluded if they had minor injuries resulting in referral to a separate outpatient clinic, or death prior to admission. Alcohol test results, subject, and injury characteristics were collected. Proportions with 95% confidence intervals (95%CIs) were calculated. Results 2,488 injured adult patients presented to the ED from November 2014 to April 2015 with 1,085 subjects (43%) included in this study. Three hundred eighty-two subjects (35%; 95%CI 32–38) tested alcohol positive. Forty-two percent of males (320/756), 40% of subjects 25–44 years (253/626), 42% of drivers (66/156), 42% of pedestrians (85/204), 49% of assaults (82/166), 40% of the seriously injured (124/311), and 53% of subjects who died in the ED (8/15) were positive for alcohol. Conclusions The frequency of alcohol-associated injury was 35% among tested subjects in this Ghanaian tertiary hospital ED. These findings have implications for health policy, ED and legislative-based interventions, and acute care. PMID:27241887

National Estimates of Emergency Department Visits for Antibiotic Adverse Events Among Adults-United States, 2011-2015.

PubMed

Geller, Andrew I; Lovegrove, Maribeth C; Shehab, Nadine; Hicks, Lauri A; Sapiano, Mathew R P; Budnitz, Daniel S

2018-04-20

Detailed, nationally representative data describing high-risk populations and circumstances involved in antibiotic adverse events (AEs) can inform approaches to prevention. Describe US burden, rates, and characteristics of emergency department (ED) visits by adults for antibiotic AEs. Nationally representative, public health surveillance of adverse drug events (National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance [NEISS-CADES]) and a nationally projected database of dispensed prescriptions (QuintilesIMS), 2011-2015. Antibiotic-treated adults (≥ 20 years) seeking ED care. Estimated annual numbers and rates of ED visits for antibiotic AEs among outpatients treated with systemically administered antibiotics. Based on 10,225 cases, US adults aged ≥ 20 years made an estimated 145,490 (95% confidence interval, 115,279-175,701) ED visits for antibiotic AEs each year in 2011-2015. Antibiotics were implicated in 13.7% (12.3-15.2%) of all estimated adult ED visits for adverse drug events. Most (56.6%; 54.8-58.4%) antibiotic AE visits involved adults aged < 50 years, and 71.8% (70.4-73.1%) involved females. Accounting for prescriptions dispensed from retail and long-term care pharmacies, adults aged 20-34 years had twice the estimated rate of ED visits for oral antibiotic AEs compared with those aged ≥ 65 years (9.7 [7.6-11.8] versus 4.6 [3.6-5.7] visits per 10,000 dispensed prescriptions, respectively). Allergic reactions accounted for three quarters (74.3%; 70.0-78.6%) of estimated ED visits for antibiotic AEs. The three most frequently implicated antibiotic classes in ED visits for antibiotic AEs were oral sulfonamides (23.2%; 20.6-25.8%), penicillins (20.8%; 19.3-22.4%), and quinolones (15.7%; 14.2-17.1%). Per-prescription rates declined with increasing age group. Antibiotics are a common cause of ED visits by adults for adverse drug events and represent an important safety issue. Quantifying risks of AEs from specific antibiotics for specific patient populations, such as younger adults, provides additional information to help clinicians assess risks versus benefits when making the decision to prescribe or not prescribe an antibiotic. AE rates may also facilitate communication with patients about antibiotic risks.

Emergency department characteristics and capabilities in Beijing, China.

PubMed

Wen, Leana S; Xu, Jun; Steptoe, Anne P; Sullivan, Ashley F; Walline, Joseph H; Yu, Xuezhong; Camargo, Carlos A

2013-06-01

Emergency Departments (EDs) are a critical, yet heterogeneous, part of international emergency care. We sought to describe the characteristics, resources, capabilities, and capacity of EDs in Beijing, China. Beijing EDs accessible to the general public 24 h per day/7 days per week were surveyed using the National ED Inventories survey instrument (www.emnet-nedi.org). ED staff were asked about ED characteristics during the calendar year 2008. Thirty-six EDs participated (88% response rate). All were located in hospitals and were independent hospital departments. Participating EDs saw a median of 80,000 patients (interquartile range 40,000-118,508). The vast majority (91%; 95% confidence interval [CI] 78-98%) had a contiguous layout, with medical and surgical care provided in one area. Most EDs (55%) saw only adults; 39% saw both adults and children, and 6% saw only children. Availability of technological and consultant resource in EDs was high. The typical ED length of stay was between 1 and 6 h in 49% of EDs (95% CI 32-67%), whereas in the other half, patients reportedly remained for over 6 h; 36% (95% CI 21-54%) of respondents considered their ED over capacity. Beijing EDs have high volume, long length of stay, and frequent reports of EDs being over capacity. To meet its rapidly growing health needs in urban areas, China should consider improving urban ED capacity and training more Emergency Medicine specialists capable of efficiently staffing its crowded EDs. Copyright © 2013 Elsevier Inc. All rights reserved.

Factors Associated With Emergency Department Visits: A Multistate Analysis of Adult Fee-for-Service Medicaid Beneficiaries.

PubMed

Agarwal, Parul; Bias, Thomas K; Madhavan, Suresh; Sambamoorthi, Nethra; Frisbee, Stephanie; Sambamoorthi, Usha

2016-04-27

The objective of this study was to examine the association of patient- and county-level factors with the emergency department (ED) visits among adult fee-for-service (FFS) Medicaid beneficiaries residing in Maryland, Ohio, and West Virginia. A cross-sectional design using retrospective observational data was implemented. Patient-level data were obtained from 2010 Medicaid Analytic eXtract files. Information on county-level health-care resources was obtained from the Area Health Resource file and County Health Rankings file. In adjusted analyses, the following patient-level factors were associated with higher number of ED visits: African Americans (incidence rate ratios [IRR] = 1.47), Hispanics (IRR = 1.63), polypharmacy (IRR = 1.89), and tobacco use (IRR = 2.23). Patients with complex chronic illness had a higher number of ED visits (IRR = 3.33). The county-level factors associated with ED visits were unemployment rate (IRR = 0.94) and number of urgent care clinics (IRR = 0.96). Patients with complex healthcare needs had a higher number of ED visits as compared to those without complex healthcare needs. The study results provide important baseline context for future policy analysis studies around Medicaid expansion options.

Effect of advanced age and vital signs on admission from an ED observation unit.

PubMed

Caterino, Jeffrey M; Hoover, Emily M; Moseley, Mark G

2013-01-01

The primary objective was to determine the relationship between advanced age and need for admission from an emergency department (ED) observation unit. The secondary objective was to determine the relationship between initial ED vital signs and admission. We conducted a prospective, observational cohort study of ED patients placed in an ED-based observation unit. Multivariable penalized maximum likelihood logistic regression was used to identify independent predictors of need for hospital admission. Age was examined continuously and at a cutoff of 65 years or more. Vital signs were examined continuously and at commonly accepted cutoffs.We additionally controlled for demographics, comorbid conditions, laboratory values, and observation protocol. Three hundred patients were enrolled, 12% (n = 35) were 65 years or older, and 11% (n = 33) required admission. Admission rates were 2.9% (95% confidence interval [CI], 0.07%-14.9%) in older adults and 12.1% (95% CI, 8.4%-16.6%) in younger adults. In multivariable analysis, age was not associated with admission (odds ratio [OR], 0.30; 95% CI, 0.05-1.67). Predictors of admission included systolic pressure 180 mm Hg or greater (OR, 4.19; 95% CI, 1.08-16.30), log Charlson comorbidity score (OR, 2.93; 95% CI, 1.57-5.46), and white blood cell count 14,000/mm(3) or greater (OR, 11.35; 95% CI, 3.42-37.72). Among patients placed in an ED observation unit, age 65 years or more is not associated with need for admission. Older adults can successfully be discharged from these units. Systolic pressure 180 mm Hg or greater was the only predictive vital sign. In determining appropriateness of patients selected for an ED observation unit, advanced age should not be an automatic disqualifying criterion. Copyright © 2013 Elsevier Inc. All rights reserved.

Trends of CT utilisation in an emergency department in Taiwan: a 5-year retrospective study

PubMed Central

Hu, Sung-Yuan; Hsieh, Ming-Shun; Lin, Meng-Yu; Hsu, Chiann-Yi; Lin, Tzu-Chieh; How, Chorng-Kuang; Wang, Chen-Yu; Tsai, Jeffrey Che-Hung; Wu, Yu-Hui; Chang, Yan-Zin

2016-01-01

Objectives To investigate the association between the trends of CT utilisation in an emergency department (ED) and changes in clinical imaging practice and patients' disposition. Setting A hospital-based retrospective observational study of a public 1520-bed referral medical centre in Taiwan. Participants Adult ED visits (aged ≥18 years) during 2009–2013, with or without receiving CT, were enrolled as the study participants. Main outcome measures For all enrolled ED visits, we retrospectively analysed: (1) demographic characteristics, (2) triage categories, (3) whether CT was performed and the type of CT scan, (4) further ED disposition, (5) ED cost and (6) ED length of stay. Results In all, 269 239 adult ED visits (148 613 male patients and 120 626 female patients) were collected during the 5-year study period, comprising 38 609 CT scans. CT utilisation increased from 11.10% in 2009 to 17.70% in 2013 (trend test, p<0.001). Four in 5 types of CT scan (head, chest, abdomen and miscellaneous) were increasingly utilised during the study period. Also, CT was increasingly ordered annually in all age groups. Although ED CT utilisation rates increased markedly, the annual ED visits did not actually increase. Moreover, the subsequent admission rate, after receiving ED CT, declined (59.9% in 2009 to 48.2% in 2013). Conclusions ED CT utilisation rates increased significantly during 2009–2013. Emergency physicians may be using CT for non-emergent studies in the ED. Further investigation is needed to determine whether increasing CT utilisation is efficient and cost-effective. PMID:27279477

Body mass index and risk of hospitalization among adults presenting with asthma exacerbation to the emergency department.

PubMed

Hasegawa, Kohei; Tsugawa, Yusuke; Lopez, Bernard L; Smithline, Howard A; Sullivan, Ashley F; Camargo, Carlos A

2014-11-01

Studies have linked obesity to incident asthma and worse chronic severity/control. However, the relationship between obesity and acute asthma morbidity remains unclear. To determine whether obese adults presenting to the emergency department (ED) with asthma exacerbation are at higher risk of hospitalization compared with normal-weight adults. Multicenter chart review study of 48 EDs across 23 U.S. states. We identified ED patients aged 18 to 54 years with asthma exacerbation during 2011 to 2012. Primary outcome was hospitalization. The analytic cohort comprised 1,227 patients. Of these, 323 patients (27%) were overweight (body mass index [BMI], 25-29.9 kg/m(2)), and 607 (50%) were obese (BMI ≥ 30 kg/m(2)). Among the 607 obese patients, 364 patients (60%) were severely obese (BMI ≥ 35 kg/m(2)). Several markers of chronic severity/control of asthma and acute severity did not differ across BMI groups. By contrast, compared with normal-weight patients, the risk of hospitalization was higher in patients who were overweight (11 vs. 18%; odds ratio [OR], 1.68; 95% confidence interval [CI], 1.05-2.68; P = 0.03) or obese (11 vs. 23%; OR, 2.30; 95% CI, 1.53-3.49; P < 0.001). In the adjusted analysis with multiple imputation, the association lost statistical significance in overweight patients (OR, 1.56; 95% CI, 0.90-2.71; P = 0.11) but persisted in obese patients (OR, 1.69; 95% CI, 1.02-2.81; P = 0.04). The latter finding was driven by an even higher risk of hospitalization in severely obese patients (OR, 1.95; 95% CI, 1.13-3.34; P = 0.02). In this multicenter study of ED patients with asthma exacerbation, we found that obese adults were at a higher risk of hospitalization compared with normal-weight adults.

A cross-sectional study of emergency care utilization and associated costs of violent-related (assault) injuries in the United States.

PubMed

Monuteaux, Michael C; Fleegler, Eric W; Lee, Lois K

2017-08-01

Violent-related (assault) injuries are a leading cause of death and disability in the United States. Many violent injury victims seek treatment in the emergency department (ED). Our objectives were to (1) estimate rates of violent-related injuries evaluated in United States EDs, (2) estimate linear trends in ED visits for violent-related injuries from 2000 to 2010, and (3) to determine the associated health care and work-loss costs. We examined adults 18 years and older from a nationally representative survey (the National Hospital Ambulatory Medical Care Survey) of ED visits, from 2000 to 2010. Violent injury was defined using International Classification of Diseases-9th Rev.-Clinical Modification, diagnosis and mechanism of injury codes. We calculated rates of ED visits for violent injuries. Medical and work-loss costs accrued by these injuries were calculated for 2005, inflation-adjusted to 2011 dollars using the WISQARS Cost of Injury Reports. An annual average of 1.4 million adults were treated for violent injuries in EDs from 2000 to 2010, comprising 1.6% (95% confidence interval, 1.5%-1.6%) of all US adult ED visits. Young adults (18-25 years), men, nonwhites, uninsured or publically insured patients, and those residing in high poverty urban areas were at increased risk for ED visits for violent injury. The 1-year, inflation-adjusted medical and work-loss cost of violent-inflicted injuries in adults in the United States was US $49.5 billion. Violent injuries account for over one million ED visits annually among adults, with no change in rates over the past decade. Young black men are at especially increased risk for ED visits for violent injuries. Overall, violent-related injuries resulted in substantial financial and societal costs. Epidemiological study, level III.

A cross-sectional study of emergency care utilization and associated costs of violent-related (assault) injuries in the United States.

PubMed

Monuteaux, Michael C; Fleegler, Eric W; Lee, Lois K

2017-11-01

Violent-related (assault) injuries are a leading cause of death and disability in the United States. Many violent injury victims seek treatment in the emergency department (ED). Our objectives were to (1) estimate rates of violent-related injuries evaluated in United States EDs, (2) estimate linear trends in ED visits for violent-related injuries from 2000 to 2010, and (3) to determine the associated health care and work-loss costs. We examined adults 18 years and older from a nationally representative survey (the National Hospital Ambulatory Medical Care Survey) of ED visits, from 2000 to 2010. Violent injury was defined using International Classification of Diseases-9th Rev.-Clinical Modification, diagnosis and mechanism of injury codes. We calculated rates of ED visits for violent injuries. Medical and work-loss costs accrued by these injuries were calculated for 2005, inflation-adjusted to 2011 dollars using the WISQARS Cost of Injury Reports. An annual average of 1.4 million adults were treated for violent injuries in EDs from 2000 to 2010, comprising 1.6% (95% confidence interval, 1.5%-1.6%) of all US adult ED visits. Young adults (18-25 years), men, nonwhites, uninsured or publically insured patients, and those residing in high poverty urban areas were at increased risk for ED visits for violent injury. The 1-year, inflation-adjusted medical and work-loss cost of violent-inflicted injuries in adults in the United States was US $49.5 billion. Violent injuries account for over one million ED visits annually among adults, with no change in rates over the past decade. Young black men are at especially increased risk for ED visits for violent injuries. Overall, violent-related injuries resulted in substantial financial and societal costs. Epidemiological study, level III.

The Two-Bag Method for Treatment of Diabetic Ketoacidosis in Adults.

PubMed

Haas, Nathan L; Gianchandani, Roma Y; Gunnerson, Kyle J; Bassin, Benjamin S; Ganti, Arun; Hapner, Christopher; Boyd, Caryn; Cranford, James A; Whitmore, Sage P

2018-05-01

The "two-bag method" of management of diabetic ketoacidosis (DKA) allows for titration of dextrose delivery by adjusting the infusions of two i.v. fluid bags of varying dextrose concentrations while keeping fluid, electrolyte, and insulin infusion rates constant. We aimed to evaluate the feasibility and potential benefits of this strategy in adult emergency department (ED) patients with DKA. This is a before-and-after comparison of a protocol using the two-bag method operationalized in our adult ED in 2015. A retrospective electronic medical record search identified adult ED patients presenting with DKA from January 1, 2013 to June 30, 2016. Clinical and laboratory data, timing of medical therapies, and safety outcomes were collected and analyzed. Sixty-eight patients managed with the two-bag method (2B) and 107 patients managed with the one-bag method (1B) were identified. The 2B and 1B groups were similar in demographics and baseline metabolic derangements, though significantly more patients in the 2B group received care in a hybrid ED and intensive care unit setting (94.1% vs. 51.4%; p < 0.01). 2B patients experienced a shorter interval to first serum bicarbonate ≥ 18 mEq/L (13.4 vs. 20.0 h; p < 0.05), shorter duration of insulin infusion (14.1 vs. 21.8 h; p < 0.05), and fewer fluid bags were charged to the patient (5.2 vs. 29.7; p < 0.01). Frequency of any measured hypoglycemia or hypokalemia trended in favor of the 2B group (2.9% vs. 10.3%; p = 0.07; 16.2% vs. 27.1%; p = 0.09; respectively), though did not reach significance. The 2B method appears feasible for management of adult ED patients with DKA, and use was associated with earlier correction of acidosis, earlier discontinuation of insulin infusion, and fewer i.v. fluid bags charged than traditional 1B methods, while no safety concerns were observed. Copyright © 2018 Elsevier Inc. All rights reserved.

Dental infections increase the likelihood of hospital admissions among adult patients with sickle cell disease

PubMed Central

Laurence, B.; Haywood, C; Lanzkron, S.

2014-01-01

The objective To determine if dental infections increase the likelihood of hospital admission among adult patients with sickle cell disease (SCD). Basic Research Design Cross-sectional analysis of data from the Nationwide Emergency Department Sample (NEDS) pooled for the years 2006 through 2008. Prevalence ratios (PR) for the effects of interest were estimated using Poisson regression with robust estimates of the variance. Participants Adults, aged 18 and over, diagnosed with SCD using ICD-9-CM codes excluding participants discharged with a code for sickle cell trait. Main outcome measure Emergency department (ED) visit disposition, dichotomised to represent whether or not the ED visit ended in admission versus being treated and released. Results Among patients having a sickle cell crisis, those with dental infections were 72% more likely to be admitted compared to those not having dental infections (PR=1.72, 95%CI 1.58-1.87). No association was observed among adult SCD patients not having a sickle crisis event. Based on preliminary data from this analysis, prevention of dental infection among patients with SCD could result in an estimated cost saving of $2.5 million dollars per year. Conclusions Having a dental infection complicated by a sickle cell crisis significantly increases the likelihood of hospital admission among adult SCD patients presenting to the ED. PMID:24151791

The effects of muscle hypotonia and weakness on balance: a study on Prader-Willi and Ehlers-Danlos syndrome patients.

PubMed

Galli, Manuela; Cimolin, Veronica; Vismara, Luca; Grugni, Graziano; Camerota, Filippo; Celletti, Claudia; Albertini, Giorgio; Rigoldi, Chiara; Capodaglio, Paolo

2011-01-01

Prader-Willi syndrome (PWS) and Ehlers-Danlos syndrome (EDS) are two different genetical disorders both characterized, among other features, by muscular hypotonia. Postural control seems to be impaired in both conditions. The aim of the present study was to quantitatively compare postural control in adult PWS and EDS using stabilometric platform to unveil possible common determinants of impaired balance. We enrolled 11 PWS and 21 EDS adult patients and 20 age-matched controls. They were instructed to maintain an upright standing position for 30s with open eyes (OEs) focusing on a 6 cm black circle positioned at a distance of 1.5m. Both PWS and EDS patients were characterized by higher RANGEML, RANGEAP and trajectory length of CoP values as compared to CG. No statistically differences were found between PWS and EDS in terms of any of these parameters. The results demonstrated that both PWS and EDS are characterized by a severe postural instability. Muscle hypotonia and weakness may account for reduced balance capacity. Quantitative characterization of instability is important to identify, develop and enhance rehabilitation interventions. Copyright © 2011 Elsevier Ltd. All rights reserved.

Frequency of Alcohol Use Among Injured Adult Patients Presenting to a Ghanaian Emergency Department.

PubMed

Forson, Paa Kobina; Gardner, Andrew; Oduro, George; Bonney, Joseph; Biney, Eno Akua; Oppong, Chris; Momade, Eszter; Maio, Ronald F

2016-10-01

Injuries are the cause of almost 6 million deaths annually worldwide, with 15% to 20% alcohol associated. The frequency of alcohol-associated injury varies among countries and is unknown in Ghana. We determined the frequency of positive alcohol test results among injured adults in a Ghanaian emergency department (ED). This is a cross-sectional chart review of consecutive injured patients aged 18 years or older presenting to the Komfo Anokye Teaching Hospital ED for care within 8 hours of injury. Patients were tested for presence of alcohol with a breathalyzer or a saliva alcohol test. Patients were excluded if they had minor injuries resulting in referral to a separate outpatient clinic, or death before admission. Alcohol test results, subject, and injury characteristics were collected. Proportions with 95% confidence intervals were calculated. Injured adult patients (2,488) presented to the ED from November 2014 to April 2015, with 1,085 subjects (43%) included in this study. Three hundred eighty-two subjects (35%; 95% confidence interval 32% to 38%) tested alcohol positive. Forty-two percent of men (320/756), 40% of subjects aged 25 to 44 years (253/626), 42% of drivers (66/156), 42% of pedestrians (85/204), 49% of assault victims (82/166), 40% of those seriously injured (124/311), and 53% of subjects who died in the ED (8/15) had positive results for presence of alcohol. The frequency of alcohol-associated injury was 35% among tested subjects in this Ghanaian tertiary care hospital ED. These findings have implications for health policy-, ED- and legislative-based interventions, and acute care. Copyright © 2016 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Cardiopulmonary resuscitation for in-hospital events in the emergency department: A comparison of adult and pediatric outcomes and care processes.

PubMed

Donoghue, Aaron J; Abella, Benjamin S; Merchant, Raina; Praestgaard, Amy; Topjian, Alexis; Berg, Robert; Nadkarni, Vinay

2015-07-01

To compare outcomes from in-hospital cardiopulmonary resuscitation (CPR) in the emergency department (ED) for pediatric and adult patients and to identify factors associated with differences in outcomes between children and adults. Retrospective analysis of the Get With The Guidelines--Resuscitation database from January 1, 2000 to September 30, 2010. All patients with CPR initiated in the ED requiring chest compressions for ≥ 2 min were eligible; trauma patients were excluded. Patients were divided into children (<18 yo) and adults (≥ 18 yo). Patient, event, treatment, and hospital factors were analyzed for association with outcomes. Univariate analysis was performed comparing children and adults. Multivariate analysis was used to determine factors associated with outcomes. 16,834 events occurred in 608 centers (16,245 adult, 537 pediatric). Adults had more frequent return of spontaneous circulation (53% vs 47%, p = 0.02), 24h survival (35% vs 30%, p = 0.02), and survival to discharge (23% vs 20%, p = NS) than children. Children were less frequently monitored (62% vs 82%) or witnessed (79% vs 88%), had longer duration (24 m vs 17 m), more epinephrine doses (3 vs 2), and more frequent intubation attempts (64% vs 55%) than adults. There were no differences in time to compressions, vasopressor administration, or defibrillation between children and adults. On multivariate analysis, age had no association with outcomes. Survival following CPR in the ED is similar for adults and children. While univariate differences exist between children and adults, neither age nor specific processes of care are independently associated with outcomes. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

Cardiopulmonary resuscitation for in-hospital events in the emergency department: A comparison of adult and pediatric outcomes and care processes☆

PubMed Central

Donoghue, Aaron J.; Abella, Benjamin S.; Merchant, Raina; Praestgaard, Amy; Topjian, Alexis; Berg, Robert; Nadkarni, Vinay

2016-01-01

Objectives To compare outcomes from in-hospital cardiopulmonary resuscitation (CPR) in the emergency department (ED) for pediatric and adult patients and to identify factors associated with differences in outcomes between children and adults. Methods Retrospective analysis of the Get With The Guidelines – Resuscitation database from January 1, 2000 to September 30, 2010. All patients with CPR initiated in the ED requiring chest compressions for ≥2 min were eligible; trauma patients were excluded. Patients were divided into children (ρ8 yo) and adults (≥18 yo). Patient, event, treatment, and hospital factors were analyzed for association with outcomes. Univariate analysis was performed comparing children and adults. Multivariate analysis was used to determine factors associated with outcomes. Results 16,834 events occurred in 608 centers (16,245 adult, 537 pediatric). Adults had more frequent return of spontaneous circulation (53% vs 47%, p = 0.02), 24 h survival (35% vs 30%, p = 0.02), and survival to discharge (23% vs 20%, p = NS) than children. Children were less frequently monitored (62% vs 82%) or witnessed (79% vs 88%), had longer duration (24 m vs 17 m), more epinephrine doses (3 vs 2), and more frequent intubation attempts (64% vs 55%) than adults. There were no differences in time to compressions, vasopressor administration, or defibrillation between children and adults. On multivariate analysis, age had no association with outcomes. Conclusions Survival following CPR in the ED is similar for adults and children. While univariate differences exist between children and adults, neither age nor specific processes of care are independently associated with outcomes. PMID:25939323

Emergency department discharge prescription interventions by emergency medicine pharmacists.

PubMed

Cesarz, Joseph L; Steffenhagen, Aaron L; Svenson, James; Hamedani, Azita G

2013-02-01

We determine the rate and details of interventions associated with emergency medicine pharmacist review of discharge prescriptions for patients discharged from the emergency department (ED). Additionally, we evaluate care providers' satisfaction with such services provided by emergency medicine pharmacists. This was a prospective observational study in the ED of an academic medical center that serves both adult and pediatric patients. Details of emergency medicine pharmacist interventions on discharge prescriptions were compiled with a standardized form. Interventions were categorized as error prevention or optimization of therapy. The staff of the ED was surveyed related to the influence and satisfaction of this new emergency medicine pharmacist-provided service. The 674 discharge prescriptions reviewed by emergency medicine pharmacists during the study period included 602 (89.3%) for adult patients and 72 (10.7%) for pediatric patients. Emergency medicine pharmacists intervened on 68 prescriptions, resulting in an intervention rate of 10.1% (95% confidence interval [CI] 8.0% to 12.7%). The intervention rate was 8.5% (95% CI 6.4% to 11.1%) for adult prescriptions and 23.6% for pediatric prescriptions (95% CI 14.7% to 35.3%) (difference 15.1%; 95% CI 5.1% to 25.2%). There were a similar number of interventions categorized as error prevention and optimization of medication therapy, 37 (54%) and 31 (46%), respectively. More than 95% of survey respondents believed that the new pharmacist services improved patient safety, optimized medication regimens, and improved patient satisfaction. Emergency medicine pharmacist review of discharge prescriptions for discharged ED patients has the potential to significantly improve patient care associated with suboptimal prescriptions and is highly valued by ED care providers. Copyright © 2012. Published by Mosby, Inc.

How do clinicians with different training backgrounds manage walk-in patients in the ED setting?

PubMed

Harris, Tim; McDonald, Keith

2014-12-01

To compare the initial assessment and management of walk-in emergency department (ED) patients between different types of healthcare providers. A large teaching hospital with an annual ED census of 140 000 adult patients. A random sample of 384 patients who self-presented to the ED was obtained. A detailed analysis of each patient record was performed by two clinicians. Data were obtained on the presenting condition, and disposition of each patient, either into the ED for further assessment, or discharge. GPs were significantly more likely to discharge patients home as compared to emergency nurses. ED senior nurses were more likely than GPs to stream patients into the ED for further assessment. Of the patients referred into the ED for further assessment by senior ED nurses, the majority were discharged home. There were insufficient numbers of emergency physician assessments for meaningful statistical analysis. The clinician groups studied here demonstrated different patterns of discharge and referral, reflecting their training and experience. When planning operational procedures, the training and background of the staff allocated to each area should be considered. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Diagnosis of Elder Abuse in US Emergency Departments

PubMed Central

Evans, Christopher S.; Hunold, Katherine M.; Rosen, Tony; Platts-Mills, Timothy F.

2016-01-01

OBJECTIVE To estimate the proportion of visits to United States emergency departments (EDs) receiving a diagnosis of elder abuse using two nationally representative datasets. DESIGN Retrospective cross-sectional analysis. SETTING U.S. ED visits recorded in either the 2012 Nationwide Emergency Department Sample (NEDS), or the 2011 National Hospital Ambulatory Medical Care Survey (NHAMCS). PARTICIPANTS All ED visits by patients aged 60 years and older. MEASUREMENTS The primary outcome was elder abuse as defined by ICD-9-CM diagnosis codes. The proportion of visits with elder abuse was estimated using survey weights. Odds ratios (OR) were calculated to identify patient demographics and common ED diagnoses associated with elder abuse. RESULTS In 2012, NEDS contained 6,723,667 ED visits by older adults, representing an estimated 29,056,673 ED visits. Elder abuse was diagnosed in an estimated 3,846 visits, corresponding to a weighted diagnosis period prevalence of elder abuse in U.S. EDs of 0.013% (95% Confidence Interval (CI) 0.012– 0.015%). Neglect and physical abuse were the most common types diagnosed, accounting for 32.9% and 32.2% of cases, respectively. Multivariable analysis showed increased weighted odds of elder abuse diagnosis in females (OR 1.95, 95% CI 1.68–2.26), and patients with contusion (OR 2.91, 95% CI 2.36–3.57), urinary tract infection (OR 2.21, 95% CI 1.84–2.65), or septicemia (OR 1.92, 95% CI 1.44–2.55). In the 2011 NHAMCS dataset, zero cases of elder abuse were recorded among the 5,965 older adult ED visits. CONCLUSION Among US ED visits by older adults, the proportion of visits receiving a diagnosis of elder abuse is at least two orders of magnitude lower than the estimated prevalence in the population. Efforts to improve the identification of elder abuse in EDs may be warranted. PMID:27753066

The impact of alcohol-related presentations on a New Zealand hospital emergency department.

PubMed

Stewart, Rebecca; Das, Manidipa; Ardagh, Michael; Deely, Joanne M; Dodd, Stuart; Bartholomew, Nadia; Pearson, Scott; Spearing, Ruth; Williams, Tracey; Than, Martin

2014-08-29

To determine the impact of alcohol-related presentations on the Christchurch Hospital Emergency Department (ED). Over 42 8-hour shifts (2 weeks) between 15 November 2013 and 9 December 2013, patients attending the ED with recent alcohol consumption were classified as screen-positive (consumed alcohol in the 4 hours prior to presentation) or not. A subset of screen-positive patients was classified as impact-positive (alcohol consumption clearly contributed to the reason for presenting). Data were analysed in relation to days/shifts for gender, age, disruptive behaviour, medical reasons for presenting, and completeness of ED records. Of the 3619 patients screened in the study, 268 (7.4%) and 182 (5%) were screen-positive and impact-positive, respectively. Most patients attended the ED on the weekends (58%: 105/182), particularly on Saturday night (31%; 56/182). More males (118) than females (64) were impact-positive. Of the impact-positive males, most were 16-25 years old (37%; 44/118) or 41-61 years old (32%; 38/118), attended the ED on weekend night shifts (24%; 28/118), and sought treatment for non- interpersonal trauma (38%; 45/118) or interpersonal trauma due to violence (17%; 20/118). Of the female impact-positive patients, most were 16-25 years old (41%; 26/64) or 41-60 years old (33%; 21/64), and presented for deliberate self-harm (36%; 23/64) or non-interpersonal trauma (27%; 17/64). Of the 182 impact-positive patients, 86% (156) were recorded in the ED computer system. Alcohol-related presentations had a significant impact on the ED, particularly on weekends. Teenagers, young adults and middle-aged adults contributed to the alcohol-related patient impact on weekends. Male patients were a significant burden on Saturday evening and night shifts.

Effectiveness of Parent Counselling in Eating Disorders

ERIC Educational Resources Information Center

Abbate-Daga, Giovanni; Quaranta, Michela; Marzola, Enrica; Cazzaniga, Giovanna; Amianto, Federico; Fassino, Secondo

2013-01-01

Eating Disorders (ED) are often severe illnesses entailing a heavy burden for families. Family therapy is recommended for young patients, but only a few studies have investigated therapeutic interventions with families tailored also to adult and longstanding patients. We recruited 87 families with daughters affected by an ED, aiming to assess the…

Characteristics of Emergency Department Visits by Older Versus Younger Homeless Adults in the United States

PubMed Central

Steinman, Michael A.

2013-01-01

Objectives. We compared the characteristics of emergency department (ED) visits of older versus younger homeless adults. Methods. We analyzed 2005–2009 data from the National Hospital Ambulatory Medical Care Survey, a nationally representative survey of visits to hospitals and EDs, and used sampling weights, strata, and clustering variables to obtain nationally representative estimates. Results. The ED visits of homeless adults aged 50 years and older accounted for 36% of annual visits by homeless patients. Although demographic characteristics of ED visits were similar in older and younger homeless adults, clinical and health services characteristics differed. Older homeless adults had fewer discharge diagnoses related to psychiatric conditions (10% vs 20%; P = .002) and drug abuse (7% vs 15%; P = .003) but more diagnoses related to alcohol abuse (31% vs 23%; P = .03) and were more likely to arrive by ambulance (48% vs 36%; P = .02) and to be admitted to the hospital (20% vs 11%; P = .003). Conclusions. Older homeless adults’ patterns of ED care differ from those of younger homeless adults. Health care systems need to account for these differences to meet the needs of the aging homeless population. PMID:23597348

Impact of a dedicated infusion clinic for acute management of adults with sickle cell pain crisis.

PubMed

Lanzkron, Sophie; Carroll, C Patrick; Hill, Peter; David, Mandy; Paul, Nicklaine; Haywood, Carlton

2015-05-01

Most adults with sickle cell disease (SCD) receive care for their acute painful episodes in an emergency department (ED) setting. The purpose of this article is to describe the impact of opening a dedicated treatment center for adults with SCD [Sickle Cell Infusion Clinic (SCIC)] on patient outcomes and on hospital discharges for SCD. Descriptive data including demographics, time to first dose of narcotic, and pain scores were collected on patients presenting to the SCIC and ED. Maryland hospital discharge data were obtained from the Maryland Health Services Cost Review Commission. Analyses were conducted using T tests, χ(2) tests, and simple generalized estimating equation regression models accounting for the clustered nature of observations, as appropriate. There were 3,874 visits to the SCIC by 361 unique patients; 85% of those visits resulted in the patient being sent home. During the same time period, there were 3,408 visits to the ED by 558 unique patients with SCD. The overall admission rate from the ED for these patients was 35.9% but decreased significantly over the time period with a rate of 20% in December 2011. There was a significant decrease in readmissions over time for the entire Baltimore Metro area with the likelihood of readmission decreasing by 7% over time. The SCIC model provides adults with SCD access to high quality care that decreases the need for hospital admission. Further research needs to be done to evaluate the cost effectiveness of this model. © 2015 Wiley Periodicals, Inc.

The diagnostic value of EEGs in patients with syncope.

PubMed

Abubakr, Abuhuziefa; Wambacq, Ilse

2005-05-01

We retrospectively reviewed reports of all EEGs performed at the New Jersey Neuroscience Institute at JFK Hospital between January 1999 and December 2003. Of 9234 EEGs performed, 1094 were of patients with syncope. Among patients with syncope, 67.18% of the EEGs were normal and 28.15% showed diffuse and focal slowing. Only 1.46% of the EEGs showed epileptiform discharges (EDs). This is similar to the incidence of EDs in healthy adults. The presence of EDs did not change the management of these patients. Therefore, EEGs have very low yield and should not be routinely obtained in patients with syncope.

Geriatric emergency department innovations: preliminary data for the geriatric nurse liaison model.

PubMed

Aldeen, Amer Z; Courtney, D Mark; Lindquist, Lee A; Dresden, Scott M; Gravenor, Stephanie J

2014-09-01

Older adults account for a large and growing segment of the emergency department (ED) population. They are often admitted to the hospital for nonurgent conditions such as dementia, impaired functional status, and gait instability. The aims of this geriatric ED innovations (GEDI) project were to develop GEDI nurse liaisons by training ED nurses in geriatric assessment and care coordination skills, describe characteristics of patients that these GEDI nurse liaisons see, and measure the admission rate of these patients. Four ED nurses participated in the GEDI training program, which consisted of 82 hours of clinical rotations in geriatrics and palliative medicine, 82 hours of didactics, and a pilot phase for refinement of the GEDI consultation process. Individuals were eligible for GEDI consultation if they had an Identification of Seniors At Risk (ISAR) score greater than 2 or at ED clinician request. GEDI consultation was available Monday through Friday from 9:00 a.m. to 8:00 p.m. An extensive database was set up to collect clinical outcomes data for all older adults in the ED before and after GEDI implementation. The liaisons underwent training from January through March 2013. From April through August 2013, 408 GEDI consultations were performed in 7,213 total older adults in the ED (5.7%, 95% confidence interval (CI) = 5.2-6.2%), 2,124 of whom were eligible for GEDI consultation (19.2%, 95% CI = 17.6-20.9%); 34.6% (95% CI = 30.1-39.3%) received social work consultation, 43.9% (95% CI = 39.1-48.7) received pharmacy consultation, and more than 90% received telephone follow-up. The admission rate for GEDI patients was 44.9% (95% CI = 40.1-49.7), compared with 60.0% (95% CI = 58.8-61.2) non-GEDI. ED nurses undergoing a 3-month training program can develop geriatric-specific assessment skills. Implementation of these skills in the ED may be associated with fewer admissions of older adults. © 2014, Copyright the Authors Journal compilation © 2014, The American Geriatrics Society.

Cost-effectiveness of influenza vaccination of older adults in the ED setting.

PubMed

Patterson, Brian W; Khare, Rahul K; Courtney, D Mark; Lee, Todd A; Kyriacou, Demetrios N

2012-09-01

Adults older than 50 years are at greater risk for death and severe disability from influenza. Persons in this age group, however, are frequently not vaccinated, despite extensive efforts by physicians to provide this preventive measure in primary care settings. We performed this study to determine if influenza vaccination of older adults in the emergency department (ED) may be cost-effective. Using a probabilistic decision model with quasi-Markov modeling of a typical influenza season, we calculated costs and health outcomes for a hypothetical cohort of patients using parameters from the literature. Three ED-based intervention strategies were compared: (1) no vaccination offered, (2) vaccination offered to patients older than 65 years (limited strategy), and (3) vaccination offered to all patients who are 50 years and older (inclusive strategy). Outcomes were measured as costs, lives saved, and incremental costs per life saved. We performed deterministic and probabilistic sensitivity analyses. Vaccination of patients 50 years of age and older results in an incremental cost of $34,610 per life saved when compared with the no-vaccination strategy. Limiting vaccination to only those older than 65 years results in an incremental cost of $13,084 per life saved. Results were sensitive to changes in vaccine cost but were insensitive to changes in other model parameters. Vaccination of older adults against influenza in the ED setting is cost-effective, especially for those older than 65 years. Emergency departments may be an important setting for providing influenza vaccination to adults who may otherwise have remained unvaccinated. Copyright © 2012 Elsevier Inc. All rights reserved.

Trends of CT utilisation in an emergency department in Taiwan: a 5-year retrospective study.

PubMed

Hu, Sung-Yuan; Hsieh, Ming-Shun; Lin, Meng-Yu; Hsu, Chiann-Yi; Lin, Tzu-Chieh; How, Chorng-Kuang; Wang, Chen-Yu; Tsai, Jeffrey Che-Hung; Wu, Yu-Hui; Chang, Yan-Zin

2016-06-08

To investigate the association between the trends of CT utilisation in an emergency department (ED) and changes in clinical imaging practice and patients' disposition. A hospital-based retrospective observational study of a public 1520-bed referral medical centre in Taiwan. Adult ED visits (aged ≥18 years) during 2009-2013, with or without receiving CT, were enrolled as the study participants. For all enrolled ED visits, we retrospectively analysed: (1) demographic characteristics, (2) triage categories, (3) whether CT was performed and the type of CT scan, (4) further ED disposition, (5) ED cost and (6) ED length of stay. In all, 269 239 adult ED visits (148 613 male patients and 120 626 female patients) were collected during the 5-year study period, comprising 38 609 CT scans. CT utilisation increased from 11.10% in 2009 to 17.70% in 2013 (trend test, p<0.001). Four in 5 types of CT scan (head, chest, abdomen and miscellaneous) were increasingly utilised during the study period. Also, CT was increasingly ordered annually in all age groups. Although ED CT utilisation rates increased markedly, the annual ED visits did not actually increase. Moreover, the subsequent admission rate, after receiving ED CT, declined (59.9% in 2009 to 48.2% in 2013). ED CT utilisation rates increased significantly during 2009-2013. Emergency physicians may be using CT for non-emergent studies in the ED. Further investigation is needed to determine whether increasing CT utilisation is efficient and cost-effective. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

The Period Prevalence of Mind and Body Practice Use by Adult Emergency Department Patients.

PubMed

Sellar, Ashleigh J; Taylor, David McD; Ross, Nicholas D; Chen, Hayley H; Plant, Luke D; McLean, Daniel; Berlingeri, Paul; Gavan, Rex; Weiland, Tracey J; Knott, Jonathan C

2018-05-01

Mind and Body Practice (MBP) use (e.g., chiropractic, acupuncture, meditation) among Emergency Department (ED) patients is largely unknown. We aimed to determine the period prevalence, nature of MBP use, and perceptions of MBP among adult ED patients. We undertook a cross-sectional survey of a convenience sample of patients presenting to three EDs between February and June 2016. Patients were eligible for inclusion if they were aged 18 years or more and had presented for medical treatment. An anonymous, self-administered questionnaire, based upon a validated pediatric questionnaire, was completed by the patient, with assistance if required. The primary outcome was the nature and 12 month period prevalence of MBP use. Secondary outcomes were variables associated with use and patient perceptions of MBP. 674 patients were enrolled. In the previous 12 months, 500 (74.2%) patients had used at least one MBP. MBP users and nonusers did not differ in gender, ancestry, or chronic illness status (p > 0.05). However, users were significantly younger and more likely to have private health insurance (p < 0.001). A total of 2094 courses of 68 different MBP had been used including massage (75.0% of users), meditation (35.2%), chiropractic (32.6%), acupuncture (32.0%), and yoga (30.6%). Users were significantly more likely (p < 0.01) to believe that MBP prevented illness, treated illness, were more effective than prescription medicines, assisted prescription medications, and were safe and provided a more holistic approach. Forty-one (6.1%) patients used MBP for their ED presenting complaint. However, only 14 (34.1%) advised their ED physician of this. The period prevalence of MBP use among ED patients is high. Knowledge of the MBP used for a patient's presenting complaint may better inform the ED physician when making management decisions.

Success of elective cholecystectomy treatment plans after emergency department visit.

PubMed

Bingener, Juliane; Thomsen, Kristine M; McConico, Andrea; Hess, Erik P; Habermann, Elizabeth B

2015-01-01

Differentiation between patients with acute cholecystitis and patients with severe biliary colic can be challenging. Patients with undiagnosed acute cholecystitis can incur repeat emergency department (ED) visits, which is resource intensive. Billing records from 2000-2013 of all adults who visited the ED in the 30 d preceding their cholecystectomy were analyzed. Patients who were discharged from the ED and underwent elective cholecystectomy were compared with those who were discharged and returned to the ED within 30 d. T-tests, chi-square tests, and multivariable analysis were used as appropriate. From 2000-2013, 3138 patients (34%) presented to the ED within 30 d before surgery, 63% were women, mean age 51 y, and of those 1625 were directly admitted from the ED for cholecystectomy, whereas 1513 patients left the ED to return for an elective cholecystectomy. Patients who were discharged were younger (mean age 49 versus 54 y, P < 0.001) and had shorter ED stays (5.9 versus 7.2 h, P < 0.001) than the patients admitted immediately. Of the discharged patients, 303 (20%) returned to the ED within 30 d to undergo urgent cholecystectomy. Compared with patients with successful elective cholecystectomy after the ED visit, those who failed the pathway were more likely to have an American Society of Anesthesiologists score ≥3 and were <40 or ≥60 compared with the successful group. One in five patients failed the elective cholecystectomy pathway after ED discharge, leading to additional patient distress and use of resources. Further risk factor assessment may help design efficient care pathways. Copyright © 2015 Elsevier Inc. All rights reserved.

Effectiveness of Emergency Department Based Palliative Care for Adults with Advanced Disease: A Systematic Review

PubMed Central

Nunes, Cristina Moura; Gomes, Barbara

2016-01-01

Abstract Background: Emergency departments (EDs) are seeing more patients with palliative care (PC) needs, but evidence on best practice is scarce. Objectives: To examine the effectiveness of ED-based PC interventions on hospital admissions (primary outcome), length of stay (LOS), symptoms, quality of life, use of other health care services, and PC referrals for adults with advanced disease. Methods: We searched five databases until August 2014, checked reference lists/conference abstracts, and contacted experts. Eligible studies were controlled trials, pre-post studies, cohort studies, and case series reporting outcomes of ED-based PC. Results: Five studies with 4374 participants were included: three case series and two cohort studies. Interventions included a screening tool, traditional ED-PC, and integrated ED-PC. Two studies reported on hospital admissions: in one study there was no statistically significant difference in 90-day readmission rates between patients who initiated integrated PC at the ED (11/50 patients, 22%) compared to those who initiated PC after hospital admission (179/1385, 13%); another study showed a high admission rate (90%) in 14 months following ED-PC, but without comparison. One study showed an LOS reduction (mean 4.32 days in ED-initiated PC group versus 8.29 days in postadmission-initiated group; p < 0.01). There was scarce evidence on other outcomes except for conflicting findings on survival: in one study, ED-PC patients were more likely to experience an interval between ED presentation and death >9 hours (OR 2.75, 95% CI 2.21–3.41); another study showed increased mortality risk in the intervention group; and a case series described a higher in-hospital death rate when PC was ED-initiated (62%), compared to ward (16%) or ICU (50%) (unknown p-value). Conclusions: There is yet no evidence that ED-based PC affects patient outcomes except for indication from one study of no association with 90-day hospital readmission but a possible reduction in LOS if integrated PC is introduced early at ED rather than after hospital admission. There is an urgent need for trials to confirm these findings alongside other potential benefits and survival effects. PMID:27115914

Comparative Analgesic Efficacy of Oxycodone/Acetaminophen Versus Hydrocodone/Acetaminophen for Short-term Pain Management in Adults Following ED Discharge.

PubMed

Chang, Andrew K; Bijur, Polly E; Holden, Lynne; Gallagher, E John

2015-11-01

The objective was to test the hypothesis that oxycodone/acetaminophen provides superior analgesia to hydrocodone/acetaminophen for the treatment of acute extremity pain following emergency department (ED) discharge. This was a prospective, randomized, double-blind clinical trial of nonelderly adult ED patients with acute musculoskeletal extremity pain, randomly allocated at discharge to receive oxycodone/acetaminophen (5 mg/325 mg) or hydrocodone/acetaminophen (5 mg/325 mg). The primary outcome was the between-group difference in improvement in numerical rating scale (NRS) pain scores over a 2-hour period following the most recent ingestion of study drug, obtained during telephone contact 24 hours after ED discharge. Secondary outcomes included proportionate decrease in pain, comparative side-effect profiles, and patient satisfaction. A total of 240 patients were enrolled. The final sample consisted of 220 patients, 107 randomly allocated to oxycodone/acetaminophen and 113 to hydrocodone/acetaminophen. At 24 hours after ED discharge, the mean NRS pain scores prior to the most recent dose of outpatient pain medication were 7.8 and 7.9 in the oxycodone/acetaminophen and hydrocodone/acetaminophen groups, respectively. The mean decreases in pain scores over 2 hours were 4.4 NRS units in the oxycodone/acetaminophen group versus 4.0 NRS units in the hydrocodone/acetaminophen group, for a difference of 0.4 NRS units (95% confidence interval = -0.2 to 1.1 NRS units). Satisfaction with the analgesics was similar. This study design could not detect a clinically or statistically significant difference in analgesic efficacy between oxycodone/acetaminophen (5 mg/325 mg) and hydrocodone/acetaminophen (5 mg/325 mg) for treatment of acute musculoskeletal extremity pain in adults following ED discharge. Both opioids reduced pain scores by approximately 50%. © 2015 by the Society for Academic Emergency Medicine.

Effect of advanced age and vital signs on admission from an emergency department observation unit

PubMed Central

Caterino, Jeffrey M.; Hoover, Emily; Moseley, Mark G.

2012-01-01

Objectives The primary objective was to determine the relationship between advanced age and need for admission from an emergency department (ED) observation unit. The secondary objective was to determine the relationship between initial ED vital signs and admission. Methods We conducted a prospective, observational cohort study of ED patients placed in an ED-based observation unit. Multivariable penalized maximum likelihood logistic regression was used to identify independent predictors of need for hospital admission. Age was examined continuously and at a cutoff of ≥65 years. Vital signs were examined continuously and at commonly accepted cutoffs. We additionally controlled for demographics, co-morbid conditions, laboratory values, and observation protocol. Results Three hundred patients were enrolled, 12% (n=35) ≥65 years old and 11% (n=33) requiring admission. Admission rates were 2.9% (95% confidence interval [CI], 0.07-14.9%) in older adults and 12.1% (95% CI, 8.4-16.6%) in younger adults. In multivariable analysis, age was not associated with admission (odds ratio [OR] 0.30, 95% CI 0.05-1.67). Predictors of admission included: systolic pressure ≥180 mmHg (OR 4.19, 95% CI 1.08-16.30), log Charlson co-morbidity score (OR 2.93, 95% CI 1.57-5.46), and white blood cell count ≥14,000/mm3 (OR11.35, 95% CI 3.42-37.72). Conclusions Among patients placed in an ED observation unit, age ≥65 years is not associated with need for admission. Older adults can successfully be discharged from these units. Systolic pressure≥180 mmHg was the only predictive vital sign. In determining appropriateness of patients selected for an ED observation unit, advanced age should not be an automatic disqualifying criterion. PMID:22386358

Elevated Steady State WBC and Platelet Counts Are Associated with Frequent Emergency Room Use in Adults with Sickle Cell Anemia

PubMed Central

Danda, Neeraja; Etzion, Zipora

2015-01-01

Introduction Sickle cell anemia has many sequelae that result in emergency department (ED) use, but a minority of patients with sickle cell disease are frequent utilizers and make up the majority of ED visits. If patients who are likely to be frequent ED can be identified in steady state, they can be treated with disease modifying agents in an attempt to reduce ED use frequency. We sought to identify steady state markers for frequent ED use. Methods We identified all patients with SS/Sβ0 seen at our facilities in 2012. Health care utilization over the entire year was calculated and ED visit numbers categorized as either 0–1, 2–5, or 6 or more visits a year. Steady state and acutely active laboratory parameters were collected and analyzed using analysis of variance models and odds ratios. Results 432 adult sickle cell patients were identified, ages 18–87, 54% female, and 38% had been prescribed hydroxyurea. Of the 432 patients,192 had 0–1 visits in the year, 144 had 2–5 visits in the year, and 96 had >6 visits for a total of 2259 visits. Those who had >6 visits accounted for 1750 (77%) of the total visits for the year. When steady state laboratory markers were examined, each additional 50x109/L platelets was associated with 22% greater risk (p < .001); each 1x109/L of WBC was associated with 11% greater risk (p = .003), and each 1g/dL Hb was associated with 23% lower risk (p = .007) of >6 ED visits/year. We did not observe a relationship between baseline HbF, LDH or reticulocyte count with >6 ED visits. Conclusion Patients with elevated white blood cell counts, elevated platelet counts, and low hemoglobin levels exhibited higher risk for frequent ED utilization and could be candidates for early and aggressive therapy with disease modifying agents. PMID:26248283

Are triage questions sufficient to assign fall risk precautions in the ED?

PubMed

Southerland, Lauren T; Slattery, Lauren; Rosenthal, Joseph A; Kegelmeyer, Deborah; Kloos, Anne

2017-02-01

The American College of Emergency Physicians Geriatric Emergency Department (ED) Guidelines and the Center for Disease Control recommend that older adults be assessed for risk of falls. The standard ED assessment is a verbal query of fall risk factors, which may be inadequate. We hypothesized that the addition of a functional balance test endorsed by the Center for Disease Control Stop Elderly Accidents, Deaths, and Injuries Falls Prevention Guidelines, the 4-Stage Balance Test (4SBT), would improve the detection of patients at risk for falls. Prospective pilot study of a convenience sample of ambulatory adults 65 years and older in the ED. All participants received the standard nursing triage fall risk assessment. After patients were stabilized in their ED room, the 4SBT was administered. The 58 participants had an average age of 74.1 years (range, 65-94), 40.0% were women, and 98% were community dwelling. Five (8.6%) presented to the ED for a fall-related chief complaint. The nursing triage screen identified 39.7% (n=23) as at risk for falls, whereas the 4SBT identified 43% (n=25). Combining triage questions with the 4SBT identified 60.3% (n=35) as at high risk for falls, as compared with 39.7% (n=23) with triage questions alone (P<.01). Ten (17%) of the patients at high risk by 4SBT and missed by triage questions were inpatients unaware that they were at risk for falls (new diagnoses). Incorporating a quick functional test of balance into the ED assessment for fall risk is feasible and significantly increases the detection of older adults at risk for falls. Copyright © 2016 Elsevier Inc. All rights reserved.

The impact of age and gender on resource utilization and profitability in ED patients seen and released.

PubMed

Henneman, Philip L; Nathanson, Brian H; Ribeiro, Kara; Balasubramanian, Hari

2014-10-01

To determine how age and gender impact resource utilization and profitability in patients seen and released from an Emergency Department (ED). Billing data for patients seen and released from an Emergency Department (ED) with >100,000 annual visits between 2003 and 2009 were collected. Resource utilization was measured by length of stay (placement in ED bed to leaving the bed) and direct clinical costs (e.g., ED nursing salary and benefits, pharmacy and supply costs, etc.) estimated using relative value unit cost accounting. The primary outcome of profitability was defined as contribution margin per hour. A patient's contribution margin by insurance type (excluding self-pay) was determined by subtracting direct clinical costs from facility contractual revenue. Results are expressed as medians and US dollars. In 523 882 outpatient ED encounters, as patients' aged, length of stay and direct clinical cost increased while the contribution margin and contribution margin by hour decreased. Women of childbearing age (15-44) had higher median length of stay (2.1 hours), direct clinical cost ($149), and contribution margin per hour ($103/hour) than men of same age (1.7, $131, $85/hour, respectively). Resource utilization and profitability by gender were similar in children and adults over 45. Resource utilization increased and profitability decreased with increasing age in patients seen and released from an ED. The care of women of childbearing age resulted in higher resource utilization and higher profitability than men of the same age. No differences in resource utilization or profitability by gender were observed in children and adults over 45. Copyright © 2014 Elsevier Inc. All rights reserved.

Comprehensive long-term management program for asthma: effect on outcomes in adult African-Americans.

PubMed

Kelso, T M; Abou-Shala, N; Heilker, G M; Arheart, K L; Portner, T S; Self, T H

1996-06-01

To determine if a comprehensive long-term management program, emphasizing inhaled corticosteroids and patient education, would improve outcomes in adult African-American asthmatics a nonrandomized control trial with a 2-year intervention was performed in a university-based clinic. Inclusion criteria consisted of (> or = 5) emergency department (ED) visits or hospitalizations (> or = 2) during the previous 2 years. Intervention patients were volunteers; a comparable control group was identified via chart review at hospitals within the same area and time period as the intervention patients. Individualized doses of beclomethasone with a spacer, inhaled albuterol "as needed," and crisis prednisone were the primary therapies. Environmental control, peak flow monitoring, and a partnership with the patient were emphasized. Detailed patient education was an integral part of management. Control patients received usual care from local physicians. ED visits and hospitalizations for 2 years before and 2 years during the intervention period were compared. Quality of life (QOL) measurements were made at baseline and every 6 months in the intervention group. Study group (n = 21) had a significant reduction in ED visits (2.3 +/- 0.2 pre-intervention versus 0.6 +/- 0.2 post-intervention; P = 0.0001). Control group (n = 18) did not have a significant change in ED visits during the 2-year post-intervention period (2.6 +/- 0.2 pre-intervention versus 2.0 +/- 0.2 post-intervention; P = 0.11). Both groups had significant reductions in hospitalizations, but the study group had a greater reduction. Sixty-two percent of study patients had complete elimination of ED visits and hospitalizations, whereas no control patients had total elimination of the need for institutional acute care. QOL in the study patients revealed significant improvements for most parameters. A comprehensive long-term management program emphasizing inhaled corticosteroids combined with other state-of-the-art management, including intensive patient education, improves outcomes in adult African-American asthmatics.

Emergency department recidivism in adults older than 65 years treated for fractures.

PubMed

Southerland, Lauren T; Richardson, Daniel S; Caterino, Jeffrey M; Essenmacher, Alex C; Swor, Robert A

2014-09-01

Fractures in older adults are a commonly diagnosed injury in the emergency department (ED). We performed a retrospective medical record review to determine the rate of return to the same ED within 72 hours (returns) and the risk factors associated with returning. A retrospective medical record review of patients at least 65 years old discharged from a large, academic ED with a new diagnosis of upper extremity, lower extremity, or rib fractures was performed. Risk factors analyzed included demographic data, type of fracture, analgesic prescriptions, assistive devices provided, other concurrent injuries, and comorbidities (Charlson Comorbidity Index). Our primary outcome was return to the ED within 72 hours. Three hundred fifteen patients qualified. Most fractures were in the upper extremity (64% [95% confidence interval {CI}, 58%-69%]). Twenty patients (6.3% [95% CI, 3.9%-9.6%]) returned within 72 hours. Most returns (15/20, 75%) were for reasons associated with the fracture itself, such as cast problems and inadequate pain control. Only 3 (<1% of all patients) patients returned for cardiac etiologies. Patients with distal forearm fractures had higher return rates (10.7% vs 4.5%, P = .03), and most commonly returned for cast or splint problems. Age, sex, other injuries, assistive devices, and Charlson Comorbidity Index score (median, 1 [interquartile range, 1-2] for both groups) did not predict 72-hour returns. Older adults with distal forearm fractures may have more unscheduled health care usage in the first 3 days after fracture diagnosis than older adults with other fracture types. Overall, revisits for cardiac reasons or repeat falls were rare (<1%). Copyright © 2014 Elsevier Inc. All rights reserved.

Is Internet search better than structured instruction for web-based health education?

PubMed

Finkelstein, Joseph; Bedra, McKenzie

2013-01-01

Internet provides access to vast amounts of comprehensive information regarding any health-related subject. Patients increasingly use this information for health education using a search engine to identify education materials. An alternative approach of health education via Internet is based on utilizing a verified web site which provides structured interactive education guided by adult learning theories. Comparison of these two approaches in older patients was not performed systematically. The aim of this study was to compare the efficacy of a web-based computer-assisted education (CO-ED) system versus searching the Internet for learning about hypertension. Sixty hypertensive older adults (age 45+) were randomized into control or intervention groups. The control patients spent 30 to 40 minutes searching the Internet using a search engine for information about hypertension. The intervention patients spent 30 to 40 minutes using the CO-ED system, which provided computer-assisted instruction about major hypertension topics. Analysis of pre- and post- knowledge scores indicated a significant improvement among CO-ED users (14.6%) as opposed to Internet users (2%). Additionally, patients using the CO-ED program rated their learning experience more positively than those using the Internet.

Screening for Victims of Sex Trafficking in the Emergency Department: A Pilot Program

PubMed Central

Mumma, Bryn E.; Scofield, Marisa E.; Mendoza, Lydia P.; Toofan, Yalda; Youngyunpipatkul, Justin; Hernandez, Bryan

2017-01-01

Introduction Estimates suggest that hundreds of thousands of sex trafficking victims live in the United States. Several screening tools for healthcare professionals to identify sex trafficking victims have been proposed, but the effectiveness of these tools in the emergency department (ED) remains unclear. Our primary objective in this study was to evaluate the feasibility of a screening survey to identify adult victims of sex trafficking in the ED. We also compared the sensitivity of emergency physician concern and a screening survey for identifying sex trafficking victims in the ED and determined the most effective question(s) for identifying adult victims of sex trafficking. Methods We enrolled a convenience sample of medically stable female ED patients, age 18–40 years. Patients completed a 14-question survey. Physician concern for sex trafficking was documented prior to informing the physician of the survey results. A “yes” answer to any question or physician concern was considered a positive screen, and the patient was offered social work consultation. We defined a “true positive” as a patient admission for or social work documentation of sex trafficking. Demographic and clinical information were collected from the electronic medical record. Results We enrolled 143 patients, and of those 39 (27%, 95% confidence interval [CI] [20%–35%]) screened positive, including 10 (25%, 95% CI [13%–41%]) ultimately identified as victims of sex trafficking. Sensitivity of the screening survey (100%, 95% CI [74%–100%]) was better than physician concern (40%, 95% CI [12%–74%]) for identifying victims of sex trafficking, difference 60%, 95% CI [30%–90%]. Physician specificity (91%, 95% CI [85%–95%]), however, was slightly better than the screening survey (78%, 95% CI [70%–85%]), difference 13%, 95% CI [4%–21%]. All 10 (100%, 95%CI [74%–100%]) “true positive” cases answered “yes” to the screening question regarding abuse. Conclusion Identifying adult victims of sex trafficking in the ED is feasible. A screening survey appears to have greater sensitivity than physician concern, and a single screening question may be sufficient to identify all adult victims of sex trafficking in the ED. PMID:28611881

Screening for Victims of Sex Trafficking in the Emergency Department: A Pilot Program.

PubMed

Mumma, Bryn E; Scofield, Marisa E; Mendoza, Lydia P; Toofan, Yalda; Youngyunpipatkul, Justin; Hernandez, Bryan

2017-06-01

Estimates suggest that hundreds of thousands of sex trafficking victims live in the United States. Several screening tools for healthcare professionals to identify sex trafficking victims have been proposed, but the effectiveness of these tools in the emergency department (ED) remains unclear. Our primary objective in this study was to evaluate the feasibility of a screening survey to identify adult victims of sex trafficking in the ED. We also compared the sensitivity of emergency physician concern and a screening survey for identifying sex trafficking victims in the ED and determined the most effective question(s) for identifying adult victims of sex trafficking. We enrolled a convenience sample of medically stable female ED patients, age 18-40 years. Patients completed a 14-question survey. Physician concern for sex trafficking was documented prior to informing the physician of the survey results. A "yes" answer to any question or physician concern was considered a positive screen, and the patient was offered social work consultation. We defined a "true positive" as a patient admission for or social work documentation of sex trafficking. Demographic and clinical information were collected from the electronic medical record. We enrolled 143 patients, and of those 39 (27%, 95% confidence interval [CI] [20%-35%]) screened positive, including 10 (25%, 95% CI [13%-41%]) ultimately identified as victims of sex trafficking. Sensitivity of the screening survey (100%, 95% CI [74%-100%]) was better than physician concern (40%, 95% CI [12%-74%]) for identifying victims of sex trafficking, difference 60%, 95% CI [30%-90%]. Physician specificity (91%, 95% CI [85%-95%]), however, was slightly better than the screening survey (78%, 95% CI [70%-85%]), difference 13%, 95% CI [4%-21%]. All 10 (100%, 95%CI [74%-100%]) "true positive" cases answered "yes" to the screening question regarding abuse. Identifying adult victims of sex trafficking in the ED is feasible. A screening survey appears to have greater sensitivity than physician concern, and a single screening question may be sufficient to identify all adult victims of sex trafficking in the ED.

Analysis of Hospital-Based Emergency Department Visits for Inflammatory Bowel Disease in the USA.

PubMed

Gajendran, Mahesh; Umapathy, Chandraprakash; Loganathan, Priyadarshini; Hashash, Jana G; Koutroubakis, Ioannis E; Binion, David G

2016-02-01

Inflammatory bowel disease (IBD) is a chronic, debilitating condition with high emergency department (ED) utilization. We aimed to investigate the utilization patterns of ED by IBD patients and measure hospitalization and surgical rates following ED visits. We conducted a cross-sectional study of adults with IBD listed as the primary ED diagnosis from the 2009 to 2011 Nationwide Emergency Department Sample. The characteristics of the IBD-related ED visits in relation to following hospitalizations and surgeries were analyzed. Adult IBD patients constitute 0.09 % of the total ED visits. Crohn's disease (CD) contributed to 69 % of the IBD-ED visits. The hospitalization rate from ED was 59.9 % nationally, ranging from 56 % in west to 69 % in northeast. The most significant factors associated with hospitalization were intra-abdominal abscess [odds ratio (OR) 24.22], bowel obstruction (OR 17.77), anemia (OR 7.54), malnutrition (OR 6.29), hypovolemia/electrolyte abnormalities (OR 5.57), and fever/abnormal white cell count (OR 3.18). Patients with CD (OR 0.66), low-income group (OR 0.90), and female gender (OR 0.87) have a lower odds of getting hospitalized. Age above 65 years (OR 1.63), CD (OR 1.89), bowel obstruction (OR 9.24), and intra-abdominal abscess (OR 18.41) were significantly associated with surgical intervention. The IBD-related ED visits have remained relatively stable from 2009 to 2011. The presence of anemia, malnutrition, hypovolemia, electrolyte abnormalities, fever, abnormal white cell count, bowel obstruction, or intra-abdominal abscess during the ED visit was associated with hospitalization. The presence of bowel obstruction and intra-abdominal abscess was strongly associated with surgical intervention.

Could inter-agency working reduce emergency department attendances due to alcohol consumption?

PubMed

Benger, J; Carter, R

2008-06-01

Excess alcohol consumption and associated harms in terms of health, crime and disorder have been highlighted by the government and media, causing considerable public concern. This study quantified the number of patient attendances at an urban adult and children's emergency department (ED) directly attributable to alcohol intoxication, and investigated ways in which the inter-agency sharing of anonymised information could be used to design, implement and monitor interventions to reduce these harms. Intoxicated patients attending either the adult or children's ED were prospectively identified by qualified nursing staff and anonymised data collected by a dedicated researcher. Collaboration and data sharing between health, police, social services, university experts and local authorities was achieved through the establishment of steering and operational groups with agreed objectives and the formation of a shared anonymised database. The proportion of patients attending the ED as a result of alcohol intoxication was 4% in adults and <1% in children. 70% of patients were male, with a mean age of 30 years, and 72% attended between 20.00 and 08.00 h. The most common reason for ED attendance was accident (34%), followed closely by assault (30%). 27% of patients had done most of their drinking at home, 36% in a pub and 16% in a nightclub. Inter-agency collaboration proved highly successful: pooling of anonymised data created a much clearer picture of the extent of the problem and immediately suggested strategies for intervention. The initiative to achieve inter-agency collaboration and data sharing was highly successful, with clear potential for the development and implementation of interventions that will reduce ED attendance due to excess alcohol consumption.

Clinical characteristics of older male military veterans seeking treatment for erectile dysfunction.

PubMed

Beaudreau, Sherry A; Rideaux, Tiffany; Zeiss, Robert A

2011-02-01

Male sexual dysfunction is a significant international public health issue affecting both middle-aged and older adults. To date, however, no studies have compared age differences in psychiatric issues, frequency of sexual activity and treatment recommendations between older and middle-aged male military Veterans seeking treatment for erectile dysfunction (ED) in the U.S.A. Data were collected between 1982 and 2003 at the Palo Alto Veterans Affairs Andrology Clinic. The 1,250 participants, aged 22 to 87 years (median = 63), completed a semi-structured interview. Using multiple linear regressions, we examined age differences in five domains: medical and endocrine risk factors; psychiatric and psychosocial risk factors; frequency of sexual behaviors; self-reported and objectively measured erectile function; and treatment recommendations. Compared with middle-aged adults, older adults were more likely to present for ED treatment with medical risk factors and were more often recommended a vacuum pump treatment. Middle-aged male Veterans were more likely to experience psychiatric risk factors for ED and were more sexually active than older Veterans. Despite greater objective erectile ability in middle-aged adults, there were no age differences in maximum self-reported erectile functioning. These results provide some evidence of age-related characteristics and treatment needs of male patients seeking treatment for sexual dysfunction. We encourage health care professionals working with adults across the lifespan to consider ways to individualize psychoeducation and brief psychotherapy for the treatment of ED to the specific needs of the patient, which may vary between middle-aged and older cohorts of patients.

Effective dose reduction in spine radiographic imaging by choosing the less radiation-sensitive side of the body.

PubMed

Ben-Shlomo, Avi; Bartal, Gabriel; Mosseri, Morris; Avraham, Boaz; Leitner, Yosef; Shabat, Shay

2016-04-01

X-ray absorption is highest in the organs and tissues located closest to the radiation source. The photon flux that crosses the body decreases from the entry surface toward the image receptor. The internal organs absorb x-rays and shield each other during irradiation. Therefore, changing the x-ray projection angle relative to the patient for specific spine procedures changes the radiation dose that each organ receives. Every organ has different radiation sensitivity, so irradiation from different sides of the body changes the biological influence and radiation risk potential on the total body, that is the effective dose (ED). The study aimed to determine the less radiation-sensitive sides of the body during lateral and anterior-posterior (AP) or posterior anterior (PA) directions. The study used exposure of patient phantoms and Monte Carlo simulation of the effective doses. Calculations for adults and 10-year-old children were included because the pediatric population has a greater lifetime radiation risk than adults. Pediatric and adult tissue and organ doses and ED from cervical, thoracic, and lumbar x-ray spine examinations were performed from different projections. Standard mathematical phantoms for adults and 10-year-old children, using PCXMC 2.0 software based on Monte Carlo simulations, were used to calculate pediatric and adult tissue and organ doses and ED. The study was not funded. The authors have no conflicts of interest to declare. Spine x-ray exposure from various right (RT) LAT projection angles was associated with lower ED compared with the same left (LT) LAT projections (up to 28% and 27% less for children aged 10 and adults, respectively). The PA spine projections showed up to 64% lower ED for children aged 10 and 65% for adults than AP projections. The AP projection at the thoracic spine causes an excess breast dose of 543.3% and 597.0% for children aged 10 and adults, respectively. Radiation ED in spine procedures can be significantly reduced by performing x-ray exposures through the less radiation-sensitive sides of the body, which are PA in the frontal position and right lateral in the lateral position. Copyright © 2015 Elsevier Inc. All rights reserved.

Slipping through the cracks: A cross-sectional study examining older adult emergency department patient fall history, post-fall treatment and prevention.

PubMed

Goldberg, Elizabeth M; McCreedy, Ellen M; Gettel, Cameron J; Merchant, Roland C

2017-12-01

Falls are the leading cause of emergency department (ED) visits for fatal and non-fatal injuries among adults 65 years old and older. We aimed to better understand the fall history, risk for further falls, and actions taken to prevent further falls among this higher fall risk population. This cross-sectional study included older adults without cognitive impairment presenting to the Rhode Island Hospital ED from February to May 2017. Of the 76 participants, 35 self-reported no prior falls, and 41 self-reported at least one prior fall, of whom 20 fell on the day of ED presentation. Participants with vs. without self-reported prior falls were similar in age, gender, race, and substance use. Participants with prior falls scored lower on cognitive testing and had more comorbidities associated with falls. Only one quarter of those with prior falls reported making changes and few were evaluated by professionals to prevent future falls. This study highlights that older adult ED patients who sustain a fall are at higher risk for subsequent falls, and that greater fall prevention efforts are needed to protect this vulnerable group. [Full article available at http://rimed.org/rimedicaljournal-2017-12.asp].

The effectiveness of physiologically based early warning or track and trigger systems after triage in adult patients presenting to emergency departments: a systematic review.

PubMed

Wuytack, Francesca; Meskell, Pauline; Conway, Aislinn; McDaid, Fiona; Santesso, Nancy; Hickey, Fergal G; Gillespie, Paddy; Raymakers, Adam J N; Smith, Valerie; Devane, Declan

2017-12-06

Changes to physiological parameters precede deterioration of ill patients. Early warning and track and trigger systems (TTS) use routine physiological measurements with pre-specified thresholds to identify deteriorating patients and trigger appropriate and timely escalation of care. Patients presenting to the emergency department (ED) are undiagnosed, undifferentiated and of varying acuity, yet the effectiveness and cost-effectiveness of using early warning systems and TTS in this setting is unclear. We aimed to systematically review the evidence on the use, development/validation, clinical effectiveness and cost-effectiveness of physiologically based early warning systems and TTS for the detection of deterioration in adult patients presenting to EDs. We searched for any study design in scientific databases and grey literature resources up to March 2016. Two reviewers independently screened results and conducted quality assessment. One reviewer extracted data with independent verification of 50% by a second reviewer. Only information available in English was included. Due to the heterogeneity of reporting across studies, results were synthesised narratively and in evidence tables. We identified 6397 citations of which 47 studies and 1 clinical trial registration were included. Although early warning systems are increasingly used in EDs, compliance varies. One non-randomised controlled trial found that using an early warning system in the ED may lead to a change in patient management but may not reduce adverse events; however, this is uncertain, considering the very low quality of evidence. Twenty-eight different early warning systems were developed/validated in 36 studies. There is relatively good evidence on the predictive ability of certain early warning systems on mortality and ICU/hospital admission. No health economic data were identified. Early warning systems seem to predict adverse outcomes in adult patients of varying acuity presenting to the ED but there is a lack of high quality comparative studies to examine the effect of using early warning systems on patient outcomes. Such studies should include health economics assessments.

[Pediatric anesthesia emergence delirium after elective ambulatory surgery: etiology, risk factors and prevalence].

PubMed

Gololobov, Alik; Todris, Liat; Berman, Yakov; Rosenberg-Gilad, Zipi; Schlaeffer, Pnina; Kenett, Ron; Ben-Jacob, Ron; Segal, Eran

2015-04-01

Emergence delirium (ED) is a common problem among children and adults recovering from general anesthesia after surgery. Its symptoms include psychomotor agitation, hallucinations, and aggressive behavior. The phenomenon, which is most probably an adverse effect of general anesthesia agents, harms the recovery process and endangers the physical safety of patients and their health. Ranging between 10% and 80%, the exact prevalence of ED is unknown, and the risk factors of the phenomenon are unclear. The aim of the current retrospective study was to determine the prevalence rate of ED in 3947 children recovering from general anesthesia after short elective ambulatory surgery, and to map the influence of various risk factors on this phenomenon. Data were collected using electronic medical records. ED severity was assessed using the Pediatric Anesthesia Emergence Delirium Scale. Results showed the prevalence of ED among children. ED was significantly correlated with patients' age, type of surgery and premedication. ED was not correlated with severity of pain, type of anesthesia or with patients' sex.

An Analysis of US Emergency Department Visits From Falls From Skiing, Snowboarding, Skateboarding, Roller-Skating, and Using Nonmotorized Scooters.

PubMed

Nathanson, Brian H; Ribeiro, Kara; Henneman, Philip L

2016-07-01

We analyzed the US incidence of emergency department (ED) visits and hospitalizations for falls from skiing, snowboarding, skateboarding, roller-skating, and nonmotorized scooters in 2011. The outcome was hospital admission from the ED. The primary analysis compared pediatric patients aged 1 to 17 years to adults aged 18 to 44 years. The analysis used ICD-9 E-codes E885.0 to E885.4 using discharge data from the Nationwide Emergency Department Sample, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. Approximately 214 000 ED visits met study criteria. Skiing injuries had the highest percentage of hospitalizations (3.30% in pediatric patients and 6.65% in adults 18-44 years old). Skateboard and snowboard injuries were more likely to require hospitalization than roller skating injuries in pediatric patients (odds ratio = 2.42; 95% CI = 2.14-2.75 and odds ratio = 1.83; 95% CI =1.55-2.15, respectively). In contrast, skateboard and snowboard injuries were less severe than roller-skating injuries in adults. © The Author(s) 2015.

Chronic Pain in the Emergency Department: A Pilot Mixed-Methods Cross-Sectional Study Examining Patient Characteristics and Reasons for Presentations.

PubMed

Poulin, Patricia A; Nelli, Jennifer; Tremblay, Steven; Small, Rebecca; Caluyong, Myka B; Freeman, Jeffrey; Romanow, Heather; Stokes, Yehudis; Carpino, Tia; Carson, Amanda; Shergill, Yaadwinder; Stiell, Ian G; Taljaard, Monica; Nathan, Howard; Smyth, Catherine E

2016-01-01

Background . Chronic pain (CP) accounts for 10-16% of emergency department (ED) visits, contributing to ED overcrowding and leading to adverse events. Objectives . To describe patients with CP attending the ED and identify factors contributing to their visit. Methods . We used a mixed-method design combining interviews and questionnaires addressing pain, psychological distress, signs of opioid misuse, and disability. Participants were adults who attended the EDs of a large academic tertiary care center for their CP problem. Results . Fifty-eight patients (66% women; mean age 46.5, SD = 16.9) completed the study. The most frequently cited reason (60%) for ED visits was inability to cope with pain. Mental health problems were common, including depression (61%) and anxiety (45%). Participants had questions about the etiology of their pain, concerns about severe pain-related impairment, and problems with medication renewals or efficacy and sometimes felt invalidated in the ED. Although most participants had a primary care physician, the ED was seen as the only or best option when pain became unmanageable. Conclusions . Patients with CP visiting the ED often present with complex difficulties that cannot be addressed in the ED. Better access to interdisciplinary pain treatment is needed to reduce the burden of CP on the ED.

Telemedicine delivery of patient education in remote Ontario communities: feasibility of an Advanced Clinician Practitioner in Arthritis Care (ACPAC)-led inflammatory arthritis education program.

PubMed

Warmington, Kelly; Flewelling, Carol; Kennedy, Carol A; Shupak, Rachel; Papachristos, Angelo; Jones, Caroline; Linton, Denise; Beaton, Dorcas E; Lineker, Sydney

2017-01-01

Telemedicine-based approaches to health care service delivery improve access to care. It was recognized that adults with inflammatory arthritis (IA) living in remote areas had limited access to patient education and could benefit from the 1-day Prescription for Education (RxEd) program. The program was delivered by extended role practitioners with advanced training in arthritis care. Normally offered at one urban center, RxEd was adapted for videoconference delivery through two educator development workshops that addressed telemedicine and adult education best practices. This study explores the feasibility of and participant satisfaction with telemedicine delivery of the RxEd program in remote communities. Participants included adults with IA attending the RxEd program at one of six rural sites. They completed post-course program evaluations and follow-up interviews. Educators provided post-course feedback to identify program improvements that were later implemented. In total, 123 people (36 in-person and 87 remote, across 6 sites) participated, attending one of three RxEd sessions. Remote participants were satisfied with the quality of the video-conference (% agree/strongly agree): could hear the presenter (92.9%) and discussion between sites (82.4%); could see who was speaking at other remote sites (85.7%); could see the slides (95.3%); and interaction between sites adequately facilitated (94.0%). Educator and participant feedback were consistent. Suggested improvements included: use of two screens (speaker and slides); frontal camera angles; equal interaction with remote sites; and slide modifications to improve the readability on screen. Interview data included similar constructive feedback but highlighted the educational and social benefits of the program, which participants noted would have been inaccessible if not offered via telemedicine. Study findings confirm the feasibility of delivering the RxEd program to remote communities by using telemedicine. Future research with a focus on the sustainability of this and other models of technology-supported patient education for adults with IA across Ontario is warranted.

How do ED patients with criminal justice contact compare with other ED users? A retrospective analysis of ED visits in California.

PubMed

McConville, Shannon; Mooney, Alyssa C; Williams, Brie A; Hsia, Renee Y

2018-06-21

To assess the patterns of emergency department (ED) utilisation among those with and without criminal justice contact in California in 2014, comparing variation in ED use, visit frequency, diagnoses and insurance coverage. Retrospective, cross-sectional study. Analyses included ED visits to all licensed hospitals in California using statewide data on all ED encounters in 2014. Study participants included 3 757 870 non-elderly adult ED patients who made at least one ED visit in 2014. We assessed the patterns and characteristics of ED visits among those with criminal justice contact-patients who were either admitted to or discharged from the ED by a correctional institution-with patients who did not have criminal justice contact recorded during an ED visit. ED patients with criminal justice contact had higher proportions of frequent ED users (27.2% vs 9.4%), were at higher risk of an ED visit resulting in hospitalisation (26.6% vs 15.2%) and had higher prevalence of mental health conditions (52.8% vs 30.4%) compared with patients with no criminal justice contact recorded during an ED visit. Of the top 10, four primary diagnoses among patients with criminal justice contact were related to behavioural health conditions, accounting for 19.0% of all primary diagnoses in this population. In contrast, behavioural health conditions were absent from the top 10 primary diagnoses in ED patients with no observed criminal justice contact. Despite a high burden of disease, a lack of health insurance coverage was more common among those with criminal justice contact than those without (41.3% vs 14.1%). Given that a large proportion of ED patients with criminal justice contact are frequent users with considerable mental health conditions, current efforts in California's Medicaid programme to identify individuals in need of coordinated services could reduce costly ED utilisation among this group. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Gait Pattern in Two Rare Genetic Conditions Characterized by Muscular Hypotonia: Ehlers-Danlos and Prader-Willi Syndrome

ERIC Educational Resources Information Center

Cimolin, Veronica; Galli, Manuela; Vismara, Luca; Grugni, Graziano; Camerota, Filippo; Celletti, Claudia; Albertini, Giorgio; Rigoldi, Chiara; Capodaglio, Paolo

2011-01-01

This study aimed to quantify and compare the gait pattern in Ehlers-Danlos (EDS) and Prader-Willi syndrome (PWS) patients to provide data for developing evidence-based rehabilitation strategies. Twenty EDS and 19 PWS adult patients were evaluated with an optoelectronic system and force platforms for measuring kinematic and kinetic parameters…

Energy drink and other substance use among adolescent and young adult emergency department patients.

PubMed

Cotter, Bradford V; Jackson, Deidrya A E; Merchant, Roland C; Babu, Kavita M; Baird, Janette R; Nirenberg, Ted; Linakis, James G

2013-10-01

This study aimed to understand current patterns of energy drink use and compare the extent of usage of energy drinks and other commonly used and misused substances between adolescent (13-17-years-old) and young adult (18-25-years-old) emergency department (ED) patients. During a 6-week period between June and August 2010, all patients presenting to an adult or pediatric ED were asked to complete a computer-based, anonymous questionnaire regarding use of energy drinks and other substances. Wilcoxon rank-sum, 2-sample tests of binomial proportions, Pearson χ(2) testing, and regression models were used to compare energy drink and substance use by age groups. Past 30-day energy drink use was greater for young adults (57.9%) than adolescents (34.9%) (P < 0.03). Adolescents typically consumed a mean of 1.5 and young adults a mean of 2.6 energy drinks per day when using energy drinks and drank at most a mean of 2.4 and 2.6 drinks per day, respectively. Among adolescents, energy drink usage was more common than alcohol, "street" or illicit drugs, and tobacco usage, but less common than caffeine product usage. For young adults, energy drink usage was more common than "street" or illicit drugs, but less common than caffeine use, and similar to tobacco and alcohol usage. Young adult energy drink users were more likely than young adult non-energy drink users also to use tobacco and caffeine. Energy drink use is common among ED patients. Given the high prevalence of energy drink use observed, emergency physicians should consider the involvement of energy drinks in the presentations of young people.

Clinical outcomes of implant therapy in ectodermal dysplasia patients: a systematic review.

PubMed

Wang, Y; He, J; Decker, A M; Hu, J C; Zou, D

2016-08-01

The purpose of this review was to determine the outcome of oral function reconstruction in ectodermal dysplasia (ED) patients who have received dental implant therapy. A search was made of the PubMed and Web of Science databases; key words used were "(ectodermal dysplasia) AND (implant OR implants)", with supplementary retrieval key words "dental implant", "zygomatic implant", "anodontia", and "edentulous". Patient age, use of bone graft, implant site, type of implant, and survival rate of the implants were included in the subsequent data analysis. Forty-five articles published between 1988 and October 2015 were included in this analysis. The cases of a total of 96 patients were retrieved (22 children and 74 adults); these patients received a total of 701 implants. Fourteen implants were removed during a median follow-up time of 24 months. The 24-month implant survival rate was 97.9% in adult subjects and 98.6% in children. Sixty-eight percent of adult patients underwent bone augmentation prior to implant placement. Based on this review, dental implants are commonly used in the oral reconstruction of ED patients. However, long-term data on bone augmentation and implant success are needed, as well as additional clinical evidence on bone resorption, the esthetic outcomes of implant therapy, and physiological considerations in ED patients. Copyright © 2016 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Black Saturday: the immediate impact of the February 2009 bushfires in Victoria, Australia.

PubMed

Cameron, Peter A; Mitra, Biswadev; Fitzgerald, Mark; Scheinkestel, Carlos D; Stripp, Andrew; Batey, Chris; Niggemeyer, Louise; Truesdale, Melinda; Holman, Paul; Mehra, Rishi; Wasiak, Jason; Cleland, Heather

2009-07-06

To examine the response of the Victorian State Trauma System to the February 2009 bushfires. A retrospective review of the strategic response required to treat patients with bushfire-related injury in the first 72 hours of the Victorian bushfires that began on 7 February 2009. Emergency department (ED) presentations and initial management of patients presenting to the state's adult burns centre (The Alfred Hospital [The Alfred]) were analysed, as well as injuries and deaths associated with the fires. There were 414 patients who presented to hospital EDs as a result of the bushfires. Patients were triaged at the emergency scene, at treatment centres and in hospital. National and statewide burns disaster plans were activated. Twenty-two patients with burns presented to the state's burns referral centres, of whom 18 were adults. Adult burns patients at The Alfred spent 48.7 hours in theatre in the first 72 hours. There were a further 390 bushfire-related ED presentations across the state in the first 72 hours. Most patients with serious burns were triaged to and managed at burns referral centres. Throughout the disaster, burns referral centres continued to have substantial surge capacity. Most bushfire victims either died, or survived with minor injuries. As a result of good prehospital triage and planning, the small number of patients with serious burns did not overload the acute health care system.

Sex and age differences in ED patients with mental and behavioral disorders due to psychoactive substance use.

PubMed

Le Querrec, Fanny; Bounes, Vincent; Mestre, Maryse Lapeyre; Azema, Olivier; Longeaux, Nicolas; Gallart, Jean-Christophe

2015-11-01

The objectives of this study are to describe an emergency department (ED) adult population with the chief complaint of mental and behavioral disorders due to psychoactive substance use and to investigate sex- and age-related differences. We analyzed data (2009-2011) from the Regional Observatory of Emergency Medicine ORU-MiP (700000 patients per year) for all patients with a primary diagnosis of mental and behavioral disorders due to psychoactive substance use. Day data were weighted by the number of days in the year and expressed for 100000 inhabitants of the area. Pearson χ(2) test and Fisher tests were used. The Brown-Mood test was used to compare medians. Of the 1411597 ED visits analyzed, 20838 consults (1.3%) were for primary diagnosis of mental and behavioral disorders due to psychoactive substance use. The median age (interquartile range) was 41 (28-51) years; 69.5% were men. More women consulted the ED for sedative or hypnotic use (4.9% vs 1.5%, P < 10(-4)) than men, and more men consulted for alcohol consumption (93.5% vs 90%, P < 10(-4)) and cannabinoids (1.4% vs 1.0%, P < 10(-3)) than women. Young consumer visits dramatically increased during weekends (average of 88 visits a day per 100000 inhabitants vs 34 on Mondays to Thursdays). Another difference was found between young adults and middle-aged adults, with a peak in visits at 2 am and 9 pm respectively. Mental and behavioral disorders due to psychoactive substance use account for 1.3% of ED visits. Older people should be screened for chronic alcohol consumption. Our findings underscore the opportunity provided by the ED for screening and brief intervention in drug- and alcohol-related problems. Copyright © 2015 Elsevier Inc. All rights reserved.

Gait Strategy in Patients with Ehlers-Danlos Syndrome Hypermobility Type: A Kinematic and Kinetic Evaluation Using 3D Gait Analysis

ERIC Educational Resources Information Center

Galli, Manuela; Cimolin, Veronica; Rigoldi, Chiara; Castori, Marco; Celletti, Claudia; Albertini, Giorgio; Camerota, Filippo

2011-01-01

The aim of this study was to quantify the gait patterns of adults with joint hypermobility syndrome/Ehlers-Danlos syndrome (JHS/EDS-HT) hypermobility type, using Gait Analysis. We quantified the gait strategy in 12 JHS/EDS-HT adults individuals (age: 43.08 + 6.78 years) compared to 20 healthy controls (age: 37.23 plus or minus 8.91 years), in…

Generalized Hyperalgesia in Children and Adults Diagnosed With Hypermobility Syndrome and Ehlers-Danlos Syndrome Hypermobility Type: A Discriminative Analysis.

PubMed

Scheper, M C; Pacey, V; Rombaut, L; Adams, R D; Tofts, L; Calders, P; Nicholson, L L; Engelbert, R H H

2017-03-01

Lowered pressure-pain thresholds have been demonstrated in adults with Ehlers-Danlos syndrome hypermobility type (EDS-HT), but whether these findings are also present in children is unclear. Therefore, the objectives of the study were to determine whether generalized hyperalgesia is present in children with hypermobility syndrome (HMS)/EDS-HT, explore potential differences in pressure-pain thresholds between children and adults with HMS/EDS-HT, and determine the discriminative value of generalized hyperalgesia. Patients were classified in 1 of 3 groups: HMS/EDS-HT, hypermobile (Beighton score ≥4 of 9), and healthy controls. Descriptive data of age, sex, body mass index, Beighton score, skin laxity, and medication usage were collected. Generalized hyperalgesia was quantified by the average pressure-pain thresholds collected from 12 locations. Confounders collected were pain locations/intensity, fatigue, and psychological distress. Comparisons between children with HMS/EDS-HT and normative values, between children and adults with HMS/EDS-HT, and corrected confounders were analyzed with multivariate analysis of covariance. The discriminative value of generalized hyperalgesia employed to differentiate between HMS/EDS-HT, hypermobility, and controls was quantified with logistic regression. Significantly lower pressure-pain thresholds were found in children with HMS/EDS-HT compared to normative values (range -22.0% to -59.0%; P ≤ 0.05). When applying a threshold of 30.8 N/cm 2 for males and 29.0 N/cm 2 for females, the presence of generalized hyperalgesia discriminated between individuals with HMS/EDS-HT, hypermobility, and healthy controls (odds ratio 6.0). Children and adults with HMS/EDS-HT are characterized by hypermobility, chronic pain, and generalized hyperalgesia. The presence of generalized hyperalgesia may indicate involvement of the central nervous system in the development of chronic pain. © 2016, American College of Rheumatology.

Correlation of Physical Exam Findings with Fever in Patients with Skin and Soft Tissue Infections.

PubMed

Mongelluzzo, Jillian; Tu, Brian; Grimes, Barbara; Ziyeh, Sharvina; Fortman, Jonathan; Neilson, Jersey; Rodriguez, Robert M

2017-04-01

The objectives of this study were to determine the prevalence of fever in adult ED patients with skin and soft tissue infections (SSTI) and to determine which, if any, physical exam, radiograph and laboratory test findings were associated with fever. We conducted a prospective, observational study at an urban county trauma center of adults who presented to the ED for evaluation of suspected SSTI. ED providers measured area of erythema and induration using a tape measure, and completed data sheets indicating comorbid conditions and the presence or absence of physical exam findings. Fever was defined as any recorded temperature ≥ 38°C during the first six hours of ED evaluation. Of the 734 patients enrolled, 96 (13.1%) had fever. Physical and laboratory exam findings associated with the presence of a fever in multivariable logistic regression were the area of erythema, particularly the largest quartile of area of erythema, 144 - 5,000 cm 2 , (odd ratio [OR] = 2.9; 95% confidence interval [CI] [1.6 - 5.2]) and leukocytosis (OR = 4.4, 95% CI [2.7 - 7.0]). Bullae, necrosis, streaks, adenopathy, and bone involvement on imaging were not associated with fever. Fever is uncommon in patients presenting to the ED for evaluation of suspected SSTI. Area of erythema and leukocytosis were associated with fever and should be considered in future decision rules for the evaluation and treatment of SSTI.

Early versus late pre-intensive care unit admission broad spectrum antibiotics for severe sepsis in adults.

PubMed

Siddiqui, Shahla; Razzak, Junaid

2010-10-06

Severe sepsis and septic shock have recently emerged as particularly acute and lethal challenges amongst critically ill patients presenting to the emergency department (ED). There are no existing data on the current practices of management of patients with severe sepsis comparing early versus late administration of appropriate broad spectrum antibiotics as part of the early goal-directed therapy that is commenced in the first few hours of presentation. To assess the difference in outcomes with early compared to late administration of antibiotics in patients with severe sepsis in the pre-intensive care unit (ICU) admission period. We defined early as within one hour of presentation to the ED. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2009); MEDLINE (1990 to February 2010); EMBASE (1990 to February 2010); and ISI web of Science (February 2010). We also searched for relevant ongoing trials in specific websites such as www.controlled-trials.com; www.clinicalstudyresults.org; and www.update-software.com. We searched the reference lists of articles. There were no constraints based on language or publication status. We planned to include randomized controlled trials of early versus late broad spectrum antibiotics in adult patients with severe sepsis in the ED, prior to admission to the intensive care unit. Two authors independently assessed articles for inclusion. We found no studies that satisfied the inclusion criteria. Based on this review we are unable to make a recommendation on the early or late use of broad spectrum antibiotics in adult patients with severe sepsis in the ED pre-ICU admission. There is a need to do large prospective double blinded randomized controlled trials on the efficacy of early (within one hour) versus late broad spectrum antibiotics in adult severe sepsis patients. Since it makes sense to start antibiotics as soon as possible in this group of seriously ill patients, administering such antibiotics earlier as opposed to later is based on anecdotal suboptimal evidence.

American Association for Emergency Psychiatry Task Force on Medical Clearance of Adults Part I: Introduction, Review and Evidence-Based Guidelines

PubMed Central

Anderson, Eric L.; Nordstrom, Kimberly; Wilson, Michael P.; Peltzer-Jones, Jennifer M.; Zun, Leslie; Ng, Anthony; Allen, Michael H.

2017-01-01

Introduction In the United States, the number of patients presenting to the emergency department (ED) for a mental health concern is significant and expected to grow. The breadth of the medical evaluation of these patients is controversial. Attempts have been made to establish a standard evaluation for these patients, but to date no nationally accepted standards exist. A task force of the American Association of Emergency Psychiatry, consisting of physicians from emergency medicine and psychiatry, and a psychologist was convened to form consensus recommendations on the medical evaluation of psychiatric patients presenting to EDs. Methods The task force reviewed existing literature on the topic of medical evaluation of psychiatric patients in the ED (Part I) and then combined this with expert consensus (Part II). Results In Part I, we discuss terminological issues and existing evidence on medical exams and laboratory studies of psychiatric patients in the ED. Conclusion Emergency physicians should work cooperatively with psychiatric receiving facilities to decrease unnecessary testing while increasing the quality of medical screening exams for psychiatric patients who present to EDs. PMID:28210358

Concordance of Advance Care Plans With Inpatient Directives in the Electronic Medical Record for Older Patients Admitted From the Emergency Department.

PubMed

Grudzen, Corita R; Buonocore, Philip; Steinberg, Jonathan; Ortiz, Joanna M; Richardson, Lynne D

2016-04-01

Measuring What Matters identified quality indicators to examine the percentage of patients with documentation of a surrogate decision maker and preferences for life-sustaining treatments. To determine the rate of advance care planning in older adults presenting to the emergency department (ED) and translation into medical directives in the electronic medical record (EMR). A convenience sample of adults 65 years or older was recruited from a large urban ED beginning in January 2012. We administered a baseline interview and survey in English or Spanish, including questions about whether patients had a documented health care proxy or living will. For patients admitted to the hospital who had a health care proxy or living will, chart abstraction was performed to determine whether their advance care preferences were documented in the EMR. From February 2012 to May 2013, 53.8% (367 of 682) of older adults who completed the survey in the ED reported having a health care proxy, and 40.2% (274 of 682) had a living will. Of those admitted to the hospital, only 4% (4 of 94) of patients who said they had a living will had medical directives documented in the EMR. Similarly, only 4% (5 of 115) of patients who had a health care proxy had the person's name or contact information documented in their medical record. About half of the patients 65 years or older arriving in the ED have done significant advance care planning, but most plans are not recorded in the EMR. Copyright © 2016 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

Trends in short-stay hospitalizations for older adults from 1990 to 2010: implications for geriatric emergency care.

PubMed

Greenwald, Peter W; Stern, Michael E; Rosen, Tony; Clark, Sunday; Flomenbaum, Neal

2014-04-01

Geriatric patients are more likely than younger patients to be admitted to the hospital when they present to the emergency department (ED). Identifying trends in geriatric short-stay admission may inform the development of interventions designed to improve acute care for the elderly. To evaluate trends in US geriatric short-stay hospitalizations from 1990 to 2010. Retrospective study using the National Hospital Discharge Survey (NHDS). Trends in short-stay hospitalizations were analyzed from 1990 to 2010 for age groups 22 to 64, 65 to 74, 75 to 84, and at least 85 years using linear regression. A total of 4.5 million survey visits representing 580 million adult hospitalizations were available for analysis; 250 million (43%) were among patients 65 years or older. Of these, 12%, 25%, and 40% were ≤ 1, ≤ 2 and ≤ 3 days' short-stay admissions, respectively. Between 1990 and 2010, short-stay admissions increased as a percentage of total hospitalizations for each geriatric age group but remained relatively constant for younger adults. Admissions from NHDS were similar to admissions from the ED for years where ED-specific data were available. The older a patient was (age >65 years), the more likely their admission was to have started in the ED. For all elderly patients, short-stay admissions represented a growing proportion of total admissions, regardless of the definition of short stay. These trends were identified despite the NHDS exclusion of observation status hospitalizations. The increase in short-stay admissions was the most pronounced in the extreme elderly (age ≥ 85 years). Future research is needed to optimize treatment for geriatric patients presenting to the ED, some of whom, with brief observation and appropriate follow-up, may be better cared for without hospitalization. Copyright © 2014 Elsevier Inc. All rights reserved.

Atypical presentations of older adults at the emergency department and associated factors.

PubMed

Limpawattana, Panita; Phungoen, Pariwat; Mitsungnern, Thapanawong; Laosuangkoon, Wannisa; Tansangworn, Natthida

2016-01-01

The objectives were to determine the prevalence of atypical presentations among older adults at the Emergency Department (ED) of a tertiary care hospital and to identify factors associated with these presentations. A retrospective medical record audit was randomly reviewed in 633 patients who were aged ≥ 65 years who attended the ED of Srinagarind Medical School Hospital in 2013. Demographic data were collected and were analyzed using descriptive statistics. Regression analysis was used to analyze the variables associated with the outcomes. The prevalence of an atypical presentation was 28.6% (181/633 cases). The failure to develop fever with a disease known to cause fever was the most common atypical presentation of illness (34.42%). Independent factors associated with atypical presentations were complicated urinary tract infection (UTI) (odds ratios (OR) 4.66, 95% confidence interval (CI) 2.0, 10.84, p=0.00) and a background of dementia (OR 3.48, 95% CI 1.38, 8.77, p=0.008). The prevalence of atypical presentations of older adults at the ED was about a third. The absence of fever with a disease known to cause fever was the most common atypical presentation. Complicated UTI and demented patients were the independent risk factors associated with the atypical presentations. Early awareness of non-specific presentations and applying comprehensive geriatric assessments among older patients at the ED is recommended. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

Insurance and Quality of Care for Adults with Acute Asthma

PubMed Central

Ferris, Timothy G; Blumenthal, David; Woodruff, Prescott G; Clark, Sunday; Camargo, Carlos A

2002-01-01

OBJECTIVE The relationship between health care insurance and quality of medical care remains incompletely studied. We sought to determine whether type of patient insurance is related to quality of care and subsequent outcomes for patients who arrive in the emergency department (ED) for acute asthma. DESIGN Using prospectively collected data from the Multicenter Airway Research Collaboration, we compared measures of quality of pre-ED care, acute severity, and short-term outcomes across 4 insurance categories: managed care, indemnity, Medicaid, and uninsured. SETTING AND PARTICIPANTS Emergency departments at 57 academic medical centers enrolled 1,019 adults with acute asthma. RESULTS Patients with managed care ranked first and uninsured patients ranked last on all 7 unadjusted quality measures. After controlling for covariates, uninsured patients had significantly lower quality of care than indemnity patients for 5 of 7 measures and had lower initial peak expiratory flow rates than indemnity insured patients. Patients with managed care insurance were more likely than indemnity-insured patients to identify a primary care physician and report using inhaled steroids in the month prior to arrival in the ED. Patients with Medicaid insurance were more likely than indemnity-insured patients to use the ED as their usual source of care for problems with asthma. We found no differences in patient outcomes among the insurance categories we studied. CONCLUSIONS Uninsured patients had consistently poorer quality of care and than insured patients. Despite differences in indicators of quality of care between types of insurance, we found no differences in short-term patient outcomes by type of insurance. PMID:12472926

Machine Learning to Predict, Detect, and Intervene Older Adults Vulnerable for Adverse Drug Events in the Emergency Department.

PubMed

Ouchi, Kei; Lindvall, Charlotta; Chai, Peter R; Boyer, Edward W

2018-06-01

Adverse drug events (ADEs) are common and have serious consequences in older adults. ED visits are opportunities to identify and alter the course of such vulnerable patients. Current practice, however, is limited by inaccurate reporting of medication list, time-consuming medication reconciliation, and poor ADE assessment. This manuscript describes a novel approach to predict, detect, and intervene vulnerable older adults at risk of ADE using machine learning. Toxicologists' expertise in ADE is essential to creating the machine learning algorithm. Leveraging the existing electronic health records to better capture older adults at risk of ADE in the ED may improve their care.

Exercise dependence score in patients with longstanding eating disorders and controls: the importance of affect regulation and physical activity intensity.

PubMed

Bratland-Sanda, Solfrid; Martinsen, Egil W; Rosenvinge, Jan H; Rø, Oyvind; Hoffart, Asle; Sundgot-Borgen, Jorunn

2011-01-01

To examine associations among exercise dependence score, amount of physical activity and eating disorder (ED) symptoms in patients with longstanding ED and non-clinical controls. Adult female inpatients (n = 59) and 53 age-matched controls participated in this cross sectional study. Assessments included the eating disorders examination, eating disorders inventory, exercise dependence scale, reasons for exercise inventory, and MTI Actigraph accelerometer. Positive associations were found among vigorous, not moderate, physical activity, exercise dependence score and ED symptoms in patients. In the controls, ED symptoms were negatively associated with vigorous physical activity and not correlated with exercise dependence score. Exercise for negative affect regulation, not weight/appearance, and amount of vigorous physical activity were explanatory variables for exercise dependence score in both groups. The positive associations among exercise dependence score, vigorous physical activity and ED symptoms need proper attention in the treatment of longstanding ED. Copyright © 2011 John Wiley & Sons, Ltd and Eating Disorders Association.

Uric acid level and erectile dysfunction in patients with coronary artery disease.

PubMed

Solak, Yalcin; Akilli, Hakan; Kayrak, Mehmet; Aribas, Alpay; Gaipov, Abduzhappar; Turk, Suleyman; Perez-Pozo, Santos E; Covic, Adrian; McFann, Kim; Johnson, Richard J; Kanbay, Mehmet

2014-01-01

Erectile dysfunction (ED) is a frequent complaint of elderly subjects and is closely associated with endothelial dysfunction and cardiovascular disease (CVD). Uric acid is also associated with endothelial dysfunction, oxidative stress, and CVD, raising the hypothesis that an increased serum uric acid might predict ED in patients who are at risk for coronary artery disease (CAD). This study aims to evaluate the association of serum uric acid levels with presence and severity of ED in patients presenting with chest pain of presumed cardiac origin. This is a cross-sectional study of 312 adult male patients with suspected CAD who underwent exercise stress test (EST) for workup of chest pain and completed a sexual health inventory for men survey form to determine the presence and severity of ED. Routine serum biochemistry (and uric acid levels) were measured. Logistic regression analysis was used to assess risk factors for ED. The short version of the International Index of Erectile Function questionnaire diagnosed ED (cutoff score ≤ 21). Serum uric acid levels were determined. Patients with chest pain of suspected cardiac origin underwent an EST. One hundred forty-nine of 312 (47.7%) male subjects had ED by survey criteria. Patients with ED were older and had more frequent CAD, hypertension, diabetes and impaired renal function, and also had significantly higher levels of uric acid, fibrinogen, glucose, C-reactive protein, triglycerides compared with patients without ED. Uric acid levels were associated with ED by univariate analysis (odds ratio = 1.36, P = 0.002); however, this association was not observed in multivariate analysis adjusted for estimated glomerular filtration rate. Subjects presenting with chest pain of presumed cardiac origin are more likely to have ED if they have elevated uric acid levels. © 2013 International Society for Sexual Medicine.

Travel distance and sociodemographic correlates of potentially avoidable emergency department visits in California, 2006-2010: an observational study.

PubMed

Chen, Brian K; Hibbert, James; Cheng, Xi; Bennett, Kevin

2015-03-21

Use of the hospital emergency department (ED) for medical conditions not likely to require immediate treatment is a controversial topic. It has been faulted for ED overcrowding, increased expenditures, and decreased quality of care. On the other hand, such avoidable ED utilization may be a manifestation of barriers to primary care access. A random 10% subsample of all ED visits with unmasked variables, or approximately 7.2% of all ED visits in California between 2006 and 2010 are used in the analysis. Using panel data methods, we employ linear probability and fractional probit models with hospital fixed effects to analyze the associations between avoidable ED utilization in California and observable patient characteristics. We also test whether shorter estimated road distances to the hospital ED are correlated with non-urgent ED utilization, as defined by the New York University ED Algorithm. We then investigate whether proximity of a Federally Qualified Health Center (FQHC) is correlated with reductions in non-urgent ED utilization among Medicaid patients. We find that relative to the reference group of adults aged 35-64, younger patients generally have higher scores for non-urgent conditions and lower scores for urgent conditions. However, elderly patients (≥65) use the ED for conditions more likely to be urgent. Relative to male and white patients, respectively, female patients and all identified racial and ethnic minorities use the ED for conditions more likely to be non-urgent. Patients with non-commercial insurance coverage also use the ED for conditions more likely to be non-urgent. Medicare and Medicaid patients who live closer to the hospital ED have higher probability scores for non-emergent visits. However, among Medicaid enrollees, those who live in zip codes with an FQHC within 0.5 mile of the zip code population centroid visit the ED for medical conditions less likely to be non-emergent. These patterns of ED utilization point to potential barriers to care among historically vulnerable groups, observable even when using rough estimates of travel distances and avoidable ED utilization.

Emergency department management of syncope: need for standardization and improved risk stratification.

PubMed

Thiruganasambandamoorthy, Venkatesh; Taljaard, Monica; Stiell, Ian G; Sivilotti, Marco L A; Murray, Heather; Vaidyanathan, Aparna; Rowe, Brian H; Calder, Lisa A; Lang, Eddy; McRae, Andrew; Sheldon, Robert; Wells, George A

2015-08-01

Variations in emergency department (ED) syncope management have not been well studied. The goals of this study were to assess variations in management, and emergency physicians' risk perception and disposition decision making. We conducted a prospective study of adults with syncope in six EDs in four cities over 32 months. We collected patient characteristics, ED management, disposition, physicians' prediction probabilities at index presentation and followed patients for 30 days for serious outcomes: death, myocardial infarction (MI), arrhythmia, structural heart disease, pulmonary embolism, significant hemorrhage, or procedural interventions. We used descriptive statistics, ROC curves, and regression analyses. We enrolled 3662 patients: mean age 54.3 years, and 12.9 % were hospitalized. Follow-up data were available for 3365 patients (91.9 %) and 345 patients (10.3 %) suffered serious outcomes: 120 (3.6 %) after ED disposition including 48 patients outside the hospital. After accounting for differences in patient case mix, the rates of ED investigations and disposition were significantly different (p < 0.0001) across the four study cities; as were the rates of 30-day serious outcomes (p < 0.0001) and serious outcomes after ED disposition (p = 0.0227). There was poor agreement between physician risk perception and both observed event rates and referral patterns (p < 0.0001). Only 76.7 % (95 % CI 68.1-83.6) of patients with serious outcomes were appropriately referred. There are large and unexplained differences in ED syncope management. Moreover, there is poor agreement between physician risk perception, disposition decision making, and serious outcomes after ED disposition. A valid risk-stratification tool might help standardize ED management and improve disposition decision making.

Determinants of Excessive Daytime Sleepiness and Fatigue in Adults with Heart Failure

PubMed Central

Riegel, Barbara; Ratcliffe, Sarah J.; Sayers, Steven L.; Potashnik, Sheryl; Buck, Harleah; Jurkovitz, Claudine; Fontana, Sarah; Weaver, Terri E.; Weintraub, William S.; Goldberg, Lee R.

2012-01-01

Little is known about excessive daytime sleepiness (EDS) in heart failure (HF). The aim of this cross-sectional descriptive study was to describe the prevalence of EDS and factors associated with it in HF. A secondary purpose was to explore the correlates of fatigue. We enrolled a consecutive sample of 280 adults with a confirmed diagnosis of chronic HF from three outpatient settings in the northeastern US. Patients with major depressive illness were excluded. Clinical, sociodemographic, behavioral, and perceptual factors were explored as possible correlates of EDS. Using an Epworth Sleepiness Scale score >10, the prevalence of EDS was 23.6%. Significant determinants of EDS were worse sleep quality (p=0.048), worse functional class (p=0.004), not taking a diuretic (p=0.005), and lack of physical activity (p=0.04). Only sleep quality was associated with fatigue (p<0.001). Sleep disordered breathing was not significantly associated with EDS or with fatigue. These factors may be amenable to intervention. PMID:21878581

Bone involvement in adult patients affected with Ehlers-Danlos syndrome.

PubMed

Eller-Vainicher, C; Bassotti, A; Imeraj, A; Cairoli, E; Ulivieri, F M; Cortini, F; Dubini, M; Marinelli, B; Spada, A; Chiodini, I

2016-08-01

The Ehlers-Danlos syndrome is characterized by abnormal connective tissue but bone involvement is debated. We found a reduced BMD and bone quality and increased prevalence of asymptomatic vertebral fractures in eugonadal patients with Ehlers-Danlos syndrome. These findings suggest the need of a bone health evaluation in these patients. The Ehlers-Danlos (EDS) syndrome is characterized by abnormalities of the connective tissue leading to ligamentous laxity and skin and tissue fragility. We evaluated the bone metabolism, bone mineral density (BMD) and bone quality (measured by trabecular bone score, TBS), and the prevalence of vertebral fractures (VFx) in a group of eugonadal adult EDS patients. Fifty consecutive Caucasian patients, aged 30-50 years (36 females, 14 males) with classical or hypermobility EDS and 50 age-, gender-, and body mass index (BMI)-matched control subjects were enrolled. In all subjects' calcium-phosphorous metabolism, bone turnover, BMD at the lumbar spine (LS) and femur (femoral neck, FN and total femur, FT) and TBS by dual-energy X-ray absorptiometry, and the VFx presence by spine radiograph were assessed. Patients showed reduced BMD (Z-scores LS -0.45 ± 1.00, FN -0.56 ± 1.01, FT -0.58 ± 0.92) and TBS (1.299 ± 0.111) and increased prevalence of morphometric VFx (32 %) than controls (Z-scores LS 0.09 ± 1.22, FN 0.01 ± 0.97, FT 0.08 ± 0.89; TBS 1.382 ± 0.176; VFx 8 %, p <0.05 for all comparisons), while vitamin D levels, calcium-phosphorous metabolism, and bone turnover were comparable. Fractured EDS patients showed lower TBS values than non-fractured ones (1.245 ± 0.138 vs 1.325 ± 0.086, p < 0.05), despite comparable BMD. In EDS patients, the VFx presence was significantly associated with TBS even after adjusting for sex, age, BMD, EDS type, and falls frequency. EDS patients have reduced BMD and bone quality (as measured by TBS) and increased prevalence of VFx.

Is there a relationship between chronic periodontitis and erectile dysfunction?

PubMed

Oğuz, Fatih; Eltas, Abubekir; Beytur, Ali; Akdemir, Ender; Uslu, Mustafa Özay; Güneş, Ali

2013-03-01

Chronic periodontitis (CP) is characterized with inflammation of the gingival tissues, which causes endothelial dysfunction in different organs. In this study, we investigated the association of CP with the erectile dysfunction (ED). The study group included 80 male patients with ED and 82 male patients without ED (control), aged between 30 and 40 years. The International Index of Erectile Function (IIEF) questionnaire was used to assess male sexual function, particularly the presence or absence of ED. The patients in the study and control groups were statistically compared according to their plaque index (PI), bleeding on probing (BoP), probing depth (PD), and clinical attachment level (CAL). In the non-ED and the ED groups, the mean age was 35.7 ± 4.8 and 34.9 ± 4.9 years, respectively. Patients' characteristics including body mass index, household income, and education status were similar in both groups (P > 0.05). Nineteen patients (23%) had severe CP in the non-ED group; 42 patients (53%) had severe CP in the ED group. Logistic regression analysis showed a significantly high association between ED and the severity of CP (odds ratio: 3.29, 95% confidence interval: 1.36-9.55, P < 0.01). The mean values of PI, BoP, and the percentages of sites with PD >4 mm and sites with CAL >4 mm were significantly higher in the ED group than in the control group (P < 0.05). The mean values of PD and CAL were not significantly different in the two groups (P > 0.05). The decayed, missing, filled teeth scores were also significantly higher in the ED group than in the non-ED group (P < 0.05).   Our results have suggested that CP had a high association with ED in young adults at 30-40 years. We think that it will be of benefit to consider periodontal disease as a causative clinical condition of ED in such patients. © 2012 International Society for Sexual Medicine.

Decreasing Emergency Department Walkout Rate and Boarding Hours by Improving Inpatient Length of Stay.

PubMed

Artenstein, Andrew W; Rathlev, Niels K; Neal, Douglas; Townsend, Vernette; Vemula, Michael; Goldlust, Sheila; Schmidt, Joseph; Visintainer, Paul

2017-10-01

Patient progress, the movement of patients through a hospital system from admission to discharge, is a foundational component of operational effectiveness in healthcare institutions. Optimal patient progress is a key to delivering safe, high-quality and high-value clinical care. The Baystate Patient Progress Initiative (BPPI), a cross-disciplinary, multifaceted quality and process improvement project, was launched on March 1, 2014, with the primary goal of optimizing patient progress for adult patients. The BPPI was implemented at our system's tertiary care, academic medical center, a high-volume, high-acuity hospital that serves as a regional referral center for western Massachusetts. The BPPI was structured as a 24-month initiative with an oversight group that ensured collaborative goal alignment and communication of operational teams. It was organized to address critical aspects of a patient's progress through his hospital stay and to create additional inpatient capacity. The specific goal of the BPPI was to decrease length of stay (LOS) on the inpatient adult Hospital Medicine service by optimizing an interdisciplinary plan of care and promoting earlier departure of discharged patients. Concurrently, we measured the effects on emergency department (ED) boarding hours per patient and walkout rates. The BPPI engaged over 300 employed clinicians and non-clinicians in the work. We created increased inpatient capacity by implementing daily interdisciplinary bedside rounds to proactively address patient progress; during the 24 months, this resulted in a sustained rate of discharge orders written before noon of more than 50% and a decrease in inpatient LOS of 0.30 days (coefficient: -0.014, 95% CI [-0.023, -0.005] P< 0.005). Despite the increase in ED patient volumes and severity of illness over the same time period, ED boarding hours per patient decreased by approximately 2.1 hours (coefficient: -0.09; 95% CI [-0.15, -0.02] P = 0.007). Concurrently, ED walkout rates decreased by nearly 32% to a monthly mean of 0.4 patients (coefficient: 0.4; 95% CI [-0.7, -0.1] P= 0.01). The BPPI realized significant gains in patient progress for adult patients by promoting earlier discharges before noon and decreasing overall inpatient LOS. Concurrently, ED boarding hours per patient and walkout rates decreased.

Orthostatic Intolerance and Postural Orthostatic Tachycardia Syndrome in Joint Hypermobility Syndrome/Ehlers-Danlos Syndrome, Hypermobility Type: Neurovegetative Dysregulation or Autonomic Failure?

PubMed

Celletti, Claudia; Camerota, Filippo; Castori, Marco; Censi, Federica; Gioffrè, Laura; Calcagnini, Giovanni; Strano, Stefano

2017-01-01

Background . Joint hypermobility syndrome/Ehlers-Danlos syndrome, hypermobility type (JHS/EDS-HT), is a hereditary connective tissue disorder mainly characterized by generalized joint hypermobility, skin texture abnormalities, and visceral and vascular dysfunctions, also comprising symptoms of autonomic dysfunction. This study aims to further evaluate cardiovascular autonomic involvement in JHS/EDS-HT by a battery of functional tests. Methods . The response to cardiovascular reflex tests comprising deep breathing, Valsalva maneuver, 30/15 ratio, handgrip test, and head-up tilt test was studied in 35 JHS/EDS-HT adults. Heart rate and blood pressure variability was also investigated by spectral analysis in comparison to age and sex healthy matched group. Results . Valsalva ratio was normal in all patients, but 37.2% of them were not able to finish the test. At tilt, 48.6% patients showed postural orthostatic tachycardia, 31.4% orthostatic intolerance, 20% normal results. Only one patient had orthostatic hypotension. Spectral analysis showed significant higher baroreflex sensitivity values at rest compared to controls. Conclusions. This study confirms the abnormal cardiovascular autonomic profile in adults with JHS/EDS-HT and found the higher baroreflex sensitivity as a potential disease marker and clue for future research.

Is the case-mix of patients who self-present to ED similar to general practice and other acute-care facilities?

PubMed

Harris, Tim; McDonald, Keith

2014-12-01

To benchmark walk-in presentations to emergency departments (ED) with those presenting to other local acute healthcare facilities. A large teaching hospital with an annual ED census of 140, 000 adult patients and surrounding associated acute healthcare providers. A random sample of 384 patients who self-presented to the ED was obtained. Benchmarking data were drawn from two general practices; the Tower Hamlets Community Services walk-in centre (co-located on-site with the ED) and the GP-run out-of-hours service. The case-mix presenting to the ED was characterised by a higher proportion of injuries and chest pain, but fewer simple infections and non-traumatic musculoskeletal conditions as compared to other acute care facilities in our region. Patients with injuries and possible cardiac chest pain were more likely to attend the ED, and those with infection or musculoskeletal problems less likely, as compared with other acute healthcare facilities. The population presenting to the ED is distinct from that presenting to general practice, out-of-hours clinics, or walk-in centres. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Patient comprehension of emergency department care and instructions: are patients aware of when they do not understand?

PubMed

Engel, Kirsten G; Heisler, Michele; Smith, Dylan M; Robinson, Claire H; Forman, Jane H; Ubel, Peter A

2009-04-01

To be able to adhere to discharge instructions after a visit to the emergency department (ED), patients should understand both the care that they received and their discharge instructions. The objective of this study is to assess, at discharge, patients' comprehension of their ED care and instructions and their awareness of deficiencies in their comprehension. We conducted structured interviews of 140 adult English-speaking patients or their primary caregivers after ED discharge in 2 health systems. Participants rated their subjective understanding of 4 domains: (1) diagnosis and cause; (2) ED care; (3) post-ED care, and (4) return instructions. We assessed patient comprehension as the degree of agreement (concordance) between patients' recall of each of these domains and information obtained from chart review. Two authors scored each case independently and discussed discrepancies before providing a final concordance rating (no concordance, minimal concordance, partial concordance, near concordance, complete concordance). Seventy-eight percent of patients demonstrated deficient comprehension (less than complete concordance) in at least 1 domain; 51% of patients, in 2 or more domains. Greater than a third of these deficiencies (34%) involved patients' understanding of post-ED care, whereas only 15% were for diagnosis and cause. The majority of patients with comprehension deficits failed to perceive them. Patients perceived difficulty with comprehension only 20% of the time when they demonstrated deficient comprehension. Many patients do not understand their ED care or their discharge instructions. Moreover, most patients appear to be unaware of their lack of understanding and report inappropriate confidence in their comprehension and recall.

Feasibility and Acceptability of a Colocated Homeless-Tailored Primary Care Clinic and Emergency Department.

PubMed

Gabrielian, Sonya; Chen, Jennifer C; Minhaj, Beena P; Manchanda, Rishi; Altman, Lisa; Koosis, Ella; Gelberg, Lillian

2017-10-01

Homeless adults have low primary care engagement and high emergency department (ED) utilization. Homeless-tailored, patient-centered medical homes (PCMH) decrease this population's acute care use. We studied the feasibility (focused on patient recruitment) and acceptability (conceptualized as clinicians' attitudes/beliefs) of a pilot initiative to colocate a homeless-tailored PCMH with an ED. After ED triage, low-acuity patients appropriate for outpatient care were screened for homelessness; homeless patients chose between a colocated PCMH or ED visit. To study feasibility, we captured (from May to September 2012) the number of patients screened for homelessness, positive screens, unique patients seen, and primary care visits. We focused on acceptability to ED clinicians (physicians, nurses, social workers); we sent a 32-item survey to ED clinicians (n = 57) who worked during clinic hours. Questions derived from an instrument measuring clinician attitudes toward homeless persons; acceptability of homelessness screening and the clinic itself were also explored. Over the 5 months of interest, 281 patients were screened; 172 (61.2%) screened positive for homelessness; 112 (65.1%) of these positive screens were seen over 215 visits. Acceptability data were obtained from 56% (n = 32) of surveyed clinicians. Attitudes toward homeless patients were similar to prior studies of primary care physicians. Most (54.6%) clinicians agreed with the homelessness screening procedures. Nearly all (90.3%) clinicians supported expansion of the homeless-tailored clinic; a minority (42.0%) agreed that ED colocation worked well. Our data suggest the feasibility of recruiting patients to a homeless-tailored primary care clinic colocated with the ED; however, the clinic's acceptability was mixed. Future quality improvement work should focus on tailoring the clinic to increase its acceptability among ED clinicians, while assessing its impact on health, housing, and costs.

Feasibility and Acceptability of a Colocated Homeless-Tailored Primary Care Clinic and Emergency Department

PubMed Central

Gabrielian, Sonya; Chen, Jennifer C.; Minhaj, Beena P.; Manchanda, Rishi; Altman, Lisa; Koosis, Ella; Gelberg, Lillian

2017-01-01

Objectives: Homeless adults have low primary care engagement and high emergency department (ED) utilization. Homeless-tailored, patient-centered medical homes (PCMH) decrease this population’s acute care use. We studied the feasibility (focused on patient recruitment) and acceptability (conceptualized as clinicians’ attitudes/beliefs) of a pilot initiative to colocate a homeless-tailored PCMH with an ED. After ED triage, low-acuity patients appropriate for outpatient care were screened for homelessness; homeless patients chose between a colocated PCMH or ED visit. Methods: To study feasibility, we captured (from May to September 2012) the number of patients screened for homelessness, positive screens, unique patients seen, and primary care visits. We focused on acceptability to ED clinicians (physicians, nurses, social workers); we sent a 32-item survey to ED clinicians (n = 57) who worked during clinic hours. Questions derived from an instrument measuring clinician attitudes toward homeless persons; acceptability of homelessness screening and the clinic itself were also explored. Results: Over the 5 months of interest, 281 patients were screened; 172 (61.2%) screened positive for homelessness; 112 (65.1%) of these positive screens were seen over 215 visits. Acceptability data were obtained from 56% (n = 32) of surveyed clinicians. Attitudes toward homeless patients were similar to prior studies of primary care physicians. Most (54.6%) clinicians agreed with the homelessness screening procedures. Nearly all (90.3%) clinicians supported expansion of the homeless-tailored clinic; a minority (42.0%) agreed that ED colocation worked well. Conclusion: Our data suggest the feasibility of recruiting patients to a homeless-tailored primary care clinic colocated with the ED; however, the clinic’s acceptability was mixed. Future quality improvement work should focus on tailoring the clinic to increase its acceptability among ED clinicians, while assessing its impact on health, housing, and costs. PMID:28367682

A Higher-Calorie Refeeding Protocol Does Not Increase Adverse Outcomes in Adult Patients with Eating Disorders.

PubMed

Matthews, Kylie; Hill, Jan; Jeffrey, Shane; Patterson, Susan; Davis, Amanda; Ward, Warren; Palmer, Michelle; Capra, Sandra

2018-04-12

Patients with eating disorders (EDs) are often considered a high-risk population to refeed. Current research advises using "start low, go slow" refeeding methods (∼1,000 kcal/day, advancing ∼500 kcal/day every 3 to 4 days) in adult patients with severe EDs to prevent the development of refeeding syndrome (RFS), typically characterized by decreases in serum electrolyte levels and fluid shifts. To compare the incidence of RFS and related outcomes using a low-calorie protocol (LC) (1,000 kcal) or a higher-calorie protocol (HC) (1,500 kcal) in medically compromised adult patients with EDs. This was a retrospective pre-test-post-test study. One hundred and nineteen participants with EDs, medically admitted to a tertiary hospital in Brisbane, Australia, between December 2010 and January 2017, were included (LC: n=26, HC: n=93). The HC refeeding protocol was implemented in September 2013. Differences in prevalence of electrolyte disturbances, hypoglycemia, edema, and RFS diagnoses were examined. χ 2 tests, Kruskal-Wallis H test, analysis of variance, and independent t tests were used to compare data between the two protocols. Descriptors were similar between groups (LC: 28±9 years, 96% female, 85% with anorexia nervosa, 31% admitted primarily because of clinical symptoms of exacerbated ED vs HC: 27±9 years, 97% female, 84% with anorexia nervosa, 44% admitted primarily because of clinical symptoms of exacerbated ED, P>0.05). Participants refed using the LC protocol had higher incidence rates of hypoglycemia (LC: 31% vs HC: 10%, P=0.012), with no statistical or clinical differences in electrolyte disturbances (LC: 65% vs HC: 45%, P=0.079), edema (LC: 8% vs HC: 6%, P=0.722) or diagnosed RFS (LC: 4% vs HC: 1%, P=0.391). A higher-calorie refeeding protocol appears to be safe, with no differences in rates of electrolyte disturbances or clinically diagnosed RFS and a lower incidence of hypoglycemia. Future research examining higher-calorie intakes, similar to those studied in adolescent patients, may be beneficial. Copyright © 2018 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.

Medicaid dental coverage alone may not lower rates of dental emergency department visits.

PubMed

Fingar, Kathryn R; Smith, Mark W; Davies, Sheryl; McDonald, Kathryn M; Stocks, Carol; Raven, Maria C

2015-08-01

Medicaid was expanded to millions of individuals under the Affordable Care Act, but many states do not provide dental coverage for adults under their Medicaid programs. In the absence of dental coverage, patients may resort to costly emergency department (ED) visits for dental conditions. Medicaid coverage of dental benefits could help ease the burden on the ED, but ED use for dental conditions might remain a problem in areas with a scarcity of dentists. We examined county-level rates of ED visits for nontraumatic dental conditions in twenty-nine states in 2010 in relation to dental provider density and Medicaid coverage of nonemergency dental services. Higher density of dental providers was associated with lower rates of dental ED visits by patients with Medicaid in rural counties but not in urban counties, where most dental ED visits occurred. County-level Medicaid-funded dental ED visit rates were lower in states where Medicaid covered nonemergency dental services than in other states, although this difference was not significant after other factors were adjusted for. Providing dental coverage alone might not reduce Medicaid-funded dental ED visits if patients do not have access to dental providers. Project HOPE—The People-to-People Health Foundation, Inc.

Predictors of 30-day mortality in patients admitted to ED for acute heart failure.

PubMed

Marchetti, Matthieu; Benedetti, Antoine; Mimoz, Olivier; Lardeur, Jean-Yves; Guenezan, Jérémy; Marjanovic, Nicolas

2017-03-01

Acute heart failure (AHF) is a leading cause of admission in emergency departments (ED). It is associated with significant in-hospital mortality, suggesting that there is room for improvement of care. Our aims were to investigate clinical patterns, biological characteristics and determinants of 30-day mortality. We conducted a single site, retrospective review of adult patients (≥18years) admitted to ED for AHF over a 12-month period. Data collected included demographics, clinical, biological and outcomes data. Epidemiologic data were collected at baseline, and patients were followed up during a 30-day period. There were a total of 322 patients. Mean age was 83.9±9.1years, and 47% of the patients were men. Among them, 59 patients (18.3%) died within 30days of admission to the ED. The following three characteristics were associated with increased mortality: age>85years (OR=1.5[95%CI:0.8-2.7], p=0.01), creatinine clearance <30mL/min (OR=2.6[95%CI:1.4-5], p<0.001) and Nt-proBNP >5000pg/mL (OR=2.2[95%CI:1.2-4], p<0.001). The best Nt-proBNP cut-off value to predict first-day mortality was 9000pg/mL (area under the curve (AUC) [95%CI] of 0.790 [0.634-0.935], p<0.001). For 7-day mortality, it was 7900pg/mL (0.698 [0.578-0.819], p<0.001) and for 30-day mortality, 5000pg/mL (0.667 [0.576-0.758], p<0.001). Nt-proBNP level on admission, age and creatinine clearance, are predictive of 30-day mortality in adult patients admitted to ED for AHF. Copyright © 2016 Elsevier Inc. All rights reserved.

Emergency Department Visits by Adolescent and Young Adult Cancer Patients Compared with Pediatric Cancer Patients in the United States.

PubMed

Kaul, Sapna; Russell, Heidi; Livingston, John A; Kirchhoff, Anne C; Jupiter, Daniel

2018-06-20

Limited information exists on emergency department (ED) visits for adolescent and young adult (AYA) patients with cancer. We examined the clinical reasons for ED visits, and outcomes, for AYAs with cancer compared to pediatric cancer patients. The 2013 Nationwide Emergency Department Sample data were used to identify 53,274 AYA (ages 15-39) and 6952 pediatric (ages 0-14) cancer ED visits. We evaluated patient (i.e., demographic and diagnosis) and hospital characteristics, and the ED event outcome (admitted to the same hospital or treated/released). Clinical reasons for visits were identified as procedures, infections, or noninfectious toxicities. Variables were compared between groups using chi-squared tests. Logistic regressions identified characteristics associated with the outcome between and within groups. AYA cancer visits were more likely to be self-paid (15.8% vs. 1.9%, p < 0.001), and be from low-income households and nonmetro counties than pediatric visits. Toxicity was the most prevalent reason for AYA visits (46.0%) and infections for pediatrics (47.3%, p < 0.001). AYA cancer visits were less likely to be admitted (OR = 0.84, 95% CI = 0.71-0.98; p = 0.03) than pediatric cancer. Among AYAs, self-paid visits were less likely to be admitted compared with privately insured visits (OR = 0.58, 95% CI: 0.52-0.66, p < 0.001). Self-pay did not affect the outcome for pediatric visits. In the United States, compared with pediatric cancer patients, AYAs with cancer visit EDs more often for toxicity-related problems, and are more often self-paid and from poorer households. These distinctive features impacting health service use should be incorporated into care plans aimed at delineating effective care for these patients.

Population-based burden of COPD-related visits in the ED: return ED visits, hospital admissions, and comorbidity risks.

PubMed

Yeatts, Karin B; Lippmann, Steven J; Waller, Anna E; Hassmiller Lich, Kristen; Travers, Debbie; Weinberger, Morris; Donohue, James F

2013-09-01

Little is known about the population-based burden of ED care for COPD. We analyzed statewide ED surveillance system data to quantify the frequency of COPD-related ED visits, hospital admissions, and comorbidities. In 2008 to 2009 in North Carolina, 97,511 COPD-related ED visits were made by adults ≥ 45 years of age, at an annual rate of 13.8 ED visits/1,000 person-years. Among patients with COPD (n = 33,799), 7% and 28% had a COPD-related return ED visit within a 30- and 365-day period of their index visit, respectively. Compared with patients on private insurance, Medicare, Medicaid, and noninsured patients were more likely to have a COPD-related return visit within 30 and 365 days and have three or more COPD-related visits within 365 days. There were no differences in return visits by sex. Fifty-one percent of patients with COPD were admitted to the hospital from the index ED visit. Subsequent hospital admission risk in the cohort increased with age, peaking at 65 to 69 years (risk ratio [RR], 1.41; 95% CI, 1.26-1.57); there was no difference by sex. Patients with congestive heart failure (RR, 1.29; 95% CI, 1.22-1.37), substance-related disorders (RR, 1.35; 95% CI, 1.13-1.60), or respiratory failure/supplemental oxygen (RR, 1.25; 95% CI, 1.19-1.31) were more likely to have a subsequent hospital admission compared with patients without these comorbidities. The population-based burden of COPD-related care in the ED is significant. Further research is needed to understand variations in COPD-related ED visits and hospital admissions.

Quality of life, unmet needs, and iatrogenic injuries in rehabilitation of patients with Ehlers-Danlos Syndrome hypermobility type/Joint Hypermobility Syndrome.

PubMed

Bovet, Claire; Carlson, Matthew; Taylor, Matthew

2016-08-01

Ehlers-Danlos Syndrome, hypermobility type (EDS-HT) and the joint hypermobility syndrome (JHS) are connective tissue disorders that form an overlapping clinical syndrome and are associated with frequent medical visits and substantial morbidity. EDS-HT/JHS-associated pain correlates with poor quality of life. While physical therapy is the recommended treatment for EDS-HT/JHS, little is known about therapy-related patient experiences and iatrogenic injuries. We studied 38 adult EDS-HT/JHS patients, eliciting health-related quality of life (HRQoL) from 28 patients through the RAND SF-36 questionnaire. We also explored physical therapy experiences through focus groups with 13 patients. Our patients displayed poor HRQoL, with 71% reporting worse health over the past year. SF-36 scores were significantly lower than the scores of the average American population (P < 0.001 for 8 of 10 categories assessed), but were comparable to EDS-HT/JHS populations in Belgium, the Netherlands, Sweden, and Italy. Focus groups identified factors associated with: negative past physical therapy experiences, iatrogenic joint injuries, positive treatment experiences, and unmet rehabilitation needs. This group of EDS-HT/JHS patients has significant decrements in HRQoL and many unmet treatment needs, as well as a risk for iatrogenic injuries. We identify several approaches to help meet patients' needs and improve joint rehabilitation in patients with EDS-HT/JHS. © 2016 Wiley Periodicals, Inc. © 2016 Wiley Periodicals, Inc.

Sub-dissociative-dose intranasal ketamine for moderate to severe pain in adult emergency department patients.

PubMed

Yeaman, Fiona; Meek, Robert; Egerton-Warburton, Diana; Rosengarten, Pamela; Graudins, Andis

2014-06-01

There are currently no studies assessing effectiveness of sub-dissociative intranasal (IN) ketamine as the initial analgesic for adult patients in the ED. The study aims to examine the effectiveness of sub-dissociative IN ketamine as a primary analgesic agent for adult patients in the ED. This is a prospective, observational study of adult ED patients presenting with severe pain (≥6 on 11-point scale at triage). IN ketamine dose was 0.7 mg/kg, with secondary dose of 0.5 mg/kg at 15 min if pain did not improve. After 6 months, initial dose was increased to 1.0 mg/kg with the same optional secondary dose. The primary outcomes are change in VAS rating at 30 min; percentage of patients reporting clinically significant reduction in VAS (≥20 mm) at 30 min; dose resulting in clinically significant pain reduction. Of the 72 patients available for analysis, median age was 34.5 years and 64% were men. Median initial VAS rating was 76 mm (interquartile range [IQR]: 65-82). Median total dose of IN ketamine for all patients was 0.98 mg/kg (IQR: 0.75-1.15, range: 0.59-1.57). Median reduction in VAS rating at 30 min was 24 mm (IQR: 2-45). Forty (56%, 95% CI: 44.0-66.7) reported VAS reduction ≥20 mm, these patients having had a total median ketamine dose of 0.94 mg/kg (IQR: 0.72-1.04). IN ketamine, at a dose of about 1 mg/kg, was an effective analgesic agent in 56% of study patients. The place of IN ketamine in analgesic guidelines for adults requires further investigation. © 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

Take charge: Personality as predictor of recovery from eating disorder.

PubMed

Levallius, Johanna; Roberts, Brent W; Clinton, David; Norring, Claes

2016-12-30

Many treatments for eating disorders (ED) have demonstrated success. However, not all patients respond the same to interventions nor achieve full recovery, and obvious candidates like ED diagnosis and symptoms have generally failed to explain this variability. The current study investigated the predictive utility of personality for outcome in ED treatment. One hundred and thirty adult patients with bulimia nervosa or eating disorder not otherwise specified enrolled in an intensive multimodal treatment for 16 weeks. Personality was assessed with the NEO Personality Inventory Revised (NEO PI-R). Outcome was defined as recovered versus still ill and also as symptom score at termination with the Eating Disorder Inventory-2 (EDI-2). Personality significantly predicted both recovery (70% of patients) and symptom improvement. Patients who recovered reported significantly higher levels of Extraversion at baseline than the still ill, and Assertiveness emerged as the personality trait best predicting variance in outcome. This study indicates that personality might hold promise as predictor of recovery after treatment for ED. Future research might investigate if adding interventions to address personality features improves outcome for ED patients. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Erectile Dysfunction in Male Adults With Atopic Dermatitis and Psoriasis.

PubMed

Egeberg, Alexander; Hansen, Peter R; Gislason, Gunnar H; Skov, Lone; Thyssen, Jacob P

2017-03-01

Patients with psoriasis have increased risk of cardiovascular disease, but data on atopic dermatitis (AD) are less clear-cut. However, it is well-established that erectile dysfunction (ED) can serve as a risk marker for coronary disease. To investigate the incidence, prevalence, and risk of ED in men with psoriasis and AD. The sample included all Danish men at least 30 years old. In patients with AD and psoriasis, we determined disease severity based on use of systemic therapy. We performed a cross-sectional study (January 1, 2008) using logistic regression to estimate the prevalence and odds ratio of ED. Moreover, in a cohort study design, patients were followed from January 1, 2008 through December 31, 2012, and Cox regression models were used to estimate adjusted hazard ratios of new-onset ED. Models were adjusted for potential confounding factors, including age, socioeconomic status, health care consumption, smoking, alcohol abuse, diabetes, and cholesterol-lowering drug use. The outcome was initiation of pharmacotherapy used for treatment of ED. The sample consisted of 1,756,679 Danish men (age range = 30-100 years), of which 2,373 and 26,536 had adult AD (mild = 1,072; severe = 1,301) and psoriasis (mild = 21,775; severe = 4,761), respectively. Mean ages (SDs) were 53.0 (14.6), 46.7 (12.0), and 56.3 (13.8) years for the general population, patients with AD, and patients with psoriasis, respectively. Prevalences of ED were 8.7%, 6.7%, and 12.8% for the general population, patients with AD, and patients with psoriasis, respectively. Adjusted odds ratios (logistic regression) of ED were decreased in patients with AD (0.68; 0.57-0.80) but increased in those with psoriasis (1.15; 1.11-1.20). Adjusted odds ratios for mild and severe AD were 0.63 (0.48-0.82) and 0.72 (0.58-0.88), respectively, and those for psoriasis these were 1.16 (1.11-1.21) and 1.13 (1.03-1.23). Adjusted hazard ratios (Cox regression) were 0.92 (0.76-1.11) for AD and 1.14 (1.08-1.20) for psoriasis. The ED risk was not increased in men with mild AD (0.85; 0.63-1.14) or severe AD (0.97; 0.76-1.24) but was significantly increased in men with mild psoriasis (1.13; 1.09-1.20) and severe psoriasis (1.17; 1.04-1.32). We found an increased prevalence and risk of ED in men with psoriasis, whereas the risk was comparable to (and even slightly lower than) the general population for men with AD. Egeberg A, Hansen PR, Gislason GH, et al. Erectile Dysfunction in Male Adults With Atopic Dermatitis and Psoriasis. J Sex Med 2017;14:380-386. Copyright © 2016 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.

The Association Between Limited English Proficiency and Unplanned Emergency Department Revisit Within 72 Hours.

PubMed

Ngai, Ka Ming; Grudzen, Corita R; Lee, Roy; Tong, Vicky Y; Richardson, Lynne D; Fernandez, Alicia

2016-08-01

Language barriers are known to negatively affect many health outcomes among limited English proficiency patient populations, but little is known about the quality of care such patients receive in the emergency department (ED). This study seeks to determine whether limited English proficiency patients experience different quality of care than English-speaking patients in the ED, using unplanned revisit within 72 hours as a surrogate quality indicator. We conducted a retrospective cohort study in an urban adult ED in 2012, with a total of 41,772 patients and 56,821 ED visits. We compared 2,943 limited English proficiency patients with 38,829 English-speaking patients presenting to the ED after excluding patients with psychiatric complaints, altered mental status, and nonverbal states, and those with more than 4 ED visits in 12 months. Two main outcomes-the risk of inpatient admission from the ED and risk of unplanned ED revisit within 72 hours-were measured with odds ratios from generalized estimating equation multivariate models. Limited English proficiency patients were more likely than English speakers to be admitted (32.0% versus 27.2%; odds ratio [OR]=1.20; 95% confidence interval [CI] 1.11 to 1.30). This association became nonsignificant after adjustments (OR=1.04; 95% CI 0.95 to 1.15). Included in the analysis of ED revisit within 72 hours were 32,857 patients with 45,546 ED visits; 4.2% of all patients (n=1,380) had at least 1 unplanned revisit. Limited English proficiency patients were more likely than English speakers to have an unplanned revisit (5.0% versus 4.1%; OR=1.19; 95% CI 1.02 to 1.45). This association persisted (OR=1.24; 95% CI 1.02 to 1.53) after adjustment for potential confounders, including insurance status. We found no difference in hospital admission rates between limited English proficiency patients and English-speaking patients. Yet limited English proficiency patients were 24% more likely to have an unplanned ED revisit within 72 hours, with an absolute difference of 0.9%, suggesting challenges in ED quality of care. Copyright © 2016 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Overdose and adverse drug event experiences among adult patients in the emergency department.

PubMed

Bohnert, Amy S B; Walton, Maureen A; Cunningham, Rebecca M; Ilgen, Mark A; Barry, Kristen; Chermack, Stephen T; Blow, Frederic C

2017-11-16

Overdose is a leading cause of injury and death in the United States. Emergency Department (ED) patients have an elevated prevalence of substance use. This study describes overdose/adverse drug event experiences among adult ED patients to inform strategies to address overdose risk. Patients seeking care at a large ED in the city of Flint, Michigan participated in a computerized self-assessment during 2011-2013 (n=4571). Overdose was assessed with a broad definition and included occurrences that could be considered adverse drug events. Among those with this type of experience, additional items assessed symptoms, outcomes, and intent. 12% reported an overdose history. Of participants' most serious overdoses, 74% were without clear intent for self-harm, although this was true of only 61% of overdoses involving opiates or sedatives, and 52% had symptoms present that indicated that it was life-threatening. Binge drinking on a monthly basis (ORs=1.4) was associated with a medically serious overdose compared to never having an overdose. Compared to no drug use in the last year, use of one drug was associated with an OR of 1.8, two drugs was associated with an OR of 5.8, three drugs was associated with an OR of 8.4, and four or more drugs was associated with an OR of 25.1 of having had a medically serious overdose (all p<0.05). Most overdose experiences among ED patients were without clear intent of self-harm. The ED may be an appropriate setting for efforts to reduce overdose risk, especially among polysubstance users. Published by Elsevier Ltd.

Adolescents' and young adults' perspectives on their emergency care.

PubMed

Hicks, Catherine F; Ward, Mary J; Platt, Shari L

2014-08-01

The aim of this study was to assess the perspectives of adolescents and young adults seen in the emergency department (ED) on the optimal age for transition from a pediatric ED (PED) to an adult ED (AED) as well as the appropriateness of their assigned ED site. Secondary aims were to determine ED physicians' understanding and assessment of their psychosocial needs, to determine whether subjects had a primary care provider (PCP), as well as to identify resources they felt would improve their ED experience. This study used in-person structured interviews on a convenience sample of ED patients aged 15 to 25 years. Data were analyzed with the SPSS for Windows (v15.0) using t tests and uncertainty coefficients. We interviewed 200 subjects; the mean age was 20.5 (SD, 3) years, 65% were female, and 54% were seen in the PED. The subjects reported a mean age of 18.5 years as optimal for transition to an AED (mode, 18; second peak, 21); only 5% chose an age older than 21 years. The AED subjects more likely felt that their site of care was appropriate (Likert scale, 1-3; 2.5 vs 2.2, P < 0.05). HEADSS (Home, Education/Employment, Activity, Drugs, Sexuality, Suicide) topics were rarely addressed in both ED sites. The PED subjects more often identified a PCP (87% vs 68%); there was no difference in notifying their PCP (27% vs 19%). The PED subjects more often desired magazines (83% vs 70%) and entertainment videos (61% vs 34%). Adolescents and young adults identify the age of 18 years as optimal for transition from a PED to an AED setting. Instituting a standardized HEADSS assessment protocol and offering age-appropriate resources may enhance the emergency experience for this population.

A Brief Interview to Detect Panic Attacks and Panic Disorder in Emergency Department Patients with Cardiopulmonary Complaints.

PubMed

Sung, Sharon C; Rush, A John; Earnest, Arul; Lim, Leslie E C; Pek, Maeve P P; Choi, Joen M F; Ng, Magdalene P K; Ong, Marcus E H

2018-01-01

Patients with panic-related anxiety often initially present to the emergency department (ED) complaining of respiratory or cardiac symptoms, but rates of detection of panic symptoms by ED physicians remain low. This study was undertaken to evaluate the relevance of panic attacks and panic disorder in ED patients who present with cardiopulmonary symptoms and to determine whether a brief symptom-based tool could be constructed to assist in rapid recognition of panic-related anxiety in the ED setting. English-speaking adult ED patients with a chief complaint of palpitations, chest pain, dizziness, or difficulty breathing were evaluated for the presence of panic attacks and panic disorder with the Structured Clinical Interview for DSM-IV Axis I Disorders. Participants completed self-report measures to assess panic-related symptoms, comorbid psychiatric conditions, health-related disability, and health service use. In this sample (N=200), 23.5% had panic attacks and 23.0% had panic disorder. Both groups reported higher rates of panic attack symptoms, greater psychiatric comorbidity, greater health-related disability, and higher rates of ED and mental health service use compared with those without either condition. A brief 7-item tool consisting of panic symptoms identified patients with panic attacks or panic disorder with 85% accuracy (area under the curve=0.90, sensitivity=82%, specificity=88%). Patients with panic attacks or panic disorder commonly present to the ED, but often go unrecognized. A brief 7-item clinician rating scale accurately identifies these patients among those ED patients presenting with cardiopulmonary complaints.

Adult emergency department patients with sickle cell pain crisis: results from a quality improvement learning collaborative model to improve analgesic management.

PubMed

Tanabe, Paula; Hafner, John W; Martinovich, Zoran; Artz, Nicole

2012-04-01

The aims of this study were to 1) estimate differences in pain management process and patient-reported outcomes, pre- and postimplementation of analgesic protocols for adults with sickle cell disease (SCD), and 2) examine the effects of site and visit frequency on changes in pain scores and time to analgesic. A multicenter, prospective, longitudinal study enrolled patients from three academic medical centers between October 2007 and September 2009. All ED patients 18 years or older with a chief complaint of a sickle cell pain episode were enrolled. Sites formed a SCD quality improvement (QI) team and implemented standard nurse-initiated emergency department (ED) analgesic protocols; outcomes were compared between study periods defined as pre- and postimplementation of protocols. Medical record review was conducted to measure time to administration of initial analgesic, opioids used, route of opioid administration, the change in pain scores from arrival to discharge (negative numbers reflect a decrease in pain scores), and the number of ED visits per individual patient during the study period at each site. On day 7 after the ED visit, a follow-up phone interview was conducted. Patients were queried about their ED pain management using a scale from 1 to 10 (1 = outstanding, 10 = worst). Descriptive statistics are used to report the results. Ordinary least-squares regression models were constructed to measure the effect of time period, site, and number of visits per patient on change in pain score. During the study period, 342 unique patients (57% female, mean ± SD age = 32 ± 11 years) were enrolled and had a total of 2,934 visits. There was no difference in time to administration of the initial analgesic between study periods. Overall, there was a significant decrease in pain scores from arrival to discharge between the pre- and postintervention study periods: the average difference in arrival to discharge pain scores (cm) was greater during the postimplementation period than during the preintervention period (-4.1 vs. -3.6, t = 2.6, p < 0.01). Site 1 had significant improvement between study periods (mean difference = -0.87, t = 2.63, p < 0.01; F = 14.3, p < 0.01). Patients with few ED visits (one to six annual visits, mean difference = -1.55, t = 2.1, p = 0.04) and those with frequent ED visits (7 to 19 annual visits, mean difference = -1.65, t = 3.52, p < 0.01) had a significant decrease in pain scores compared to patients with very frequent ED visits (>19 visits). There was an overall decrease in the use of morphine sulfate (MS) and increase in the use of hydromorphone (χ(2) = 105.67, p < 0.001) between study periods and a significant increase in the use of oral (PO) and subcutaneous (SC) routes, with a corresponding decrease in the intravenous (IV) route (χ(2) = 13.67, p < 0.001). There were no statistically significant differences in patient-reported satisfaction with the attempt to manage pain in the ED between study periods (p = 0.54). While the use of a learning collaborative and implementation of nurse-initiated analgesic protocols was not associated with improvement in time to administration of the initial analgesic, improvements in the decrease in the arrival to discharge pain score and increased use of hydromorphone and the SC route were noted in adults with SCD in the ED. © 2012 by the Society for Academic Emergency Medicine.

Trends and Characteristics of Emergency Department Visits for Fall-Related Injuries in Older Adults, 2003–2010

PubMed Central

Shankar, Kalpana N.; Liu, Shan W.; Ganz, David A.

2017-01-01

Introduction One third of older adults fall each year, and falls are costly to both the patient in terms of morbidity and mortality and to the health system. Given that falls are a preventable cause of injury, our objective was to understand the characteristics and trends of emergency department (ED) fall-related visits among older adults. We hypothesize that falls among older adults are increasing and examine potential factors associated with this rise, such as race, ethnicity, gender, insurance and geography. Methods We conducted a secondary analysis of data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) to determine fall trends over time by examining changes in ED visit rates for falls in the United States between 2003 and 2010, detailing differences by gender, sociodemographic characteristics and geographic region. Results Between 2003 and 2010, the visit rate for falls and fall-related injuries among people age ≥ 65 increased from 60.4 (95% confidence interval [CI][51.9–68.8]) to 68.8 (95% CI [57.8–79.8]) per 1,000 population (p=0.03 for annual trend). Among subgroups, visits by patients aged 75–84 years increased from 56.2 to 82.1 per 1,000 (P <.01), visits by women increased from 67.4 to 81.3 (p = 0.04), visits by non-Hispanic Whites increased from 63.1 to 73.4 (p < 0.01), and visits in the South increased from 54.4 to 71.1 (p=0.03). Conclusion ED visit rates for falls are increasing over time. There is a national movement to increase falls awareness and prevention. EDs are in a unique position to engage patients on future fall prevention and should consider ways they can also partake in such initiatives in a manner that is feasible and appropriate for the ED setting. PMID:28874929

A Prospective Evaluation of Shared Decision-making Regarding Analgesics Selection for Older Emergency Department Patients With Acute Musculoskeletal Pain.

PubMed

Holland, Wesley C; Hunold, Katherine M; Mangipudi, Sowmya A; Rittenberg, Alison M; Yosipovitch, Natalie; Platts-Mills, Timothy F

2016-03-01

Musculoskeletal pain is a common reason for emergency department (ED) visit by older adults. Outpatient pain management following ED visits in this population is challenging as a result of contraindications to, and side effects from, available therapies. Shared decision-making (SDM) between patients and emergency physicians may improve patient experiences and health outcomes. Among older ED patients with acute musculoskeletal pain, we sought to characterize their desire for involvement in the selection of outpatient analgesics. We also sought to assess the impact of SDM on change in pain at 1 week, patient satisfaction, and side effects. This was a prospective study of adults aged 60 years and older presenting to the ED with acute musculoskeletal pain. Participants' desire to contribute to outpatient analgesic selection was assessed by phone within 24 hours of ED discharge using the Control Preferences Scale and categorized as active, collaborative, or passive. The extent to which SDM occurred in the ED was also assessed within 24 hours of discharge using the 9-item Shared Decision Making Questionnaire, and scores were subsequently grouped into tertiles of low, middle, and high SDM. The primary outcome was change in pain severity between the ED visit and 1 week. Secondary outcomes included satisfaction regarding the decision about how to treat pain at home, satisfaction with the pain medication itself, and side effects. Desire of participants (N = 94) to contribute to the decision regarding selection of outpatient analgesics varied: 16% active (i.e., make the final decision themselves), 37% collaborative (i.e., share decision with provider), and 47% passive (i.e., let the doctor make the final decision). The percentage of patients who desired an active role in the decision was higher for patients who were college educated versus those who were not college educated (28% vs. 11%; difference 17%, 95% confidence interval [CI] = 0% to 35%), received care from a nurse practitioner versus a resident or an attending physician (32% vs. 9%; difference 23%, 95% CI = 4% to 42%), or received care from a female versus a male provider (24% vs. 5%; difference 19%, 95% = CI 5% to 32%). After potential confounders were adjusted for, the mean decrease in pain severity from the ED visit to 1-week follow-up was not significantly different across tertiles of SDM (p = 0.06). Higher SDM scores were associated with greater satisfaction with the discharge pain medications (p = 0.006). SDM was not associated with the class of analgesic received. In this sample of older adults with acute musculoskeletal pain, the reported desire of patients to contribute to decisions regarding analgesics varied based on both patient and provider characteristics. SDM was not significantly related to pain reduction in the first week or type of pain medication received, but was associated with greater patient satisfaction. © 2016 by the Society for Academic Emergency Medicine.

A Prospective Evaluation of Shared Decision-making Regarding Analgesics Selection for Older Emergency Department Patients With Acute Musculoskeletal Pain

PubMed Central

Holland, Wesley C.; Hunold, Katherine M.; Mangipudi, Sowmya A.; Rittenberg, Alison M.; Yosipovitch, Natalie; Platts-Mills, Timothy F.

2016-01-01

Objectives Musculoskeletal pain is a common reason for emergency department (ED) visit by older adults. Outpatient pain management following ED visits in this population is challenging as a result of contraindications to, and side effects from, available therapies. Shared decision-making (SDM) between patients and emergency physicians may improve patient experiences and health outcomes. Among older ED patients with acute musculoskeletal pain, we sought to characterize their desire for involvement in the selection of outpatient analgesics. We also sought to assess the impact of SDM on change in pain at 1 week, patient satisfaction, and side effects. Methods This was a prospective study of adults aged 60 years and older presenting to the ED with acute musculoskeletal pain. Participants’ desire to contribute to outpatient analgesic selection was assessed by phone within 24 hours of ED discharge using the Control Preferences Scale and categorized as active, collaborative, or passive. The extent to which SDM occurred in the ED was also assessed within 24 hours of discharge using the 9-item Shared Decision Making Questionnaire, and scores were subsequently grouped into tertiles of low, middle, and high SDM. The primary outcome was change in pain severity between the ED visit and 1 week. Secondary outcomes included satisfaction regarding the decision about how to treat pain at home, satisfaction with the pain medication itself, and side effects. Results Desire of participants (N = 94) to contribute to the decision regarding selection of outpatient analgesics varied: 16% active (i.e., make the final decision themselves), 37% collaborative (i.e., share decision with provider), and 47% passive (i.e., let the doctor make the final decision). The percentage of patients who desired an active role in the decision was higher for patients who were college educated versus those who were not college educated (28% vs. 11%; difference 17%, 95% confidence interval [CI] = 0% to 35%), received care from a nurse practitioner versus a resident or an attending physician (32% vs. 9%; difference 23%, 95% CI = 4% to 42%), or received care from a female versus a male provider (24% vs. 5%; difference 19%, 95% = CI 5% to 32%). After potential confounders were adjusted for, the mean decrease in pain severity from the ED visit to 1-week follow-up was not significantly different across tertiles of SDM (p = 0.06). Higher SDM scores were associated with greater satisfaction with the discharge pain medications (p = 0.006). SDM was not associated with the class of analgesic received. Conclusions In this sample of older adults with acute musculoskeletal pain, the reported desire of patients to contribute to decisions regarding analgesics varied based on both patient and on provider characteristics. SDM was not significantly related to pain reduction in the first week or type of pain medication received, but was associated with greater patient satisfaction. PMID:26728174

A simple scoring algorithm predicting extended-spectrum β-lactamase producers in adults with community-onset monomicrobial Enterobacteriaceae bacteremia: Matters of frequent emergency department users.

PubMed

Lee, Chung-Hsun; Chu, Feng-Yuan; Hsieh, Chih-Chia; Hong, Ming-Yuan; Chi, Chih-Hsien; Ko, Wen-Chien; Lee, Ching-Chi

2017-04-01

The incidence of community-onset bacteremia caused by extended-spectrum-β-lactamase (ESBL) producers is increasing. The adverse effects of ESBL production on patient outcome have been recognized and this antimicrobial resistance has significant implications in the delay of appropriate therapy. However, a simple scoring algorithm that can easily, inexpensively, and accurately be applied to clinical settings was lacking. Thus, we established a predictive scoring algorithm for identifying patients at the risk of ESBL-producer infections among patients with community-onset monomicrobial Enterobacteriaceae bacteremia (CoMEB).In a retrospective cohort, multicenter study, adults with CoMEB in the emergency department (ED) were recruited during January 2008 to December 2013. ESBL producers were determined based on ESBL phenotype. Clinical information was obtained from chart records.Of the total 1141 adults with CoMEB, 65 (5.7%) caused by ESBL producers were identified. Four independent multivariate predictors of ESBL-producer bacteremia with high odds ratios (ORs)-recent antimicrobial use (OR, 15.29), recent invasive procedures (OR, 12.33), nursing home residents (OR, 27.77), and frequent ED user (OR, 9.98)-were each assigned +1 point to obtain the CoMEB-ESBL score. Using the proposed scoring algorithm, a cut-off value of +2 yielded a high sensitivity (84.6%) and an acceptable specificity (92.5%); the area under the receiver operating characteristic curve was 0.92.In conclusion, this simple scoring algorithm can be used to identify CoMEB patients with a high ESBL-producer infection risk. Of note, frequent ED user was firstly demonstrated to be a crucial predictor in predicting ESBL-producer infections. ED clinicians should consider adequate empirical therapy with coverage of these pathogens for patients with risk factors.

Risk factors associated with difficult venous access in adult ED patients.

PubMed

Fields, J Matthew; Piela, Nicole E; Au, Arthur K; Ku, Bon S

2014-10-01

The objective was to determine risk factors associated with difficult venous access (DVA) in the emergency department (ED). This was a prospective, observational study conducted in the ED of an urban tertiary care hospital. Adult patients undergoing intravenous (IV) placement were consecutively enrolled during periods of block enrollment. The primary outcome was DVA, defined as 3 or more IV attempts or use of a method of rescue vascular access to establish IV access. Univariate and multivariate analyses for factors predicting DVA were performed using logistic regression. A total of 743 patients were enrolled, of which 88 (11.8%) met the criteria for DVA. In the adjusted analysis, only 3 medical conditions were significantly associated with DVA: diabetes (odds ratio [OR] 1.72, 95% confidence interval [CI] 1.1-2.8), sickle cell disease (OR 3.8, 95% CI 1.5-9.5), and history of IV drug abuse (OR 2.5, 95% CI 1.1-5.7). Notably, age, body mass index, and dialysis were not. Of patients who reported a history of requiring multiple IV attempts in the past for IV access, 14% met criteria for DVA on this visit (OR 7.7 95% CI 3-18). Of the patients who reported a history of IV insertion into the external jugular, ultrasound-guided IV placement, or a central venous catheter for IV access, 26% had DVA on this visit (OR 16.7, 95% CI 6.8-41). Nearly 1 of every 9 to 10 adults in an urban ED had DVA. Diabetes, IV drug abuse, and sickle cell disease were found to be significantly associated with DVA. Copyright © 2014 Elsevier Inc. All rights reserved.

Increased analgesia administration in emergency medicine after implementation of revised guidelines.

PubMed

Van Woerden, Geesje; Van Den Brand, Crispijn L; Den Hartog, Cornelis F; Idenburg, Floris J; Grootendorst, Diana C; Van Der Linden, M Christien

2016-12-01

The most common complaint of patients attending the emergency department (ED) is pain, caused by different diseases. Yet the treatment of pain at the ED is suboptimal, and oligoanalgesia remains common. The objective of this study is to determine whether the administration of analgesia at the ED increases by implementation of revised guidelines in pain management. We conducted a prospective pre-post intervention cohort study with implementation of a revised guideline for pain management at our ED, in which nurses are allowed to administer analgesia (including low-dosage piritramid (opioid) intravenous) without doctor intervention. Numeric Rating Scales (NRS) were measured, and administration of medication (main outcome) was documented. We included every adult patient presenting with pain (NRS 4-10) at the ED. A total of 2107 patients (1089 pre-implementation phase and 1018 post-implementation phase) were included in our study. During pre-implementation, 25.4 % of the patients with NRS between 4 and 10 received analgesia. After implementation, 32.0 % of these patients received analgesia (p < 0.001). After implementation of the revised guidelines in pain management at the ED, the administration of pain medication increased significantly. Nevertheless, the percentage of patients in pain receiving analgesia remain low (32 % after implementation).

A randomized trial of intravenous ketorolac versus intravenous metoclopramide plus diphenhydramine for tension-type and all nonmigraine, noncluster recurrent headaches.

PubMed

Friedman, Benjamin W; Adewunmi, Victoria; Campbell, Caron; Solorzano, Clemencia; Esses, David; Bijur, Polly E; Gallagher, E John

2013-10-01

We compare metoclopramide 20 mg intravenously, combined with diphenhydramine 25 mg intravenously, with ketorolac 30 mg intravenously in adults with tension-type headache and all nonmigraine, noncluster recurrent headaches. In this emergency department (ED)-based randomized, double-blind study, we enrolled adults with nonmigraine, noncluster recurrent headaches. Patients with tension-type headache were a subgroup of special interest. Our primary outcome was a comparison of the improvement in pain score between baseline and 1 hour later, assessed on a 0 to 10 verbal scale. We defined a between-group difference of 2.0 as the minimum clinically significant difference. Secondary endpoints included need for rescue medication in the ED, achieving headache freedom in the ED and sustaining it for 24 hours, and patient's desire to receive the same medication again. We included 120 patients in the analysis. The metoclopramide/diphenhydramine arm improved by a median of 5 (interquartile range 3, 7) scale units, whereas the ketorolac arm improved by a median of 3 (IQR 2, 6) (95% confidence interval [CI] for difference 0 to 3). Metoclopramide+diphenhydramine was superior to ketorolac for all 3 secondary outcomes: the number needed to treat for not requiring ED rescue medication was 3 (95% CI 2 to 6); for sustained headache freedom, 6 (95% CI 3 to 20); and for wish to receive the same medication again, 7 (95% CI 4 to 65). Tension-type headache subgroup results were similar. For adults who presented to an ED with tension-type headache or with nonmigraine, noncluster recurrent headache, intravenous metoclopramide+diphenhydramine provided more headache relief than intravenous ketorolac. Copyright © 2013 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.

Screening for Fall Risks in the Emergency Department: A Novel Nursing-Driven Program.

PubMed

Huded, Jill M; Dresden, Scott M; Gravenor, Stephanie J; Rowe, Theresa; Lindquist, Lee A

2015-12-01

Seniors represent the fasting growing population in the U.S., accounting for 20.3 million visits to emergency departments (EDs) annually. The ED visit can provide an opportunity for identifying seniors at high risk of falls. We sought to incorporate the Timed Up & Go Test (TUGT), a commonly used falls screening tool, into the ED encounter to identify seniors at high fall risk and prompt interventions through a geriatric nurse liaison (GNL) model. Patients aged 65 and older presenting to an urban ED were evaluated by a team of ED nurses trained in care coordination and geriatric assessment skills. They performed fall risk screening with the TUGT. Patients with abnormal TUGT results could then be referred to physical therapy (PT), social work or home health as determined by the GNL. Gait assessment with the TUGT was performed on 443 elderly patients between 4/1/13 and 5/31/14. A prior fall was reported in 37% of patients in the previous six months. Of those screened with the TUGT, 368 patients experienced a positive result. Interventions for positive results included ED-based PT (n=63, 17.1%), outpatient PT referrals (n=56, 12.2%) and social work consultation (n=162, 44%). The ED visit may provide an opportunity for older adults to be screened for fall risk. Our results show ED nurses can conduct the TUGT, a validated and time efficient screen, and place appropriate referrals based on assessment results. Identifying and intervening on high fall risk patients who visit the ED has the potential to improve the trajectory of functional decline in our elderly population.

Revisit rates and associated costs after an emergency department encounter: a multistate analysis.

PubMed

Duseja, Reena; Bardach, Naomi S; Lin, Grace A; Yazdany, Jinoos; Dean, Mitzi L; Clay, Theodore H; Boscardin, W John; Dudley, R Adams

2015-06-02

Return visits to the emergency department (ED) or hospital after an index ED visit strain the health system, but information about rates and determinants of revisits is limited. To describe revisit rates, variation in revisit rates by diagnosis and state, and associated costs. Observational study using the Healthcare Cost and Utilization Project databases. 6 U.S. states. Adults with ED visits between 2006 and 2010. Revisit rates and costs. Within 3 days of an index ED visit, 8.2% of patients had a revisit; 32% of those revisits occurred at a different institution. Revisit rates varied by diagnosis, with skin infections having the highest rate (23.1% [95% CI, 22.3% to 23.9%]). Revisit rates also varied by state. For skin infections, Florida had higher risk-adjusted revisit rates (24.8% [CI, 23.5% to 26.2%]) than Nebraska (10.6% [CI, 9.2% to 12.1%]). In Florida, the only state with complete cost data, total revisit costs for the 19.8% of patients with a revisit within 30 days were 118% of total index ED visit costs for all patients (including those with and without a revisit). Whether a revisit reflects inadequate access to primary care, a planned revisit, the patient's nonadherence to ED recommendations, or poor-quality care at the initial ED visit remains unknown. Revisits after an index ED encounter are more frequent than previously reported, in part because many occur outside the index institution. Among ED patients in Florida, more resources are spent on revisits than on index ED visits. Agency for Healthcare Research and Quality.

The organizational culture of emergency departments and the effect on care of older adults: a modified scoping study.

PubMed

Skar, Pål; Bruce, Anne; Sheets, Debra

2015-04-01

How does the organizational micro culture in emergency departments (EDs) impact the care of older adults presenting with a complaint or condition perceived as non-acute? This scoping study reviews the literature and maps three levels of ED culture (artifacts, values and beliefs, and assumptions). Findings on the artifact level indicate that EDs are poorly designed for the needs of older adults. Findings on the ED value and belief level indicate that EDs are for urgent cases (not geriatric care), that older adults do not receive the care and respect they should be given, that older adults require too much time, and that the basic nursing needs of older adults are not a priority for ED nurses. Finally, finding on the assumptions level underpinning ED behaviors suggest that older adults do not belong in the ED, most older adults in the ED are not critically ill and therefore can wait, and staff need to be available for acute cases at all times. A systematic review on the effect of ED micro culture on the quality of geriatric care is warranted. Copyright © 2014. Published by Elsevier Ltd.

Population-Based Burden of COPD-Related Visits in the ED

PubMed Central

Lippmann, Steven J.; Waller, Anna E.; Hassmiller Lich, Kristen; Travers, Debbie; Weinberger, Morris; Donohue, James F.

2013-01-01

Background: Little is known about the population-based burden of ED care for COPD. Methods: We analyzed statewide ED surveillance system data to quantify the frequency of COPD-related ED visits, hospital admissions, and comorbidities. Results: In 2008 to 2009 in North Carolina, 97,511 COPD-related ED visits were made by adults ≥ 45 years of age, at an annual rate of 13.8 ED visits/1,000 person-years. Among patients with COPD (n = 33,799), 7% and 28% had a COPD-related return ED visit within a 30- and 365-day period of their index visit, respectively. Compared with patients on private insurance, Medicare, Medicaid, and noninsured patients were more likely to have a COPD-related return visit within 30 and 365 days and have three or more COPD-related visits within 365 days. There were no differences in return visits by sex. Fifty-one percent of patients with COPD were admitted to the hospital from the index ED visit. Subsequent hospital admission risk in the cohort increased with age, peaking at 65 to 69 years (risk ratio [RR], 1.41; 95% CI, 1.26-1.57); there was no difference by sex. Patients with congestive heart failure (RR, 1.29; 95% CI, 1.22-1.37), substance-related disorders (RR, 1.35; 95% CI, 1.13-1.60), or respiratory failure/supplemental oxygen (RR, 1.25; 95% CI, 1.19-1.31) were more likely to have a subsequent hospital admission compared with patients without these comorbidities. Conclusions: The population-based burden of COPD-related care in the ED is significant. Further research is needed to understand variations in COPD-related ED visits and hospital admissions. PMID:23579283

Older adults and high-risk medication administration in the emergency department

PubMed Central

Kim, Mitchell; Mitchell, Steven H; Gatewood, Medley; Bennett, Katherine A; Sutton, Paul R; Crawford, Carol A; Bentov, Itay; Damodarasamy, Mamatha; Kaplan, Stephen J; Reed, May J

2017-01-01

Background Older adults are susceptible to adverse effects from opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), and benzodiazepines (BZDs). We investigated factors associated with the administration of elevated doses of these medications of interest to older adults (≥65 years old) in the emergency department (ED). Patients and methods ED records were queried for the administration of medications of interest to older adults at two academic medical center EDs over a 6-month period. Frequency of recommended versus elevated (“High doses” were defined as doses that ranged between 1.5 and 3 times higher than the recommended starting doses; “very high doses” were defined as higher than high doses) starting doses of medications, as determined by geriatric pharmacy/medicine guidelines and expert consensus, was compared by age groups (65–69, 70–74, 75–79, 80–84, and ≥85 years), gender, and hospital. Results There were 17896 visits representing 11374 unique patients >65 years of age (55.3% men, 44.7% women). A total of 3394 doses of medications of interest including 1678 high doses and 684 very high doses were administered to 1364 different patients. Administration of elevated doses of medications was more common than that of recommended doses. Focusing on opioids and BZDs, the 65–69-year age group was much more likely to receive very high doses (1481 and 412 doses, respectively) than the ≥85-year age groups (relative risk [RR] 5.52, 95% CI 2.56–11.90), mainly reflecting elevated opioid dosing (RR 8.28, 95% CI 3.69–18.57). Men were more likely than women to receive very high doses (RR 1.47, 95% CI 1.26–1.72), primarily due to BZDs (RR 2.12, 95% CI 2.07–2.16). Conclusion Administration of elevated doses of opioids and BZDs in the older population occurs frequently in the ED, especially to the 65–69-year age group and men. Further attention to potentially unsafe dosing of high-risk medications to older adults in the ED is warranted. PMID:29184448

Electroencephalography findings in patients presenting to the ED for evaluation of seizures.

PubMed

Kadambi, Pooja; Hart, Kimberly W; Adeoye, Opeolu M; Lindsell, Christopher J; Knight, William A

2015-01-01

Status epilepticus is a life-threatening, time-sensitive emergency. Acquiring an electroencephalogram (EEG) in the emergency department (ED) could impact therapeutic and disposition decisions for patients with suspected status epilepticus. The objective of this study is to estimate the proportion of EEGs diagnostic for seizures in patients presenting to an ED with a complaint of seizures. This retrospective chart review included adults presenting to the ED of an urban, academic, tertiary care hospital with suspected seizures or status epilepticus, who received an EEG within 24 hours of hospital admission. Data abstraction was performed by a single, trained, nonblinded abstractor. Seizures were defined as an epileptologist's diagnosis of either seizures or status epilepticus on EEG. The proportion of patients with seizures is given with confidence interval95 (CI95). Of 120 included patients, 67 (56%) had a history of epilepsy. Mean age was 52 years (SD, 16), 58% were White, and 61% were male. Within 24 hours, 3% had an EEG diagnostic for seizures. Electroencephalogram was obtained in the ED in 32 (27%) of 120 (CI95, 19%-35%), and 2 (6%) of 32 (CI95, 1%-19%) had seizures. Electroencephalogram was performed inpatient for 88 (73%) of 120 (CI95, 65%-81%), and 2 (2%) of 88 (CI95, 0.5%-7.1%) had seizures. Only 3% of ED patients with suspected seizures or status epilepticus had EEG confirmation of seizures within 24 hours. Early EEG acquisition in the ED may identify a group of patients amenable to ED observation and subsequent discharge from the hospital. Copyright © 2014 Elsevier Inc. All rights reserved.

Patient Perspectives on Accessing Acute Illness Care

PubMed Central

Finta, Mary K.; Borkenhagen, Amy; Werner, Nicole E.; Duckles, Joyce; Sellers, Craig R.; Seshadri, Sandhya; Lampo, Denise; Shah, Manish N.

2017-01-01

Introduction Older adults use the emergency department (ED) at high rates, including for illnesses that could be managed by their primary care providers (PCP). Policymakers have implemented barriers and incentives, often financial, to try to modify use patterns but with limited success. This study aims to understand the factors that influence older adults’ decision to obtain acute illness care from the ED rather than from their PCPs. Methods We performed a qualitative study using a directed content analysis approach from February to October 2013. Fifteen community-dwelling older adults age≥65 years who presented to the ED of an academic medical center hospital for care and who were discharged home were enrolled. Semi-structured interviews were conducted initially in the ED and subsequently in patients’ homes over the following six weeks. All interviews were audio-recorded, transcribed, verified, and coded. The study team jointly analyzed the data and identified themes that emerged from the interviews. Results The average age of study participants was 74 years (standard deviation ±7.2 years); 53% were female; 80% were white. We found five themes that influenced participants’ decisions to obtain acute illness care from the ED: limited availability of PCP-based care, variable interactions with healthcare providers and systems, limited availability of transportation for illness care, desire to avoid burdening friends and family, and previous experiences with illnesses. Conclusion Community-dwelling older adults integrate multiple factors when deciding to obtain care from an ED rather than their PCPs. These factors relate to personal and social considerations, practical issues, and individual perceptions based on previous experiences. If these findings are validated in confirmatory studies, policymakers wishing to modify where older adults receive care should consider person-centered interventions at the system and individual level, such as decision support, telemedicine, improved transport services, enhancing PCPs’ capabilities, and enhancing EDs’ resources to care for older patients. PMID:28611875

The impact of electronic health records on care of heart failure patients in the emergency room

PubMed Central

Park, Young-Taek; Du, Jing; Theera-Ampornpunt, Nawanan; Gordon, Bradley D; Bershow, Barry A; Gensinger, Raymond A; Shrift, Michael; Routhe, Daniel T; Speedie, Stuart M

2011-01-01

Objective To evaluate if electronic health records (EHR) have observable effects on care outcomes, we examined quality and efficiency measures for patients presenting to emergency departments (ED). Materials and methods We conducted a retrospective study of 5166 adults with heart failure in three metropolitan EDs. Patients were termed internal if prior information was in the EHR upon ED presentation, otherwise external. Associations of internality with hospitalization, mortality, length of stay (LOS), and numbers of tests, procedures, and medications ordered in the ED were examined after adjusting for age, gender, race, marital status, comorbidities and hospitalization as a proxy for acuity level where appropriate. Results At two EDs internals had lower odds of mortality if hospitalized (OR 0.55; 95% CI 0.38 to 0.81 and 0.45; 0.21 to 0.96), fewer laboratory tests during the ED visit (−4.6%; −8.9% to −0.1% and −14.0%; −19.5% to −8.1%) as well as fewer medications (−33.6%; −38.4% to −28.4% and −21.3%; −33.2% to −7.3%). At one of these two EDs, internals had lower odds of hospitalization (0.37; 0.22 to 0.60). At the third ED, internal patients only experienced a prolonged ED LOS (32.3%; 6.3% to 64.8%) but no other differences. There was no association with hospital LOS or number of procedures ordered. Discussion EHR availability was associated with salutary outcomes in two of three ED settings and prolongation of ED LOS at a third, but evidence was mixed and causality remains to be determined. Conclusions An EHR may have the potential to be a valuable adjunct in the care of heart failure patients. PMID:22071528

Identifying Patients With Problematic Drug Use in the Emergency Department: Results of a Multisite Study

PubMed Central

Konstantopoulos, Wendy L. Macias; Dreifuss, Jessica A.; McDermott, Katherine A.; Parry, Blair Alden; Howell, Melissa L.; Mandler, Raul N.; Fitzmaurice, Garrett M.; Bogenschutz, Michael P.; Weiss, Roger D.

2014-01-01

Study objective Drug-related emergency department (ED) visits have steadily increased, with substance users relying heavily on the ED for medical care. The present study aims to identify clinical correlates of problematic drug use that would facilitate identification of ED patients in need of substance use treatment. Methods Using previously validated tests, 15,224 adult ED patients across 6 academic institutions were prescreened for drug use as part of a large randomized prospective trial. Data for 3,240 participants who reported drug use in the past 30 days were included. Self-reported variables related to demographics, substance use, and ED visit were examined to determine their correlative value for problematic drug use. Results Of the 3,240 patients, 2,084 (64.3%) met criteria for problematic drug use (Drug Abuse Screening Test score ≥3). Age greater than or equal to 30 years, tobacco smoking, daily or binge alcohol drinking, daily drug use, primary noncannabis drug use, resource-intense ED triage level, and perceived drug-relatedness of ED visit were highly correlated with problematic drug use. Among primary cannabis users, correlates of problematic drug use were age younger than 30 years, tobacco smoking, binge drinking, daily drug use, and perceived relatedness of the ED visit to drug use. Conclusion Clinical correlates of drug use problems may assist the identification of ED patients who would benefit from comprehensive screening, intervention, and referral to treatment. A clinical decision rule is proposed. The correlation between problematic drug use and resource-intense ED triage levels suggests that ED-based efforts to reduce the unmet need for substance use treatment may help decrease overall health care costs. PMID:24999283

The Association of Health Literacy With Preventable Emergency Department Visits: A Cross-sectional Study.

PubMed

Balakrishnan, Meenakshi P; Herndon, Jill Boylston; Zhang, Jingnan; Payton, Thomas; Shuster, Jonathan; Carden, Donna L

2017-09-01

Policymakers argue that emergency department (ED) visits for conditions preventable with high-quality outpatient care contribute to waste in the healthcare system. However, access to ambulatory care is uneven, especially for vulnerable populations like minorities, the poor, and those with limited health literacy. The impact of limited health literacy on ED visits that are preventable with timely, high-quality ambulatory care is unknown. The objective was to determine the association of health literacy with preventable ED visits. We conducted an observational cross-sectional study of potentially preventable ED visits (outcome) among adults (≥18 years old) in an ED serving an urban community. We assessed health literacy (predictor) through structured interviews with the Rapid Estimate of Adult Literacy in Medicine (REALM). We recorded age, sex, race, employment, payer, marital and health status, and number of comorbidities through structured interviews or electronic record review. We identified potentially preventable ED visits in the 2 years before the index ED visit by applying Agency for Healthcare Research and Quality technical specifications to identify ambulatory care sensitive conditions using ED discharge diagnoses in hospital administrative data. We used Poisson regression to evaluate the number of preventable ED visits among patients with limited (REALM < 61) versus adequate (REALM ≥ 61) health literacy after adjusting for covariates. Of 1,201 participants, 709 (59%) were female, 370 (31%) were African American, mean age was 41.6 years, and 394 (33%) had limited health literacy. Of 4,444 total ED visits, 423 (9.5%) were potentially preventable. Of these, 260 (61%) resulted in hospital admission and 163 (39%) were treat and release. After covariates were adjusted for, patients with limited literacy had 2.3 (95% confidence interval [CI] = 1.7-3.1) times the number of potentially preventable ED visits resulting in hospital admission compared to individuals with adequate health literacy, 1.4 (95% CI = 1.0-2.0) times the number of treat-and-release visits, and 1.9 (95% CI = 1.5-2.4) times the number of total preventable ED visits. Our results suggest that the ED may be an important site to deploy universal literacy-sensitive precautions and to test literacy-sensitive interventions with the goal of reducing the burden of potentially preventable ED visits on patients and the healthcare system. © 2017 by the Society for Academic Emergency Medicine.

Improving Sickle Cell Transitions of Care Through Health Information Technology.

PubMed

Frost, Jennifer R; Cherry, Rebecca K; Oyeku, Suzette O; Faro, Elissa Z; Crosby, Lori E; Britto, Maria; Tuchman, Lisa K; Horn, Ivor B; Homer, Charles J; Jain, Anjali

2016-07-01

Transitions between inpatient and outpatient care and pediatric to adult care are associated with increased mortality for sickle cell disease (SCD) patients. As accurate and timely sharing of health information is essential during transitions, a health information technology (HIT)-enabled tool holds promise to improve care transitions. From 2012 through 2014, the team conducted and analyzed data from an environmental scan, key informant interviews, and focus groups to inform the development of an HIT-enabled tool for SCD patients' use during care transitions. The scan included searches of peer-reviewed and gray literature to understand SCD patient needs, transition concerns, and best practices in mobile health applications, and searches of websites and online stores to identify existing transition tools and their features. Eleven focus groups consisted of four groups of SCD patients of varying ages (≥9 years); three groups of parents/caregivers of SCD patients; three groups of providers; and one with IT developers. In focus groups, patients and caregivers reported that the transition from home to the emergency department (ED) was the most challenging; the ED was also where transitions from pediatric to adult care usually occurred. Patients felt they were not taken seriously by unfamiliar ED providers, and their inability to convey their diagnosis, pain regimen, and detailed medical history while in significant pain hindered care. The environmental scan did not reveal an existing suitable transition tool, but patients, parents, providers, and IT experts saw the potential and appeal of creating a tool to meet ED health information needs to improve care transitions. Copyright © 2016 American Journal of Preventive Medicine. All rights reserved.

Adult emergency department patients with sickle cell pain crisis: a learning collaborative model to improve analgesic management.

PubMed

Tanabe, Paula; Artz, Nicole; Mark Courtney, D; Martinovich, Zoran; Weiss, Kevin B; Zvirbulis, Elena; Hafner, John W

2010-04-01

The objectives were to report the baseline (prior to quality improvement interventions) patient and visit characteristics and analgesic management practices for each site participating in an emergency department (ED) sickle cell learning collaborative. A prospective, multisite longitudinal cohort study in the context of a learning-collaborative model was performed in three midwestern EDs. Each site formed a multidisciplinary team charged with improving analgesic management for patients with sickle cell disease (SCD). Each team developed a nurse-initiated analgesic protocol for SCD patients (implemented after a baseline data collection period of 3.5 months at one site and 10 months at the other two sites). All sites prospectively enrolled adults with an acute pain crisis and SCD. All medical records for patients meeting study criteria were reviewed. Demographic, health services, and analgesic management data were abstracted, including ED visit frequency data, ED disposition, arrival and discharge pain score, and name and route of initial analgesic administered. Ten interviews per quarter per site were conducted with patients within 14 days of their ED discharge, and subjects were queried about the highest level of pain acceptable at discharge. The primary outcome variable was the time to initial analgesic administration. Variable data were described as means and standard deviations (SDs) or medians and interquartile ranges (IQR) for nonnormal data. A total of 155 patients met study criteria (median age = 32 years, IQR = 24-40 years) with a total of 701 ED visits. Eighty-six interviews were conducted. Most patients (71.6%) had between one and three visits to the ED during the study period. However, after removing Site 3 from the analysis because of the short data enrollment period (3.5 months), which influenced the mean number of visits for the entire cohort, 52% of patients had between one and three ED visits over 10 months, 21% had four to nine visits, and 27% had between 10 and 67 visits. Fifty-nine percent of patients were discharged home. The median time to initial analgesic for the cohort was 74 minutes (IQR = 48-135 minutes). Differences between choice of analgesic agent and route selected were evident between sites. For the cohort, 680 initial analgesic doses were given (morphine sulfate, 42%; hydromorphone, 46%; meperidine, 4%; morphine sulfate and ibuprofen or ketorolac, 7%) using the following routes: oral (2%), intravenous (67%), subcutaneous (3%), and intramuscular (28%). Patients reported a significantly lower targeted discharge pain score (mean +/- SD = 4.19 +/- 1.18) compared to the actual documented discharge pain score within 45 minutes of discharge (mean +/- SD = 5.77 +/- 2.45; mean difference = 1.58, 95% confidence interval = .723 to 2.44, n = 43). While half of the patients had one to three ED visits during the study period, many patients had more frequent visits. Delays to receiving an initial analgesic were common, and post-ED interviews reveal that sickle cell pain patients are discharged from the ED with higher pain scores than what they perceive as desirable.

Identification of intraluminal thrombus by ultrasonography in emergency department patients with acute deep venous thrombosis.

PubMed

Mehta, Ninfa; Schecter, Joshua; Stone, Michael

2012-05-01

Traditionally, the diagnosis of deep venous thrombosis (DVT) using duplex ultrasonography (DU) has relied on the absence of venous compressibility. Visualization of an intraluminal thrombus is considered an uncommon finding. The purpose of this study is to determine the frequency of intraluminal thrombus in emergency department (ED) patients diagnosed with acute DVT. Retrospective chart review of adult ED patients with DU examinations demonstrating acute DVT. Patients with chronic DVT or patients in whom DU did not demonstrate DVT were excluded from data analysis. Study reports and ultrasound images were reviewed and analyzed for the presence of intraluminal thrombus. There were 189 patients who met inclusion criteria, of which 160 (85%) were found to have intraluminal thrombus. Intraluminal thrombi are present in the majority of patients in our ED in whom acute DVT is identified by DU. Copyright © 2012 Elsevier Inc. All rights reserved.

Revisit, Subsequent Hospitalization, Recurrent Fall, and Death Within 6 Months After a Fall Among Elderly Emergency Department Patients.

PubMed

Sri-On, Jiraporn; Tirrell, Gregory P; Bean, Jonathan F; Lipsitz, Lewis A; Liu, Shan W

2017-10-01

We seek to describe the risk during 6 months and specific risk factors for recurrent falls, emergency department (ED) revisits, subsequent hospitalizations, and death within 6 months after a fall-related ED presentation. This was a secondary analysis of a retrospective cohort of elderly fall patients who presented to the ED from one urban teaching hospital. We included patients aged 65 years and older who had an ED fall visit in 2012. We examined the frequency and risk factors of adverse events (composite of recurrent falls, ED revisits, subsequent hospitalization, and death, selected a priori) at 6 months. Our study included 350 older adults. Adverse events steadily increased, from 7.7% at 7 days, 21.4% at 30 days, and 50.3% at 6 months. Within 6 months, 22.6% of patients had at least one recurrent fall, 42.6% revisited the ED, 31.1% had subsequent hospitalizations, and 2.6% died. In multivariable logistic regression analysis, psychological or sedative drug use predicted recurrent falls, ED revisits, subsequent hospitalizations, and adverse events. More than half of fall patients had an adverse event within 6 months of presenting to the ED after a fall. The risk during 6 months of these adverse events increased with psychological or sedative drug use. Larger future studies should confirm this association and investigate methods to minimize recurrent falls through management of such medications. Copyright © 2017 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Older adults and high-risk medication administration in the emergency department.

PubMed

Kim, Mitchell; Mitchell, Steven H; Gatewood, Medley; Bennett, Katherine A; Sutton, Paul R; Crawford, Carol A; Bentov, Itay; Damodarasamy, Mamatha; Kaplan, Stephen J; Reed, May J

2017-01-01

Older adults are susceptible to adverse effects from opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), and benzodiazepines (BZDs). We investigated factors associated with the administration of elevated doses of these medications of interest to older adults (≥65 years old) in the emergency department (ED). ED records were queried for the administration of medications of interest to older adults at two academic medical center EDs over a 6-month period. Frequency of recommended versus elevated ("High doses" were defined as doses that ranged between 1.5 and 3 times higher than the recommended starting doses; "very high doses" were defined as higher than high doses) starting doses of medications, as determined by geriatric pharmacy/medicine guidelines and expert consensus, was compared by age groups (65-69, 70-74, 75-79, 80-84, and ≥85 years), gender, and hospital. There were 17896 visits representing 11374 unique patients >65 years of age (55.3% men, 44.7% women). A total of 3394 doses of medications of interest including 1678 high doses and 684 very high doses were administered to 1364 different patients. Administration of elevated doses of medications was more common than that of recommended doses. Focusing on opioids and BZDs, the 65-69-year age group was much more likely to receive very high doses (1481 and 412 doses, respectively) than the ≥85-year age groups (relative risk [RR] 5.52, 95% CI 2.56-11.90), mainly reflecting elevated opioid dosing (RR 8.28, 95% CI 3.69-18.57). Men were more likely than women to receive very high doses (RR 1.47, 95% CI 1.26-1.72), primarily due to BZDs (RR 2.12, 95% CI 2.07-2.16). Administration of elevated doses of opioids and BZDs in the older population occurs frequently in the ED, especially to the 65-69-year age group and men. Further attention to potentially unsafe dosing of high-risk medications to older adults in the ED is warranted.

A Comparison of Patient Visits to Retail Clinics, Primary Care Physicians, and Emergency Departments

PubMed Central

Wang, Margaret C.; Lave, Judith R.; Adams, John L.; McGlynn, Elizabeth A.

2009-01-01

In this study we compared the demographics and reason for visits in national samples of visits to retail clinics, primary care physicians (PCPs), and emergency departments (EDs). We find that retail clinics appear to be serving a patient population underserved by PCPs. Just 10 clinical issues such as sinusitis and immunizations encompass more than 90% of retail clinic visits. These same 10 clinical issues make up 13% of adult PCP visits, 30% of pediatric PCP visits, and 12% of ED visits. Whether there will be a shift of care from EDs or PCPs to retail clinics in the future is unknown. PMID:18780911

Identification of fall risk factors in older adult emergency department patients.

PubMed

Carpenter, Christopher R; Scheatzle, Mark D; D'Antonio, Joyce A; Ricci, Paul T; Coben, Jeffrey H

2009-03-01

Falls represent an increasingly frequent source of injury among older adults. Identification of fall risk factors in geriatric patients may permit the effective utilization of scarce preventative resources. The objective of this study was to identify independent risk factors associated with an increased 6-month fall risk in community-dwelling older adults discharged from the emergency department (ED). This was a prospective observational study with a convenience sampling of noninstitutionalized elders presenting to an urban teaching hospital ED who did not require hospital admission. Interviews were conducted to determine the presence of fall risk factors previously described in non-ED populations. Subjects were followed monthly for 6 months through postcard or telephone contact to identify subsequent falls. Univariate and Cox regression analysis were used to determine the association of risk factors with 6-month fall incidence. A total of 263 patients completed the survey, and 161 (61%) completed the entire 6 months of follow-up. Among the 263 enrolled, 39% reported a fall in the preceding year, including 15% with more than one fall and 22% with injurious falls. Among those completing the 6 months of follow-up, 14% reported at least one fall. Cox regression analysis identified four factors associated with falls during the 6-month follow-up: nonhealing foot sores (hazard ratio [HR] = 3.71, 95% confidence interval [CI] = 1.73 to 7.95), a prior fall history (HR = 2.62, 95% CI = 1.32 to 5.18), inability to cut one's own toenails (HR = 2.04, 95% CI = 1.04 to 4.01), and self-reported depression (HR = 1.72, 95% CI = 0.83 to 3.55). Falls, recurrent falls, and injurious falls in community-dwelling elder ED patients being evaluated for non-fall-related complaints occur at least as frequently as in previously described outpatient cohorts. Nonhealing foot sores, self-reported depression, not clipping one's own toenails, and previous falls are all associated with falls after ED discharge.

Tick bite and Lyme disease-related emergency department encounters in New Hampshire, 2010-2014.

PubMed

Daly, E R; Fredette, C; Mathewson, A A; Dufault, K; Swenson, D J; Chan, B P

2017-12-01

Lyme disease (LD) is a common tick-borne disease in New Hampshire (NH). While LD is a reportable condition and cases are counted for public health surveillance, many more people receive care for tick bites or diagnoses of LD than are reflected in surveillance data. NH's emergency department (ED) data system was queried for tick bite and LD-related encounters. Chief complaint text was queried for words related to LD or tick bites. International Classification of Diseases 9th Revision (ICD-9) codes were queried for the LD diagnosis code (088.81). Emergency department patient data were matched to reportable disease data to determine the proportion of ED patients reported to the health department as a suspected LD case. Data were analysed to calculate frequencies for key demographic and reporting characteristics. From 2010 to 2014, 13,615 tick bite or LD-related ED encounters were identified in NH, with most due to tick bites (76%). Of 3,256 patients with a LD-related ED encounter, 738 (23%) were reported to the health department as a suspected LD case. The geographic distribution of ED patients was similar to reported LD cases; however, the regions of the state that experienced higher rates of ED encounters were different than the regions that observed higher rates of reported LD cases. Seasonal distribution of ED encounters peaked earlier than reported LD cases with a second peak in the fall. While age and sex distribution was similar among ED patients and reported LD cases, the rates for children 5 years and younger and adults 65 years and older were greater for ED encounters. Patients frequently visit the ED to seek care for tick bites and suspected LD. Results of ED data analyses can be used to target education, in particular for ED providers and the public through timely distribution of evidence-based educational materials and training programmes. © 2017 Blackwell Verlag GmbH.

Asia, Australia and New Zealand Dyspnoea in Emergency Departments (AANZDEM) study: Rationale, design and analysis.

PubMed

Kelly, Anne-Maree; Keijzers, Gerben; Klim, Sharon; Graham, Colin A; Craig, Simon; Kuan, Win Sen; Jones, Peter; Holdgate, Anna; Lawoko, Charles; Laribi, Said

2015-06-01

Shortness of breath is a common reason for ED attendance. This international study aims to describe the epidemiology of dyspnoea presenting to EDs in the South East Asia-Pacific region, to compare disease patterns across regions, to understand how conditions are investigated and treated, and to assess quality of care. This is a prospective, interrupted time series cohort study conducted in EDs in Australia, New Zealand, Singapore, Hong Kong and Malaysia of consecutive adult patients presenting to the ED with dyspnoea as a main symptom. Data were collected over three 72 h periods in May, August and October 2014 (autumn, winter and spring), and included demographics, comorbidities, mode of arrival, usual medications, pre-hospital treatment, initial assessment, ED investigations, treatment in the ED, ED diagnosis, disposition from ED, in-hospital outcome and final hospital diagnosis. The primary outcomes of interest are the epidemiology and outcome of patients presenting to ED with dyspnoea. Secondary outcomes of interest are seasonal and geographic comparisons of diagnoses and outcomes, disease-specific descriptions of epidemiology, investigation, treatment and disposition, and compliance with treatment guidelines. This novel study will explore dyspnoea from the viewpoint of the patient's symptom (shortness of breath) rather than that of a single disease. The results will provide robust data about the epidemiology, investigation, treatment and disposition of this diverse patient group. The obtained data also have the potential to inform service planning and to quantify the proportion of patients with mixed cardiac and respiratory disease. © 2015 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

Erectile Dysfunction in Patients with Sleep Apnea--A Nationwide Population-Based Study.

PubMed

Chen, Chia-Min; Tsai, Ming-Ju; Wei, Po-Ju; Su, Yu-Chung; Yang, Chih-Jen; Wu, Meng-Ni; Hsu, Chung-Yao; Hwang, Shang-Jyh; Chong, Inn-Wen; Huang, Ming-Shyan

2015-01-01

Increased incidence of erectile dysfunction (ED) has been reported among patients with sleep apnea (SA). However, this association has not been confirmed in a large-scale study. We therefore performed a population-based cohort study using Taiwan National Health Insurance (NHI) database to investigate the association of SA and ED. From the database of one million representative subjects randomly sampled from individuals enrolled in the NHI system in 2010, we identified adult patients having SA and excluded those having a diagnosis of ED prior to SA. From these suspected SA patients, those having SA diagnosis after polysomnography were defined as probable SA patients. The dates of their first SA diagnosis were defined as their index dates. Each SA patient was matched to 30 randomly-selected, age-matched control subjects without any SA diagnosis. The control subjects were assigned index dates as their corresponding SA patients, and were ensured having no ED diagnosis prior to their index dates. Totally, 4,835 male patients with suspected SA (including 1,946 probable SA patients) were matched to 145,050 control subjects (including 58,380 subjects matched to probable SA patients). The incidence rate of ED was significantly higher in probable SA patients as compared with the corresponding control subjects (5.7 vs. 2.3 per 1000 patient-year; adjusted incidence rate ratio = 2.0 [95% CI: 1.8-2.2], p<0.0001). The cumulative incidence was also significantly higher in the probable SA patients (p<0.0001). In multivariable Cox regression analysis, probable SA remained a significant risk factor for the development of ED after adjusting for age, residency, income level and comorbidities (hazard ratio = 2.0 [95%CI: 1.5-2.7], p<0.0001). In line with previous studies, this population-based large-scale study confirmed an increased ED incidence in SA patients in Chinese population. Physicians need to pay attention to the possible underlying SA while treating ED patients.

Duration of Mechanical Ventilation in the Emergency Department.

PubMed

Angotti, Lauren B; Richards, Jeremy B; Fisher, Daniel F; Sankoff, Jeffrey D; Seigel, Todd A; Al Ashry, Haitham S; Wilcox, Susan R

2017-08-01

Due to hospital crowding, mechanically ventilated patients are increasingly spending hours boarding in emergency departments (ED) before intensive care unit (ICU) admission. This study aims to evaluate the association between time ventilated in the ED and in-hospital mortality, duration of mechanical ventilation, ICU and hospital length of stay (LOS). This was a multi-center, prospective, observational study of patients ventilated in the ED, conducted at three academic Level I Trauma Centers from July 2011 to March 2013. All consecutive adult patients on invasive mechanical ventilation were eligible for enrollment. We performed a Cox regression to assess for a mortality effect for mechanically ventilated patients with each hour of increasing LOS in the ED and multivariable regression analyses to assess for independently significant contributors to in-hospital mortality. Our primary outcome was in-hospital mortality, with secondary outcomes of ventilator days, ICU LOS and hospital LOS. We further commented on use of lung protective ventilation and frequency of ventilator changes made in this cohort. We enrolled 535 patients, of whom 525 met all inclusion criteria. Altered mental status without respiratory pathology was the most common reason for intubation, followed by trauma and respiratory failure. Using iterated Cox regression, a mortality effect occurred at ED time of mechanical ventilation > 7 hours, and the longer ED stay was also associated with a longer total duration of intubation. However, adjusted multivariable regression analysis demonstrated only older age and admission to the neurosciences ICU as independently associated with increased mortality. Of interest, only 23.8% of patients ventilated in the ED for over seven hours had changes made to their ventilator. In a prospective observational study of patients mechanically ventilated in the ED, there was a significant mortality benefit to expedited transfer of patients into an appropriate ICU setting.

CURB-65 Performance Among Admitted and Discharged Emergency Department Patients With Community-acquired Pneumonia.

PubMed

Sharp, Adam L; Jones, Jason P; Wu, Ivan; Huynh, Dan; Kocher, Keith E; Shah, Nirav R; Gould, Michael K

2016-04-01

Pneumonia severity tools were primarily developed in cohorts of hospitalized patients, limiting their applicability to the emergency department (ED). We describe current community ED admission practices and examine the accuracy of the CURB-65 to predict 30-day mortality for patients, either discharged or admitted with community-acquired pneumonia (CAP). A retrospective, observational study of adult CAP encounters in 14 community EDs within an integrated healthcare system. We calculated CURB-65 scores for all encounters and described the use of hospitalization, stratified by each score (0-5). We then used each score as a cutoff to calculate sensitivity, specificity, positive predictive value, negative predictive value (NPV), positive likelihood ratios, and negative likelihood ratios for predicting 30-day mortality. The sample included 21,183 ED encounters for CAP (7,952 discharged and 13,231 admitted). The C-statistic describing the accuracy of CURB-65 for predicting 30-day mortality in the full sample was 0.761 (95% confidence interval [CI], 0.747-0.774). The C-statistic was 0.864 (95% CI, 0.821-0.906) among patients discharged from the ED compared with 0.689 (95% CI, 0.672-0.705) among patients who were admitted. Among all ED encounters a CURB-65 threshold of ≥1 was 92.8% sensitive and 38.0% specific for predicting mortality, with a 99.9% NPV. Among all encounters, 62.5% were admitted, including 36.2% of those at lowest risk (CURB-65 = 0). CURB-65 had very good accuracy for predicting 30-day mortality among patients discharged from the ED. This severity tool may help ED providers risk stratify patients to assist with disposition decisions and identify unwarranted variation in patient care. © 2016 by the Society for Academic Emergency Medicine.

Balancing safety and harm for older adults with dementia in rural emergency departments: healthcare professionals' perspectives.

PubMed

Hunter, Kathleen F; Parke, Belinda; Babb, Maureen; Forbes, Dorothy; Strain, Laurel

2017-01-01

The emergency department (ED) is a potentially harmful environment for older adults with dementia, and rural EDs face unique challenges in providing care to this population. The purpose of this study was to understand safety and harm in rural ED transitional care for community dwelling older adults with dementia from the perspective of healthcare professionals (HCPs). An interpretive, descriptive exploratory design from a social ecological perspective was used. Using purposive and snowball sampling, HCPs were recruited from two rural hospital EDs in two Canadian provinces. Data collection involved participant interviews using a semi-structured interview guide. Audio-recorded interviews were transcribed, transcripts coded, and themes identified using constant comparative analysis with thematic coding. A total of 12 HCPs, seven from one province and five from the other, participated in the study. HCPs worked directly in the ED or consulted in the ED from hospital-based social work, rehabilitation and community liaison services. Three themes were identified: physical environment (space, design and equipment), work environment (pressure to perform) and practice environment (family, knowledge and processes). A conceptual model was developed to illustrate how HCPs worked to balance safety and harm for older patients with dementia within a milieu created by the overlapping and synergistically interacting environments. HCPs in rural EDs working at the interface of hospital and community constantly attempt to balance promoting safety and avoiding harm for older adults with dementia. Participants perceived safety broadly, understanding that the consequences of the milieu were created through an interaction between physical, work and practice environments. These consequences related to the physical, cognitive and emotional wellbeing of older adults with dementia and their caregivers. Within the practice environment, participants identified a 'rural advantage' that was tied to their knowledge of community and the people with dementia and their caregivers who sought care in the participating EDs. However, familiarity can be a double-edged sword and to minimize potential harm healthcare professionals must seek input from caregivers regarding altered functional status, and policies to change triage to include gerontological knowledge and create elder-friendly rural ED environments are needed.

Insurance Expansion and Hospital Emergency Department Access: Evidence From the Affordable Care Act.

PubMed

Garthwaite, Craig; Gross, Tal; Notowidigdo, Matthew; Graves, John A

2017-02-07

Little is known about whether insurance expansion affects the location and type of emergency department (ED) use. Understanding these changes can inform state-level decisions about the Medicaid expansion under the Patient Protection and Affordable Care Act (ACA). To investigate the effect of the 2014 ACA Medicaid expansion on the location, insurance status, and type of ED visits. Quasi-experimental observational study from 2012 to 2014. 126 investor-owned, hospital-based EDs. Uninsured and Medicaid-insured adults aged 18 to 64 years. ACA expansion of Medicaid in January 2014. Number of ED visits overall, type of visit (for example, nondiscretionary or nonemergency), and average travel time to the ED. Interrupted time-series analyses comparing changes from the end of 2013 to end of 2014 for patients from Medicaid expansion versus nonexpansion states were done. There were 1.06 million ED visits among patients from 17 Medicaid expansion states, and 7.87 million ED visits among patients from 19 nonexpansion states. The EDs treating patients from Medicaid expansion states saw an overall 47.1% decrease in uninsured visits (95% CI, -65.0% to -29.3%) and a 125.7% (CI, 89.2% to 162.6%) increase in Medicaid visits after 12 months of ACA expansion. Average travel time for nondiscretionary conditions requiring immediate medical care decreased by 0.9 minutes (-6.2% [CI, -8.9% to -3.5%]) among all Medicaid patients from expansion states. We found little evidence of similar changes among patients from nonexpansion states. Results reflect shifts in ED care at investor-owned facilities, which limits generalizability to other hospital types. Meaningful changes in insurance status and location and type of ED visits in the first year of ACA Medicaid expansion were found, suggesting that expansion provides patients with a greater choice of hospital facilities. Robert Wood Johnson Foundation.

Care plan program reduces the number of visits for challenging psychiatric patients in the ED.

PubMed

Abello, Arthur; Brieger, Ben; Dear, Kim; King, Ben; Ziebell, Chris; Ahmed, Atheer; Milling, Truman J

2012-09-01

A small number of patients representing a significant demand on emergency department (ED) services present regularly for a variety of reasons, including psychiatric or behavioral complaints and lack of access to other services. A care plan program was created as a database of ED high users and patients of concern, as identified by ED staff and approved by program administrators to improve care and mitigate ED strain. A list of medical record numbers was assembled by searching the care plan program database for adult patients initially enrolled between the dates of November 1, 2006, and October 21, 2007. Inclusion criteria were the occurrence of a psychiatric International Classification Diseases, Ninth Revision, code in their medical record and a care plan level implying a serious psychiatric disorder causing harmful behavior. Additional data about these patients were acquired using an indigent care tracking database and electronic medical records. Variables collected from these sources were analyzed for changes before and after program enrollment. Of 501 patients in the database in the period studied, 48 patients fulfilled the criteria for the cohort. There was a significant reduction in the number of visits to the ED from the year before program enrollment to the year after enrollment (8.9, before; 5.9, after; P < .05). There was also an increase in psychiatric hospital visits (2%, before; 25%, after; P < .05). An alert program that identifies challenging ED patients with psychiatric conditions and creates a care plan appears to reduce visits and lead to more appropriate use of other resources. Copyright © 2012 Elsevier Inc. All rights reserved.

Predicting Geriatric Falls Following an Episode of Emergency Department Care: A Systematic Review

PubMed Central

Carpenter, Christopher R.; Avidan, Michael S.; Wildes, Tanya; Stark, Susan; Fowler, Susan A.; Lo, Alexander X.

2015-01-01

Background Falls are the leading cause of traumatic mortality in geriatric adults. Despite recent multispecialty guideline recommendations that advocate for proactive fall prevention protocols in the emergency department (ED), the ability of risk factors or risk stratification instruments to identify subsets of geriatric patients at increased risk for short-term falls is largely unexplored. Objectives This was a systematic review and meta-analysis of ED-based history, physical examination, and fall risk stratification instruments with the primary objective of providing a quantitative estimate for each risk factor’s accuracy to predict future falls. A secondary objective was to quantify ED fall risk assessment test and treatment thresholds using derived estimates of sensitivity and specificity. Methods A medical librarian and two emergency physicians (EPs) conducted a medical literature search of PUBMED, EMBASE, CINAHL, CENTRAL, DARE, the Cochrane Registry, and Clinical Trials. Unpublished research was located by a hand search of emergency medicine (EM) research abstracts from national meetings. Inclusion criteria for original studies included ED-based assessment of pre-ED or post-ED fall risk in patients 65 years and older with sufficient detail to reproduce contingency tables for meta-analysis. Original study authors were contacted for additional details when necessary. The Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2) was used to assess individual study quality for those studies that met inclusion criteria. When more than one qualitatively similar study assessed the same risk factor for falls at the same interval following an ED evaluation, then meta-analysis was performed using Meta-DiSc software. The primary outcomes were sensitivity, specificity, and likelihood ratios for fall risk factors or risk stratification instruments. Secondary outcomes included estimates of test and treatment thresholds using the Pauker method based on accuracy, screening risk, and the projected benefits or harms of fall prevention interventions in the ED. Results A total of 608 unique and potentially relevant studies were identified, but only three met our inclusion criteria. Two studies that included 660 patients assessed 29 risk factors and two risk stratification instruments for falls in geriatric patients in the 6 months following an ED evaluation, while one study of 107 patients assessed the risk of falls in the preceding 12 months. A self-report of depression was associated with the highest positive likelihood ratio (LR) of 6.55 (95% confidence interval [CI] = 1.41 to 30.48). Six fall predictors were identified in more than one study (past falls, living alone, use of walking aid, depression, cognitive deficit, and more than six medications) and meta-analysis was performed for these risk factors. One screening instrument was sufficiently accurate to identify a subset of geriatric ED patients at low risk for falls with a negative LR of 0.11 (95% CI = 0.06 to 0.20). The test threshold was 6.6% and the treatment threshold was 27.5%. Conclusions This study demonstrates the paucity of evidence in the literature regarding ED-based screening for risk of future falls among older adults. The screening tools and individual characteristics identified in this study provide an evidentiary basis on which to develop screening protocols for geriatrics adults in the ED to reduce fall risk PMID:25293956

Predicting geriatric falls following an episode of emergency department care: a systematic review.

PubMed

Carpenter, Christopher R; Avidan, Michael S; Wildes, Tanya; Stark, Susan; Fowler, Susan A; Lo, Alexander X

2014-10-01

Falls are the leading cause of traumatic mortality in geriatric adults. Despite recent multispecialty guideline recommendations that advocate for proactive fall prevention protocols in the emergency department (ED), the ability of risk factors or risk stratification instruments to identify subsets of geriatric patients at increased risk for short-term falls is largely unexplored. This was a systematic review and meta-analysis of ED-based history, physical examination, and fall risk stratification instruments with the primary objective of providing a quantitative estimate for each risk factor's accuracy to predict future falls. A secondary objective was to quantify ED fall risk assessment test and treatment thresholds using derived estimates of sensitivity and specificity. A medical librarian and two emergency physicians (EPs) conducted a medical literature search of PUBMED, EMBASE, CINAHL, CENTRAL, DARE, the Cochrane Registry, and Clinical Trials. Unpublished research was located by a hand search of emergency medicine (EM) research abstracts from national meetings. Inclusion criteria for original studies included ED-based assessment of pre-ED or post-ED fall risk in patients 65 years and older with sufficient detail to reproduce contingency tables for meta-analysis. Original study authors were contacted for additional details when necessary. The Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2) was used to assess individual study quality for those studies that met inclusion criteria. When more than one qualitatively similar study assessed the same risk factor for falls at the same interval following an ED evaluation, then meta-analysis was performed using Meta-DiSc software. The primary outcomes were sensitivity, specificity, and likelihood ratios for fall risk factors or risk stratification instruments. Secondary outcomes included estimates of test and treatment thresholds using the Pauker method based on accuracy, screening risk, and the projected benefits or harms of fall prevention interventions in the ED. A total of 608 unique and potentially relevant studies were identified, but only three met our inclusion criteria. Two studies that included 660 patients assessed 29 risk factors and two risk stratification instruments for falls in geriatric patients in the 6 months following an ED evaluation, while one study of 107 patients assessed the risk of falls in the preceding 12 months. A self-report of depression was associated with the highest positive likelihood ratio (LR) of 6.55 (95% confidence interval [CI] = 1.41 to 30.48). Six fall predictors were identified in more than one study (past falls, living alone, use of walking aid, depression, cognitive deficit, and more than six medications) and meta-analysis was performed for these risk factors. One screening instrument was sufficiently accurate to identify a subset of geriatric ED patients at low risk for falls with a negative LR of 0.11 (95% CI = 0.06 to 0.20). The test threshold was 6.6% and the treatment threshold was 27.5%. This study demonstrates the paucity of evidence in the literature regarding ED-based screening for risk of future falls among older adults. The screening tools and individual characteristics identified in this study provide an evidentiary basis on which to develop screening protocols for geriatrics adults in the ED to reduce fall risk. © 2014 by the Society for Academic Emergency Medicine.

Validation of patient and nurse short forms of the Readiness for Hospital Discharge Scale and their relationship to return to the hospital.

PubMed

Weiss, Marianne E; Costa, Linda L; Yakusheva, Olga; Bobay, Kathleen L

2014-02-01

To validate patient and nurse short forms for discharge readiness assessment and their associations with 30-day readmissions and emergency department (ED) visits. A total of 254 adult medical-surgical patients and their discharging nurses from an Eastern US tertiary hospital between May and November, 2011. Prospective longitudinal design, multinomial logistic regression analysis. Nurses and patients independently completed an eight-item Readiness for Hospital Discharge Scale on the day of discharge. Patient characteristics, readmissions, and ED visits were electronically abstracted. Nurse assessment of low discharge readiness was associated with a six- to nine-fold increase in readmission risk. Patient self-assessment was not associated with readmission; neither was associated with ED visits. Nurse discharge readiness assessment should be added to existing strategies for identifying readmission risk. © Health Research and Educational Trust.

Patient Preferences regarding Shared Decision-making in the Emergency Department: Findings from a multi-site survey.

PubMed

Schoenfeld, Elizabeth M; Kanzaria, Hemal K; Quigley, Denise D; Marie, Peter St; Nayyar, Nikita; Sabbagh, Sarah H; Gress, Kyle L; Probst, Marc A

2018-06-13

As Shared Decision-Making (SDM) has received increased attention as a method to improve the patient-centeredness of emergency department (ED) care, we sought to determine patients' desired level of involvement in medical decisions and their perceptions of potential barriers and facilitators to SDM in the ED. We surveyed a cross-sectional sample of adult ED patients at three academic medical centers across the United States. The survey included 32 items regarding patient involvement in medical decisions including a modified Control Preference Scale (CPS) and questions about barriers and facilitators to SDM in the ED. Items were developed and refined based on prior literature and qualitative interviews with ED patients. Research assistants administered the survey in person. Of 797 patients approached, 661 (83%) agreed to participate. Participants were 52% female, 45% white, and 30% Hispanic. The majority of respondents (85-92%, depending on decision type) expressed a desire for some degree of involvement in decision-making in the ED, while 8-15% preferred to leave decision-making to their physician alone. Ninety-eight percent wanted to be involved with decisions when "something serious is going on." The majority of patients (94%) indicated that self-efficacy was not a barrier to SDM in the ED. However, most patients (55%) reported a tendency to defer to the physician's decision-making during an ED visit, with about half reporting they would wait for a physician to ask them to be involved. We found the majority of ED patients in our large, diverse sample wanted to be involved in medical decisions, especially in the case of a "serious" medical problem, and felt that they had the ability to do so. Nevertheless, many patients were unlikely to actively seek involvement and defaulted to allowing the physician to make decisions during the ED visit. After fully explaining the consequences of a decision, clinicians should make an effort to explicitly ascertain patients' desired level of involvement in decision-making. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

Rates and Predictors of Professional Interpreting Provision for Patients With Limited English Proficiency in the Emergency Department and Inpatient Ward

PubMed Central

Ryan, Jennifer; Abbato, Samantha; Greer, Ristan; Vayne-Bossert, Petra; Good, Phillip

2017-01-01

The provision of professional interpreting services in the hospital setting decreases communication errors of clinical significance and improves clinical outcomes. A retrospective audit was conducted at a tertiary referral adult hospital in Brisbane, Australia. Of 20 563 admissions of patients presenting to the hospital emergency department (ED) and admitted to a ward during 2013-2014, 582 (2.8%) were identified as requiring interpreting services. In all, 19.8% of admissions were provided professional interpreting services in the ED, and 26.1% were provided on the ward. Patients were more likely to receive interpreting services in the ED if they were younger, spoke an Asian language, or used sign language. On the wards, using sign language was associated with 3 times odds of being provided an interpreter compared with other languages spoken. Characteristics of patients including their age and type of language spoken influence the clinician’s decision to engage a professional interpreter in both the ED and inpatient ward. PMID:29144184

Use of the gait profile score for the evaluation of patients with joint hypermobility syndrome/Ehlers-Danlos syndrome hypermobility type.

PubMed

Celletti, Claudia; Galli, Manuela; Cimolin, Veronica; Castori, Marco; Tenore, Nunzio; Albertini, Giorgio; Camerota, Filippo

2013-11-01

Gait analysis (GA) is widely used for clinical evaluations in various pathological states, both in children and in adults, such as in patients with joint hypermobility syndrome/Ehlers-Danlos syndrome hypermobility type (JHS/EDS-HT). Otherwise, GA produces a large volume of data and there is the clinical need to provide also a quantitative measure of the patient's overall gait. Starting from this aim some global indexes were proposed by literature as a summary measure of the patient's gait, such as the Gait Profile Score (GPS). While validity of the GPS was demonstrated for the evaluation of the functional limitation of children with Cerebral Palsy, no studies have been conducted in patients JHS/EDS-HT. The aim of our study was therefore to investigate the effectiveness of the GPS in the quantification of functional limitation of patients with JHS/EDS-HT. Twenty-one adult (age: 36.1 ± 12.7 years) individuals with JHS/EDS-HT were evaluated using GA and from GA data the GPS was computed. The results evidenced that the GPS value of patients was 8.9 ± 2.6, statistically different from 4.6 ± 0.9 displayed by the control group. In particular, all values of Gait Variable Scores (GVS) which compose the GPS were higher if compared to controls, with the exception of Pelvic Tilt and Foot Progression. The correlations between GPS/GVS and Lower Extremity Functional Scale (LEFS) showed significant relationship between GPS and the item 11 ("Walking 2 blocks") (ρ=-0.56; p<0.05) and 12 ("Walking a mile") of LEFS (ρ=-0.76; p<0.05). Our results showed that GPS and GVS seem to be appropriate outcome measures for the evaluation of the functional limitation during gait of patients with JHS/EDS-HT. Copyright © 2013 Elsevier Ltd. All rights reserved.

Compliance with telephone triage advice among adults aged 45 years and older: an Australian data linkage study.

PubMed

Tran, Duong Thuy; Gibson, Amy; Randall, Deborah; Havard, Alys; Byrne, Mary; Robinson, Maureen; Lawler, Anthony; Jorm, Louisa R

2017-08-01

Middle-aged and older patients are prominent users of telephone triage services for timely access to health information and appropriate referrals. Non-compliance with advice to seek appropriate care could potentially lead to poorer health outcomes among those patients. It is imperative to assess the extent to which middle-aged and older patients follow triage advice and how this varies according to their socio-demographic, lifestyle and health characteristics as well as features of the call. Records of calls to the Australian healthdirect helpline (July 2008-December 2011) were linked to baseline questionnaire data from the 45 and Up Study (participants age ≥ 45 years), records of emergency department (ED) presentations, hospital admissions, and medical consultation claims. Outcomes of the call included compliance with the advice "Attend ED immediately"; "See a doctor (immediately, within 4 hours, or within 24 hours)"; "Self-care"; and self-referral to ED or hospital within 24 h when given a self-care or low-urgency care advice. Multivariable logistic regression was used to investigate associations between call outcomes and patient and call characteristics. This study included 8406 adults (age ≥ 45 years) who were subjects of 11,088 calls to the healthdirect helpline. Rates of compliance with the advices "Attend ED immediately", "See a doctor" and "Self-care" were 68.6%, 64.6% and 77.5% respectively, while self-referral to ED within 24 h followed 7.0% of calls. Compliance with the advice "Attend ED immediately" was higher among patients who had three or more positive lifestyle behaviours, called after-hours, or stated that their original intention was to attend ED, while it was lower among those who lived in rural and remote areas or reported high or very high levels of psychological distress. Compliance with the advice "See a doctor" was higher in patients who were aged ≥65 years, worked full-time, or lived in socio-economically advantaged areas, when another person made the call on the patient's behalf, and when the original intention was to seek care from an ED or a doctor. It was lower among patients in rural and remote areas and those taking five medications or more. Patients aged ≥65 years were less likely to comply with the advice "Self-care". The rates of self-referral to ED within 24 h were greater in patients from disadvantaged areas, among calls made after-hours or by another person, and when the original intention was to attend ED. Patients who were given a self-care or low-urgency care advice, whose calls concerned bleeding, cardiac, gastrointestinal, head and facial injury symptoms, were more likely to self-refer to ED. Compliance with telephone triage advice among middle-age and older patients varied substantially according to both patient- and call-related factors. Knowledge about the patients who are less likely to comply with telephone triage advice, and about characteristics of calls that may influence compliance, will assist in refining patient triage protocols and referral pathways, training staff and tailoring service design and delivery to achieve optimal patient compliance.

Thromboprophylaxis for Patients with High-risk Atrial Fibrillation and Flutter Discharged from the Emergency Department.

PubMed

Vinson, David R; Warton, E Margaret; Mark, Dustin G; Ballard, Dustin W; Reed, Mary E; Chettipally, Uli K; Singh, Nimmie; Bouvet, Sean Z; Kea, Bory; Ramos, Patricia C; Glaser, David S; Go, Alan S

2018-03-01

Many patients with atrial fibrillation or atrial flutter (AF/FL) who are high risk for ischemic stroke are not receiving evidence-based thromboprophylaxis. We examined anticoagulant prescribing within 30 days of receiving dysrhythmia care for non-valvular AF/FL in the emergency department (ED). This prospective study included non-anticoagulated adults at high risk for ischemic stroke (ATRIA score ≥7) who received emergency AF/FL care and were discharged home from seven community EDs between May 2011 and August 2012. We characterized oral anticoagulant prescribing patterns and identified predictors of receiving anticoagulants within 30 days of the index ED visit. We also describe documented reasons for withholding anticoagulation. Of 312 eligible patients, 128 (41.0%) were prescribed anticoagulation at ED discharge or within 30 days. Independent predictors of anticoagulation included age (adjusted odds ratio [aOR] 0.89 per year, 95% confidence interval [CI] 0.82-0.96); ED cardiology consultation (aOR 1.89, 95% CI [1.10-3.23]); and failure of sinus restoration by time of ED discharge (aOR 2.65, 95% CI [1.35-5.21]). Reasons for withholding anticoagulation at ED discharge were documented in 139 of 227 cases (61.2%), the most common of which were deferring the shared decision-making process to the patient's outpatient provider, perceived bleeding risk, patient refusal, and restoration of sinus rhythm. Approximately 40% of non-anticoagulated AF/FL patients at high risk for stroke who presented for emergency dysrhythmia care were prescribed anticoagulation within 30 days. Physicians were less likely to anticoagulate older patients and those with ED sinus restoration. Opportunities exist to improve rates of thromboprophylaxis in this high-risk population.

Do instability markers predict satisfactory reduction and requirement for later surgery in emergency department patients with wrist fracture?

PubMed

Winayak, Amar; Gossat, Alyza; Cooper, Jenny; Ritchie, Peter; Lim, Wei; Klim, Sharon; Kelly, Anne-Maree

2018-02-01

Research suggests that the presence of instability markers in patients with displaced distal radial fractures is associated with poorer outcome. Our aims were to determine whether the presence of previously defined instability markers could predict the likelihood of successful ED reduction and requirement for a secondary procedure after ED reduction. Retrospective cohort study performed by medical record review. Adult ED patients coded as having an isolated wrist fracture and having fracture reduction in ED were eligible for inclusion. Data collected included demographics, history of osteoporosis, mechanism of injury, radiological features on X-rays and performance of a secondary procedure. Outcomes of interest were the rate of successful fracture reduction in ED (against defined radiological criteria), the rate of secondary procedures and the association between the number of defined instability risk factors and successful reduction and performance of a secondary surgical procedure. Analysis was by χ 2 test, receiver operating characteristic curve, logistic regression analyses. Three hundred and nineteen patients were studied; median age 62 years, 77% female. Sixty-five per cent of patients had satisfactory fracture reduction in ED (95% CI 59%-70%). Eighty-six patients underwent a secondary procedure to reduce/stabilise their fracture (28%, 95% CI 23%-33%). Younger age, lack of satisfactory ED reduction and increased number of instability factors were independently predictive of the performance of a secondary procedure. Instability risk factors are common in patients with wrist fractures requiring reduction in ED. The number of instability factors is not a strong predictor of the performance of secondary procedures. © 2017 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

American Association for Emergency Psychiatry Task Force on Medical Clearance of Adult Psychiatric Patients. Part II: Controversies over Medical Assessment, and Consensus Recommendations

PubMed Central

Wilson, Michael P.; Nordstrom, Kimberly; Anderson, Eric L.; Ng, Anthony T.; Zun, Leslie S.; Peltzer-Jones, Jennifer M.; Allen, Michael H.

2017-01-01

Introduction The emergency medical evaluation of psychiatric patients presenting to United States emergency departments (ED), usually termed “medical clearance,” often varies between EDs. A task force of the American Association for Emergency Psychiatry (AAEP), consisting of physicians from emergency medicine, physicians from psychiatry and a psychologist, was convened to form consensus recommendations for the medical evaluation of psychiatric patients presenting to U.S.EDs. Methods The task force reviewed existing literature on the topic of medical evaluation of psychiatric patients in the ED and then combined this with expert consensus. Consensus was achieved by group discussion as well as iterative revisions of the written document. The document was reviewed and approved by the AAEP Board of Directors. Results Eight recommendations were formulated. These recommendations cover various topics in emergency medical examination of psychiatric patients, including goals of medical screening in the ED, the identification of patients at low risk for co-existing medical disease, key elements in the ED evaluation of psychiatric patients including those with cognitive disorders, specific language replacing the term “medical clearance,” and the need for better science in this area. Conclusion The evidence indicates that a thorough history and physical examination, including vital signs and mental status examination, are the minimum necessary elements in the evaluation of psychiatric patients. With respect to laboratory testing, the picture is less clear and much more controversial. PMID:28611885

American Association for Emergency Psychiatry Task Force on Medical Clearance of Adult Psychiatric Patients. Part II: Controversies over Medical Assessment, and Consensus Recommendations.

PubMed

Wilson, Michael P; Nordstrom, Kimberly; Anderson, Eric L; Ng, Anthony T; Zun, Leslie S; Peltzer-Jones, Jennifer M; Allen, Michael H

2017-06-01

The emergency medical evaluation of psychiatric patients presenting to United States emergency departments (ED), usually termed "medical clearance," often varies between EDs. A task force of the American Association for Emergency Psychiatry (AAEP), consisting of physicians from emergency medicine, physicians from psychiatry and a psychologist, was convened to form consensus recommendations for the medical evaluation of psychiatric patients presenting to U.S.EDs. The task force reviewed existing literature on the topic of medical evaluation of psychiatric patients in the ED and then combined this with expert consensus. Consensus was achieved by group discussion as well as iterative revisions of the written document. The document was reviewed and approved by the AAEP Board of Directors. Eight recommendations were formulated. These recommendations cover various topics in emergency medical examination of psychiatric patients, including goals of medical screening in the ED, the identification of patients at low risk for co-existing medical disease, key elements in the ED evaluation of psychiatric patients including those with cognitive disorders, specific language replacing the term "medical clearance," and the need for better science in this area. The evidence indicates that a thorough history and physical examination, including vital signs and mental status examination, are the minimum necessary elements in the evaluation of psychiatric patients. With respect to laboratory testing, the picture is less clear and much more controversial.

Clinical and Economic Burden of Emergency Department Presentations for Neutropenia Following Outpatient Chemotherapy for Cancer in Victoria, Australia

PubMed Central

Craike, Melinda; Slavin, Monica

2012-01-01

Objective. To examine the clinical characteristics and financial charges associated with treating adult cancer patients receiving chemotherapy in outpatient clinics who presented to the emergency department (ED) with neutropenia. Design and Setting. A retrospective audit was conducted across two health services involving ED episodes and subsequent hospital admissions of patients who received chemotherapy through day oncology from January 1 to December 31, 2007 and presented to the ED with neutropenia. ED data were collected from the Victorian Emergency Minimum Dataset and charges were collected from Health Information Services. Descriptive and bivariate statistics were used to describe the patient and clinical characteristics and financial outcomes, and to explore associations between these factors. Results. In total, 200 neutropenic episodes in 159 outpatients were seen in the ED over the survey period. The mean patient age was 56.6 years (standard deviation, 13.2 years) and 47.2% were male. Overall, 70.0% of ED episodes were triaged as Australasian Triage Scale 2 (emergency). The median ED wait time was 10 minutes and the median ED length of stay was 6.8 hours. The median charge for each ED episode was $764.08 Australian dollars. The total combined ED and inpatient charge per episode was in the range of $144.27–$174,732.68, with a median charge of $5,640.87. Conclusions. This study provides important insights into the clinical and economic burden of neutropenia from both the ED and inpatient perspectives. Alternative treatment models, such as outpatient treatment, early discharge programs or prophylactic interventions to reduce the clinical and economic burden of neutropenia on our health system, must be explored. PMID:22707511

Should we fear "flu fear" itself? Effects of H1N1 influenza fear on ED use.

PubMed

McDonnell, William M; Nelson, Douglas S; Schunk, Jeff E

2012-02-01

Surges in patient volumes compromise emergency departments' (EDs') ability to deliver care, as shown by the recent H1N1 influenza (flu) epidemic. Media reports are important in informing the public about health threats, but the effects of media-induced anxiety on ED volumes are unclear. The aim of this study is to examine the effect of widespread public concern about flu on ED use. We reviewed ED data from an integrated health system operating 18 hospital EDs. We compared ED visits during three 1-week periods: (a) a period of heightened public concern regarding flu before the disease was present ("Fear Week"), (b) a subsequent period of active disease ("Flu Week"), and (c) a week before widespread concern ("Control Week"). Fear Week was identified from an analysis of statewide Google electronic searches for "swine flu" and from media announcements about flu. Flu Week was identified from statewide epidemiological data. Data were reviewed from 22 608 visits during the study periods. Fear Week (n = 7712) and Flu Week (n = 7687) were compared to Control Week (n = 7209). Fear Week showed a 7.0% increase in visits (95% confidence interval, 6-8). Pediatric visits increased by 19.7%, whereas adult visits increased by 1%. Flu Week showed an increase over Control Week of 6.6% (95% confidence interval, 6-7). Pediatric visits increased by 10.6%, whereas adult visits increased by 4.8%. At a time of heightened public concern regarding flu but little disease prevalence, EDs experienced substantial increases in patient volumes. These increases were significant and comparable to the increases experienced during the subsequent epidemic of actual disease. Copyright © 2012 Elsevier Inc. All rights reserved.

Knowledge, assessment, and management of adults with joint hypermobility syndrome/Ehlers-Danlos syndrome hypermobility type among Flemish physiotherapists.

PubMed

Rombaut, Lies; Deane, Janet; Simmonds, Jane; De Wandele, Inge; De Paepe, Anne; Malfait, Fransiska; Calders, Patrick

2015-03-01

Physiotherapy plays a fundamental role in managing adults with the joint hypermobility syndrome/Ehlers-Danlos syndrome hypermobility type (JHS/EDS-HT). However, it is a challenge for both the patient and the physiotherapist as the condition is poorly understood and treatment for JHS/EDS-HT is currently undefined. Insight into current practice is, therefore, necessary in order to establish baseline knowledge in this area and in the long term to improve the standard of patient care. Therefore, the purpose of this study was to evaluate current physiotherapists' knowledge of JHS/EDS-HT and to gain insight into current physiotherapy practice with emphasis on assessment, management, and treatment efficacy. Three hundred twenty-five Flemish physiotherapists participated in the study by filling out electronically a modified version of the "Hypermobility and Hypermobility Syndrome Questionnaire" (HHQ), which covered theoretical constructs such as general knowledge, assessment, management, and learning in relation to generalized joint hypermobility and JHS/EDS-HT. The results show that physiotherapists report a low level of confidence with regard to assessment and management of JHS/EDS-HT. Knowledge of hypermobility and JHS/EDS-HT is weak, especially regarding the features associated with JHS/EDS-HT. Many treatment approaches are used by physiotherapists with the majority showing preference for education, reassurance, muscle strengthening, proprioceptive and core stability training. Almost all approaches were perceived as being clinically effective by the physiotherapists, highlighting a lack of consensus. In conclusion, this study in Flemish physiotherapists confirms that JHS/EDS-HT is under-recognized, not well known and deemed difficult to treat. Further education is required and sought by the physiotherapists surveyed, and future research is needed. © 2015 Wiley Periodicals, Inc.

The Effects of Muscle Hypotonia and Weakness on Balance: A Study on Prader-Willi and Ehlers-Danlos Syndrome Patients

ERIC Educational Resources Information Center

Galli, Manuela; Cimolin, Veronica; Vismara, Luca; Grugni, Graziano; Camerota, Filippo; Celletti, Claudia; Albertini, Giorgio; Rigoldi, Chiara; Capodaglio, Paolo

2011-01-01

Prader-Willi syndrome (PWS) and Ehlers-Danlos syndrome (EDS) are two different genetical disorders both characterized, among other features, by muscular hypotonia. Postural control seems to be impaired in both conditions. The aim of the present study was to quantitatively compare postural control in adult PWS and EDS using stabilometric platform…

Low-acuity presentations to the emergency department in Canada: exploring the alternative attempts to avoid presentation.

PubMed

Krebs, Lynette D; Kirkland, Scott W; Chetram, Rajiv; Nikel, Taylor; Voaklander, Britt; Davidson, Alan; Holroyd, Bryn; Villa-Roel, Cristina; Crick, Katelynn; Couperthwaite, Stephanie; Alexiu, Chris; Cummings, Garnet; Rowe, Brian H

2017-04-01

ED visits have been rising year on year worldwide. It has been suggested that some of these visits could be avoided if low-acuity patients had better primary care access. This study explored patients' efforts to avoid ED presentation and alternative care sought prior to presentation. Consecutive adult patients presenting to three urban EDs in Edmonton, Canada, completed a questionnaire collecting demographics, actions attempted to avoid presentation and reasons for presentation. Survey data were cross-referenced to a minimal patient dataset containing ED and demographic information. A total of 1402 patients (66.5%) completed the survey. Although 89.3% of the patients felt that the ED was their best care option, the majority of patients (60.1%) sought alternative care or advice prior to presentation. Men, individuals who presented with injury only, and individuals with less than a high school education were all less likely to seek alternative care. Alternative care actions included visiting a physician (54.1%) or an alternative healthcare professional (eg, chiropractor, physiotherapist, etc; 21.2%), calling physician offices (47%) or the regional health information line (13%). Of those who called their physicians, the majority received advice to present to the ED (67.5%). Most low-acuity patients attempt to avoid ED presentation by seeking alternative care. This analysis identifies groups of individuals in the study region who are less likely to seek alternative care first and may benefit from targeted interventions/education. Other regions may wish to complete a similar profile to determine which patients are less likely to seek alternative care first. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Emergency Department Visits Following Elective Total Hip and Knee Replacement Surgery: Identifying Gaps in Continuity of Care.

PubMed

Finnegan, Micaela A; Shaffer, Robyn; Remington, Austin; Kwong, Jereen; Curtin, Catherine; Hernandez-Boussard, Tina

2017-06-21

Major joint replacement surgical procedures are common, elective procedures with a care episode that includes both inpatient readmissions and postoperative emergency department (ED) visits. Inpatient readmissions are well studied; however, to our knowledge, little is known about ED visits following these procedures. We sought to characterize 30-day ED visits following a major joint replacement surgical procedure. We used administrative records from California, Florida, and New York, from 2010 through 2012, to identify adults undergoing total knee and hip arthroplasty. Factors associated with increased risk of an ED visit were estimated using hierarchical regression models controlling for patient variables with a fixed hospital effect. The main outcome was an ED visit within 30 days of discharge. Among the 152,783 patients who underwent major joint replacement, 5,229 (3.42%) returned to the inpatient setting and 8,883 (5.81%) presented to the ED for care within 30 days. Among ED visits, 17.94% had a primary diagnosis of pain and 25.75% had both a primary and/or a secondary diagnosis of pain. Patients presenting to the ED for subsequent care had more comorbidities and were more frequently non-white with public insurance relative to those not returning to the ED (p < 0.001). There was a significantly increased risk (p < 0.05) of isolated ED visits with regard to type of insurance when patients with Medicaid (odds ratio [OR], 2.28 [95% confidence interval (CI), 2.04 to 2.55]) and those with Medicare (OR, 1.38 [95% CI, 1.29 to 1.47]) were compared with patients with private insurance and with regard to race when black patients (OR, 1.38 [95% CI, 1.25 to 1.53]) and Hispanic patients (OR, 1.12 [95% CI, 1.03 to 1.22]) were compared with white patients. These increases in risk were stronger for isolated ED visits for patients with a pain diagnosis. ED visits following an elective major joint replacement surgical procedure were numerous and most commonly for pain-related diagnoses. Medicaid patients had almost double the risk of an ED or pain-related ED visit following a surgical procedure. The future of U.S. health-care insurance coverage expansions are uncertain; however, there are ongoing attempts to improve quality across the continuum of care. It is therefore essential to ensure that all patients, particularly vulnerable populations, receive appropriate postoperative care, including pain management. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Establishing an NP-staffed minor emergency area.

PubMed

Buchanan, L; Powers, R D

1997-04-01

Patients with problems of high acuity need fully trained emergency physicians and nurses. Some patients with nonurgent problems can be cared for within the emergency department (ED) in a lower-cost setting designed and staffed specifically for this purpose. Staffing a fast track or minor emergency area (MEA) with nurse practitioners (NPs) is one way to satisfy the ED's care needs. One site analysis of the effectiveness of NPs indicates that patients are satisfied with their care, that nurses' interpersonal skills are better than those of physicians, that technical skills are equivalent, that patient outcomes are equivalent or superior and that NPs improve access to care. A nurse practitioner-staffed minor emergency area provides high quality care for approximately 21% of this site's adult emergency department population. Patients are triaged based on set criteria, allowing for short treatment times. The physical layout, triage criteria, and the NPs' scope of practice in the level 1 trauma center's ED are detailed.

Validity and reliability of the attention deficit hyperactivity disorder self-report scale (ASRS-v1.1) in a clinical sample with eating disorders.

PubMed

Carlucci, Samantha; Ivanova, Iryna; Bissada, Hany; Tasca, Giorgio A

2017-08-01

Individuals with eating disorders (EDs) commonly experience comorbid attention deficit hyperactivity disorder (ADHD). The shared features of EDs and ADHD, such as inattention, impulsivity and hyperactivity, may exacerbate ED symptomatology and pose challenges to treatment. It is important to screen patients with EDs for symptoms of ADHD to optimize their treatment outcomes. However, the psychometrics of common measures of ADHD have not yet been examined within an ED population. An example of such a measure is the ADHD self-report scale (ASRS-v1.1) symptom checklist, which identifies the presence of ADHD symptoms. This study reports a psychometric study of the ASRS-v1.1 in a clinical sample of 500 adults with an ED. A confirmatory factor analysis indicated the ASRS-v1.1 maintained its two-factor structure of inattention and impulsivity/hyperactivity. The item loadings demonstrated path invariance across ED diagnostic groups indicating construct validity. Further, the subscales exhibited good internal consistency and they were significantly correlated with other measures of impulsivity indicating convergent validity. The ED sample had significantly higher mean scores than published nonclinical norms indicating predictive validity, but the ASRS-v1.1 scores were not significantly different among ED diagnostic groups. Results suggest the ASRS-v1.1 is a valid and reliable screening tool for identifying symptoms of ADHD among adults seeking treatment for ED. Copyright © 2017 Elsevier Ltd. All rights reserved.

Emergency department characteristics and capabilities in Bogotá, Colombia.

PubMed

Bustos, Yury; Castro, Jenny; Wen, Leana S; Sullivan, Ashley F; Chen, Dinah K; Camargo, Carlos A

2015-12-01

Emergency departments (EDs) are a critical, yet heterogeneous, part of international emergency care. The National ED Inventories (NEDI) survey has been used in multiple countries as a standardized method to benchmark ED characteristics. We sought to describe the characteristics, resources, capabilities, and capacity of EDs in the densely populated capital city of Bogotá, Colombia. Bogotá EDs accessible to the general public 24/7 were surveyed using the 23-item NEDI survey used in several other countries ( www.emnet-nedi.org ). ED staff were asked about ED characteristics with reference to calendar year 2011. Seventy EDs participated (82 % response). Most EDs (87 %) were located in hospitals, and 83 % were independent hospital departments. The median annual ED visit volume was approximately 50,000 visits. Approximately 90 % (95 % confidence interval (CI) 80-96 %) had a contiguous layout, with medical and surgical care provided in one area. Almost all EDs saw both adults and children (91 %), while 6 % saw only adults and 3 % saw only children. Availability of technological and consultant resources in EDs was variable. Nearly every ED had cardiac monitoring (99 %, 95 % CI 92-100 %), but less than half had a dedicated CT scanner (39 %, 95 % CI 28-52 %). While most EDs were able to treat trauma 24/7 (81 %, 95 % CI 69-89 %), few could manage oncological (22 %, 95 % CI 13-34 %) or dental (3 %, 95 % CI 0-11 %) emergencies 24/7. The typical ED length-of-stay was between 1 and 6 h in 59 % of EDs (95 % CI, 46-70 %), while most others reported that patients remained for >6 h (39 %). Almost half of respondents (46 %, 95 % CI 34-59 %) reported their ED was over capacity. Bogotá EDs have high annual visit volumes and long length-of-stay, and half are over capacity. To meet the emergency care needs of people in Bogotá and other large cities, Colombia should consider improving urban ED capacity and training more emergency medicine specialists capable of efficiently staffing its large and crowded EDs.

Does diagnosis change as a result of repeat renal colic computed tomography scan in patients with a history of kidney stones?

PubMed

Goldstone, Adam; Bushnell, Andrew

2010-03-01

We sought to determine the incidence of alternative diagnosis in patients with a history of kidney stones who experience recurrent symptoms and undergo repeat computed tomography (CT) imaging at their return to the emergency department (ED). This was a retrospective chart review of ED patients at a tertiary care hospital. Inclusion criteria were all adult ED patients who received a repeat CT for renal colic, after having previously received the diagnosis of obstructive kidney stone confirmed by CT, in our ED. Patients were identified by reviewing the charts of those patients with repeat visits to the ED after January 1, 2004, in which they complained of symptoms suggestive of renal colic and received a CT scan. We determined the frequency of the same diagnosis on repeat CT scan in this population compared with the frequency of alternative diagnosis. Two hundred thirty-one patients met criteria for the study. Fifty-nine percent were male. One hundred eighty-nine (81.8%) patients had no change in diagnosis as a result of a repeat renal colic CT scan. Twenty-seven (11.6%) patients received an alternative diagnosis that did not require urgent intervention, and 15 (6.5%) patients received a diagnosis that did require an urgent intervention. Repeat CT imaging of patients with known nephrolithiasis changed management in a minority of patients (6.5%). Knowing the frequency of alternative diagnosis in this population may help clinicians and patients balance the risks and benefits of repeat renal colic CT scans in patients with a history of kidney stones who return to the ED with similar symptoms. 2010 Elsevier Inc. All rights reserved.

Study protocol for evaluating the implementation and effectiveness of an emergency department longitudinal patient monitoring system using a mixed-methods approach.

PubMed

Ward, Marie; McAuliffe, Eilish; Wakai, Abel; Geary, Una; Browne, John; Deasy, Conor; Schull, Michael; Boland, Fiona; McDaid, Fiona; Coughlan, Eoin; O'Sullivan, Ronan

2017-01-23

Early detection of patient deterioration is a key element of patient safety as it allows timely clinical intervention and potential rescue, thus reducing the risks of serious patient safety incidents. Longitudinal patient monitoring systems have been widely recommended for use to detect clinical deterioration. However, there is conflicting evidence on whether they improve patient outcomes. This may in part be related to variation in the rigour with which they are implemented and evaluated. This study aims to evaluate the implementation and effectiveness of a longitudinal patient monitoring system designed for adult patients in the unique environment of the Emergency Department (ED). A novel participatory action research (PAR) approach is taken where socio-technical systems (STS) theory and analysis informs the implementation through the improvement methodology of 'Plan Do Study Act' (PDSA) cycles. We hypothesise that conducting an STS analysis of the ED before beginning the PDSA cycles will provide for a much richer understanding of the current situation and possible challenges to implementing the ED-specific longitudinal patient monitoring system. This methodology will enable both a process and an outcome evaluation of implementing the ED-specific longitudinal patient monitoring system. Process evaluations can help distinguish between interventions that have inherent faults and those that are badly executed. Over 1.2 million patients attend EDs annually in Ireland; the successful implementation of an ED-specific longitudinal patient monitoring system has the potential to affect the care of a significant number of such patients. To the best of our knowledge, this is the first study combining PAR, STS and multiple PDSA cycles to evaluate the implementation of an ED-specific longitudinal patient monitoring system and to determine (through process and outcome evaluation) whether this system can significantly improve patient outcomes by early detection and appropriate intervention for patients at risk of clinical deterioration.

Gait pattern in two rare genetic conditions characterized by muscular hypotonia: Ehlers-Danlos and Prader-Willi syndrome.

PubMed

Cimolin, Veronica; Galli, Manuela; Vismara, Luca; Grugni, Graziano; Camerota, Filippo; Celletti, Claudia; Albertini, Giorgio; Rigoldi, Chiara; Capodaglio, Paolo

2011-01-01

This study aimed to quantify and compare the gait pattern in Ehlers-Danlos (EDS) and Prader-Willi syndrome (PWS) patients to provide data for developing evidence-based rehabilitation strategies. Twenty EDS and 19 PWS adult patients were evaluated with an optoelectronic system and force platforms for measuring kinematic and kinetic parameters during walking. The results were compared with those obtained in a group of 20 normal-weight controls (CG). The results showed that PWS patients walked with longer stance duration and reduced velocity than EDS, close to CG. Both EDS and PWS showed reduced anterior step length than CG. EDS kinematics evidenced a physiological position at proximal joints (pelvis and hip joint) while some deficits were displayed at knee (reduced flexion in swing phase) and ankle level (plantar flexed position in stance and reduced dorsal flexion in swing). PWS showed a forward tilted pelvis in the sagittal plane, excessive hip flexion during the whole gait cycle and an increased hip movement in the frontal plane. Their knees were flexed at initial contact with reduced range of motion while ankle joints showed a plantar flexed position during stance. No differences were found in terms of ankle kinetics and joint stiffness. Our data showed that EDS and PWS patients were characterized by a different gait strategy: PWS showed functional limitations at every level of the lower limb joints, whereas in EDS limitations, greater than PWS, were reported mainly at the distal joints. PWS patients should be encouraged to walk for its positive impact on muscle mass and strength and energy balance. For EDS patients the rehabilitation program should be focused on ankle strategy improvement. Copyright © 2011 Elsevier Ltd. All rights reserved.

Impact on patients triage distribution utilizing the Australasian Triage Scale compared with its predecessor the National Triage Scale.

PubMed

Yousif, Khalid; Bebbington, Jane; Foley, Bernard

2005-01-01

To assess the impact of the change from the National Triage Scale (NTS) to the Australasian Triage Scale (ATS) within a hospital ED. A retrospective audit of consecutive adult patients attending the ED of Auckland Hospital from July to September 2001, during which patients were triaged according to the NTS, were compared with patients triaged according to the ATS during July to September 2002. In total, 8715 patients attended the department during July to September 2001 compared with 9047 patients during July to September 2002. There was a significant shift in the triage ratios with patient number increases of 28 and 24% in triage categories two and three, respectively, and decreases of 15 and 67% in categories four and five, respectively. The revision of the ATS has had a significant impact on the triage distribution of patients who present to ED. The change of distribution might have implications for meeting performance criteria and assessing casemix.

Pain management in the emergency department and its relationship to patient satisfaction.

PubMed

Downey, La Vonne A; Zun, Leslie S

2010-10-01

Pain is the most common reason due to which patients come to the emergency department (ED). The purpose of this study was to measure the correlation, if any, between pain reduction and the level of satisfaction in patients who presented to the ED with pain as their chief complaint. This study used a randomly selected group of patients who presented to the ED with pain of 4 or more on the Visual Analogue Pain Scale (VAS) as their chief complaint to a level one adult and pediatric trauma center. Instruments that were used in this study were the VAS, Brief Pain Inventory (BPI), and the Medical Interview Satisfaction Scale (MISS). They were administered to patients by research fellows in the treatment rooms. Statistical analysis included frequencies, descriptive, and linear regression. This study was approved by the Internal Review Board. A total of 159 patients were enrolled in the study. All patients were given some type of treatment for their pain upon arrival to the ED. A logistic regression showed a significant relationship to reduction in pain by 40% or more and customer service questions. A reduction in perceived pain levels does directly relate to several indicators of customer service. Patients who experienced pain relief during their stay in the ED had significant increases in distress relief, rapport with their doctor, and intent to comply with given instructions.

The epidemiology of adults with severe sepsis and septic shock in Scottish emergency departments.

PubMed

Gray, Alasdair; Ward, Kirsty; Lees, Fiona; Dewar, Colin; Dickie, Sarah; McGuffie, Crawford

2013-05-01

The Surviving Sepsis Campaign (SSC) promotes a bundle approach to the care of septic patients to improve outcome. Some have questioned the capability of delivering the bundle in emergency departments (EDs). The authors report the epidemiology and 6 h bundle compliance of patients with severe sepsis/septic shock presenting to Scottish EDs. Analysis of the previously reported Scottish Trauma Audit Group sepsis database was performed including 20 mainland Scottish EDs. A total of 308,910 attendances were screened (between 2 March and 31 May 2009), and 5285 of 27,046 patients were identified after case note review and included on the database. This analysis includes patients who had severe sepsis/septic shock before leaving the ED. Epidemiological, severity of illness criteria, and ED management data were analysed. 626 patients (median age 73; M/F ratio 1:1; 637 presentations) met entrance criteria. The median number of cases per site was 16 (range 3-103). 561 (88.1%) patients arrived by ambulance. The most common source of infection was the respiratory tract (n=411, 64.5%) The most common physiological derangements were heart rate (n=523, 82.1%), respiratory rate (n=452, 71%) and white cell count (n=432, 67.8%). The median hospital stay was 9 days (IQR 4-17 days). 201 (31.6%) patients were admitted to critical care within 2 days, 130 (20.4%) directly from the ED. 180 patients (28.3%) died. There was poor compliance with all aspect of the SSC resuscitation bundle. Sepsis presentations are of variable frequency but have typical epidemiology and clinical outcomes. SSC bundle resuscitation uptake is poor in Scottish EDs.

Creation of an intensive care unit and organizational changes in an adult emergency department: Impact on acute stroke management.

PubMed

Puy, Laurent; Lamy, Chantal; Canaple, Sandrine; Arnoux, Audrey; Laine, Nicolas; Iacob, Ella; Constans, Jean-Marc; Godefroy, Olivier

2017-05-01

Following the reorganization of a University Medical Center onto a single campus, an Intensive Care Unit was created within the adult Emergency Department (ED ICU). We assessed the effects of these organizational changes on acute stroke management and the intravenous administration of recombinant tissue plasminogen activator (IV rtPA), as characterized by the thrombolysis rate, door-to-needle time (DNT) and outcome at 3months. Between October 2013 and September 2015, we performed a retrospective, observational, single-center, comparative study of patients admitted for ischemic stroke and treated with IV rtPA during two 321-day periods (before and after the creation of the ED ICU). All patients with ischemic stroke were included. Multivariable logistic regression models were performed. The DNT was stratified according to a threshold of 60min. A favorable long-term outcome was defined as a modified Rankin score≤2 at 3months. A total of 1334 ischemic stroke patients were included. Among them, 101 patients received IV rtPA. The frequency of IV rtPA administration was 5.8% (39 out of 676) before the creation of the ED ICU, and 9.3% (62 out of 668) afterwards (odds ratio (OR) [95% confidence interval (CI)]: 1.67 [1.08-2.60]; p=0.02). Additionally, the DNT was shorter (OR [95%CI]: 4.30 [1.17-20.90]; p=0.04) and there was an improvement in the outcome (OR [95%CI]=1.30 [1.01-2.10]; p=0.045). Our results highlight the benefits of a separate ED ICU within conventional ED for acute stroke management, with a higher thrombolysis rate, reduced intrahospital delays and better safety. Copyright © 2017 Elsevier Inc. All rights reserved.

A comparison of ED and direct admission care of cancer patients with febrile neutropenia.

PubMed

Owolabi, Diwura K; Rowland, Richard; King, Lauren; Miller, Rick; Hegde, Gajanan G; Shang, Jennifer; Lister, John; Venkat, Arvind

2015-07-01

We compared the quality of care in admitted febrile neutropenic cancer patients presenting through the emergency department (ED) vs those directly admitted (DA) from the clinic or infusion center. We hypothesized that the quality of care would be comparable between these 2 pathways. We conducted a retrospective, observational cohort study of all adult cancer patients hospitalized with subjective or objective fever (≥100.4°F) and documented neutropenia (absolute neutrophil count ≤1000/mm(3)) from January 1, 2011 to June 30, 2013, at 2 hospitals. Two investigators retrieved data including patient age, sex, race, tumor type, blood culture growth, temperature (actual or reported), pathway to admission (ED or DA), time to antibiotic administration, length of stay, and the Multinational Association for Supportive Care in Cancer (MASCC) risk score. The primary outcome measures were time to antibiotic administration, appropriateness of antibiotic(s) administered based on published guidelines, length of stay, and MASCC score-based risk assessment. We used the t test for the difference between 2 means with unequal population variances to compare these outcome measures between ED and DA patients. One hundred twenty-seven visits met inclusion criteria (42 [33%] ED visits, 85 [67%] DA visits). Mean time to antibiotic administration, mean length of stay, appropriateness of antibiotics, and MASCC score-based risk assessment were comparable between ED and DA visits (P>.05 for all comparisons). The quality of care for febrile neutropenia in patients presenting through the ED was comparable to those directly admitted to the hospital in this 2-center study. Copyright © 2015 Elsevier Inc. All rights reserved.

Feasibility of a computer-delivered driver safety behavior screening and intervention program initiated during an emergency department visit.

PubMed

Murphy, Mary; Smith, Lucia; Palma, Anton; Lounsbury, David; Bijur, Polly; Chambers, Paul; Gallagher, E John

2013-01-01

Injuries from motor vehicle crashes are a significant public health problem. The emergency department (ED) provides a setting that may be used to screen for behaviors that increase risk for motor vehicle crashes and provide brief interventions to people who might otherwise not have access to screening and intervention. The purpose of the present study was to (1) assess the feasibility of using a computer-assisted screening program to educate ED patients about risky driving behaviors, (2) evaluate patient acceptance of the computer-based traffic safety educational intervention during an ED visit, and (3) assess postintervention changes in risky driving behaviors. Pre/posteducational intervention involving medically stable adult ED patients in a large urban academic ED serving over 100,000 patients annually. Patients completed a self-administered, computer-based program that queried patients on risky driving behaviors (texting, talking, and other forms of distracted driving) and alcohol use. The computer provided patients with educational information on the dangers of these behaviors and data were collected on patient satisfaction with the program. Staff called patients 1 month post-ED visit for a repeat query. One hundred forty-nine patients participated, and 111 completed 1-month follow up (75%); the mean age was 39 (range: 21-70), 59 percent were Hispanic, and 52 percent were male. Ninety-seven percent of patients reported that the program was easy to use and that they were comfortable receiving this education via computer during their ED visit. All driving behaviors significantly decreased in comparison to baseline with the following reductions reported: talking on the phone, 30 percent; aggressive driving, 30 percent; texting while driving, 19 percent; drowsy driving, 16 percent; driving while multitasking, 12 percent; and drinking and driving, 9 percent. Overall, patients were very satisfied receiving educational information about these behaviors via computer during their ED visits and found the program easy to use. We found a high prevalence of self-reported risky driving behaviors in our ED population. At 1-month follow-up, patients reported a significant decrease in these behaviors. This study indicates that a low-intensity, computer-based educational intervention during an ED visit may be a useful approach to educate patients about safe driving behaviors and safe drinking limits and help promote behavior change.

Toxic nodular goiter

MedlinePlus

... Groot LJ, de Kretser DM, et al, eds. Endocrinology: Adult and Pediatric . 7th ed. Philadelphia, PA: Elsevier ... Groot LJ, de Kretser DM, et al, eds. Endocrinology: Adult and Pediatric . 7th ed. Philadelphia, PA: Elsevier ...

Involvement of oxidative and nitrosative stress in promoting retinal vasculitis in patients with Eales' disease.

PubMed

Rajesh, Mohanraj; Sulochana, Konerirajapuram N; Punitham, Ranganathan; Biswas, Jyotirmay; Lakshmi, Soundarajan; Ramakrishnan, Sivaramakrishnan

2003-07-01

Eales' disease (ED) is an idiopathic retinal vasculitis condition, which affects retina of young adult males. The histopathological hallmark in ED is the adhesion of leukocytes to the endothelium and the infiltration of these cells into the retinal parenchyma. Phagocyte generated free radicals have been implicated in mediating tissue damage associated with various inflammatory vasculopathies. In the present study, we have investigated the possible role of reactive oxygen species (ROS) and reactive nitrogen species (RNS) in causing retinal tissue damage in ED. 35 patients with ED and 20 healthy control subjects were included in the study. Monocytes (MC) were separated from peripheral blood of the respective study participants. Inducible nitric oxide synthase (iNOS) protein expression was assessed using Western blot and 3 nitrotyrosine (3NTYR) by reversed phase high performance liquid chromatography (RP HPLC). Thiobarbituric acid reactive substances (TBARS) were determined by measuring malondialdehyde (MDA) formed. Superoxide dismutase (SOD) activity was assayed based on the ability of SOD to inhibit auto-oxidation of epinephrine. Iron, copper and zinc content were determined using Atomic Absorption Spectrophotometer. Immunolocalization of iNOS and 3NTYR was performed on the surgically excised epiretinal membranes (ERM) from patients with ED. There was a significant increase in the expression of iNOS, as well as 3NTYR accumulation, diminished SOD activity, elevated lipid peroxides, iron, copper and decreased zinc content in the MC of patients with ED when compared with healthy control subjects. The elevated levels of ROS and RNS products correlated with diminished antioxidant status in patients with ED. Strong immunoreactivity for iNOS and 3NTYR was observed in inflammatory cells and endothelial cells in ERM obtained from patients with ED. Our findings from this study clearly reveal the involvement of RNS and ROS in the development of retinal vasculitis in ED. Based on our present study and earlier studies we confirm the role of free radicals in mediating retinal tissue damage in ED. Hence we believe selective inhibition of iNOS or supplementation with antioxidants vitamin E and C might be beneficial in controlling retinal vasculitis in patients with ED.

Diet - full liquid

MedlinePlus

... and Fordtran's Gastrointestinal and Liver Disease: Pathophysiology/Diagnosis/Management . 10th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap 6. Read More Diarrhea - overview Food poisoning Intestinal obstruction Nausea and vomiting - adults Patient ...

Disparities in Treatment of Older Adults with Suicide Risk in the Emergency Department.

PubMed

Arias, Sarah A; Boudreaux, Edwin D; Segal, Daniel L; Miller, Ivan; Camargo, Carlos A; Betz, Marian E

2017-10-01

We described characteristics and treatment received for older (≥60 years) vs younger (<60 years) adult emergency department (ED) patients with suicide risk. Retrospective chart review. An ED with universal screening for suicide risk. Eligible charts included a random sample of adults (≥18 years) who screened positive for suicidal ideation (SI) in past 2 weeks and/or a suicide attempt (SA) within the past 6 months. Visit dates were from May 2014 to September 2016. A total of 800 charts were reviewed, with oversampling of older adults. Of the 200 older adults sampled, fewer older adults compared to younger adults (n = 600) had a chief complaint involving psychiatric behavior (53% vs 70%) or self-harm behavior (26% vs 36%). Although a higher number of older adults (93%) had documentation of current SI compared to younger adults (79%), fewer older adults (17%) reported SA in the past 2 weeks compared to younger adults (23%). Of those with a positive suicide screen who were discharged home, less than half of older adults received a mental health evaluation during their visit (42%, 95% CI 34-52) compared to 66% (95% CI 61-70) of younger adults who met the same criteria. Similarly, fewer older, than younger, adult patients with current SI/SA received referral resources (34%; 95% CI 26-43; vs 60%; 95% CI 55-65). Significantly fewer suicidal older adult patients who were discharged home received a mental health evaluation when compared to similar younger adults. These findings highlight an important area for improvement in the treatment of older adults at risk for suicide. © 2017, Copyright the Authors Journal compilation © 2017, The American Geriatrics Society.

Injuries associated with the use of riding mowers in the United States, 2002-2007.

PubMed

Hammig, Bart; Childers, Elizabeth; Jones, Ches

2009-10-01

To examine injuries among patients treated in an emergency department (ED) related to the use of a riding lawn mower. Data were obtained from the National Electronic Injury Surveillance System for the years 2002-2007. National estimates of ED visits for injuries associated with the use of a riding lawn mower were analyzed. Narrative text entries were categorized to provide a detailed record of the circumstances precipitating the injury. Average annual rates were calculated and logistic regression analyses were employed to determine risk estimates for patient disposition and demographic characteristics related to ED visits for injuries associated with riding mowers. From 2002 through 2007, there were an estimated 66,341 ED visits for injuries related to the use of riding lawnmowers in the U.S., with an average annual rate of 6.0 ED visits per 100,000 males, and 1.6 ED visits per 100,000 females. Older adults had higher rates of ED visits for injuries (7.2/100,000) than younger age groups. The most common injuries involved contusions (24%); sprains/strains (22%) and fractures (17%). The majority of patients (90%) were treated and released the same day. Results of logistic regression analyses revealed that older adults were more likely to be hospitalized when compared to younger age groups; and incidents involving rollovers [OR=5.45 (95% CI=3.22-9.23)] and being run over [6.01 (95% CI 3.23-11.17)] were more likely to result in hospitalization when compared to all other circumstances of injury. Riding mowers present injury patterns and circumstances that are different than those reported for push mowers. Circumstances related to injuries and age groups affected were varied, making prevention of riding mower injuries challenging. APPLICATION/IMPACT: Findings support the need to increase awareness and/or change the design of riding mowers with respect to risk of rollover injuries.

Home blood sugar testing

MedlinePlus

... Groot LJ, de Kretser DM, et al, eds. Endocrinology: Adult and Pediatric . 7th ed. Philadelphia, PA: Elsevier ... Groot LJ, de Kretser DM, et al, eds. Endocrinology: Adult and Pediatric . 7th ed. Philadelphia, PA: Elsevier ...

Delayed puberty in boys

MedlinePlus

... Groot LJ, de Kretser DM, et al, eds. Endocrinology: Adult and Pediatric. 7th ed. Philadelphia, PA: Elsevier ... Groot LJ, de Kretser DM, et al. eds. Endocrinology: Adult and Pediatric . 7th ed. Philadelphia, PA: Elsevier ...

Management of Food-Related Diarrhea Outbreak in the Emergency Department: Lessons Learned from the German STEC O104:H4 Epidemic.

PubMed

Sayk, Friedhelm; Asselborn, Niels Henrik; Eisemann, Nora; Katalinic, Alexander; Metzner, Jörg; Wolfrum, Sebastian; Fellermann, Klaus; Knobloch, Johannes; Nitschke, Martin

2015-01-01

Emergency department (ED) management of the German STEC O104:H4 outbreak in 2011 was not limited to patients being truly infected with STEC. In parallel to spread of alarming news in public media, patients suffering from diarrhea due to other reasons fearfully presented, equally. We retrospectively characterized these two cohorts for anamnestic, clinical, and laboratory findings at their first ED contact. From 15th of May to July 2011, 302 adult patients with diarrheal complaint presented at the EDs of two tertiary hospitals in Lubeck, northern Germany. Fecal testing for STEC was obtained in 245 (81%) patients: 105 were STEC-positive and 140 were STEC-negative. Anamnestic characteristics (defecation rate, visible bloody diarrhea, and lower abdominal pain), abdominal tenderness, and some laboratory findings were significantly different between both cohorts but not reliable to exclude STEC. In >90% of STEC-positive patients diarrheal symptoms had started in May, reflecting the retrospective nationwide peak of infections, whereas the majority of STEC-negative patients became symptomatic in June 2011. During the German STEC O104:H4 outbreak a definite distinction at initial ED contact between STEC-positive versus STEC-negative patients by clinical judgment alone was not reliable. Fecal testing in the ED, however, might survey the outbreak of foodborne infections with the utmost precision.

The Abbreviated Mental Test 4 for cognitive screening of older adults presenting to the Emergency Department.

PubMed

Dyer, Adam H; Briggs, Robert; Nabeel, Shamis; O'Neill, Desmond; Kennelly, Sean P

2017-12-01

A commonly cited reason for the infrequent detection of cognitive impairment in the Emergency Department (ED) is the lack of an appropriate screening tool. The Abbreviated Mental Test 4 (AMT4) is a brief instrument recommended for cognitive screening of older adults in the ED. However, its exact utility in the detection of altered mental status in the ED is yet to be fully determined. The present study evaluated the ability of the AMT4 to identify impaired mental status in the ED, defined as positive scores on either the Confusion Assessment Method-ICU for delirium, the standardized Mini Mental State Examination as a general cognitive screener or the Eight-item Interview to Differentiate Aging and Dementia for dementia. Of 196 adults at least 70 years of age (mean: 78.5±5.9), the AMT4 had a sensitivity of 0.53 (0.42-0.63) and a specificity of 0.96 (0.89-0.99) for impaired mental status in the ED. The AMT4 was positive in almost all patients (92%; 24/26) screening positive for delirium, but less than half (47.8%; 22/46) of those screening positive for probable dementia, and less than a quarter (22.2%; 6/27) of those screening positive for probable cognitive impairment. The present study found that the limited sensitivity of the AMT4 in identifying the majority of cognitively impaired persons restricts its use in isolation as a general cognitive screener in the ED.

Alcohol-related emergency department injury presentations in Queensland adolescents and young adults over a 13-year period.

PubMed

Hides, Leanne; Limbong, Jesani; Vallmuur, Kirsten; Barker, Ruth; Daglish, Mark; Young, Ross McD

2015-03-01

The rate of alcohol-related emergency department (ED) presentations in young people has increased dramatically in recent decades. Injuries are the most common type of youth alcohol-related ED presentation, yet little is known about these injuries in young people. This paper describes the characteristics of alcohol-related ED injury presentations in young people over a 13-year period and determines if they differ by gender and/or age group (adolescents: 12-17 years; young adults: 18-24 years). The Queensland Injury Surveillance Unit (QISU) database collects injury surveillance data at triage in participating EDs throughout Queensland, Australia. A total of 4667 cases of alcohol-related injuries in young people (aged 12-24 years) were identified in the QISU database between January 1999 and December 2011, using an injury surveillance code and nursing triage text-based search strategy. Overall, young people accounted for 38% of all QISU alcohol-related ED injury presentations in patients aged 12 years or over. The majority of young adults presented with injuries due to violence and falls, whereas adolescents presented due to self-harm or intoxication without other injury. Males presented with injuries due to violence, whereas females presented with alcohol-related self-harm and intoxication. There is a need for more effective ways of identifying the degree of alcohol involvement in injuries among young people presenting to EDs. © 2014 Australasian Professional Society on Alcohol and other Drugs.

Geographic clustering of emergency department presentations for atrial fibrillation and flutter in Alberta, Canada.

PubMed

Rosychuk, Rhonda J; Mariathas, Hensley H; Graham, Michelle M; Holroyd, Brian R; Rowe, Brian H

2015-08-01

Atrial fibrillation and flutter (AFF) are the most common arrhythmias seen in the outpatient setting, and they affect more than 300,000 adult Canadians. The aims of this study were to examine temporal and geographic trends in emergency department (ED) presentations made by adults (age ≥ 35 years) for AFF in Alberta, Canada, from 1999 to 2011. Statistical disease cluster detection techniques were used to identify geographic areas with higher numbers of individuals presenting with AFF and higher numbers of ED presentations for AFF than expected by chance alone. Geographic clusters of individuals with stroke or heart failure follow-up within 365 days of ED presentations for AFF were also identified. All ED presentations for AFF made by individuals aged ≥35 years were extracted from Alberta's Ambulatory Care Classification System. The Alberta Health Care Insurance Plan provided population counts and demographics for the patients presenting (age, sex, year, geographic unit). The Physician Claims File provided non-ED physician claims data after a patient's ED presentation. Statistical analyses included numerical and graphical summaries, directly standardized rates, and statistical disease cluster detection tests. During 12 years, there were 63,395 ED presentations for AFF made by 32,101 individuals. Standardized rates remained relatively stable over time, at about two per 1,000 for individuals presenting to the ED for AFF and about three per 1,000 for ED presentations for AFF. The northern and southeastern parts of the province were identified as clusters of individuals presenting for AFF, and ED presentations for AFF, and several of the areas demonstrated clusters in multiple years. Further, several of the geographic clusters were also identified as potential clusters for stroke or heart failure within 365 days after the ED presentations for AFF. This population-based study spanned 12 fiscal years and showed variations in the number of people presenting to EDs for AFF and the number of ED presentations for AFF over geography. The potential clusters identified may represent geographic areas with higher disease severity or a lower availability of non-ED health services. The clusters are not all likely to have occurred by chance, and further investigation and intervention could occur to reduce ED presentations for AFF. © 2015 by the Society for Academic Emergency Medicine.

An analysis of ED utilization by adults with intellectual disability.

PubMed

Venkat, Arvind; Pastin, Rene B; Hegde, Gajanan G; Shea, John M; Cook, Jeffrey T; Culig, Carl

2011-05-01

We sought to identify factors increasing the odds of ED utilization among intellectually disabled (ID) adults and differentiate their discharge diagnoses from the general adult ED population. This was a retrospective, observational open cohort study of all ID adults residing at an intermediate care facility and their ED visits to a tertiary center (January 1, 2007-July 30, 2008). We abstracted from the intermediate care facility database subjects' demographic, ID, health and adaptive status variables, and their requirement of ED care/hospitalization. We obtained from the hospital database the primary International Classification of Diseases 9 ED/hospital discharge diagnoses for the study and general adult population. Using multivariate logistic regression, we computed odds ratios (OR) for ED utilization/hospitalization in the cohort. Using the conditional large-sample binomial test, we differentiated the study and general populations' discharge diagnoses. A total of 433 subjects met the inclusion criteria. Gastrostomy/jejunostomy increased the odds of ED utilization (OR, 4.16; confidence interval [CI], 1.64-10.58). Partial help to feed (OR, 2.59; CI, 1.14-5.88), gastrostomy/jejunostomy (OR, 3.26; CI, 1.30-8.18), and increasing number of prescribed medications (OR, 1.08; CI, 1.03-1.14) increased the odds of hospitalization. Auditory impairment (OR, 0.45; CI, 0.23-0.88) decreased the odds of hospitalization. For ED discharge diagnoses, ID adults were more likely (P < .05) than the general population to have diagnoses among digestive disorders and ill-defined symptoms/signs. For hospital discharge diagnoses, ID adults were more likely (P < .05) to have diagnoses among infectious/parasitic, nervous system, and respiratory disorders. Among ID adults, feeding status increased the odds of ED utilization, feeding status, and increasing number of prescribed medications of that hospitalization. Intellectually disabled adults' discharge diagnoses differed significantly from the general adult ED population. Copyright © 2011 Elsevier Inc. All rights reserved.

Development of a guideline for treatment of deep and superficial venous thrombosis in the emergency department.

PubMed

Tosone, Nancy C; Costanzo, Cindy

2012-01-01

Patients with DVT, aged 45.64 years, often present to the ED, with an annual cost of $1.5-$3.2 billion per year. This paper describes the process used to implement an evidence-based guideline on deep venous thrombosis (DVT) for the emergency department (ED). Specific aims were to (a) conduct an organizational assessment of DVT treatment practices; (b) compare organizational results with evidence-based treatment guidelines; (c) develop recommendations for the treatment of DVT for ED discharge; and (d) conduct an interdisciplinary evaluation of the evidence-based guideline. A retrospective review of 149 records of adults in an urban Midwestern ED in 2010 was undertaken. Differences in provider practices were identified. A guideline was developed that included clinical management, social/financial concerns, patient education, anticoagulation monitoring, and outpatient follow-up. Implementation and evaluation were accomplished through electronic and paper communication, medical record monitoring, and patient call back. Evaluation also included simulation exercises with an interdisciplinary team.

Upper Airway Sequelae in Burn Patients Requiring Endotracheal Intubation or Tracheostomy

DTIC Science & Technology

1985-03-01

airways. In adult patients, our experi - It was remarkable that autopsy findings in 12 patients ence is that as long as the nasotracheal tube is not...tracheostomy. Acta Anaesthesiol TB et al., eds. Progress in Anaesthesiology : Proceedings of the Scand 1979; 23:57-68. Fourth World Congress of

Biomarkers from distinct biological pathways improve early risk stratification in medical emergency patients: the multinational, prospective, observational TRIAGE study.

PubMed

Schuetz, Philipp; Hausfater, Pierre; Amin, Devendra; Amin, Adina; Haubitz, Sebastian; Faessler, Lukas; Kutz, Alexander; Conca, Antoinette; Reutlinger, Barbara; Canavaggio, Pauline; Sauvin, Gabrielle; Bernard, Maguy; Huber, Andreas; Mueller, Beat

2015-10-29

Early risk stratification in the emergency department (ED) is vital to reduce time to effective treatment in high-risk patients and to improve patient flow. Yet, there is a lack of investigations evaluating the incremental usefulness of multiple biomarkers measured upon admission from distinct biological pathways for predicting fatal outcome and high initial treatment urgency in unselected ED patients in a multicenter and multinational setting. We included consecutive, adult, medical patients seeking ED care into this observational, cohort study in Switzerland, France and the USA. We recorded initial clinical parameters and batch-measured prognostic biomarkers of inflammation (pro-adrenomedullin [ProADM]), stress (copeptin) and infection (procalcitonin). During a 30-day follow-up, 331 of 7132 (4.6 %) participants reached the primary endpoint of death within 30 days. In logistic regression models adjusted for conventional risk factors available at ED admission, all three biomarkers strongly predicted the risk of death (AUC 0.83, 0.78 and 0.75), ICU admission (AUC 0.67, 0.69 and 0.62) and high initial triage priority (0.67, 0.66 and 0.58). For the prediction of death, ProADM significantly improved regression models including (a) clinical information available at ED admission (AUC increase from 0.79 to 0.84), (b) full clinical information at ED discharge (AUC increase from 0.85 to 0.88), and (c) triage information (AUC increase from 0.67 to 0.83) (p <0.01 for each comparison). Similarly, ProADM also improved clinical models for prediction of ICU admission and high initial treatment urgency. Results were robust in regard to predefined patient subgroups by center, main diagnosis, presenting symptoms, age and gender. Combination of clinical information with results of blood biomarkers measured upon ED admission allows early and more adequate risk stratification in individual unselected medical ED patients. A randomized trial is needed to answer the question whether biomarker-guided initial patient triage reduces time to initial treatment of high-risk patients in the ED and thereby improves patient flow and clinical outcomes. ClinicalTrials.gov NCT01768494 . Registered January 9, 2013.

Safety of an ED High-Dose Opioid Protocol for Sickle Cell Disease Pain.

PubMed

Tanabe, Paula; Martinovich, Zoran; Buckley, Barbara; Schmelzer, Annie; Paice, Judith A

2015-05-01

A nurse-initiated high dose, opioid protocol for vaso-occlusive crisis (VOC) was implemented. Total intravenous morphine sulfate equivalents (IVMSE) in mgs] and safety was evaluated. A medical record review was conducted for all ED visits in adult patients with VOC post protocol implementation. Opioids doses and routes administered during the ED stay, and six hours into the hospital admission were abstracted and total IVMSE administered calculated. Oxygen saturation (SPO2), respiratory rate (RR), administration of naloxone or vasoactive medications, evidence of respiratory arrest, or any other types of resuscitation effort were abstracted. A RR of <10 or SPO2 <92% were coded as abnormal. Descriptive statistics report the total dose. Logistic regression was used to predict abnormal events. Predictors were age, gender, ED dose (10 mg increments) administered, and time from 1st dose to discharge from ED. 72 patients, 603 visits, 276 admitted. The total (ED & hospital dose) mean (95% CI) mg IVMSE administered for all visits was 93 mg (CI 86, 100), ED visit 63 mg (CI 59, 67) and hospital 66 mg (CI 59, 72). The mean (SD) time from administration of 1st analgesic dose to discharge from the ED was 203 (143) minutes, (range = 30-1396 minutes). During two visits, patients experienced a RR <10; while 61 visits were associated with a SPO2 <92%. No medications were administered, or resuscitative measures required. Controlling for demographics and evaluated at the average total ED dose, the longer patients were in the ED, patients were 1.359 times more likely to experience an abnormal vital sign. Controlling for demographics and evaluated at the average total time in the ED, for every 10 mg increase in IVMSE, patients were 1.057 times more likely to experience an abnormal vital sign. The effect of ED dose on the odds of experiencing an abnormal vital sign decreased by a multiplicative factor of 0.0970 for every 1 hour increase in time until discharge. The larger the dose administered in less time, the more likely patients experienced an abnormal vital sign. High opioid doses were safely administered to patients with sickle cell disease. Copyright © 2015 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved.

Returns to Emergency Department, Observation, or Inpatient Care Within 30 Days After Hospitalization in 4 States, 2009 and 2010 Versus 2013 and 2014.

PubMed

Nuckols, Teryl K; Fingar, Kathryn R; Barrett, Marguerite L; Martsolf, Grant; Steiner, Claudia A; Stocks, Carol; Owens, Pamela L

2018-05-01

Nationally, readmissions have declined for acute myocardial infarction (AMI) and heart failure (HF) and risen slightly for pneumonia, but less is known about returns to the hospital for observation stays and emergency department (ED) visits. To describe trends in rates of 30-day, all-cause, unplanned returns to the hospital, including returns for observation stays and ED visits. By using Healthcare Cost and Utilization Project data, we compared 210,007 index hospitalizations in 2009 and 2010 with 212,833 matched hospitalizations in 2013 and 2014. Two hundred and one hospitals in Georgia, Nebraska, South Carolina, and Tennessee. Adults with private insurance, Medicaid, or no insurance and seniors with Medicare who were hospitalized for AMI, HF, and pneumonia. Thirty-day hospital return rates for inpatient, observation, and ED visits. Return rates remained stable among adults with private insurance (15.1% vs 15.3%; P = 0.45) and declined modestly among seniors with Medicare (25.3% vs 25.0%; P = 0.04). Increases in observation and ED visits coincided with declines in readmissions (8.9% vs 8.2% for private insurance and 18.3% vs 16.9% for Medicare, both P ≤ 0.001). Return rates rose among patients with Medicaid (31.0% vs 32.1%; P = 0.04) and the uninsured (18.8% vs 20.1%; P = 0.004). Readmissions remained stable (18.7% for Medicaid and 9.5% for uninsured patients, both P > 0.75) while observation and ED visits increased. Total returns to the hospital are stable or rising, likely because of growth in observation and ED visits. Hospitalists' efforts to improve the quality and value of hospital care should consider observation and ED care. © 2017 Society of Hospital Medicine

Emergency Department Placement and Management of Indwelling Urinary Catheters in Older Adults: Knowledge, Attitudes, and Practice

PubMed Central

Viswanathan, Kartik; Rosen, Tony; Mulcare, Mary R.; Clark, Sunday; Hayes, Jaime; Lachs, Mark S.; Flomenbaum, Neal

2015-01-01

BACKGROUND Indwelling Urinary Catheters (IUCs) are placed frequently in older adults in the emergency department (ED). While often a critical intervention, IUCs carry significant risks, particularly for geriatric patients, including infection, delirium, and falls. In addition, once placed, IUCs are rarely removed in the ED and may remain for an extended period after transfer of care, leading to poor outcomes. The purpose of this research was to examine the current knowledge, attitudes, and practice of ED nurses and other providers regarding IUC placement and management in older adults. METHODS We surveyed ED providers including nurses, attending physicians, Emergency Medicine (EM) residents, nurse practitioners (NPs), and physician assistants (PAs) at a large, urban, academic medical center. We developed comprehensive written questionnaires designed using items from previously validated instruments and questions created specifically for this study. In addition, we assessed providers' management of 25 unique clinical scenarios, each representing an established appropriate or inappropriate indication for IUC placement. RESULTS 127 ED providers participated: 43 nurses, 21 attending physicians, 47 residents, and 17 NP/PAs. 91% of nurses and 88% of other providers reported comfort with appropriate indications for IUC placement. Despite this, in the clinical vignettes nurses correctly identified the appropriate approach for IUC placement in only 40% of cases and other providers in only 37%. Reported practices were most divergent from accepted standards in delirium, with 3% of nurses and 1% of other providers appropriately avoiding IUC placement. Practice varied widely between individual providers, with the nurse participants reporting appropriate practice in 16%–64% of clinical scenarios and other providers in 8%–68%. Few nurses or other providers reported reassessing their patients for IUC removal at transfer to the hospital upstairs (28% of nurses and 7% of other providers), admission (24% and 14%), or shift change (14% and 8%). CONCLUSIONS Although ED nurses and other providers report comfort with appropriate indications for IUC placement, their reported practice patterns showed inconsistencies with established guidelines. Wide practice variation exists between individual providers. Moreover, nurses and other providers infrequently consider IUC removal after placement. Future research should focus on development of educational interventions and protocols to assist ED nurses and other providers with appropriate indications for and management of IUCs in older adults. PMID:25872970

Screening for violence risk factors identifies young adults at risk for return emergency department visit for injury.

PubMed

Hankin, Abigail; Wei, Stanley; Foreman, Juron; Houry, Debra

2014-08-01

Homicide is the second leading cause of death among youth aged 15-24. Prior cross-sectional studies, in non-healthcare settings, have reported exposure to community violence, peer behavior, and delinquency as risk factors for violent injury. However, longitudinal cohort studies have not been performed to evaluate the temporal or predictive relationship between these risk factors and emergency department (ED) visits for injuries among at-risk youth. The objective was to assess whether self-reported exposure to violence risk factors in young adults can be used to predict future ED visits for injuries over a 1-year period. This prospective cohort study was performed in the ED of a Southeastern US Level I trauma center. Eligible participants were patients aged 18-24, presenting for any chief complaint. We excluded patients if they were critically ill, incarcerated, or could not read English. Initial recruitment occurred over a 6-month period, by a research assistant in the ED for 3-5 days per week, with shifts scheduled such that they included weekends and weekdays, over the hours from 8AM-8PM. At the time of initial contact in the ED, patients were asked to complete a written questionnaire, consisting of previously validated instruments measuring the following risk factors: a) aggression, b) perceived likelihood of violence, c) recent violent behavior, d) peer behavior, e) community exposure to violence, and f) positive future outlook. At 12 months following the initial ED visit, the participants' medical records were reviewed to identify any subsequent ED visits for injury-related complaints. We analyzed data with chi-square and logistic regression analyses. Three hundred thirty-two patients were approached, of whom 300 patients consented. Participants' average age was 21.1 years, with 60.1% female, 86.0% African American. After controlling for participant gender, ethnicity, or injury complaint at time of first visit, return visits for injuries were significantly associated with: hostile/aggressive feelings (Odds ratio (OR) 3.5, 95% Confidence interval (CI): 1.3, 9.8), self-reported perceived likelihood of violence (OR 10.1, 95% CI: 2.5, 40.6), and peer group violence (OR 6.7, 95% CI: 2.0, 22.3). A brief survey of risk factors for violence is predictive of increased probability of a return visit to the ED for injury. These findings identify a potentially important tool for primary prevention of violent injuries among at-risk youth seen in the ED for trauma-related and non-traumatic complaints.

Palliative Care Needs of Seriously Ill, Older Adults Presenting to the Emergency Department

PubMed Central

Grudzen, Corita R.; Richardson, Lynne D.; Morrison, Matthew; Cho, Elizabeth; Morrison, R. Sean

2010-01-01

Objectives To identify the palliative care needs of seriously ill, older adults in the emergency department (ED) Methods The authors conducted a cross-sectional structured survey. A convenience sample of 50 functionally impaired adults 65 years or older with coexisting cancer, congestive heart failure, end-stage liver or renal disease, stroke, oxygen-dependent pulmonary disease, or dementia was recruited from an urban academic tertiary care ED. Face-to-face interviews were conducted using the Needs Near the End-of-Life Screening Tool (NEST), McGill Quality of Life Index (MQOL), and Edmonton Symptom Assessment Survey (ESAS) to assess 1) range and severity of symptoms, 2) goals of care, 3) psychological well-being, 4) health care utilization, 5) spirituality, 6) social connectedness, 7) financial burden, 8) the patient-clinician relationship, and 9) overall quality of life. Results Mean age was 74.3 (SD ± 6.5) years and cancer was the most common diagnosis. Mean quality of life on the MQOL was 3.6 (SD ± 2.9). Over half of the patients exceeded intra-test severity-of-needs cutoffs in four categories of the NEST: physical symptoms (47/50, 94%), finances (36/50, 72%), mental health (31/50, 62%), and access to care (29/50, 58%). The majority of patients reported moderate to severe fatigue, pain, dyspnea, and depression on the ESAS. Conclusions Seriously ill, older adults in an urban ED have substantial palliative care needs. Future work should focus on the role of emergency medicine and the new specialty of palliative care in addressing these needs. PMID:21175525

Using music to reduce anxiety among older adults in the emergency department: a randomized pilot study.

PubMed

Belland, Laura; Rivera-Reyes, Laura; Hwang, Ula

2017-11-01

An emergency department (ED) visit may be distressing and anxiety-provoking for older adults (age > 65 years). No studies have specifically evaluated the effect of music listening on anxiety in older adults in the ED. The objective of this pilot study was to evaluate the effect of music listening on anxiety levels in older ED patients. This was a randomized pilot study in the geriatric ED of an urban academic tertiary medical center. This was a sample of English-speaking adults (age > 65 years) who were not deaf (n = 35). Subjects consented to participate and were randomized to receive up to 60 min of music listening with routine care, while the control group received routine care with no music. Subjects in the music treatment group received headphones and an electronic tablet with pre-downloaded music, and were allowed to choose from 5 selections. The primary outcome was change in anxiety levels, measured by the state-trait anxiety inventory (STAI), at enrollment and 1 h later. A total of 35 participants were enrolled: 74% were female, 40% were white, and 40% were black; of these, 32 subjects completed the study protocol. When comparing control (n = 18) against intervention subjects (n = 17), there were no significant differences in enrollment STAI scores (43.00 ± 15.00 vs. 40.30 ± 12.80, P = 0.57). STAI scores 1 hour after enrollment (after the music intervention) were significantly reduced in the intervention subjects compared to the control subjects (with reduction of 10.00 ± 12.29 vs. 1.88 ± 7.97, P = 0.03). These pilot results suggest that music listening may be an effective tool for reducing anxiety among older adults in the ED.

Concussion diagnoses among adults presenting to three Canadian emergency departments: Missed opportunities.

PubMed

Rowe, Brian H; Eliyahu, Leeor; Lowes, Justin; Gaudet, Lindsay A; Beach, Jeremy; Mrazik, Martin; Cummings, Garnet; Voaklander, Donald

2018-03-20

Patients with concussion commonly present to the emergency department (ED) for assessment. Misdiagnosis of concussion has been documented in children and likely impacts treatment and discharge instructions. This study aimed to examine diagnosis of concussion in a general adult population. Patients >17years old presenting meeting the World Health Organization's definition of concussion were recruited in one academic (Hospital 1) and two community (Hospitals 2 and 3) EDs in a Canadian city. A physician questionnaire and patient interviews documented recommendations given by emergency physicians. Bi-variable comparisons are reported using chi-square tests, t-tests or Mann-Whitney tests, as appropriate. Multivariate analyses were performed using logistic regression methods. Overall, the study enrolled 250 patients. The median age was 35 (IQR: 23 to 49) and 52% were female. A variety of concussion causes were documented. Forty-one (16%) patients were not diagnosed with a concussion despite meeting criteria. Concussion diagnosis was less likely with a longer ED length of stay (OR=0.71; 95% CI: 0.60 to 0.83), presenting to the non-academic centers (Hospital 2: OR=0.21, 95% CI: 0.08 to 0.58; Hospital 3: OR=0.07, 95% CI: 0.02 to 0.24), or involvement in a motor vehicle collision (OR=0.11; 95% CI: 0.03 to 0.46). One in six patients with concussion signs and symptoms were misdiagnosed in the ED. Misdiagnosis was related to injury mechanism, length of stay, and enrolment site. Closer examination of institutional factors is needed to identify effective strategies to promote accurate diagnosis of concussion. Copyright © 2018 Elsevier Inc. All rights reserved.

Pain control methods in use and perceived effectiveness by patients with Ehlers-Danlos syndrome: a descriptive study.

PubMed

Arthur, Karen; Caldwell, Karen; Forehand, Samantha; Davis, Keith

2016-01-01

The purpose of this study was to assess the pain control methods in use by patients who have Ehlers-Danlos Syndrome (EDS), a group of connective tissue disorders, and their perceived effectiveness. This descriptive study involved 1179 adults diagnosed with EDS who completed an anonymous on-line survey. The survey consisted of demographics information, the Patient Reported Outcomes Measurement Information System (PROMIS) Pain-Behavior, PROMIS Pain-Interference, and Neuro QOL Satisfaction with Social Roles and Activities scales, as well as a modified version of the Pain Management Strategies Survey. Respondents reported having to seek out confirmation of their EDS diagnosis with multiple healthcare providers, which implies the difficulty many people with EDS face when trying to gain access to appropriate treatment. Patients with EDS experience higher levels of pain interference and lower satisfaction with social roles and activities compared to national norms. Among the treatment modalities in this study, those perceived as most helpful for acute pain control were opioids, surgical interventions, splints and braces, avoidance of potentially dangerous activities and heat therapy. Chronic pain treatments rated as most helpful were opioids, splints or braces and surgical interventions. For methods used for both acute and chronic pain, those perceived as most helpful were opioids, massage therapies, splints or braces, heat therapy and avoiding potentially dangerous activities. EDS is a complex, multi-systemic condition that can be difficult to diagnose and poses challenges for healthcare practitioners who engage with EDS patients in holistic care. Improved healthcare provider knowledge of EDS is needed, and additional research on the co-occurring diagnoses with EDS may assist in comprehensive pain management for EDS patients. Ehlers-Danlos Syndrome (EDS) is a group of connective tissue disorders associated with defective production of collagen, which can dramatically reduce musculoskeletal functioning by symptoms of joint laxity and frequent dislocations eventually leading to disability. Respondents to an on-line survey reported having to seek out confirmation of their EDS diagnosis with multiple physicians, which implies the difficulty many people with EDS face when trying to gain access to appropriate treatment. Participants with EDS reported the most helpful methods for managing acute pain were opioids, surgical interventions, splints and braces, heat therapy, nerve blocks and physical therapy, while chronic pain was treated most effectively with opioids, heat therapy, splints or braces and surgical interventions.

Patient activation and disparate health care outcomes in a racially diverse sample of chronically ill older adults.

PubMed

Ryvicker, Miriam; Peng, Timothy R; Feldman, Penny Hollander

2012-11-01

The Patient Activation Measure (PAM) assesses people's ability to self-manage their health. Variations in PAM score have been linked with health behaviors, outcomes, and potential disparities. This study assessed the relative impacts of activation, socio-demographic and clinical factors on health care outcomes in a racially diverse sample of chronically ill, elderly homecare patients. Using survey and administrative data from 249 predominantly non-White patients, logistic regression was conducted to examine the effects of activation level and patient characteristics on the likelihood of subsequent hospitalization and emergency department (ED) use. Activation was not a significant predictor of hospitalization or ED use in adjusted models. Non-Whites were more likely than Whites to have a hospitalization or ED visit. Obesity was a strong predictor of both outcomes. Further research should examine potential sources of disadvantage among chronically ill homecare patients to design effective interventions to reduce health disparities in this population.

Incidental findings of elevated random plasma glucose in the ED as a prompt for outpatient diabetes screening: a retrospective study

PubMed Central

Friedman, Steven Marc; Vallipuram, Janaki; Baswick, Brenda

2013-01-01

Objective To determine whether random plasma glucose (RPG) collected from patients without known impaired glucose metabolism (IGM) in the emergency department (ED) is a useful screen for diabetes or prediabetes. Design Retrospective cohort study. Setting ED of a Canadian teaching hospital over 1 month. Participants Adult patients in ED with RPG over 7 mmol/L were recruited for participation. Exclusion criteria included known diabetes, hospital admission and inability to consent. Participants were contacted by mail, encouraged to follow-up with their family physician (FP) for further testing and subsequently interviewed. Outcome measures The primary outcome measure was the proportion of patients in the ED with RPG over 7 mmol/L and no previous diagnosis of IGM who were diagnosed with diabetes or prediabetes after secondary testing by FP with oral glucose tolerance test or fasting plasma glucose (FPG). Secondary outcomes included patient characteristics (age, gender, body mass index and language) and (2) compliance with advice to seek an appropriate follow-up care. Results RPG was drawn on approximately one-third (33%, n=1149) of the 3470 patients in the ED in March 2010. RPG over 7 mmol/L was detected in 24% (n=278) of patients, and after first telephone follow-up, 32% (n=88/278) met the inclusion criteria and were advised to seek confirmatory testing. 41% (n=114/278) of patients were excluded for known diabetes. 73% of patients contacted (n=64/88) followed up with their FP. 12.5% (n=11/88) of patients had abnormal FPG, and of these 11% (n=10/88) were encouraged to initiate lifestyle modifications and 1% (n=1/88) was started on an oral hypoglycaemic agent. For 7% (n=6/88) of patients, FP's declined to do follow-up fasting blood work. Conclusions Elevated RPG in the ED is useful for identification of patients at risk for IGM and in need of further diabetic screening. Emergency physicians should advise patients with elevated RPG to consider screening for diabetes. For ED screening to be successful, patient education and collaboration with FPs are essential. PMID:24353254

Incidental findings of elevated random plasma glucose in the ED as a prompt for outpatient diabetes screening: a retrospective study.

PubMed

Friedman, Steven Marc; Vallipuram, Janaki; Baswick, Brenda

2013-12-18

To determine whether random plasma glucose (RPG) collected from patients without known impaired glucose metabolism (IGM) in the emergency department (ED) is a useful screen for diabetes or prediabetes. Retrospective cohort study. ED of a Canadian teaching hospital over 1 month. Adult patients in ED with RPG over 7 mmol/L were recruited for participation. Exclusion criteria included known diabetes, hospital admission and inability to consent. Participants were contacted by mail, encouraged to follow-up with their family physician (FP) for further testing and subsequently interviewed. The primary outcome measure was the proportion of patients in the ED with RPG over 7 mmol/L and no previous diagnosis of IGM who were diagnosed with diabetes or prediabetes after secondary testing by FP with oral glucose tolerance test or fasting plasma glucose (FPG). Secondary outcomes included patient characteristics (age, gender, body mass index and language) and (2) compliance with advice to seek an appropriate follow-up care. RPG was drawn on approximately one-third (33%, n=1149) of the 3470 patients in the ED in March 2010. RPG over 7 mmol/L was detected in 24% (n=278) of patients, and after first telephone follow-up, 32% (n=88/278) met the inclusion criteria and were advised to seek confirmatory testing. 41% (n=114/278) of patients were excluded for known diabetes. 73% of patients contacted (n=64/88) followed up with their FP. 12.5% (n=11/88) of patients had abnormal FPG, and of these 11% (n=10/88) were encouraged to initiate lifestyle modifications and 1% (n=1/88) was started on an oral hypoglycaemic agent. For 7% (n=6/88) of patients, FP's declined to do follow-up fasting blood work. Elevated RPG in the ED is useful for identification of patients at risk for IGM and in need of further diabetic screening. Emergency physicians should advise patients with elevated RPG to consider screening for diabetes. For ED screening to be successful, patient education and collaboration with FPs are essential.

US Emergency Department Visits for Outpatient Adverse Drug Events, 2013-2014.

PubMed

Shehab, Nadine; Lovegrove, Maribeth C; Geller, Andrew I; Rose, Kathleen O; Weidle, Nina J; Budnitz, Daniel S

2016-11-22

The Patient Protection and Affordable Care Act of 2010 brought attention to adverse drug events in national patient safety efforts. Updated, detailed, nationally representative data describing adverse drug events can help focus these efforts. To describe the characteristics of emergency department (ED) visits for adverse drug events in the United States in 2013-2014 and describe changes in ED visits for adverse drug events since 2005-2006. Active, nationally representative, public health surveillance in 58 EDs located in the United States and participating in the National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance project. Drugs implicated in ED visits. National weighted estimates of ED visits and subsequent hospitalizations for adverse drug events. Based on data from 42 585 cases, an estimated 4.0 (95% CI, 3.1-5.0) ED visits for adverse drug events occurred per 1000 individuals annually in 2013 and 2014 and 27.3% (95% CI, 22.2%-32.4%) of ED visits for adverse drug events resulted in hospitalization. An estimated 34.5% (95% CI, 30.3%-38.8%) of ED visits for adverse drug events occurred among adults aged 65 years or older in 2013-2014 compared with an estimated 25.6% (95% CI, 21.1%-30.0%) in 2005-2006; older adults experienced the highest hospitalization rates (43.6%; 95% CI, 36.6%-50.5%). Anticoagulants, antibiotics, and diabetes agents were implicated in an estimated 46.9% (95% CI, 44.2%-49.7%) of ED visits for adverse drug events, which included clinically significant adverse events, such as hemorrhage (anticoagulants), moderate to severe allergic reactions (antibiotics), and hypoglycemia with moderate to severe neurological effects (diabetes agents). Since 2005-2006, the proportions of ED visits for adverse drug events from anticoagulants and diabetes agents have increased, whereas the proportion from antibiotics has decreased. Among children aged 5 years or younger, antibiotics were the most common drug class implicated (56.4%; 95% CI, 51.8%-61.0%). Among children and adolescents aged 6 to 19 years, antibiotics also were the most common drug class implicated (31.8%; 95% CI, 28.7%-34.9%) in ED visits for adverse drug events, followed by antipsychotics (4.5%; 95% CI, 3.3%-5.6%). Among older adults (aged ≥65 years), 3 drug classes (anticoagulants, diabetes agents, and opioid analgesics) were implicated in an estimated 59.9% (95% CI, 56.8%-62.9%) of ED visits for adverse drug events; 4 anticoagulants (warfarin, rivaroxaban, dabigatran, and enoxaparin) and 5 diabetes agents (insulin and 4 oral agents) were among the 15 most common drugs implicated. Medications to always avoid in older adults according to Beers criteria were implicated in 1.8% (95% CI, 1.5%-2.1%) of ED visits for adverse drug events. The prevalence of emergency department visits for adverse drug events in the United States was estimated to be 4 per 1000 individuals in 2013 and 2014. The most common drug classes implicated were anticoagulants, antibiotics, diabetes agents, and opioid analgesics.

Randomized controlled pilot study of an educational video plus telecare for the early outpatient management of musculoskeletal pain among older emergency department patients.

PubMed

Platts-Mills, Timothy F; Hollowell, Allison G; Burke, Gary F; Zimmerman, Sheryl; Dayaa, Joseph A; Quigley, Benjamin R; Bush, Montika; Weinberger, Morris; Weaver, Mark A

2018-01-05

Musculoskeletal pain is a common reason for emergency department (ED) visits. Following discharge from the ED, patients, particularly older patients, often have difficulty controlling their pain and managing analgesic side effects. We conducted a pilot study of an educational video about pain management with and without follow-up telephone support for older adults presenting to the ED with musculoskeletal pain. ED patients aged 50 years and older with musculoskeletal pain were randomized to: (1) usual care, (2) a brief educational video only, or (3) a brief educational video plus a protocol-guided follow-up telephone call from a physician 48-72 hours after discharge (telecare). The primary outcome was the change from the average pain severity before the ED visit to the average pain severity during the past week assessed one month after the ED visit. Pain was assessed using a 0-10 numerical rating scale. Of 75 patients randomized (mean age 64 years), 57 (76%) completed follow up at one month. Of the 18 patients lost to follow up, 12 (67%) had non-working phone numbers. Among patients randomized to the video (arms 2 and 3), 46/50 viewed the entire video; among the 25 patients randomized to the video plus telecare (arm 3), 23 were reached for telecare. Baseline pain scores for the usual care, video, and video plus telecare groups were 7.3, 7.1, and 7.5. At one month, pain scores were 5.8, 4.9, and 4.5, corresponding to average decreases in pain of -1.5, -2.2, and -3.0, respectively. In the pairwise comparison between intervention groups, the video plus telecare group had a 1.7-point (95% CI 1.2, 2.1) greater decrease in pain compared to usual care, and the video group had a 1.1-point (95% CI 0.6, 1.6) greater decrease in pain compared to usual care after adjustment for baseline pain, age, and gender. At one month, clinically important differences were also observed between the video plus telecare and usual care groups for analgesic side effects, ongoing opioid use, and physical function. Results of this pilot trial suggest the potential value of an educational video plus telecare to improve outcomes for older adults presenting to the ED with musculoskeletal pain. Changes to the protocol are identified to increase retention for assessment of outcomes. ClinicalTrials.gov, NCT02438384 . Registered on 5 May 2015.

A randomized controlled trial of brief interventions to reduce drug use among adults in a low-income urban emergency department: the HealthiER You study.

PubMed

Blow, Frederic C; Walton, Maureen A; Bohnert, Amy S B; Ignacio, Rosalinda V; Chermack, Stephen; Cunningham, Rebecca M; Booth, Brenda M; Ilgen, Mark; Barry, Kristen L

2017-08-01

To examine efficacy of drug brief interventions (BIs) among adults presenting to a low-income urban emergency department (ED). Randomized controlled trial on drug use outcomes at 3, 6 and 12 months. Participants were assigned to (1) computer-delivered BI (Computer BI), (2) therapist-delivered, computer-guided BI (Therapist BI) or (3) enhanced usual care (EUC-ED) for drug-using adults. Participants were re-randomized after the 3-month assessment to either adapted motivational enhancement therapy (AMET) booster or enhanced usual care booster (EUC-B). Patients recruited from low-income urban emergency departments (ED) in Flint, Michigan, USA. A total of 780 ED patients reporting recent drug use, 44% males, mean age = 31 years. Computer BI consisted of an interactive program guided by a virtual health counselor. Therapist BI included computer guidance. The EUC-ED conditions included review of community health and HIV prevention resources. The BIs and boosters were based on motivational interviewing, focusing on reduction of drug use and HIV risk behaviors. Primary outcome was past 90 days using drugs at 6 and 12 months and secondary outcomes were weighted drug-days and days of marijuana use. Percentage changes in mean days used any drug from baseline to 12 months were: Computer BI + EUC-B: -10.9%, P = 0.0844; Therapist BI + EUC-B: -26.7%, P = 0.0041, for EUC-ED + EUC-B: -20.9, P = 0.0011. In adjusted analyses, there was no significant interaction between ED intervention and booster AMET for primary and secondary outcomes. Compared with EUC-ED, Therapist BI reduced number of days using any drug [95% confidence interval (CI) = -0.41, -0.07, P = 0.0422] and weighted drug-days (95% CI = -0.41, -0.08, P = 0.0283). Both Therapist and Computer BI had significantly fewer number of days using marijuana compared to EUC-ED (Therapist BI: 95% CI = -0.42, -0.06, P = 0.0104, Computer BI: 95% CI = -0.34, -0.01, P = 0.0406). Booster effects were not significant. An emergency department-based motivational brief intervention, delivered by a therapist and guided by computer, appears to reduce drug use among adults seeking emergency department care compared with enhanced usual care. Published 2017. This article is a U.S. Government work and is in the public domain in the USA.

Recall of discharge advice given to patients with minor head injury presenting to a Singapore emergency department.

PubMed

Heng, K W J; Tham, K Y; How, K Y; Foo, J S; Lau, Y H; Li, A Y K

2007-12-01

Most patients presenting to the emergency department (ED) with minor head injury (HI) can be discharged, provided a caregiver is present and careful discharge instructions are given. The study ED uses an advice leaflet with verbal reinforcement to patients and caregivers detailing post-discharge instructions and warning symptoms of worsening HI. We aim to evaluate local patients' and caregivers' compliance to discharge instructions and their ability to recall HI advice. A prospective study was conducted in an adult ED between April 10, 2006 and May 1, 2006. All patients with minor HI discharged from the ED or its 24-hour observation ward were included in the study. A telephone survey was conducted within 48 hours of discharge using a standardised questionnaire. During the study period, 292 patients had HI, of which 182 were eligible for the study. 71 were uncontactable and one refused to participate, leaving 110 patients in the study. Patients' age ranged between 7 and 109 years (median 41 years). 100 confirmed receiving HI advice (57 percent received by patients, 26 percent caregivers, 16 percent both patients and caregivers). 29 percent of respondents reported non-compliance to discharge advice. Mean HI-symptom recall score was 1.9 (SD 1.6) (total 9 symptoms). 30 percent cited other symptoms not part of the HI advice, which they believed necessitated a return to the ED. Recall scores were not statistically different, regardless of mode of instruction (verbal or printed) or the recipient (patient, caregiver or both). Our study raises concerns about the reliability of discharge advice for minor HI patients.

Risk factors for early return visits to the emergency department in patients with urinary tract infection.

PubMed

Jorgensen, Sarah; Zurayk, Mira; Yeung, Samantha; Terry, Jill; Dunn, Maureen; Nieberg, Paul; Wong-Beringer, Annie

2018-01-01

Optimal management of urinary tract infections (UTIs) in the emergency department (ED) is challenging due to high patient turnover, decreased continuity of care, and treatment decisions made in the absence of microbiologic data. We sought to identify risk factors for return visits in ED patients treated for UTI. A random sample of 350 adult ED patients with UTI by ICD 9/10 codes was selected for review. Relevant data was extracted from medical charts and compared between patients with and without ED return visits within 30days (ERVs). We identified 51 patients (15%) with 59 ERVs, of whom 6% returned within 72h. Nearly half of ERVs (47%) were UTI-related and 33% of ERV patients required hospitalization. ERVs were significantly more likely (P<0.05) in patients with the following: age≥65years; pregnancy; skilled nursing facility residence; dementia; psychiatric disorder; obstructive uropathy; healthcare exposure; temperature≥38 °C heart rate>100; and bacteremia. Escherichia coli was the most common uropathogen (70%) and susceptibility rates to most oral antibiotics were below 80% in both groups except nitrofurantoin (99% susceptible). Cephalexin was the most frequently prescribed antibiotic (51% vs. 44%; P=0.32). Cephalexin bug-drug mismatches were more common in ERV patients (41% vs. 15%; P=0.02). Culture follow-up occurred less frequently in ERV patients (75% vs. 100%; P<0.05). ERV in UTI patients may be minimized by using ED-source specific antibiogram data to guide empiric treatment decisions and by targeting at-risk patients for post-discharge follow-up. Copyright © 2017 Elsevier Inc. All rights reserved.

Clinical presentation and epidemiology of brain tumors firstly diagnosed in adults in the Emergency Department: a 10-year, single center retrospective study.

PubMed

Comelli, Ivan; Lippi, Giuseppe; Campana, Valentina; Servadei, Franco; Cervellin, Gianfranco

2017-07-01

Several patients with new onset brain tumors present to the Emergency Department (ED) complaining for new symptoms. Although information exists on symptom prevalence in the entire population of patients with brain tumors, little is known about the clinical presentation in ED. This retrospective study was planned to investigate clinical presentation and epidemiology of brain tumors firstly diagnosed in a large urban ED throughout a 10-year period. All medical records of patients aged ≥18 years, discharged from our ED with a diagnosis of brain tumor were retrieved from the electronic hospital database during a 10-year period (2006 to 2015). The records were reassessed for selecting only brain tumors firstly diagnosed in the ED. The symptoms at presentation were divided in six categories: (I) headache; (II) seizures; (III) focal signs; (IV) altered mental status; (V) nausea/vomiting/dizziness; (VI) trauma. For all cases, the hospital record was retrieved, to obtain histologic classification of tumors. Patients with inflammatory neoformations were excluded from the study. Overall, 205 patients with firstly diagnosed brain tumor were identified among 870,135 ED visits (i.e., <1%). Glial tumors were the most frequent (50% of the entire sample). No significant differences were found between mean age of patients in the different histologically based groups (meningiomas 66±14; glioblastomas 65±16 years; metastases 66±13 years; other miscellaneous 66±19 years). Focal signs accounted for more than 50% of all presentation signs/symptoms. First presentation of brain tumor in the ED is not a rare occurrence, so that the emergency physicians should be aware of this possibility.

A time-motion study of ambulance-to-emergency department radio communications.

PubMed

Penner, Mark S; Cone, David C; MacMillan, Don

2003-01-01

A prospective time-motion study of radio communication between inbound ambulances and emergency department (ED) triage personnel was conducted to assess hospital triage staff time utilized, and how often radio reports result in actions taken in the ED to prepare for patient arrival. The study hypothesis was that reports for "priority 2" (P2, nonemergent) patients rarely provide information that is acted upon in the ED prior to the patient's arrival. The study was conducted at an academic adult ED receiving 22,000 ambulances per year. An observer in the ED monitored and timed (to the second) all radio reports as well as the activities of triage nurses and arriving emergency medical services (EMS) personnel. A convenience sample of 437 reports was collected: 83 priority 1 (P1, emergent) and 354 P2. Average report times (minutes:seconds) with ranges were 0:53 (0:07-1:57) for P1, and 0:44 (0:04-3:50) for P2. Only 16% of the P2 reports resulted in any preparatory action, and 55% of these were requests to have hospital police officers available to receive intoxicated patients, as per local protocol. An in-person report was given in the ED for 61% of the P2 cases, and in 48% of these, the in-person report was longer than the radio report. In the system studied, P2 reports rarely provide information that is acted on prior to the patient's arrival. The time spent giving a radio report is frequently duplicated in the ED. Radio reports for low-priority patients may not be an efficient or productive use of providers' or nurses' time.

Assessing the Burden of Diabetes Mellitus in Emergency Departments in the United States: The National Hospital Ambulatory Medical Care Survey (NHAMCS)

PubMed Central

Asao, Keiko; Kaminski, James; McEwen, Laura N.; Wu, Xiejian; Lee, Joyce M.; Herman, William H.

2014-01-01

Objective To evaluate the performance of three alternative methods to identify diabetes in patients visiting Emergency Departments (EDs), and to describe the characteristics of patients with diabetes who are not identified when the alternative methods are used. Research Design and Methods We used data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) 2009 and 2010. We assessed the sensitivity and specificity of using providers’ diagnoses and diabetes medications (both excluding and including biguanides) to identify diabetes compared to using the checkbox for diabetes as the gold standard. We examined the characteristics of patients whose diabetes was missed using multivariate Poisson regression models. Results The checkbox identified 5,567 ED visits by adult patients with diabetes. Compared to the checkbox, the sensitivity was 12.5% for providers’ diagnoses alone, 20.5% for providers’ diagnoses and diabetes medications excluding biguanides, and 21.5% for providers’ diagnoses and diabetes medications including biguanides. The specificity of all three of the alternative methods was >99%. Older patients were more likely to have diabetes not identified. Patients with self-payment, those who had glucose measured or received IV fluids in the ED, and those with more diagnosis codes and medications, were more likely to have diabetes identified. Conclusions NHAMCS's providers’ diagnosis codes and medication lists do not identify the majority of patients with diabetes visiting EDs. The newly introduced checkbox is helpful in measuring ED resource utilization by patients with diabetes. PMID:24680472

Detecting child abuse based on parental characteristics: does the Hague Protocol cause parents to avoid the emergency department?

PubMed

Diderich, Hester M; Fekkes, Minne; Dechesne, Mark; Buitendijk, Simone E; Oudesluys-Murphy, Anne Marie

2015-04-01

The Hague Protocol is used by professionals at the adult Emergency Departments (ED) in The Netherlands to detect child abuse based on three parental characteristics: (1) domestic violence, (2) substance abuse or (3) suicide attempt or self-harm. After detection, a referral is made to the Reporting Center for Child Abuse and Neglect (RCCAN). This study investigates whether implementing this Protocol will lead parents to avoid medical care. We compared the number of patients (for whom the Protocol applied) who attended the ED prior to implementation with those attending after implementation. We conducted telephone interviews (n = 14) with parents whose children were referred to the RCCAN to investigate their experience with the procedure. We found no decline in the number of patients, included in the Protocol, visiting the ED during the 4 year implementation period (2008-2011). Most parents (n = 10 of the 14 interviewed) were positive and stated that they would, if necessary, re-attend the ED with the same complaints in the future. ED nurses and doctors referring children based on parental characteristics do not have to fear losing these families as patients. Copyright © 2014 Elsevier Ltd. All rights reserved.

Eating Disorder Examination Questionnaire (EDE-Q) and Clinical Impairment Assessment (CIA): clinical norms and functional impairment in male and female adults with eating disorders.

PubMed

Dahlgren, Camilla Lindvall; Stedal, Kristin; Rø, Øyvind

2017-05-01

The aim of the current study was to collect clinical normative data for the Clinical Impairment Assessment questionnaire (CIA) and the Eating Disorder Examination Questionnaire (EDE-Q) from adult patients with eating disorders (EDs). This study also examined unique contributions of eating disorder (ED) symptoms on levels of ED-related impairment. A sample of 667 patients, 620 females and 47 males, was recruited from six specialist centres across Norway. The majority of the sample (40.3%) was diagnosed with eating disorder not otherwise specified (EDNOS), 34.5% had bulimia nervosa (BN), and 25.2% were diagnosed with anorexia nervosa (AN). There were significant differences for global EDE-Q and CIA scores between females and males. In the female sample, significant differences were found on several EDE-Q sub-scales between the AN and BN group, and between the AN and EDNOS group. No significant differences were found between the diagnostic groups on the CIA. In the male sample, no significant differences were found between diagnostic groups on the EDE-Q or CIA. A multiple regression analysis revealed that 46.8% of the variance in impairment as measured by the CIA was accounted for by ED symptoms. Body mass index, Eating Concern, Shape/Weight Concern, and binge eating served as significant, unique predictors of impairment. The results from the present study contribute to the interpretation of EDE-Q and CIA scores in ED samples.

Emergency Department Use among Adults with Autism Spectrum Disorders (ASD)

PubMed Central

Vohra, Rini; Madhavan, Suresh; Sambamoorthi, Usha

2016-01-01

A cross-sectional analyses using Nationwide Emergency Department Sample (2006-2011) was conducted to examine the trends, type of ED visits, and mean total ED charges for adults aged 22-64 years with and without ASD (matched 1:3). Around 0.4% ED visits (n = 25,527) were associated with any ASD and rates of such visits more than doubled from 2006 to 2011 (2,549 to 6,087 per 100,000 admissions). Adults with ASD visited ED for: primary psychiatric disorder (15%ASD vs. 4.2%noASD), primary non-psychiatric disorder (16%ASD vs. 14%noASD), and any injury (24%ASD vs. 28%noASD). Mean total ED charges for adults with ASD were 2.3 times higher than adults without ASD. Findings emphasize the need to examine the extent of frequent ED use in this population. PMID:26762115

Point-of-Care Ultrasonography for Evaluation of Acute Dyspnea in the ED.

PubMed

Zanobetti, Maurizio; Scorpiniti, Margherita; Gigli, Chiara; Nazerian, Peiman; Vanni, Simone; Innocenti, Francesca; Stefanone, Valerio T; Savinelli, Caterina; Coppa, Alessandro; Bigiarini, Sofia; Caldi, Francesca; Tassinari, Irene; Conti, Alberto; Grifoni, Stefano; Pini, Riccardo

2017-06-01

Acute dyspnea is a common symptom in the ED. The standard approach to dyspnea often relies on radiologic and laboratory results, causing excessive delay before adequate therapy is started. Use of an integrated point-of-care ultrasonography (PoCUS) approach can shorten the time needed to formulate a diagnosis, while maintaining an acceptable safety profile. Consecutive adult patients presenting with dyspnea and admitted after ED evaluation were prospectively enrolled. The gold standard was the final diagnosis assessed by two expert reviewers. Two physicians independently evaluated the patient; a sonographer performed an ultrasound evaluation of the lung, heart, and inferior vena cava, while the treating physician requested traditional tests as needed. Time needed to formulate the ultrasound and the ED diagnoses was recorded and compared. Accuracy and concordance of the ultrasound and the ED diagnoses were calculated. A total of 2,683 patients were enrolled. The average time needed to formulate the ultrasound diagnosis was significantly lower than that required for ED diagnosis (24 ± 10 min vs 186 ± 72 min; P = .025). The ultrasound and the ED diagnoses showed good overall concordance (κ = 0.71). There were no statistically significant differences in the accuracy of PoCUS and the standard ED evaluation for the diagnosis of acute coronary syndrome, pneumonia, pleural effusion, pericardial effusion, pneumothorax, and dyspnea from other causes. PoCUS was significantly more sensitive for the diagnosis of heart failure, whereas a standard ED evaluation performed better in the diagnosis of COPD/asthma and pulmonary embolism. PoCUS represents a feasible and reliable diagnostic approach to the patient with dyspnea, allowing a reduction in time to diagnosis. This protocol could help to stratify patients who should undergo a more detailed evaluation. Copyright © 2017 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.

Effect of a nurse-led psychoeducational intervention on healthcare service utilization among adults with advanced cancer

PubMed Central

Martinez, Kathryn A.; Friese, Christopher; Kershaw, Trace; Given, Charles W.; Fendrick, A. Mark; Northouse, Laurel

2015-01-01

Purpose/Objectives To examine differences in healthcare service utilization among patients with advanced cancer participating in a nurse-led psychoeducational intervention. Design Secondary analysis of trial data. Setting Four Michigan cancer centers. Sample 484 patients with advanced cancer. Methods Patients were randomized to three groups: brief intervention, extensive intervention, or control. Medical chart review took place at baseline, three months, and six months to measure patients’ healthcare service utilization, defined as emergency department (ED) visits or inpatient hospitalizations. Multivariable logistic regression was used to examine the odds, by study arm, of visiting the ED and being hospitalized, controlling for patient sociodemographic and health status factors, as well as baseline health-related quality of life (QOL). Main Research Variables Study arm (brief, extensive, or control), ED visitation (one or more times versus none), inpatient hospitalizations (one or more times versus none), and covariates. Findings No significant differences in ED visits or inpatient hospitalizations were observed among study arms. ED visits were more frequent for patients with lung or colorectal cancer, more comorbidities, and lower baseline QOL. Baseline QOL was associated with inpatient hospitalizations in the adjusted analysis. Conclusions The psychoeducational intervention, either in brief or extensive format, is unlikely to increase healthcare service utilization. Implications for Nursing Efficacious nurse-led psychoeducational interventions to improve QOL do not place undue burdens on the healthcare system and may improve care. PMID:26148327

Role of brain natriuretic peptide (BNP) in risk stratification of adult syncope

PubMed Central

Reed, Matthew J; Newby, David E; Coull, Andrew J; Jacques, Keith G; Prescott, Robin J; Gray, Alasdair J

2007-01-01

Aims To assess the value of a near‐patient brain natriuretic peptide (BNP) test to predict medium term (3 month) serious outcome for adult syncope patients presenting to a UK emergency department (ED). Methods This was a prospective cohort pilot study. Consecutive patients aged ⩾16 years presenting with syncope over a 3 month period were eligible for prospective enrolment. All patients who were medium or high risk according to our ED's existing syncope guidelines underwent near‐patient BNP testing using the Triage point of care machine. Results 99 patients were recruited. 72 of 82 high and medium risk patients underwent BNP measurement. 11 patients had a serious outcome, 9 of whom had BNP measured. In 25 (35%) patients, BNP was ⩾100 pg/ml, and in 3 of these it was >1000 pg/ml. 6 of the 25 patients (24%) with a BNP >100 pg/ml, and all 3 patients with a BNP >1000 pg/ml, were in the serious outcome group. BNP was raised over 100 pg/ml in 6 of the 9 serious outcome patients having a BNP measured (66%), and over 1000 pg/ml in 3 (33%). Conclusions This early work suggests that BNP may have a role in the risk assessment of syncope patients in the ED. Further work is required to see how BNP interacts with other clinical variables. Near‐patient BNP testing may be shown to be an independent predictor of adverse outcome either alone or incorporated into existing syncope clinical decision rules and scores in order to improve their sensitivity and specificity. Further studies are required to evaluate this. PMID:17954830

Trends in the Incidence of Hypertensive Emergencies in US Emergency Departments From 2006 to 2013.

PubMed

Janke, Alexander T; McNaughton, Candace D; Brody, Aaron M; Welch, Robert D; Levy, Phillip D

2016-12-05

The incidence of hypertensive emergency in US emergency departments (ED) is not well established. This study is a descriptive epidemiological analysis of nationally representative ED visit-level data from the Nationwide Emergency Department Sample for 2006-2013. Nationwide Emergency Department Sample is a publicly available database maintained by the Healthcare Cost and Utilization Project. An ED visit was considered to be a hypertensive emergency if it met all the following criteria: diagnosis of acute hypertension, at least 1 diagnosis indicating acute target organ damage, and qualifying disposition (admission to the hospital, death, or transfer to another facility). The incidence of adult ED visits for acute hypertension increased monotonically in the period from 2006 through 2013, from 170 340 (1820 per million adult ED visits overall) to 496 894 (4610 per million). Hypertensive emergency was rare overall, accounting for 63 406 visits (677 per million adult ED visits overall) in 2006 to 176 769 visits (1670 per million) in 2013. Among adult ED visits that had any diagnosis of hypertension, hypertensive emergency accounted for 3309 per million in 2006 and 6178 per million in 2013. The estimated number of visits for hypertensive emergency and the rate per million adult ED visits has more than doubled from 2006 to 2013. However, hypertensive emergencies are rare overall, occurring in about 2 in 1000 adult ED visits overall, and 6 in 1000 adult ED visits carrying any diagnosis of hypertension in 2013. This figure is far lower than what has been sometimes cited in previous literature. © 2016 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.

Do palliative care interventions reduce emergency department visits among patients with cancer at the end of life? A systematic review.

PubMed

DiMartino, Lisa D; Weiner, Bryan J; Mayer, Deborah K; Jackson, George L; Biddle, Andrea K

2014-12-01

Frequent emergency department (ED) visits are an indicator of poor quality of cancer care. Coordination of care through the use of palliative care teams may limit aggressive care and improve outcomes for patients with cancer at the end of life. To systematically review the literature to determine whether palliative care interventions implemented in the hospital, home, or outpatient clinic are more effective than usual care in reducing ED visits among patients with cancer at the end of life. PubMed, EMBASE, and CINAHL databases were searched from database inception to May 7, 2014. Only randomized/non-randomized controlled trials (RCTs) and observational studies examining the effect of palliative care interventions on ED visits among adult patients with cancer with advanced disease were considered. Data were abstracted from the articles that met all the inclusion criteria. A second reviewer independently abstracted data from 2 articles and discrepancies were resolved. From 464 abstracts, 2 RCTs, 10 observational studies, and 1 non-RCT/quasi-experimental study were included. Overall there is limited evidence to support the use of palliative care interventions to reduce ED visits, although studies examining effect of hospice care and those conducted outside of the United States reported a statistically significant reduction in ED visits. Evidence regarding whether palliative care interventions implemented in the hospital, home or outpatient clinic are more effective than usual care at reducing ED visits is not strongly substantiated based on the literature reviewed. Improvements in the quality of reporting for studies examining the effect of palliative care interventions on ED use are needed.

Substance use patterns and in-hospital care of adolescents and young adults attending music concerts.

PubMed

Ruest, Stephanie M; Stephan, Alexander M; Masiakos, Peter T; Biddinger, Paul D; Camargo, Carlos A; Kharasch, Sigmund

2018-01-09

Few studies describe medical complaints and substance use patterns related to attending music concerts. As such, the objective of this study is to describe patient demographics, substance use and intoxication patterns, and medical interventions provided to adolescents and young adults assessed in an emergency department (ED) for complaints directly related to concert attendance. A retrospective chart review of patients 13-30 years old who were transported to the ED directly from music concerts between January 2011 and December 2015 was conducted. Descriptive statistics and logistic regression were used to analyze patient demographic, intervention, and substance use data. There were 115 concerts identified, of which 48 (42%) were linked to 142 relevant ED visits; the total number of attendees at each concert is unknown. The mean age of the 142 described patients was 19.5 years (SD 3.3) with 72% < 21 and 33% < 18; 71% of patients were female and 96% of visits were substance-use related. Mean blood alcohol level was 242 mg/dL (range 104-412, SD 70). Glasgow Coma Scale (GCS) scores ranged from 3 to 15, with a mean of 14. Two patients required intubation and 61% of patients received interventions, including medications (47%), intravenous fluids (46%), specialty consultation (20%), restraints (14%), imaging (6%), and laceration repair (3%). Attendance at pop and electronic dance music concerts was associated with the widest ranges of GCS scores (8-15 and 6-14 respectively), mass casualty incident declarations, and among the highest mean blood alcohol levels (246 and 244 mg/dL, respectively). Substance use is the predominant reason for music concert related ED visits and patients may have serious levels of intoxication, receiving multiple medical interventions. These data demonstrate the need for additional large-scale studies to confirm trends and increase awareness of this important public health problem.

ED presentations of acute renal infarction.

PubMed

Huang, Chien-Cheng; Lo, Hong-Chang; Huang, Hsien-Hao; Kao, Wei-Fong; Yen, David Hung-Tsang; Wang, Lee-Min; Huang, Chun-I; Lee, Chen-Hsen

2007-02-01

The objective of the study was to investigate initial clinical characteristics that can suggest an early diagnosis of patients with acute renal infarction presenting with flank and/or abdominal pain in the emergency department (ED). From January 1, 1996, through December 31, 2005, 20 adult patients with renal infarction diagnosed by contrast-enhanced computed tomography in the ED were enrolled. Medical records, including demographic data, risk factors for thromboembolism, initial clinical presentations, laboratory data, treatment programs and outcomes, were retrospectively reviewed and analyzed. Mean patient age was 60.3 years (range, 21-80). The estimated incidence of renal infarction was 0.004% (20 of 481,540) among the ED census. The median time of onset of symptoms before the ED visit was 31 hours (range, 1-285). Eighteen patients (90%) had a history of more than 1 risk factor for thromboembolic events. In clinical presentations, all the patients had either abdominal or flank pain and tenderness. Nineteen patients (95%) had an elevated serum lactate dehydrogenase level with a mean +/- SD of 812.1 +/- 569.4 U/L. Sixteen patients (80%) presented with the triad--persisting flank or abdominal pain/tenderness, elevated serum lactate dehydrogenase level, and proteinuria. Among all 20 patients, 10 patients (50%) were diagnosed as having renal infarction at the initial ED visit. No specific clinical characteristics could be identified to distinguish those patients diagnosed early and those with delayed diagnosis. All 20 patients received medical treatment with coumadin, which was given in combination with heparin treatment in 11, peripheral intravenous and/or local intra-arterial thrombolytics with urokinase in 5, and mitral valve replacement in 1. No patient died. Although 4 patients had a mildly elevated serum creatinine level (>1.5 mg/dL) during hospitalization, none of them needs dialysis after more than 1 year of follow-up. In this study, we delineated specifically clinical features for emergency physicians to raise their suspicion index for an early diagnosis of patients with renal infarction, a disease which is uncommon and is usually delayed or missed at initial ED presentation.

The Trail-making Test B and driver screening in the emergency department.

PubMed

Betz, Marian E; Fisher, Jonathan

2009-10-01

Emergency departments (EDs) rarely screen for older driving safety. The Trail-Making Test B (TMT-B) is a neuropsychological test that may predict ability to drive. We sought to examine the driving patterns of older ED patients and the feasibility of screening patients in the ED using the TMT-B. At a single ED at a tertiary care center, we administered the TMT-B and a survey of health status and driving habits to a convenience sample of adult (age 18 and older) ED patients. We excluded those with altered mentation, critical illness, or language barriers. The TMT-B, scored by the time of first attempt, requires connection of letters and numbers in sequence on paper, and a time > or = 180 s may suggest elevated driving risk. We compared time to complete the TMT-B among ED patients to published norms. Of 144 patients ages 18 to 95, 95 (72.2%) were current drivers, and 91.4 percent of drivers were able to complete the TMT-B; 47.1 percent of drivers were older (65+), and 88.8 percent of older drivers rated their ability as good or excellent. In multivariate logistic regression, neither TMT-B performance nor being older predicted a recent collision. The mean TMT-B completion time was 66.1 (SD = 36.3, median = 56) s among drivers under age 65 and 117.5 (SD = 79.2, median = 95) s among those 65 or older. Approximately 1.9 percent (95% CI: 0.04-10.2) of drivers under 65 and 14.0 percent (95% CI: 5.3-27.9%) of drivers 65 or older required 180 s or more for the TMT-B. Using unpaired T-tests, study TMT-B times were not significantly different from previously published norms except among 25- to 34-year-olds (79.2 versus 50.7 s; p < 0.05) and 80- to 84-year-olds (223.9 versus 146.8 s; p < 0.01). Many older ED patients drive, and relatively healthy ED patients are able to complete the TMT-B with results similar to standard nomograms. The TMT-B may prove useful as part of targeted driver screening programs in EDs.

Acute management and outcomes of patients with diabetes mellitus presenting to Canadian emergency departments with hypoglycemia.

PubMed

Rowe, Brian H; Singh, Mira; Villa-Roel, Cristina; Leiter, Lawrence A; Hramiak, Irene; Edmonds, Marcia L; Lang, Eddy; Sivilotti, Marco; Scheuermeyer, Frank; Worster, Andrew; Riley, Jennifer; Afilalo, Marc; Stiell, Ian; Yale, Jean-Francois; Woo, Vincent C; Campbell, Samuel

2015-02-01

This retrospective chart audit examined the demographics, investigations, management and outcomes of adult patients with diabetes mellitus presenting to Canadian emergency departments (EDs). All sites conducted a search of their electronic medical records using International Classification of Diseases, Tenth Revision, codes to identify ED visits for hypoglycemia between 2008 and 2010. Patient characteristics, demographics, ED management, ED resources and outcome are reported. A total of 1039 patients over the age of 17 years were included in the study; 347 (33.4%) were classified as type 1 diabetes and 692 (66.6%) were classified as type 2 diabetes. Type 2 diabetes patients were significantly older (73 vs. 49 years; p<0.0001) and had more chronic conditions recorded on their chart (all p<0.001). Most subjects arrived by ambulance, and triage scores revealed severe presentations in 39% of cases. Treatments for hypoglycemia were common (75.7%) during prehospital transport; 38.5% received intravenous glucose and 40.1% received glucagon. Hypoglycemia treatments in the ED included oral (76.8%), intravenous (29.6%) and continuous infusion (27.7%) of glucose. Diagnostic testing (81.9%) commonly included electrocardiograms (51.9%), chest radiography (37.5%) and head computed tomography scans (14.5%). Most patients (73.5%) were discharged; however, more subjects with type 2 diabetes required admission (30.3 vs. 8.8%). Discharge instructions were documented in only 55.5% of patients, and referral to diabetes services occurred in fewer than 20% of cases. Considerable variation existed in the management of hypoglycemia across EDs. Patients with diabetes presenting to an ED with hypoglycemia consume considerable healthcare resources, and practice variation exists. Emergency departments should develop protocols for the management of hypoglycemia, with attention to discharge planning to reduce recurrence. Copyright © 2015 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved.

Care of the elderly in emergency departments: conclusions and recommendations.

PubMed

Sanders, A B

1992-07-01

Little attention is being paid to the special needs of elderly persons in emergency departments. Emergency health care professionals feel less comfortable caring for elderly than for nonelderly patients. The social and personal concerns of the elderly frequently are not addressed in ED encounters. There is a paucity of research and education in geriatric emergency medicine. Overall principles of care for elderly patients seeking emergency care have not been defined as they have for other special populations such as children. The disease-oriented model used for caring for nonelderly adult patients in EDs may not be appropriate for elderly patients. The emergency care of the elderly requires significantly more health care resources than does that of the nonelderly. Compared with nonelderly patients, elderly patients seeking emergency care are four times more likely to use ambulance services, five times more likely to be admitted to the hospital, five times more likely to be admitted to an intensive care bed, and six times more likely to receive comprehensive emergency services. Although 12% of the population is 65 years or older, this group accounted for 36% of all ambulance patient transports to EDs, 43% of all hospital ED admissions, and 48% of all critical care admissions from EDs. These problems are particularly important at this time because many hospitals and their EDs are faced with significant problems of overcrowding and inadequate resources to meet the health care needs of the communities they serve. Although the elderly are the fastest-growing segment of the population, little or no planning is ongoing to meet the emergency health care needs of the elderly in the future. The task force has provided specific recommendations for addressing these problems.

Emergency Department Visits for Nontraumatic Dental Problems: A Mixed-Methods Study

PubMed Central

Chi, Donald L.; Schwarz, Eli; Milgrom, Peter; Yagapen, Annick; Malveau, Susan; Chen, Zunqui; Chan, Ben; Danner, Sankirtana; Owen, Erin; Morton, Vickie; Lowe, Robert A.

2015-01-01

Objectives. We documented emergency department (ED) visits for nontraumatic dental problems and identified strategies to reduce ED dental visits. Methods. We used mixed methods to analyze claims in 2010 from a purposive sample of 25 Oregon hospitals and Oregon’s All Payer All Claims data set and interviewed 51 ED dental visitors and stakeholders from 6 communities. Results. Dental visits accounted for 2.5% of ED visits and represented the second-most-common discharge diagnosis in adults aged 20 to 39 years, were associated with being uninsured (odds ratio [OR] = 5.2 [reference: commercial insurance]; 95% confidence interval [CI] = 4.8, 5.5) or having Medicaid insurance (OR = 4.0; 95% CI = 3.7, 4.2), resulted in opioid (56%) and antibiotic (56%) prescriptions, and generated $402 (95% CI = $396, $408) in hospital costs per visit. Interviews revealed health system, community, provider, and patient contributors to ED dental visits. Potential solutions provided by interviewees included Medicaid benefit expansion, care coordination, water fluoridation, and patient education. Conclusions. Emergency department dental visits are a significant and costly public health problem for vulnerable individuals. Future efforts should focus on implementing multilevel interventions to reduce ED dental visits. PMID:25790415

Increased Emergency Department Use in Illinois After Implementation of the Patient Protection and Affordable Care Act.

PubMed

Dresden, Scott M; Powell, Emilie S; Kang, Raymond; McHugh, Megan; Cooper, Andrew J; Feinglass, Joe

2017-02-01

We examine emergency department (ED) use and hospitalizations through the ED after Patient Protection and Affordable Care Act (ACA) health insurance expansion in Illinois, a Medicaid expansion state. Using statewide hospital administrative data from 2011 through 2015 from 201 nonfederal Illinois hospitals for patients aged 18 to 64 years, mean monthly ED visits were compared before and after ACA implementation by disposition from the ED and primary payer. Visit data were combined with 2010 to 2014 census insurance estimates to compute payer-specific ED visit rates. Interrupted time-series analyses tested changes in ED visit rates and ED hospitalization rates by insurance type after ACA implementation. Average monthly ED visit volume increased by 14,080 visits (95% confidence interval [CI] 4,670 to 23,489), a 5.7% increase, after ACA implementation. Changes by payer were as follows: uninsured decreased by 24,158 (95% CI -27,037 to -21,279), Medicaid increased by 28,746 (95% CI 23,945 to 33,546), and private insurance increased by 9,966 (95% 6,241 to 13,690). The total monthly ED visit rate increased by 1.8 visits per 1,000 residents (95% CI 0.6 to 3.0). The monthly ED visit rate decreased by 8.7 visit per 1,000 uninsured residents (95% CI -11.1 to -6.3) and increased by 10.2 visit per 1,000 Medicaid beneficiaries (95% CI 4.4 to 16.1) and 1.3 visits per 1,000 privately insured residents (95% CI 0.6 to 1.9). After adjusting for baseline trends and season, these changes remained statistically significant. The total number of hospitalizations through the ED was unchanged. ED visits by adults aged 18 to 64 years in Illinois increased after ACA health insurance expansion. The increase in total ED visits was driven by an increase in visits resulting in discharge from the ED. A large post-ACA increase in Medicaid visits and a modest increase in privately insured visits outpaced a large reduction in ED visits by uninsured patients. These changes are larger than can be explained by population changes alone and are significantly different from trends in ED use before ACA implementation. Copyright © 2016 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Feasibility, acceptability, and preliminary effectiveness of patient advocates for improving adult asthma outcomes

PubMed Central

Apter, Andrea J.; Wan, Fei; Reisine, Susan; Bogen, Daniel K.; Rand, Cynthia; Bender, Bruce; Bennett, Ian M.; Gonzalez, Rodalyn; Priolo, Chantel; Sonnad, Seema S.; Bryant-Stephens, Tyra; Ferguson, Monica; Boyd, Rhonda C.; Have, Thomas Ten; Roy, Jason

2014-01-01

Background Asthmatic adults from low-income urban neighborhoods have inferior health outcomes which in part may be due to barriers accessing care and with patient-provider communication. We adapted a patient advocate (PA) intervention to overcome these barriers. Objective To conduct a pilot study to assess feasibility, acceptability, and preliminary evidence of effectiveness. Methods A prospective randomized design was employed with mixed methods evaluation. Adults with moderate or severe asthma were randomized to 16 weeks of PA or a minimal intervention (MI) comparison condition. The PA, a nonprofessional, modeled preparations for a medical visit, attended the visit, and confirmed understanding. The PA facilitated scheduling, obtaining insurance coverage, and overcoming barriers to implementing medical advice. Outcomes included electronically-monitored inhaled corticosteroid adherence, asthma control, quality of life, FEV1, ED visits, and hospitalizations. Mixed-effects models guided an intention-to-treat analysis. Results 100 adults participated: age 47±14 years, 75% female, 71% African American, 16% white, baseline FEV1 69% ± 18%, 36% experiencing hospitalizations and 56% ED visits for asthma in the prior year. Ninety-three subjects completed all visits; 36 of 53 PA-assigned had a PA visit. Adherence declined significantly in the control (p= 0.001) but not significantly in the PA group (p=.30). Both PA and MI groups demonstrated improved asthma control (p=0.01 in both) and quality of life (p=0.001, p=0.004). Hospitalizations and ED visits for asthma did not differ between groups. The observed changes over time tended to favor the PA group, but this study was underpowered to detect differences between groups. Conclusion The PA intervention was feasible and acceptable and demonstrated potential for improving asthma control and quality of life. PMID:23800333

Practice Characteristics of Emergency Department Extracorporeal Cardiopulmonary Resuscitation (eCPR) Programs in the United States: The Current State of the Art of Emergency Department Extracorporeal Membrane Oxygenation (ED ECMO)

PubMed Central

Tonna, Joseph E.; Johnson, Nicholas J; Greenwood, John; Gaieski, David F; Shinar, Zachary; Bellezo, Joseph M.; Becker, Lance; Shah, Atman P.; Youngquist, Scott T.; Mallin, Michael P; Fair, James Franklin; Gunnerson, Kyle J.; Weng, Cindy; McKellar, Stephen

2017-01-01

Purpose To characterize the current scope and practices of centers performing extracorporeal cardiopulmonary resuscitation (eCPR) on the undifferentiated patient with cardiac arrest in the emergency department. Methods We contacted all US centers in January 2016 that had submitted adult eCPR cases to the Extracorporeal Life Support Organization (ELSO) registry and surveyed them, querying for programs that had performed eCPR in the Emergency Department (ED ECMO). Our objective was to characterize the following domains of ED ECMO practice: program characteristics, patient selection, devices and techniques, and personnel. Results Among 99 centers queried, 70 responded. Among these, 36 centers performed ED ECMO. Nearly 93% of programs are based at academic/teaching hospitals. 65% of programs are less than 5 years old, and 60% of programs perform ≤ 3 cases per year. Most programs (90%) had inpatient eCPR or salvage ECMO programs prior to starting ED ECMO programs. The majority of programs do not have formal inclusion and exclusion criteria. Most programs preferentially obtain vascular access via the percutaneous route (70%) and many (40%) use mechanical CPR during cannulation. The most commonly used console is the Maquet Rotaflow®. Cannulation is most often performed by cardiothoracic (CT) surgery, and nearly all programs (>85%) involve CT surgeons, perfusionists, and pharmacists. Conclusions Over a third of centers that submitted adult eCPR cases to ELSO have performed ED ECMO. These programs are largely based at academic hospitals, new, and have low volumes. They do not have many formal inclusion or exclusion criteria, and devices and techniques are variable. PMID:27523953

Practice characteristics of Emergency Department extracorporeal cardiopulmonary resuscitation (eCPR) programs in the United States: The current state of the art of Emergency Department extracorporeal membrane oxygenation (ED ECMO).

PubMed

Tonna, Joseph E; Johnson, Nicholas J; Greenwood, John; Gaieski, David F; Shinar, Zachary; Bellezo, Joseph M; Becker, Lance; Shah, Atman P; Youngquist, Scott T; Mallin, Michael P; Fair, James Franklin; Gunnerson, Kyle J; Weng, Cindy; McKellar, Stephen

2016-10-01

To characterize the current scope and practices of centers performing extracorporeal cardiopulmonary resuscitation (eCPR) on the undifferentiated patient with cardiac arrest in the emergency department. We contacted all US centers in January 2016 that had submitted adult eCPR cases to the Extracorporeal Life Support Organization (ELSO) registry and surveyed them, querying for programs that had performed eCPR in the Emergency Department (ED ECMO). Our objective was to characterize the following domains of ED ECMO practice: program characteristics, patient selection, devices and techniques, and personnel. Among 99 centers queried, 70 responded. Among these, 36 centers performed ED ECMO. Nearly 93% of programs are based at academic/teaching hospitals. 65% of programs are less than 5 years old, and 60% of programs perform ≤3 cases per year. Most programs (90%) had inpatient eCPR or salvage ECMO programs prior to starting ED ECMO programs. The majority of programs do not have formal inclusion and exclusion criteria. Most programs preferentially obtain vascular access via the percutaneous route (70%) and many (40%) use mechanical CPR during cannulation. The most commonly used console is the Maquet Rotaflow(®). Cannulation is most often performed by cardiothoracic (CT) surgery, and nearly all programs (>85%) involve CT surgeons, perfusionists, and pharmacists. Over a third of centers that submitted adult eCPR cases to ELSO have performed ED ECMO. These programs are largely based at academic hospitals, new, and have low volumes. They do not have many formal inclusion or exclusion criteria, and devices and techniques are variable. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Engaging patients in health care decisions in the emergency department through shared decision-making: a systematic review.

PubMed

Flynn, Darren; Knoedler, Meghan A; Hess, Erik P; Murad, M Hassan; Erwin, Patricia J; Montori, Victor M; Thomson, Richard G

2012-08-01

Many decisions in the emergency department (ED) may benefit from patient involvement, even though this setting has been considered least conducive to shared decision-making (SDM). The objective was to conduct a systematic review to evaluate the approaches, methods, and tools used to engage patients or their surrogates in SDM in the ED. Five electronic databases were searched in conjunction with contacting content experts, reviewing selected bibliographies, and conducting citation searches using the Web of Knowledge database. Two reviewers independently selected eligible studies that addressed patient involvement and engagement in decision-making in the ED setting via the use of decision support interventions (DSIs), defined as decision aids or decision support designed to communicate probabilistic information on the risks and benefits of treatment options to patients as part of an SDM process. Eligible studies described and assessed at least one of the following outcomes: patient knowledge, experiences and perspectives on participating in treatment or management decisions, clinician or patient satisfaction, preference for involvement and/or degree of engagement in decision-making and treatment preferences, and clinical outcomes (e.g., rates of hospital admission/readmission, rates of medical or surgical interventions). Two reviewers extracted data on study characteristics, methodologic quality, and outcomes. The authors also assessed the extent to which SDM interventions adhered to good practice for the presentation of information on outcome probabilities (eight probability items from the International Patient Decision Aid Standards Instrument [IPDASi]) and had comprehensive development processes. Five studies met inclusion criteria and were synthesized using a narrative approach. Each study was of satisfactory methodologic quality and used a DSI to engage patients or their surrogates in decision-making in the ED across four domains: 1) management options for children with small lacerations; 2) options for rehydrating children presenting with vomiting or diarrhea or both; 3) risk of bacteremia (and associated complications), tests, and treatment options for febrile children; and 4) short-term risk of acute coronary syndrome (ACS) in adults with low-risk nontraumatic chest pain. Three studies had poor IPDASi probabilities and development process scores and lacked development informed by theory or involvement of clinicians and patients in development and usability testing. Overall, DSIs were associated with improvements in patients' knowledge and satisfaction with the explanation of their care, preferences for involvement, and engagement in decision-making and demonstrated utility for eliciting patients' preferences and values about management and treatment options. Two computerized DSIs (designed to predict risk of ACS in adults presenting to the ED with chest pain) were shown to reduce health care use without evidence of harm. None of the studies reported lack of feasibility of SDM in the ED. Early investigation of SDM in the ED suggests that patients may benefit from involvement in decision-making and offers no empirical evidence to suggest that SDM is not feasible. Future work is needed to develop and test additional SDM interventions in the ED and to identify contextual barriers and facilitators to implementation in practice. © 2012 by the Society for Academic Emergency Medicine.

New guidelines for geriatric EDs: guidance focused on boosting environment, care processes.

PubMed

2014-05-01

A cadre of prominent medical groups, including the ACEP, ENA, AGS, and SAEM, has unveiled a comprehensive set of Geriatric Emergency Department Guidelines to aid hospitals that are either in the process of opening senior-focused EDs or revamping their policies and procedures to better meet the needs of an aging population. The guidelines offer recommendations related to staffing, infrastructure, education, and transition-of-care strategies. In addition, they outline a host of screenings that studies have shown are beneficial for older adults. Experts note that hospital systems around the country have already opened 50 geriatric EDs, with many more facilities in development. Guideline authors state that the guidelines take an evidence-based approach to managing senior patients. While more cost and outcomes data are needed, experts say that senior-focused improvements to emergency care can reduce admissions and return visits to the ED while also boosting patient satisfaction. Future efforts will focus on prioritizing the guideline recommendations so that ED administrators concerned with improving senior care will tackle the most important changes first.

Binge drinking among young adults in an urban tertiary care emergency department in Israel.

PubMed

Levinson, Daphna; Rosca, Paola; Vilner, Doron; Brimberg, Idit; Stall, Yael; Rimon, Ayelet

2017-07-01

Alcohol use is a major preventable public health problem with serious health and social consequences especially among youth. In Israel, alcohol use has become an emerging problem during the last decade, and its use has increased among adolescents and young adults. Binge drinking is the common pattern of alcohol consumption among young adults who drink for recreational purposes. The present survey was conducted among 16-35 years old visitors to the ED. The aim was specifically to identify binge drinkers in order to assess the scope of the need for a brief counseling intervention among young people who arrive intoxicated to a large tertiary care urban ED in Israel. The survey was conducted throughout a 1 week period (24 h per day) at the general EDs in a large, tertiary care center, situated in Tel Aviv. During the survey week, 946 individuals, aged 16-35, visited the ED and 573 (63%) of them were approached for an interview. 89% of those approached agreed to be interviewed. Consenting patients [N = 348] were asked whether they drink any alcohol, how often they drink and how much. About one fifth of those interviewed were in the habit of consuming more than four units of alcohol per occasion. Drinking several times a week or every day was reported by 19% of the males and 26% of the females. Frequency of the drinking episodes was highly correlated with the number of units of drink per occasion. The study found a very high rate of binge drinking among ED visitors, and this suggests a need for large scale ED-based interventions. As binge drinkers are at elevated risk for accidents, violence and related problems, effective ED-based interventions could make an important contribution to public health. Accordingly, Israel is in the process of assessing the effectiveness of a large-scale ED-based counseling intervention. Trial registration number 0230-13-TLV.

A National Study of Outpatient Health Care Providers' Effect on Emergency Department Visit Acuity and Likelihood of Hospitalization.

PubMed

Raven, Maria C; Steiner, Faye

2018-06-01

Many policymakers believe that expanding access to outpatient care will reduce emergency department (ED) use. However, outpatient health care providers often refer their patients to EDs for evaluation and management. We examine the factors underlying outpatient provider referral, its effect on ED visit volume, and whether referred ED visits are more likely to result in hospitalization than self-referred visits. We conducted a cross-sectional study of 19,342 adult (>18 years) respondents to the 2012 to 2014 National Health Interview Survey who reported they had visited an ED at least once in the past 12 months, representing an estimated 44,152,870 US adults. We categorized individuals as having been referred to the ED by an outside health care provider if they responded affirmatively to "your health care provider advised you to go" as a reason for their most recent ED visit. We performed descriptive analyses and logistic regressions to examine factors associated with outpatient health care provider referral to the ED. Respondents could choose multiple other reasons for their most recent ED visit, and we used existing Centers for Disease Control and Prevention guidelines to group these reasons into 2 categories: seriousness of the medical condition and lack of access to other providers. Our 2 main outcomes were whether an outpatient health care provider referred an individual to the ED and whether that ED visit resulted in hospitalization. Of the 44,152,870 US adults (18.58%; 95% confidence interval [CI] 18.21% to 18.95%) with one or more ED visits in the previous 12 months, 10,913,271 (24.72%; 95% CI 23.80% to 25.64%) were referred to the ED by an outpatient provider. Respondents who reported their ED visit was due to the seriousness of their medical condition were more likely to be referred to the ED (odds ratio [OR] 2.18; 95% CI 1.91 to 2.49), whereas those reporting a lack of access to other providers were less likely to be referred (OR 0.58; 95% CI 0.52 to 0.64). Visits referred to the ED were more likely to result in hospitalization than self-referrals (OR 2.07; 95% CI 1.87 to 2.31). Almost one quarter of individuals' most recent ED visits were driven by referrals from outpatient health care providers. Being referred to the ED by an outpatient provider is strongly associated with the seriousness of one's medical condition, which also increases the odds of hospitalization compared with ED discharge. After controlling for seriousness of medical condition, ED referral by an outpatient provider continues to have an independent association with hospitalization. Copyright © 2017 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Risk Factors for Malnutrition among Older Adults in the Emergency Department: A Multicenter Study.

PubMed

Burks, Collin E; Jones, Christopher W; Braz, Valerie A; Swor, Robert A; Richmond, Natalie L; Hwang, Kay S; Hollowell, Allison G; Weaver, Mark A; Platts-Mills, Timothy F

2017-08-01

Among older adults, malnutrition is common, often missed by healthcare providers, and influences recovery from illness or injury. To identify modifiable risk factors associated with malnutrition in older patients. Prospective cross-sectional multicenter study. 3 EDs in the South, Northeast, and Midwest. Non-critically ill, English-speaking adults aged ≥65 years. Random time block sampling was used to enroll patients. The ED interview assessed malnutrition using the Mini Nutritional Assessment Short-Form. Food insecurity and poor oral health were assessed using validated measures. Other risk factors examined included depressive symptoms, limited mobility, lack of transportation, loneliness, and medication side effects, qualified by whether the patient reported the risk factor affected their diet. The population attributable risk proportion (PARP) for malnutrition was estimated for each risk factor. In our sample (n = 252), the prevalence of malnutrition was 12%. Patient characteristics associated with malnutrition included not having a college degree, being admitted to the hospital, and residence in an assisted living facility. Of the risk factors examined, the PARPs for malnutrition were highest for poor oral health (54%; 95% CI 16%, 78%), food insecurity (14%; 95% CI 3%, 31%), and lack of transportation affecting diet (12%; 95% CI 3%, 28%). Results of this observational study identify multiple modifiable factors associated with the problem of malnutrition in older adults. © 2017, Copyright the Authors Journal compilation © 2017, The American Geriatrics Society.

Assessing sensitivity and specificity of the Manchester Triage System in the evaluation of acute coronary syndrome in adult patients in emergency care: a systematic review.

PubMed

Nishi, Fernanda Ayache; de Oliveira Motta Maia, Flávia; de Souza Santos, Itamar; de Almeida Lopes Monteiro da Cruz, Dina

2017-06-01

Triage is the first assessment and sorting process used to prioritize patients arriving in the emergency department (ED). As a triage tool, the Manchester Triage System (MTS) must have a high sensitivity to minimize the occurrence of under-triage, but must not compromise specificity to avoid the occurrence of overtriage. Sensitivity and specificity of the MTS can be calculated using the frequency of appropriately assigned clinical priority levels for patients presenting to the ED. However, although there are well established criteria for the prioritization of patients with suspected acute coronary syndrome (ACS), several studies have reported difficulties when evaluating patients with this condition. The objective of this review was to synthesize the best available evidence on assessing the sensitivity and specificity of the MTS for screening high-level priority adult patients presenting to the ED with ACS. The current review considered studies that evaluated the use of the MTS in the risk classification of adult patients in the ED. In this review, studies that investigated the priority level, as established by the MTS to screen patients under suspicion of ACS or the sensitivity and specificity of the MTS, for screening patients before the medical diagnosis of ACS were included. This review included both experimental and epidemiological study designs. The results were presented in a narrative synthesis. Six studies were appraised by the independent reviewers. All appraised studies enrolled a consecutive or random sample of patients and presented an overall moderate methodological quality, and all of them were included in this review. A total of 54,176 participants were included in the six studies. All studies were retrospective. Studies included in this review varied in content and data reporting. Only two studies reported sensitivity and specificity values or all the necessary data to calculate sensitivity and specificity. The remaining four studies presented either a sensitivity analysis or the number of true positives and false negatives. However, these four studies were conducted considering only data from patients diagnosed with ACS. Sensitivity values were relatively uniform among the studies: 0.70-0.80. A specificity of 0.59 was reported in the study including only patients with non-traumatic chest pain. On the other hand, in the study that included patients with any complaint, the specificity of MTS to screen patients with ACS was 0.97. The current review demonstrates that the MTS has a moderate sensitivity to evaluate patients with ACS. This may compromise time to treatment in the ED, an important variable in the prognosis of ACS. Atypical presentation of ACS, or high specificity, may also explain the moderate sensitivity demonstrated in this review. However, because of minimal data, it is not possible to confirm this hypothesis. It is difficult to determine the acceptable level of sensitivity or specificity to ensure that a certain triage system is safe.

Quality improvement in pediatric sepsis.

PubMed

Melendez, Elliot; Bachur, Richard

2015-06-01

Although there is abundant literature detailing the impact of quality improvement in adult sepsis, the pediatric literature is lacking. Despite consensus definitions for sepsis, which patients along the sepsis spectrum should receive aggressive management and the exact onset of sepsis ('time zero') are not clearly established. In the adult emergency department (ED), sepsis onset is defined as the time of entry into the ED; however, this definition cannot be applied to hospitalized patients or patients who evolve during their ED course. Since the time of sepsis onset will dictate the timeliness of subsequent process measures, the variable definitions in the literature make it difficult to generalize findings among prior studies. Despite the variation in defining time zero, aggressive fluid administration, timely antibiotics, and compliance with sepsis bundles have been shown to improve mortality and to reduce hospital and intensive care length of stay. In addition, early identification tools show promise in beginning to define sepsis onset and retrospective search tools may allow improved case finding of those children of concern for sepsis. Quality improvement in pediatric sepsis is evolving. As we continue to define quality measures, we must standardize the definition of sepsis onset. This definition should be applicable to any treatment venue to ensure measures can be evaluated across all settings. In addition, we must delineate which patients along the sepsis spectrum should be candidates for timely interventions and standardize other outcome measures beyond mortality.

Improving asthma care in emergency departments: results of a multihospital collaborative quality initiative in rural western North Carolina.

PubMed

Crane, Steven; Sailer, Douglas; Patch, Steven C

2011-01-01

In North Carolina, nearly one-fourth of persons with asthma visit an emergency department (ED) or urgent care center at least once a year because of an exacerbation of asthma symptoms. The Emergency Department Asthma Program was a quality-improvement initiative designed to better understand the population of patients who use the ED for asthma care in rural western North Carolina and to demonstrate whether EDs at small hospitals could, by implementing National Asthma Education and Prevention Program treatment guidelines, improve asthma care and reduce subsequent asthma-related ED visits. Eight hospitals in western North Carolina participated in the project, which lasted from November 2003 through December 2007. The intervention consisted of a series of individual and structured continuing medical education events directed at ED physicians and staff. Additionally, patients presenting to EDs for asthma-related problems were selected to receive a short patient questionnaire, to determine their basic understanding of asthma and barriers to asthma care; to undergo asthma staging by the treating physician; to receive focused bedside asthma education by a respiratory therapist; and, finally, at the treating physician's discretion, to receive a free packet of asthma medications, including rescue therapy with a beta-agonist and corticosteroid therapy delivered via a metered-dose inhaler, before discharge. During the 37-month project, a total of 1,739 patients presented to the participating EDs for 2,481 asthma-related episodes of care; at 11% of these visits, patients received the intervention, with nearly 100 ED physicians referring patients to the program. Most of the patients using the ED for asthma treatment were judged to have the mildest stages, and nearly half were uninsured or were covered by Medicaid. For only 20% of the visits was a primary care physician or practice identified. The patient intervention did not appear to lessen the rate of return visits for asthma-related symptoms at 30 and 60 days. Selection bias is likely, as patients enrolled in the study were more likely than patients in the target sample to be adults and insured. Because we did not measure ED staff attendance at educational sessions or their knowledge of and attitudes about asthma care before and after the educational program, we cannot draw conclusions about the effectiveness of the program to change their knowledge, attitudes, or behavior. Many patients who use the ED for care appear to have mild, intermittent asthma and do not identify a regular source of primary care. Efforts to improve asthma care on a communitywide basis and to reduce preventable exacerbations should include care provided in EDs, as this may be the only source of asthma care for many asthma patients. The project demonstrated that regional, collaborative performance improvement efforts in EDs are possible but that many barriers exist to this approach.

Addressing unmet need for HIV testing in emergency care settings: a role for computer-facilitated rapid HIV testing?

PubMed

Kurth, Ann E; Severynen, Anneleen; Spielberg, Freya

2013-08-01

HIV testing in emergency departments (EDs) remains underutilized. The authors evaluated a computer tool to facilitate rapid HIV testing in an urban ED. Randomly assigned nonacute adult ED patients were randomly assigned to a computer tool (CARE) and rapid HIV testing before a standard visit (n = 258) or to a standard visit (n = 259) with chart access. The authors assessed intervention acceptability and compared noted HIV risks. Participants were 56% nonWhite and 58% male; median age was 37 years. In the CARE arm, nearly all (251/258) of the patients completed the session and received HIV results; four declined to consent to the test. HIV risks were reported by 54% of users; one participant was confirmed HIV-positive, and two were confirmed false-positive (seroprevalence 0.4%, 95% CI [0.01, 2.2]). Half (55%) of the patients preferred computerized rather than face-to-face counseling for future HIV testing. In the standard arm, one HIV test and two referrals for testing occurred. Computer-facilitated HIV testing appears acceptable to ED patients. Future research should assess cost-effectiveness compared with staff-delivered approaches.

Clinical- and cost-effectiveness of a nurse led self-management intervention to reduce emergency visits by people with epilepsy.

PubMed

Noble, Adam J; McCrone, Paul; Seed, Paul T; Goldstein, Laura H; Ridsdale, Leone

2014-01-01

People with chronic epilepsy (PWE) often make costly, and clinically unnecessary emergency department (ED) visits. Some do it frequently. No studies have examined interventions to reduce them. An intervention delivered by an epilepsy nurse specialist (ENS) might reduce visits. The rationale is it may optimize patients' self-management skills and knowledge of appropriate ED use. We examined such an intervention's clinical- and cost-effectiveness. Eighty-five adults with epilepsy were recruited from three London EDs with similar catchment populations. Forty-one PWE recruited from two EDs received treatment-as-usual (TAU) and formed the comparison group. The remaining 44 PWE were recruited from the ED of a hospital that had implemented a new ENS service for PWE attending ED. These participants formed the intervention group. They were offered 2 one-to-one sessions with an ENS, plus TAU. Participants completed questionnaires on health service use and psychosocial well-being at baseline, 6- and 12-month follow-up. Covariates were identified and adjustments made. Sixty-nine (81%) participants were retained at follow-up. No significant effect of the intervention on ED visits at 12 months or on other outcomes was found. However, due to less time as inpatients, the average service cost for intervention participants over follow-up was less than for TAU participants' (adjusted difference £558, 95% CI, -£2409, £648). Covariates most predictive of subsequent ED visits were patients' baseline feelings of stigmatization due to epilepsy and low confidence in managing epilepsy. The intervention did not lead to a reduction in ED use, but did not cost more, partly because those receiving the intervention had shorter hospital admissions. Our findings on long-term ED predictors clarifies what causes ED use, and suggests that future interventions might focus more on patients' perceptions of stigma and on their confidence in managing epilepsy. If addressed, ED visits might be reduced and efficiency-savings generated.

Is Low Health Literacy Associated with Increased Emergency Department Utilization and Recidivism?

PubMed Central

Griffey, Richard T.; Kennedy, Sarah K.; McGownan, Lucy; Goodman, Melody; Kaphingst, Kimberly A.

2015-01-01

Objectives To determine whether patients with low health literacy have higher ED utilization and higher ED recidivism than patients with adequate health literacy. Methods The study was conducted at an urban academic ED with over 95,000 annual visits that is part of a 13-hospital health system, using electronic records that are captured in a central data repository. As part of a larger, cross sectional, convenience sample study, health literacy testing was performed using the short test of functional health literacy in adults (STOFHLA), and standard test thresholds identifying those with inadequate, marginal, and adequate health literacy. The authors collected patients' demographic and clinical data, including items known to affect recidivism. This was a structured electronic record review directed at determining 1) the median number of total ED visits in this health system within a 2-year period, and 2) the proportion of patients with each level of health literacy who had return visits within 3, 7, and 14 days of index visits. Descriptive data for demographics and ED returns are reported, stratified by health literacy level. The Mantel-Haenszel chi-square was used to test whether there is an association between health literacy and ED recidivism. A negative binomial multivariable model was performed to examine whether health literacy affects ED use, including variables significant at the 0.1 alpha level on bivariate analysis, and retaining those significant at an alpha of 0.05 in the final model. Results Among 431 patients evaluated, 13.2% had inadequate, 10% had marginal, and 76.3% had adequate health literacy as identified by S-TOFHLA. Patients with inadequate health literacy had higher ED utilization compared to those with adequate health literacy (p = 0.03). Variables retained in the final model included S-TOFHLA score, number of medications, having a personal doctor, being a property owner, race, insurance, age, and simple comorbidity score. During the study period, 118 unique patients each made at least one return ED visit within a 14-day period. The proportion of patients with inadequate health literacy making at least one return visit was higher than that of patients with adequate health literacy at 14 days, but was not significantly higher within 3 or 7 days. Conclusions In this single-center study, higher utilization of the ED by patients with inadequate health literacy when compared to those with adequate health literacy was observed. Patients with inadequate health literacy made a higher number of return visits at 14 days but not at 3 or 7 days. PMID:25308133

Potentially Preventable Hospital and Emergency Department Events: Lessons from a Large Innovation Project.

PubMed

Solberg, Leif I; Ohnsorg, Kris A; Parker, Emily D; Ferguson, Robert; Magnan, Sanne; Whitebird, Robin R; Neely, Claire; Brandenfels, Emily; Williams, Mark D; Dreskin, Mark; Hinnenkamp, Todd; Ziegenfuss, Jeanette Y

2018-06-04

There are few proven strategies to reduce the frequency of potentially preventable hospitalizations and Emergency Department (ED) visits. To facilitate strategy development, we documented these events among complex patients and the factors that contribute to them in a large care-improvement initiative. Observational study with retrospective audits and selective interviews by the patients' care managers among 12 diverse medical groups in California, Minnesota, Pennsylvania, and Washington that participated in an initiative to implement collaborative care for patients with both depression and either uncontrolled diabetes, uncontrolled hypertension, or both. We reviewed information about 373 adult patients with the required conditions who belonged to these medical groups and had experienced 389 hospitalizations or ED visits during the 12-month study period from March 30, 2014, through March 29, 2015. The main outcome measures were potentially preventable hospitalizations or ED visit events. Of the studied events, 28% were considered to be potentially preventable (39% of ED visits and 14% of hospitalizations) and 4.6% of patients had 40% of events. Only type of insurance coverage; patient lack of resources, caretakers, or understanding of care; and inability to access clinic care were more frequent in those with potentially preventable events. Neither disease control nor ambulatory care-sensitive conditions were associated with potentially preventable events. Among these complex patients, patient characteristics, disease control, and the presence of ambulatory care-sensitive conditions were not associated with likelihood of ED visits or hospital admissions, including those considered to be potentially preventable. The current focus on using ambulatory care-sensitive conditions as a proxy for potentially preventable events needs further evaluation.

Identification of seniors at risk (ISAR) screening tool in the emergency department: implementation using the plan-do-study-act model and validation results.

PubMed

Asomaning, Nana; Loftus, Carla

2014-07-01

To better meet the needs of older adults in the emergency department, Senior Friendly care processes, such as high-risk screening are recommended. The identification of Seniors at Risk (ISAR) tool is a 6-item validated screening tool for identifying elderly patients at risk of the adverse outcomes post-ED visit. This paper describes the implementation of the tool in the Mount Sinai Hospital emergency department using a Plan-Do-Study-Act model; and demonstrates whether the tool predicts adverse outcomes. An observational study tracked tool implementation. A retrospective chart audit was completed to collect data about elderly ED patients during 2 time periods in 2010 and 2011. Data analysis compared the characteristics of patients with positive and negative screening tool results. The identification of Seniors at Risk tool was completed for 51.6% of eligible patients, with 61.2% of patients having a positive result. Patients with positive screening results were more likely to be over age 79 (P = .003); be admitted to hospital (P < .001); have a longer mean ED length of stay (P < .001). For patients admitted to hospital, those with positive screening results had a longer mean inpatient stay (P = .012). Implementing the Idenfitication of Seniors at Risk tool was challenged by problematic compliance with tool completion. Strategies to address this included tool adaptation; and providing staff with knowledge of ED and inpatient geriatric resources and feedback on completion rates. Positive screening results predicted adverse outcomes in elderly Mount Sinai Hospital ED patients. © 2014. Published by Elsevier Inc. All rights reserved.

Emotion Regulation as a Transdiagnostic Feature Among Eating Disorders: Cross-sectional and Longitudinal Approach.

PubMed

Mallorquí-Bagué, Núria; Vintró-Alcaraz, Cristina; Sánchez, Isabel; Riesco, Nadine; Agüera, Zaida; Granero, Roser; Jiménez-Múrcia, Susana; Menchón, José M; Treasure, Janet; Fernández-Aranda, Fernando

2018-01-01

Emotion regulation (ER) difficulties are observed in eating disorders (EDs). However, few studies have explored ER before and after treatment. The aims are as follows: to explore ER difficulties across ED types and a healthy control (HC) group (Study 1) and to assess pretreatment and post-treatment changes among ED types (Study 2). In Study 1, adult women with EDs (n = 438) and HC (n = 126) completed an assessment including Eating Disorders Inventory-2, Difficulties in Emotion Regulation Scale and Symptom Checklist-90-Revised. Patients in Study 2 (n = 69) were also reassessed after treatment. All ED types reported worse ER compared with HC (p < .001); also, ER differences were found between ED types. Prospective analyses show ER improvements after treatment (p < .001; |d| = 0.51), especially in patients with bulimia nervosa (p < .001; |d| = 1.03; Reliable Change Index = 9.79) with greater improvement in those with a better treatment outcome (p = .034). In conclusion, emotion dysregulation is a part of all forms of EDs. Furthermore, emotional dysregulation can be modified. ED treatments for anorexia nervosa and binge eating disorder might be enhanced by targeting ER skills. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

The information needs of patients receiving procedural sedation in a hospital emergency department.

PubMed

Revell, Sue; Searle, Judy; Thompson, Shona

2017-07-01

This research investigated the information needs of patients receiving ED procedural sedation to determine the best format to consistently deliver key information in a way acceptable to all involved. Of particular interest was the question concerning patients' need for receiving written information. A descriptive exploratory study gathered qualitative data through face-to-face interviews and focus groups involving patients, nurses and medical staff. Individual interviews were conducted with eight adult patients following procedural sedation. They identified very few gaps in terms of specific information they needed pertaining to procedural sedation and rejected the need for receiving information in a written format. Their information needs related to a central concern for safety and trust. Focus groups, reflecting on the findings from patients, were conducted with five ED nurses and four emergency medicine consultants/registrars who regularly provided procedural sedation. Themes that emerged from the analysis of data from all three groups identified the issues concerning patient information needs as being: competence and efficiency of staff; explanations of procedures and progress; support person presence; and medico-legal issues. The research confirms that the quality of the patient's ED experience, specifically related to procedural sedation, is enhanced by ED staff, especially nurses, providing them with ongoing and repeated verbal information relevant to their circumstances. Copyright © 2017 Elsevier Ltd. All rights reserved.

The real victims of the islamic feast of sacrifice: injuries related to the sacrifice.

PubMed

Bildik, Fikret; Yardan, Türker; Demircan, Ahmet; Uçkan, Mustafa Ulkü; Ergin, Mehmet; Hacioğlu, Emel Gülçin

2010-07-01

During the Feast of Sacrifice in Muslim countries, thousands of animals are slaughtered every year. Many injuries occur during the sacrifice. Thus, the aim of this study was to determine the demographic characteristics of patients, their slaughtering experience, types of injury, and related hospital costs. This prospective observational study was conducted in Emergency Departments (EDs) of Gazi University and Ankara Training and Research Hospital. One hundred and twenty adult patients were admitted to EDs with injuries related to the slaughter and processing of meat during two consecutive Feasts of Sacrifice. The average age of patients was 41.85 +/- 13.6, and 101 patients (84.2%) were male. One hundred sixteen patients (96.7%) were not professionals. Ninety-seven patients (80.8%) were admitted to EDs on the first day of the feasts. Ninety-nine injuries (82.5%) were related to cutting tools, and 21 patients (17.5%) were admitted with complaints of either falling or being harmed by animals. Fourteen patients (11.7%) with tendon lacerations, finger amputations, extremity fractures, and eye traumas were taken into surgery. Hospital costs were a median 104.76 [67.48-322.12] Turkish Liras (74.30 [47.86-228.45] USD). Proper conditions for slaughter should be provided and professionals should perform the slaughter and/or processing of the meat. EDs should be supplied both more equipment and physicians, especially on the first days of the feast.

Hunger and Food Insecurity among Patients in an Urban Emergency Department

PubMed Central

Westgard, Bjorn; Olives, Travis D.; Patel, Roma; Biros, Michelle

2013-01-01

Introduction: To determine the prevalence of hunger and food insecurity among patients presenting to the emergency department (ED) over 3 consecutive years. Methods: This was a cross-sectional study of patients presenting to the ED at Hennepin County Medical Center, and urban, Level I trauma center. We prospectively screened adult (age >18) patients presenting to the ED during randomized daily 8-hour periods between June 1 and August 31, 2007 and 2008, and randomized every-other-day periods between June 1 and August 31, 2009. We excluded patients with high acuity complaints, altered mental status, prisoners, those who did not speak Spanish or English, or those considered to be vulnerable. Consenting participants completed a brief demographic survey. The main outcome measures included age, gender, ethnicity, employment, housing status, insurance, access to food, and having to make choices between buying food and buying medicine. All responses were self reported. Results: 26,211 patients presented during the study; 15,732 (60%) were eligible, 8,044 (51%) were enrolled, and 7,852 (98%) were included in the analysis. The rate of patients reporting hunger significantly increased over the 3-year period [20.3% in 2007, 27.8% in 2008, and 38.3% in 2009 (p<0.001)]. The rate of patients reporting ever having to choose between food and medicine also increased [20.0% in 2007, 18.5% in 2008, and 22.6% in 2009 (p=0.006)]. Conclusion: A significant proportion of our ED patients experience food insecurity and hunger. Hunger and food insecurity have become more prevalent among patients seen in this urban county ED over the past 3 years. Emergency physicians should be aware of the increasing number of patients who must choose between obtaining food and their prescribed medications, and should consider the contribution of hunger and food insecurity to the development of health conditions for which ED treatment is sought. PMID:23687545

Hunger and Food Insecurity among Patients in an Urban Emergency Department.

PubMed

Miner, James R; Westgard, Bjorn; Olives, Travis D; Patel, Roma; Biros, Michelle

2013-05-01

To determine the prevalence of hunger and food insecurity among patients presenting to the emergency department (ED) over 3 consecutive years. This was a cross-sectional study of patients presenting to the ED at Hennepin County Medical Center, and urban, Level I trauma center. We prospectively screened adult (age >18) patients presenting to the ED during randomized daily 8-hour periods between June 1 and August 31, 2007 and 2008, and randomized every-other-day periods between June 1 and August 31, 2009. We excluded patients with high acuity complaints, altered mental status, prisoners, those who did not speak Spanish or English, or those considered to be vulnerable. Consenting participants completed a brief demographic survey. The main outcome measures included age, gender, ethnicity, employment, housing status, insurance, access to food, and having to make choices between buying food and buying medicine. All responses were self reported. 26,211 patients presented during the study; 15,732 (60%) were eligible, 8,044 (51%) were enrolled, and 7,852 (98%) were included in the analysis. The rate of patients reporting hunger significantly increased over the 3-year period [20.3% in 2007, 27.8% in 2008, and 38.3% in 2009 (p<0.001)]. The rate of patients reporting ever having to choose between food and medicine also increased [20.0% in 2007, 18.5% in 2008, and 22.6% in 2009 (p=0.006)]. A significant proportion of our ED patients experience food insecurity and hunger. Hunger and food insecurity have become more prevalent among patients seen in this urban county ED over the past 3 years. Emergency physicians should be aware of the increasing number of patients who must choose between obtaining food and their prescribed medications, and should consider the contribution of hunger and food insecurity to the development of health conditions for which ED treatment is sought.

Prevalence of victims of violence admitted to an emergency department

PubMed Central

Hofner, M; Python, N; Martin, E; Gervasoni, J; Graz, B; Yersin, B

2005-01-01

Objective: To collect data on the consultation frequency and demographic profile of victims of violence attending an emergency department (ED) in Switzerland. Methods: We undertook screening of all admitted adult patients (>16 years) in the ED of the CHUV, Lausanne, Switzerland, over a 1 month period, using a modified version of the Partner Violence Screen questionnaire. Exclusionary criteria were: life threatening injury (National Advisory Committee on Aeronautics score ⩾4), or inability to understand or speak French, to give oral informed consent, or to be questioned without a family member or accompanying person being present. Data were collected on history of physical and/or psychological violence during the previous 12 months, the type of violence experienced by the patient, and if violence was the reason for the current consultation. Sociodemographic data were obtained from the registration documents. Results: The final sample consisted of 1602 patients (participation rate of 77.2%), with a refusal rate of 1.1%. Violence during the past 12 months was reported by 11.4% of patients. Of the total sample, 25% stated that violence was the reason for the current consultation; of these, 95% of patients were confirmed as victims of violence by the ED physicians. Patients reporting violence were more likely to be young and separated from their partner. Men were more likely to be victims of public violence and women more commonly victims of domestic violence. Conclusions: Based on this monthly prevalence rate, we estimate that over 3000 adults affected by violence consult our ED per annum. This underlines the importance of the problem and the need to address it. Health services organisations should establish measures to improve quality of care for victims. Guidelines and educational programmes for nurses and physicians should be developed in order to enhance providers' skills and basic knowledge of all types of violence, how to recognise and interact appropriately with victims, and where to refer these patients for follow up care in their local networks. PMID:15983082

Biomechanical reposition techniques in anterior shoulder dislocation: a randomised multicentre clinical trial- the BRASD-trial protocol.

PubMed

Baden, David N; Roetman, Martijn H; Boeije, Tom; Roodheuvel, Floris; Mullaart-Jansen, Nieke; Peeters, Suzanne; Burg, Mike D

2017-07-20

Glenohumeral (shoulder) dislocations are the most common large joint dislocations seen in the emergency department (ED). They cause pain, often severe, and require timely interventions to minimise discomfort and tissue damage. Commonly used reposition or relocation techniques often involve traction and/or leverage. These techniques have high success rates but may be painful and time consuming. They may also cause complications. Recently, other techniques-the biomechanical reposition techniques (BRTs)-have become more popular since they may cause less pain, require less time and cause fewer complications. To our knowledge, no research exists comparing the various BRTs. Our objective is to establish which BRT or BRT combination is fastest, least painful and associated with the lowest complication rate for adult ED patients with anterior glenohumeral dislocations (AGDs). Adults presenting to the participating EDs with isolated AGDs, as determined by radiographs, will be randomised to one of three BRTs: Cunningham, modified Milch or scapular manipulation. Main study parameters/endpoints are ED length of stay and patients' self-report of pain. Secondary study parameters/endpoints are procedure times, need for analgesic and/or sedative medications, iatrogenic complications and rates of successful reduction. Non-biomechanical AGD repositioning techniques based on traction and/or leverage are inherently painful and potentially harmful. We believe that the three BRTs used in this study are more physiological, more patient friendly, less likely to cause pain, more time efficient and less likely to produce complications. By comparing these three techniques, we hope to improve the care provided to adults with acute AGDs by reducing their ED length of stay and minimising pain and procedure-related complications. We also hope to define which of the three BRTs is quickest, most likely to be successful and least likely to require sedative or analgesic medications to achieve reduction. NTR5839. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

The Ambulatory Integration of the Medical and Social (AIMS) model: A retrospective evaluation.

PubMed

Rowe, Jeannine M; Rizzo, Victoria M; Shier Kricke, Gayle; Krajci, Kate; Rodriguez-Morales, Grisel; Newman, Michelle; Golden, Robyn

2016-01-01

An exploratory, retrospective evaluation of Ambulatory Integration of the Medical and Social (AIMS), a care coordination model designed to integrate medical and non-medical needs of patients and delivered exclusively by social workers was conducted to examine mean utilization of costly health care services for older adult patients. Results reveal mean utilization of 30-day hospital readmissions, emergency department (ED) visits, and hospital admissions are significantly lower for the study sample compared to the larger patient population. Comparisons with national population statistics reveal significantly lower mean utilization of 30-day admissions and ED visits for the study sample. The findings offer preliminary support regarding the value of AIMS.

A rare cause of headache: cerebral venous sinus thrombosis due to hyperthyroidism.

PubMed

Pekdemir, Murat; Yilmaz, Serkan; Ersel, Murat; Sarisoy, Hasan Tahsin

2008-03-01

Headache represents up to 4% of all emergency department (ED) visits. Emergency physicians generally are concerned with identifying those patients whose headaches are caused by life-threatening conditions. Cerebral venous sinus thrombosis may be difficult to diagnose clinically because of its various and nonspecific manifestations. The most frequent but least specific symptom of sinus thrombosis is severe headache, which is present in more than 90% of adult patients. In the case report we present, a patient had severe headache and was diagnosed until third ED visit at different hospitals. He had one of the most unusual causes of headache, that is, cerebral venous sinus thrombosis due to hyperthyroidism.

Characterising non-urgent users of the emergency department (ED): A retrospective analysis of routine ED data.

PubMed

O'Keeffe, Colin; Mason, Suzanne; Jacques, Richard; Nicholl, Jon

2018-01-01

The pressures of patient demand on emergency departments (EDs) continue to be reported worldwide, with an associated negative impact on ED crowding and waiting times. It has also been reported that a proportion of attendances to EDs in different international systems could be managed in settings such as primary care. This study used routine ED data to define, measure and profile non-urgent ED attendances that were suitable for management in alternative, non-emergency settings. We undertook a retrospective analysis of three years of Hospital Episode and Statistics Accident Emergency (HES A&E) data for one large region in England, United Kingdom (April 1st 2011 to March 31st 2014). Data was collected on all adult (>16 years) ED attendances from each of the 19 EDs in the region. A validated process based definition of non-urgent attendance was refined for this study and applied to the data. Using summary statistics non-urgent attenders were examined by variables hypothesised to influence them as follows: age at arrival, time of day and day of week and mode of arrival. Odds ratios were calculated to compare non-urgent attenders between groups. There were 3,667,601 first time attendances to EDs, of which 554,564 were defined as non-urgent (15.1%). Non-urgent attendances were significantly more likely to present out of hours than in hours (OR = 1.19, 95% CI: 1.18 to 1.20, P<0.001). The odds of a non-urgent attendance were significantly higher for younger patients (aged 16-44) compared to those aged 45-64 (odds ratio: 1.42, 95% CI: 1.41 to 1.43, P<0.001) and the over 65's (odds ratio: 3.81, 95% CI: 3.78 to 3.85, P<0.001). Younger patients were significantly more likely to attend non-urgently out of hours compared to the 45-64's (OR = 1.24, 95% CI: 1.22 to 1.25, P<0.001) and the 65+'s (OR = 1.38, 95% CI: 1.35 to 1.40, P<0.001). 110,605/554,564 (19.9%) of the non-urgent attendances arrived by ambulance, increasing significantly out of hours versus in hours (OR = 2.12, 95% CI: 2.09 to 2.15, P<0.001). Younger adults are significantly more likely as older counterparts to use the ED to obtain healthcare that could be provided in a less urgent setting and also more likely to do this out of hours. Alternative services are required to manage non-urgent demand, currently being borne by the ED and the ambulance service, particularly in out of hours.

Biomechanical reposition techniques in anterior shoulder dislocation: a randomised multicentre clinical trial— the BRASD-trial protocol

PubMed Central

Roetman, Martijn H; Boeije, Tom; Roodheuvel, Floris; Mullaart-Jansen, Nieke; Peeters, Suzanne; Burg, Mike D

2017-01-01

Introduction Glenohumeral (shoulder) dislocations are the most common large joint dislocations seen in the emergency department (ED). They cause pain, often severe, and require timely interventions to minimise discomfort and tissue damage. Commonly used reposition or relocation techniques often involve traction and/or leverage. These techniques have high success rates but may be painful and time consuming. They may also cause complications. Recently, other techniques—the biomechanical reposition techniques (BRTs)—have become more popular since they may cause less pain, require less time and cause fewer complications. To our knowledge, no research exists comparing the various BRTs. Our objective is to establish which BRT or BRT combination is fastest, least painful and associated with the lowest complication rate for adult ED patients with anterior glenohumeral dislocations (AGDs). Methods and analysis Adults presenting to the participating EDs with isolated AGDs, as determined by radiographs, will be randomised to one of three BRTs: Cunningham, modified Milch or scapular manipulation. Main study parameters/endpoints are ED length of stay and patients’ self-report of pain. Secondary study parameters/endpoints are procedure times, need for analgesic and/or sedative medications, iatrogenic complications and rates of successful reduction. Ethics and dissemination Non-biomechanical AGD repositioning techniques based on traction and/or leverage are inherently painful and potentially harmful. We believe that the three BRTs used in this study are more physiological, more patient friendly, less likely to cause pain, more time efficient and less likely to produce complications. By comparing these three techniques, we hope to improve the care provided to adults with acute AGDs by reducing their ED length of stay and minimising pain and procedure-related complications. We also hope to define which of the three BRTs is quickest, most likely to be successful and least likely to require sedative or analgesic medications to achieve reduction. Trial registration number NTR5839. PMID:28729305

Reducing High-Users' Visits to the Emergency Department by a Primary Care Intervention for the Uninsured: A Retrospective Study.

PubMed

Tsai, Meng-Han; Xirasagar, Sudha; Carroll, Scott; Bryan, Charles S; Gallagher, Pamela J; Davis, Kim; Jauch, Edward C

2018-01-01

Reducing avoidable emergency department (ED) visits is an important health system goal. This is a retrospective cohort study of the impact of a primary care intervention including an in-hospital, free, adult clinic for poor uninsured patients on ED visit rates and emergency severity at a nonprofit hospital. We studied adult ED visits during August 16, 2009-August 15, 2011 (preintervention) and August 16, 2011-August 15, 2014 (postintervention). We compared pre- versus post-mean annual visit rates and discharge emergency severity index (ESI; triage and resource use-based, calculated Agency for Healthcare Research and Quality categories) among high-users (≥3 ED visits in 12 months) and occasional users. Annual adult ED visit volumes were 16 372 preintervention (47.5% by high-users), versus 18 496 postintervention. High-users' mean annual visit rates were 5.43 (top quartile) and 0.94 (bottom quartile) preintervention, versus 3.21 and 1.11, respectively, for returning high-users, postintervention (all P < .001). Postintervention, the visit rates of new high-users were lower (lowest and top quartile rates, 0.6 and 3.23) than preintervention high-users' rates in the preintervention period. Visit rates of the top quartile of occasional users also declined. Subgroup analysis of medically uninsured high-users showed similar results. Upon classifying preintervention high-users by emergency severity, postintervention mean ESI increased 24.5% among the lowest ESI quartile, and decreased 12.2% among the top quartile. Pre- and post-intervention sample demographics and comorbidities were similar. The observed reductions in overall ED visit rates, particularly low-severity visits; highest reductions observed among high-users and the top quartile of occasional users; and the pattern of changes in emergency severity support a positive impact of the primary care intervention.

Reducing High-Users’ Visits to the Emergency Department by a Primary Care Intervention for the Uninsured: A Retrospective Study

PubMed Central

Tsai, Meng-Han; Xirasagar, Sudha; Carroll, Scott; Bryan, Charles S.; Gallagher, Pamela J.; Davis, Kim; Jauch, Edward C.

2018-01-01

Reducing avoidable emergency department (ED) visits is an important health system goal. This is a retrospective cohort study of the impact of a primary care intervention including an in-hospital, free, adult clinic for poor uninsured patients on ED visit rates and emergency severity at a nonprofit hospital. We studied adult ED visits during August 16, 2009-August 15, 2011 (preintervention) and August 16, 2011-August 15, 2014 (postintervention). We compared pre- versus post-mean annual visit rates and discharge emergency severity index (ESI; triage and resource use–based, calculated Agency for Healthcare Research and Quality categories) among high-users (≥3 ED visits in 12 months) and occasional users. Annual adult ED visit volumes were 16 372 preintervention (47.5% by high-users), versus 18 496 postintervention. High-users’ mean annual visit rates were 5.43 (top quartile) and 0.94 (bottom quartile) preintervention, versus 3.21 and 1.11, respectively, for returning high-users, postintervention (all P < .001). Postintervention, the visit rates of new high-users were lower (lowest and top quartile rates, 0.6 and 3.23) than preintervention high-users’ rates in the preintervention period. Visit rates of the top quartile of occasional users also declined. Subgroup analysis of medically uninsured high-users showed similar results. Upon classifying preintervention high-users by emergency severity, postintervention mean ESI increased 24.5% among the lowest ESI quartile, and decreased 12.2% among the top quartile. Pre- and post-intervention sample demographics and comorbidities were similar. The observed reductions in overall ED visit rates, particularly low-severity visits; highest reductions observed among high-users and the top quartile of occasional users; and the pattern of changes in emergency severity support a positive impact of the primary care intervention. PMID:29591539

Emotion regulation in disordered eating: Psychometric properties of the Difficulties in Emotion Regulation Scale among Spanish adults and its interrelations with personality and clinical severity

PubMed Central

Wolz, Ines; Agüera, Zaida; Granero, Roser; Jiménez-Murcia, Susana; Gratz, Kim L.; Menchón, José M.; Fernández-Aranda, Fernando

2015-01-01

Objective: The aims of the study were to (1) validate the Difficulties in Emotion Regulation Scale (DERS) in a sample of Spanish adults with and without eating disorders, and (2) explore the role of emotion regulation difficulties in eating disorders (ED), including its mediating role in the relation between key personality traits and ED severity. Methods: One hundred and thirty four patients (121 female, mean age = 29 years) with anorexia nervosa (n = 30), bulimia nervosa (n = 54), binge eating (n = 20), or Other Specified Feeding or Eating Disorders (n = 30) and 74 healthy control participants (51 female, mean age = 21 years) reported on general psychopathology, ED severity, personality traits and difficulties in emotion regulation. Exploratory and confirmatory factor analyses were conducted to examine the psychometrics of the DERS in this Spanish sample (Aim 1). Additionally, to examine the role of emotion regulation difficulties in ED (Aim 2), differences in emotion regulation difficulties across eating disorder subgroups were examined and structural equation modeling was used to explore the interrelations among emotion regulation, personality traits, and eating disorder severity. Results: Results support the validity and reliability of the DERS within this Spanish adult sample and suggest that this measure has a similar factor structure in this sample as in the original sample. Moreover, emotion regulation difficulties were found to differ as a function of eating disorder subtype and to mediate the relation between two specific personality traits (i.e., high harm avoidance and low self-directedness) and ED severity. Conclusions: Personality traits of high harm avoidance and low self-directedness may increase vulnerability to ED pathology indirectly, through emotion regulation difficulties. PMID:26175710

Non-Traumatic Dental Condition-Related Emergency Department Visits and Associated Costs for Children and Adults with Autism Spectrum Disorders

PubMed Central

Nakao, Sy; Scott, JoAnna M.; Masterson, Erin E.; Chi, Donald L.

2014-01-01

We analyzed 2010 U.S. National Emergency Department Sample data and ran regression models to test the hypotheses that individuals with ASD are more likely to have non-traumatic dental condition (NTDC)-related emergency department (ED) visits and to incur greater costs for these visits than those without ASD. There were nearly 2.3 million NTDC-related ED visits in 2010. Less than 1.0% (children) and 2.1% (adults) of all ED visits were for NTDC. There was no significant difference in NTDC-related ED visits or costs for children by ASD status. Adults with ASD had significantly lower odds of NTDC-related ED visits (OR=0.39; 95% CI: 0.29, 0.52; P<0.001) but incurred significantly greater mean costs for NTDC-related ED visits (P<0.006) than did adults without ASD. PMID:25374135

Predictive value of the complement system for sepsis-induced disseminated intravascular coagulation in septic patients in emergency department.

PubMed

Zhao, Xin; Chen, Yun-Xia; Li, Chun-Sheng

2015-04-01

To investigate changes in circulating complement component C3, membrane attack complex (MAC), and mannose-binding lectin (MBL) in patients with sepsis-induced disseminated intravascular coagulation (DIC). Adult septic patients admitted to the emergency department (ED) of Beijing Chao-Yang Hospital were enrolled. A DIC score of 5 or higher was considered sepsis-induced DIC. Circulating C3, MAC, and MBL levels were detected on ED arrival and compared between patients with and without DIC. The predictive value of C3, MAC, and MBL for sepsis-induced DIC at ED arrival and development of DIC after admission were assessed by receiver operating characteristic curve and logistic regression. We enrolled 267 septic patients between February and December 2013. Complement 3, MAC, and MBL were higher in the DIC group (P < .01). Membrane attack complex was the independent predictor of sepsis-induced DIC. The area under the curve of MAC in predicting sepsis-induced DIC was 0.793. During hospitalization, 25 patients without DIC at enrollment developed DIC. Membrane attack complex and Sequential Organ Failure Assessment independently predicted progress to DIC. The area under the curve of MAC was 0.741. Complement 3, MAC, and MBL were significantly increased in septic patients with DIC. Membrane attack complex independently predicted sepsis-induced DIC and development of DIC after ED admission. Copyright © 2014 Elsevier Inc. All rights reserved.

Implementation of the Canadian CT Head Rule and Its Association With Use of Computed Tomography Among Patients With Head Injury

PubMed Central

Sharp, Adam L.; Huang, Brian Z.; Tang, Tania; Shen, Ernest; Melnick, Edward R.; Venkatesh, Arjun K.; Kanter, Michael H.; Gould, Michael K.

2018-01-01

Study objective Approximately 1 in 3 computed tomography (CT) scans performed for head injury may be avoidable. We evaluate the association of implementation of the Canadian CT Head Rule on head CT imaging in community emergency departments (EDs). Methods We conducted an interrupted time-series analysis of encounters from January 2014 to December 2015 in 13 Southern California EDs. Adult health plan members with a trauma diagnosis and Glasgow Coma Scale score at ED triage were included. A multicomponent intervention included clinical leadership endorsement, physician education, and integrated clinical decision support. The primary outcome was the proportion of patients receiving a head CT. The unit of analysis was ED encounter, and we compared CT use pre- and postintervention with generalized estimating equations segmented logistic regression, with physician as a clustering variable. Secondary analysis described the yield of identified head injuries pre- and postintervention. Results Included were 44,947 encounters (28,751 preintervention and 16,196 postintervention), resulting in 14,633 (32.6%) head CTs (9,758 preintervention and 4,875 postintervention), with an absolute 5.3% (95% confidence interval [CI] 2.5% to 8.1%) reduction in CT use postintervention. Adjusted pre-post comparison showed a trend in decreasing odds of imaging (odds ratio 0.98; 95% CI 0.96 to 0.99). All but one ED reduced CTs postintervention (0.3% to 8.7%, one ED 0.3% increase), but no interaction between the intervention and study site over time existed (P=.34). After the intervention, diagnostic yield of CT-identified intracranial injuries increased by 2.3% (95% CI 1.5% to 3.1%). Conclusion A multicomponent implementation of the Canadian CT Head Rule was associated with a modest reduction in CT use and an increased diagnostic yield of head CTs for adult trauma encounters in community EDs. PMID:28739290

Adherence to national exercise guidelines by patients attending emergency departments: A multi-site survey.

PubMed

Berlingeri, Paul; Cunningham, Neil; Taylor, David McD; Knott, Jonathan; McLean, Daniel; Gavan, Rex; Plant, Luke; Chen, Hayley; Weiland, Tracey

2017-06-01

The proportion of adults in Australia meeting or exceeding the national guidelines for physical activity has remained relatively static over the past 10 years. The research objective was to measure self-reported physical activity and sedentary behaviour among ED patients in accordance with Australia's current physical activity and sedentary behaviour guidelines, revised in 2014. A convenience sample of participants was recruited from three EDs in Melbourne between February and May 2016. Eligible participants were administered the International Physical Activity Questionnaire - Short Form plus researcher-derived questions. Participants were assessed as whether meeting the physical activity guidelines or not, using pre-defined criteria. The proportion of 18-64 year olds meeting all of the physical activity guidelines was 19.0% (95% confidence interval [CI] 15.2-22.8). A majority of participants (63.1%, 95% CI 58.5-67.7) met the aerobic component of the guidelines although only 28.9% (95% CI 24.5-33.3) of participants reported undertaking strength building exercises two or more times per week. Adults in the oldest age group were found to be less likely to engage in muscle strengthening exercises (23.3%, n = 30) than those in the youngest age group (40.0%, n = 60, P = 0.005). Average daily sitting time (minutes) did not differ between men (median = 300) and women (median = 360, P = 0.118). Overall adherence with physical activity guidelines is low among adults attending the ED. All adults need to be encouraged to undertake muscle strengthening activities, especially adults in older age groups. © 2017 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

Does Orthopaedic Outpatient Care Reduce Emergency Department Utilization After Total Joint Arthroplasty?

PubMed

Chaudhary, Muhammad Ali; Lange, Jeffrey K; Pak, Linda M; Blucher, Justin A; Barton, Lauren B; Sturgeon, Daniel J; Koehlmoos, Tracey; Haider, Adil H; Schoenfeld, Andrew J

2018-05-22

Emergency department (ED) visits after elective surgical procedures are a potential target for interventions to reduce healthcare costs. More than 1 million total joint arthroplasties (TJAs) are performed each year with postsurgical ED utilization estimated in the range of 10%. We asked whether (1) outpatient orthopaedic care was associated with reduced ED utilization and (2) whether there were identifiable factors associated with ED utilization within the first 30 and 90 days after TJA. An analysis of adult TRICARE beneficiaries who underwent TJA (2006-2014) was performed. TRICARE is the insurance program of the Department of Defense, covering > 9 million beneficiaries. ED use within 90 days of surgery was the primary outcome and postoperative outpatient orthopaedic care the primary explanatory variable. Patient demographics (age, sex, race, beneficiary category), clinical characteristics (length of hospital stay, prior comorbidities, complications), and environment of care were used as covariates. Logistic regression adjusted for all covariates was performed to determine factors associated with ED use. We found that orthopaedic outpatient care (odds ratio [OR], 0.73; 95% confidence interval [CI], 0.68-0.77) was associated with lower odds of ED use within 90 days. We also found that index hospital length of stay (OR, 1.07; 95% CI, 1.04-1.10), medical comorbidities (OR, 1.16; 95% CI, 1.08-1.24), and complications (OR, 2.47; 95% CI, 2.24-2.72) were associated with higher odds of ED use. When considering that at 90 days, only 3928 patients sustained a complication, a substantial number of ED visits (11,486 of 15,414 [75%]) after TJA may be avoidable. Enhancing access to appropriate outpatient care with improved discharge planning may reduce ED use after TJA. Further research should be directed toward unpacking the situations, outside of complications, that drive patients to access the ED and devise interventions that could mitigate such behavior. Level III, therapeutic study.

ED antibiotic use for acute respiratory illnesses since pneumonia performance measure inception.

PubMed

Fee, Christopher; Metlay, Joshua P; Camargo, Carlos A; Maselli, Judith H; Gonzales, Ralph

2010-01-01

The study aimed to determine if emergency department (ED)-administered antibiotics for patients discharged home with nonpneumonia acute respiratory tract infections (ARIs) have increased since national pneumonia performance measure implementation, including antibiotic administration within 4 hours of arrival. Time series analysis. Six university and 7 Veterans Administration EDs participating in the Improving Antibiotic Use for Acute Care Treatment (IMPAACT) trial (randomized educational intervention to reduce antibiotics for bronchitis). Randomly selected adult (age >18 years) ED visits for acute cough, diagnosed with nonpneumonia ARIs, discharged home during winters (November-February) of 2003 to 2007. Time trend in ED-administered antibiotics, adjusted for patient demographics, comorbidities, vital signs, ED length of stay, IMPAACT intervention status, geographic region, Veterans Administration/university setting, and site and provider level clustering. Six thousand four hundred seventy-six met study criteria. Three hundred ninety-four (6.1%) received ED-administered antibiotics. Emergency department-administered antibiotics did not increase across the study period among all IMPAACT sites (odds ratio [OR], 0.88; 95% confidence interval [CI], 0.76-1.01) after adjusting for age, congestive heart failure history, temperature higher than 100 degrees F, heart rate more than 100, blood cultures obtained, diagnoses, and ED length of stay. The ED-administered antibiotic rate decreased at IMPAACT intervention (OR, 0.80; 95% CI, 0.69-0.93) but not nonintervention sites (OR, 1.04; 95% CI, 0.91-1.19). Adjusted proportions receiving ED-administered antibiotics were 6.1% (95% CI, 2.7%-13.2%) for 2003 to 2004; 4.8% (95% CI, 2.2%-10.0%) for 2004 to 2005; 4.6% (95% CI, 2.7%-7.8%) for 2005 to 2006; and 4.2% (95% CI, 2.2%-8.0%) for 2006 to 2007. Emergency department-administered antibiotics did not increase for patients with acute cough discharged home with nonpneumonia ARIs since pneumonia antibiotic timing performance measure implementation in these academic EDs.

Exploring deficient emotion regulation in adult ADHD: electrophysiological evidence.

PubMed

Shushakova, Anna; Ohrmann, Patricia; Pedersen, Anya

2018-06-01

Emotional dysregulation (ED) is being increasingly recognized as a core feature of attention-deficit/hyperactivity disorder (ADHD), but the pathophysiological underpinnings remain unclear. In this study, we provide meaningful electrophysiological evidence of ED in adult patients with ADHD (n = 39) compared to healthy controls (n = 40) by exploring the electrophysiological correlates of the emotion regulation strategies reappraisal, distraction, and expressive suppression. Event-related potentials (ERPs) were recorded during passive viewing of neutral and negative images, as well as during emotion regulation. The patients with ADHD exhibited increased frontal late positive potential (LPP) amplitudes during passive viewing of the aversive images and during emotion regulation. Compared with the healthy controls, a subgroup of medication-naïve patients with ADHD (n = 25) also exhibited larger centroparietal LPP amplitudes and provided more negative ratings of the aversive and neutral images. Both the frontal and centroparietal LPP amplitudes were associated with ADHD symptom severity. However, no significant deficit in LPP modulation during emotion regulation was found. These findings strongly support the clinical observation of increased emotional responsivity toward negative stimuli and difficulty during the implementation of emotion regulation strategies and thus encourage the implementation of emotion regulation modules in the treatment of adult patients with ADHD.

Lung-protective ventilation initiated in the emergency department (LOV-ED): a study protocol for a quasi-experimental, before-after trial aimed at reducing pulmonary complications.

PubMed

Fuller, Brian M; Ferguson, Ian; Mohr, Nicholas M; Stephens, Robert J; Briscoe, Cristopher C; Kolomiets, Angelina A; Hotchkiss, Richard S; Kollef, Marin H

2016-04-11

In critically ill patients, acute respiratory distress syndrome (ARDS) and ventilator-associated conditions (VACs) are associated with increased mortality, survivor morbidity and healthcare resource utilisation. Studies conclusively demonstrate that initial ventilator settings in patients with ARDS, and at risk for it, impact outcome. No studies have been conducted in the emergency department (ED) to determine if lung-protective ventilation in patients at risk for ARDS can reduce its incidence. Since the ED is the entry point to the intensive care unit for hundreds of thousands of mechanically ventilated patients annually in the USA, this represents a knowledge gap in this arena. A lung-protective ventilation strategy was instituted in our ED in 2014. It aims to address the parameters in need of quality improvement, as demonstrated by our previous research: (1) prevention of volutrauma; (2) appropriate positive end-expiratory pressure setting; (3) prevention of hyperoxia; and (4) aspiration precautions. The lung-protective ventilation initiated in the emergency department (LOV-ED) trial is a single-centre, quasi-experimental before-after study testing the hypothesis that lung-protective ventilation, initiated in the ED, is associated with reduced pulmonary complications. An intervention cohort of 513 mechanically ventilated adult ED patients will be compared with over 1000 preintervention control patients. The primary outcome is a composite outcome of pulmonary complications after admission (ARDS and VACs). Multivariable logistic regression with propensity score adjustment will test the hypothesis that ED lung-protective ventilation decreases the incidence of pulmonary complications. Approval of the study was obtained prior to data collection on the first patient. As the study is a before-after observational study, examining the effect of treatment changes over time, it is being conducted with waiver of informed consent. This work will be disseminated by publication of full-length manuscripts, presentation in abstract form at major scientific meetings and data sharing with other investigators through academically established means. NCT02543554. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Comparison of QSOFA score and SIRS criteria as screening mechanisms for emergency department sepsis.

PubMed

Haydar, Samir; Spanier, Matthew; Weems, Patricia; Wood, Samantha; Strout, Tania

2017-11-01

The Quick Sequential [Sepsis-related] Organ Failure Assessment (qSOFA) score has been shown to accurately predict mortality in septic patients and is part of recently proposed diagnostic criteria for sepsis. We sought to ascertain the sensitive of the score in diagnosing sepsis, as well as the diagnostic timeliness of the score when compared to traditional systemic inflammatory response syndrome (SIRS) criteria in a population of emergency department (ED) patients treated in the ED, admitted, and subsequently discharged with a diagnosis of sepsis. Electronic health records of 200 patients who were treated for suspected sepsis in our ED and ultimately discharged from our hospital with a diagnosis of sepsis were randomly selected for review from a population of adult ED patients (N=1880). Data extracted included the presence of SIRS criteria and the qSOFA score as well as time required to meet said criteria. In this cohort, 94.5% met SIRS criteria while in the ED whereas only 58.3% met qSOFA. The mean time from arrival to SIRS documentation was 47.1min (95% CI: 36.5-57.8) compared to 84.0min (95% CI: 62.2-105.8) for qSOFA. The median ED "door" to positive SIRS criteria was 12min and 29min for qSOFA. Although qSOFA may be valuable in predicting sepsis-related mortality, it performed poorly as a screening tool for identifying sepsis in the ED. As the time to meet qSOFA criteria was significantly longer than for SIRS, relying on qSOFA alone may delay initiation of evidence-based interventions known to improve sepsis-related outcomes. Copyright © 2017 Elsevier Inc. All rights reserved.

Utilization of and Direct Expenditure for Emergency Medical 
Care in Taiwan: A Population-based Descriptive Study

PubMed Central

Yang, Nan-Ping; Lee, Yi-Hui; Lin, Ching-Heng; Chung, Yuan-Chang; Chen, Wen-Jone; Chou, Pesus

2009-01-01

Background We surveyed the emergency medical system (EMS) in Taiwan to provide information to policymakers responsible for decisions regarding the redistribution of national medical resources. Methods A systematic sampling method was used to randomly sample a representative database from the National Health Insurance (NHI) database in Taiwan, during the period from 2000 to 2004. Results We identified 10,124, 10,408, 11,209, 10,686, and 11,914 emergency room visits in 2000, 2001, 2002, 2003, and 2004, respectively. There were more males than females, and the majority of adults were younger than 50 years. Diagnose of injury/poisoning was the most frequently noted diagnostic category in emergency departments (EDs) in Taiwan. There were 13,196 (24.3%) and 2,952 (5.4%) patients with 2 and 3 concomitant diagnoses, respectively. There was a significant association between advanced age and the existence of multiple diagnoses (P < 0.001). With the exception of the ill-defined symptoms/signs/conditions, the two most frequent diagnoses were diseases of the circulatory system and diseases of the respiratory system in patients aged 65 years or older. On average, treatment-associated expenditure and drug-associated expenditure in Taiwan EDs averaged NT$1,155 ($35.0) and NT$190 ($5.8), respectively, which was equal to 64.5% and 10.6% of the total ED-associated cost. General ED medical expenditure increased with patient age; the increased cost ratio due to age was estimated at 8% per year (P < 0.001). Conclusions The frequency of major health problems diagnosed at ED visits varied by age: more complicated complaints and multiple diagnoses were more frequent in older patients. In Taiwan, the ED system remains overloaded, possibly because of the low cost of an ED visit. PMID:19164870

Does Sexual Assault Nurse Examiner (SANE) Training Affect Attitudes of Emergency Department Nurses Toward Sexual Assault Survivors?

PubMed

Nielson, Mary Hugo; Strong, Linda; Stewart, Julie G

2015-01-01

There are over 243,800 female sexual assaults in the United States annually. Of those who seek healthcare services after being sexually assaulted, 90% present to hospitals. Unfortunately, care and services for women who have been sexually assaulted are inconsistent. Increased burnout, frustration, and feelings of inadequacy can lead healthcare providers to exhibit personal biases or negative attitudes toward their patients. The Joint Commission, responsible for accreditation of healthcare organizations, has stated that nurses must provide competent care to all patients. Therefore, Sexual Assault Nurse Examiner (SANE) training needs to be available for emergency department (ED) nurses who care for patients who have been sexually assaulted. A survey using the Attitude Toward Rape Victims Scale was sent to 1503 ED nurses throughout the United States, from the Emergency Nursing Association's mailing list. The results of the survey showed that there was a significant difference in attitudes toward the patients between SANE-trained emergency nurses and those without training. This study also showed that 35.5% of hospitals represented by the respondents did not have SANE services available for adult patients who had been sexually assaulted, and furthermore, 85.5% of the respondents who cared for adult patients who had been sexually assaulted were not SANE trained. The negative attitudes held toward such patients as found in this study, coupled with a lack of training provides evidence that ED nurses may benefit from education related to appropriate treatment for patients who have been sexually assaulted. As evidence-based practice becomes the gold standard of care, ensuring that nurses are properly trained to care for all patients must be the goal.

Adrenaline in anaphylaxis treatment and self-administration: experience from an inner city emergency department.

PubMed

Mostmans, Y; Grosber, M; Blykers, M; Mols, P; Naeije, N; Gutermuth, J

2017-03-01

Anaphylaxis is a life-threatening emergency of which reliable epidemiological data are lacking. This study aimed to analyze how quickly patients presenting with anaphylaxis were treated in emergency and whether treatment followed the European Academy of Allergy and Clinical Immunology (EAACI) guidelines. Patient data were collected between April 2009 and April 2013. Emergency doctors completed a questionnaire for adult patients presenting at the emergency department (ED) of the St. Pierre hospital in Brussels with anaphylaxis. Inclusion criteria were based on the Sampson criteria of anaphylaxis. Data were analyzed using a Microsoft Excel database. About 0.04% (100/230878) of all emergency visits in adults presented with anaphylaxis. 64% of patients received their first medical help later than 30 min after symptom onset. 67% of patients received adrenaline, 85% oral antihistamines, and 89% received IV glucocorticosteroids. 46/100 patients were discharged directly from the ED, of which 87% received further medical prescriptions for self-administration: 67% corticosteroids, 83% antihistamines, and 9% intramuscular adrenaline. 74% were instructed to consult an allergologist for adequate diagnosis. 54/100 patients were hospitalized. The majority of patients were treated according to the EAACI guidelines for management of anaphylaxis, but only a minority received the recommended adrenaline auto-injector for self-administration at discharge. Because the majority of patients received medical help later than 30 min after symptom onset, adrenaline auto-injector prescription is a necessity. The low rate of doctors prescribing adrenaline auto-injectors in the ED setting underlines the need to train doctors of various backgrounds in prevention and treatment of anaphylaxis and the close collaboration with allergologists. © 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Emergency department presentations for atrial fibrillation and flutter in Alberta: a large population-based study.

PubMed

Rosychuk, Rhonda J; Graham, Michelle M; Holroyd, Brian R; Rowe, Brian H

2017-01-10

Atrial fibrillation or flutter (AFF) are not infrequent presenting problems in Emergency Departments (ED); however, little is known of the pattern of these presentations. This study provides a description of AFF presentations and outcomes after ED discharge in Alberta. Provincial administrative databases were used to obtain all primary ED encounters for AFF during 1999 to 2011 for patients aged >35 years. Data extracted included demographics, ED visit timing, and subsequent visits to non-ED settings. Analysis included summaries and standardized rates. During the study period, there were 63,398 ED AFF visits from 32,104 distinct adults. Median ages for females and males were 75 and 67 years, respectively; more men (52%) and patients > 65 presented. Overall, the standardized rates remained similar (2.8 per 1,000 over the study period). Specific populations of human services recipients and First Nations had higher ED visit rates for AFF than other groups. Predictable daily, weekly, and monthly trends were observed. The ED visits were followed by numerous subsequent visits in non-ED settings; however, First Nations and women had lower rates of specialist follow-up. Annually, over 5,000 ED presentations of patients experiencing AFF occur in Alberta and admissions proportions are declining. While presentation rates across the province are stable, follow-up with physicians, consultation with cardiologists and health outcomes vary based on socio-economic, age, sex, and First Nations status. Further research is required to understand the causes and consequences of these inequalities and to standardize care.

A sex risk reduction text-message program for young adult females discharged from the emergency department.

PubMed

Suffoletto, Brian; Akers, Aletha; McGinnis, Kathleen A; Calabria, Jaclyn; Wiesenfeld, Harold C; Clark, Duncan B

2013-09-01

To pilot test a text message (SMS) sex risk reduction program among at-risk young adult female patients discharged from an emergency department (ED). A convenience sample of 52 female patients with hazardous drinking behavior and recent risky sexual encounters were recruited from an urban ED and randomized to the SMS program (n = 23) or a control group (n = 29). All participants completed a web-based questionnaire in the ED and at 3-month follow-up. For 12 weeks, SMS participants were asked to report whether they had a risky sexual encounter in the past week, received theory-based feedback, and were asked if they were willing set a goal to refrain from having another risky encounter. Thirty-nine percent of SMS participants completed all weeks of SMS reports, and noncompletion increasing from 12% on week 1 to a 33% by week 12. Three-month follow-up was completed in 56% of participants. In the intervention group, there was an increase in the proportion with condom use with last vaginal sex from 20% (95% CI 4%-48%) to 53% (95% CI 27%-79%) and an increase in always condom use over the past 28 days from 0% (95% CI 0%-22%) to 33% (95% CI 12%-62%). These changes were not statistically different from control participants. SMS programs may be useful to reduce risk for sexually transmitted diseases among at-risk young adults being discharged from the ED. Future trials should examine ways to improve adherence to SMS dialog over time and measure objective outcomes in a larger sample. Copyright © 2013 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.

Softball injuries treated in US EDs, 1994 to 2010.

PubMed

Birchak, John C; Rochette, Lynne M; Smith, Gary A

2013-06-01

Softball is a popular participant sport in the United States. This study investigated the epidemiology of softball injuries with comparisons between children and adults. Data from the National Electronic Injury Surveillance System for patients 7 years and older treated in an emergency department (ED) for a softball injury from 1994 through 2010 were analyzed. An estimated 2107823 (95% confidence interval [CI], 1736417-2479229) patients were treated in US EDs for a softball injury during the 17-year study period. The annual number of injuries decreased by 23.0% from 1994 to 2010 (P < .001); however, during the last 6 years of the study, injuries increased by 11.7% (P = .008). The annual rate of softball injuries increased significantly during the study period (P = .035). The most commonly injured body regions were the hand/wrist (22.2%) and face (19.3%). Being hit by a ball was the most common mechanism of injury (52.4%) and accounted for most of face (89.6%) and head (75.7%) injuries. Injuries associated with running (relative risk, 2.36; 95% CI, 1.97-2.82) and diving for a ball (relative risk, 4.61; 95% CI, 3.50-6.09) were more likely to occur among adult than pediatric patients. To our knowledge, this is the first study to investigate softball injuries using a nationally representative sample. Softball is a common source of injury among children and adults. Increased efforts are needed to promote safety measures, such as face guards, mouth guards, safety softballs, and break-away bases, to decrease these injuries. Copyright © 2013 Elsevier Inc. All rights reserved.

Application of the Ottawa Knee Rules in assessing acute knee injuries.

PubMed

O'Sullivan, M J A; O'Sullivan, I

2006-01-01

The Ottawa Knee Rules (OKR) were established to identify which adults with acute knee injuries require knee x-rays as part of their assessment. This study evaluates the compliance of non-consultant hospital doctors (NCHDs), working in an Irish Emergency Dept., with these guidelines and assesses the impact of raising the profile of these rules on their implementation. Emergency Dept. (ED) notes of all adults who presented with an acute knee injury in a 3-month period were analysed retrospectively and compliance with the OKR was assessed. ED NCHDs were then educated on the details and value of these guidelines. In the subsequent three months, the improvement in compliance with the OKR was audited. In the initial audit, according to the Ottawa criteria, 65.5% of all x-rays of acute knee injuries were performed unnecessarily. In the second audit, performed after increasing awareness of the OKR, this figure had dropped to 39.1%. The NCHDs involved in this project cited 'patient expectation' for an x-ray as the primary reason why full compliance was not achieved. This study highlights a lack of awareness of and compliance with the OKR in the assessment of acute knee injuries in adults. It shows how the implementation of simple measures, which raised the profile of the OKR among ED staff, significantly improved compliance with the rules, thus cutting patient waiting times and cutting hospital costs. Futhermore, this study revealed that patients, when injured, expect to get x-rayed and ofter doctors comply with these expectations even if no indication exists.

Emergency department attendance by patients with cancer in their last month of life: a systematic review and meta-analysis.

PubMed

Henson, Lesley A; Gao, Wei; Higginson, Irene J; Smith, Melinda; Davies, Joanna M; Ellis-Smith, Clare; Daveson, Barbara A

2015-02-01

To explore factors associated with emergency department (ED) attendance by patients with cancer in their last month of life. Five electronic databases (MEDLINE, EMBASE, CINAHL, PsycINFO, and the Cochrane Library) were searched through February 2014 for studies investigating ED attendance toward the end of life by adult patients (age 18 years or older) with cancer. No time or language limitations were applied. We performed meta-analysis of factors using a random-effects model, with results expressed as odds ratios (OR) for ED attendance. Sensitivity analyses explored heterogeneity. Thirty studies were identified, reporting three demographic, five clinical, and 13 environmental factors, combining data from five countries and 1,181,842 patients. An increased likelihood of ED attendance was found for men (OR, 1.24; 95% CI, 1.19 to 1.29; I(2), 58.2%), black race (OR, 1.45; 95% CI, 1.40 to 1.50; I(2), 0.0%; reference, white race), patients with lung cancer (OR, 1.17; 95% CI, 1.10 to 1.23; I(2), 59.5%; reference, other cancers), and those patients of the lowest socioeconomic status (SES; OR, 1.15; 95% CI, 1.10 to 1.19; I(2), 0.0%; reference, highest SES). Patients receiving palliative care were less likely to attend the ED in their last month of life (OR, 0.43; 95% CI, 0.36 to 0.51; I(2), 59.4%). We identified demographic (men; black race), clinical (lung cancer), and environmental (low SES; no palliative care) factors associated with an increased risk of ED attendance by patients with cancer in their last month of life. Our findings may be used to develop screening interventions and assist policy-makers to direct resources. Future studies should also investigate previously neglected areas of research, including psychosocial factors, and patients' and caregivers' emergency care preferences. © 2014 by American Society of Clinical Oncology.

Prehospital analgesia in adults using inhaled methoxyflurane.

PubMed

Buntine, Paul; Thom, Ogilvie; Babl, Franz; Bailey, Michael; Bernard, Stephen

2007-12-01

For many years, ambulance services throughout Australia have been administering methoxyflurane as a first-line analgesic agent. However, there is a paucity of literature regarding its efficacy, safety and usage profile. The present study was designed to examine the efficacy of methoxyflurane in adults. An observational case series was conducted over a 10 month period. Adults to whom methoxyflurane was administered while traveling by ambulance to an urban teaching hospital were enrolled. Data analysed included indications for use, verbal numerical pain scores, depth of sedation and adverse effects. Data were collected via paramedic, patient and ED staff surveys. Eighty-three adult patients were enrolled over a 10 month period. A mean reduction in verbal numerical rating scale (VNRS) scores of 2.47 +/- 0.24 (on a 10-point scale) was recorded 5 min post methoxyflurane, with a total reduction of 3.21 +/- 0.24 at time of arrival at the ED. Both VNRS scores were significantly different from baseline (P < 0.0001). Fifteen patients (18.1%, 95% CI 9.8-26.4%) reported mild side-effects either during or shortly after administration. A total of 68 (81.9%, 95% CI 72.0-89.5%) of the paramedics and 60 (72.3%, 95% CI 61.4-81.6%) of the patients interviewed said that they felt satisfied with the level of analgesia provided by methoxyflurane. The use of methoxyflurane as a prehospital analgesic significantly reduced pain in patients, with no significant side-effects attributed to its use. The majority of patients and paramedics interviewed were satisfied with its effects and indicated a willingness to use it again.

Self-Reported Versus Performance-Based Assessments of a Simple Mobility Task Among Older Adults in the Emergency Department.

PubMed

Roedersheimer, Kyle M; Pereira, Greg F; Jones, Christopher W; Braz, Valerie A; Mangipudi, Sowmya A; Platts-Mills, Timothy F

2016-02-01

Accurate information about the mobility of independently living older adults is essential in determining whether they may be safely discharged home from the emergency department (ED). We assess the accuracy of self-reported ability to complete a simple mobility task among older ED patients. This was a cross-sectional study of cognitively intact patients aged 65 years and older who were neither nursing home residents nor critically ill, conducted in 2 academic EDs. Consenting participants were asked whether they could get out of bed, walk 10 feet, turn around, and get back in bed without assistance, and if not, whether they could perform this task with a cane, walker, or assistance. Each participant was then asked to perform the task and was provided with a mobility device or assistance as needed. Of 272 patients who met eligibility criteria and answered the physical task question, 161 (59%) said they could do the task unassisted, 45 (17%) said they could do it with a cane or walker, 21 (8%) said they could do it with assistance, and 45 (17%) said they would be unable to do it even with assistance. Among those who said they could do the task either with or without assistance and who were subsequently willing to attempt the task (N=172), discrepancies between self-reported ability and actual performance were common. Of those who said they could perform the task without assistance, 12% required some assistance or were unable to complete the task. Of those who said they could perform the task with a cane or walker, 48% required either assistance or were unable to perform the task. Of those who said they could perform the task with assistance, 24% were unable to perform the task even with assistance. In this sample of older adults receiving care in the ED, the accuracy of their self-reported ability to perform a simple mobility task was poor, particularly for those who reported some need for assistance. For older adults being considered for discharge who report a need for assistance with mobility, direct observation of the patient's mobility by a member of the emergency care team should be considered. Copyright © 2015 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

A Review of "Older, Wiser, Sexually Smarter: 30 Sex Ed Lessons for Adults Only"

ERIC Educational Resources Information Center

Garrity, Joan Mogul

2010-01-01

While virtually all sex ed curricula are designed to be used with children, teens and young adults, "Older, Wiser, Sexually Smarter: 30 Sex Ed Lessons for Adults Only" ([C] 2009, Planned Parenthood of Greater Northern New Jersey) offers lessons to help participants fully embrace the possibility of sexual pleasure and intimacy from mid-life through…

Emergency Visits for Prescription Opioid Poisonings

PubMed Central

Tadros, Allison; Layman, Shelley M.; Davis, Stephen M.; Davidov, Danielle M.; Cimino, Scott

2016-01-01

Background Prescription opioid abuse and overdose has steadily increased in the United States (U.S.) over the past two decades and current research has shown a dramatic increase in hospitalizations resulting from opioid poisonings. Still, much is unknown about the clinical and demographic features of patients presenting to emergency departments for poisoning from prescription drugs. Objective We sought to evaluate ED visits by adults for prescription opioids. Methods This was a retrospective cohort study utilizing 2006 – 2011 data from the Nationwide Emergency Department Sample (NEDS). Total number of admissions (weighted), disposition, gender, age, expected payer, income, geographic region, charges, and procedures performed were examined. Results From 2006 – 2010, there were 259,093 ED visits by adults for poisoning by opioids and 53.50% of these were unintentional. The overall mean age of patients was 45.5 with more visits made by females (52.37%). Patients who unintentionally overdosed were more likely to have Medicare (36.54%), whereas those who intentionally overdosed had private insurance (29.41%). The majority of patients reside in the South (40.93%) and come from lower-income neighborhoods. Approximately 108,504 patients were discharged and 140,395 were admitted. Conclusions There were over 250,000 visits to U.S. EDs from 2006 – 2011 with a primary diagnosis of poisoning by a prescription opioid. The majority of visits were made by females and over half were admitted to the hospital, resulting in over $4 billion in charges. Future studies should examine preventative measures, optimal screening and intervention programs for these patients. PMID:26409674

Computed tomography of the head for adult patients with minor head injury: are clinical decision rules a necessary evil?

PubMed Central

Tan, Desmond Wei; Lim, Annabelle Mei En; Ong, Daniel Yuxuan; Peng, Li Lee; Chan, Yiong Huak; Ibrahim, Irwani; Kuan, Win Sen

2018-01-01

INTRODUCTION This study aimed to evaluate compliance with and performance of the Canadian Computed Tomography Head Rule (CCHR), and its applicability to the Singapore adult population with minor head injury. METHODS We conducted a retrospective study over six months of consecutive patients who presented to the adult emergency department (ED) with minor head injury. Data on predictor variables indicated in the CCHR was collected and compliance with the CCHR was assessed by comparing the recommendations for head computed tomography (CT) to its actual usage. RESULTS In total, 349 patients satisfied the inclusion criteria. Common mechanisms of injury were falls (59.3%), motor vehicle crashes (16.9%) and assault (12.0%). 249 (71.3%) patients underwent head CT, yielding 42 (12.0%) clinically significant findings. 1 (0.3%) patient required neurosurgical intervention. According to the CCHR, head CT was recommended for 209 (59.9%) patients. Compliance with the CCHR was 71.3%. Among the noncompliant group, head CT was overperformed for 20.1% and underperformed for 8.6% of patients. Multivariate logistic regression analysis revealed that absence of retrograde amnesia (odds ratio [OR] 4.1, 95% confidence interval [CI] 1.8–9.7) was associated with noncompliance to the CCHR. Factors associated with underperformance were absence of motor vehicle crashes as a mechanism of injury (OR 6.6, 95% CI 1.2–36.3) and absence of headache (OR 10.8, 95% CI 1.3–87.4). CONCLUSION Compliance with the CCHR for adult patients with minor head injury remains low in the ED. A qualitative review of physicians’ practices and patients’ preferences may be carried out to evaluate reasons for noncompliance. PMID:28540393

National Early Warning Score (NEWS) as an emergency department predictor of disease severity and 90-day survival in the acutely dyspneic patient - a prospective observational study.

PubMed

Bilben, Bente; Grandal, Linda; Søvik, Signe

2016-06-02

National Early Warning Score (NEWS) was designed to detect deteriorating patients in hospital wards, specifically those at increased risk of ICU admission, cardiac arrest, or death within 24 h. NEWS is not validated for use in Emergency Departments (ED), but emerging data suggest it may be useful. A criticism of NEWS is that patients with chronic poor oxygenation, e.g. severe chronic obstructive pulmonary disease (COPD), will have elevated NEWS also in the absence of acute deterioration, possibly reducing the predictive power of NEWS in this subgroup. We wanted to prospectively evaluate the usefulness of NEWS in unselected adult patients emergently presenting in a Norwegian ED with respiratory distress as main symptom. In respiratory distressed patients, NEWS was calculated on ED arrival, after 2-4 h, and the next day. Manchester Triage Scale (MTS) category, age, gender, comorbidity (ASA score), ICU-admission, ventilatory support, and discharge diagnoses were noted. Survival status was tracked for >90 days through the Population Registry. Data are medians (25-75th percentiles). Factors predicting 90-day survival were analysed with multiple logistic regression. We included 246 patients; 71 years old (60-80), 89 % home-dwelling, 74 % ASA 3-4, 72 % MTS 1-2, 88 % admitted to hospital. NEWS on arrival was 5 (3-7). NEWS correlated closely with MTS category and maximum in-hospital level of care (ED, ward, high-dependency unit, ICU). Sixteen patients died in-hospital, 26 died after discharge within 90 days. Controlled for age, ASA score, and COPD, a higher NEWS on ED arrival predicted poorer 90-day survival. Increased NEWS also correlated with decreased 30-day- and in-hospital survival and a decreased probability for home-dwelling patients to be discharged directly home. In respiratory distressed patients, NEWS on ED arrival correlated closely with triage category and need of ICU admission and predicted long-term out-of-hospital survival controlled for age, comorbidity, and COPD. NEWS should be explored in the ED setting to determine its role in clinical decision-making and in communication along the acute care chain.

Test-Retest Reliability of a Serious Game for Delirium Screening in the Emergency Department.

PubMed

Tong, Tiffany; Chignell, Mark; Tierney, Mary C; Lee, Jacques S

2016-01-01

Introduction: Cognitive screening in settings such as emergency departments (ED) is frequently carried out using paper-and-pencil tests that require administration by trained staff. These assessments often compete with other clinical duties and thus may not be routinely administered in these busy settings. Literature has shown that the presence of cognitive impairments such as dementia and delirium are often missed in older ED patients. Failure to recognize delirium can have devastating consequences including increased mortality (Kakuma et al., 2003). Given the demands on emergency staff, an automated cognitive test to screen for delirium onset could be a valuable tool to support delirium prevention and management. In earlier research we examined the concurrent validity of a serious game, and carried out an initial assessment of its potential as a delirium screening tool (Tong et al., 2016). In this paper, we examine the test-retest reliability of the game, as it is an important criterion in a cognitive test for detecting risk of delirium onset. Objective: To demonstrate the test-retest reliability of the screening tool over time in a clinical sample of older emergency patients. A secondary objective is to assess whether there are practice effects that might make game performance unstable over repeated presentations. Materials and Methods: Adults over the age of 70 were recruited from a hospital ED. Each patient played our serious game in an initial session soon after they arrived in the ED, and in follow up sessions conducted at 8-h intervals (for each participant there were up to five follow up sessions, depending on how long the person stayed in the ED). Results: A total of 114 adults (61 females, 53 males) between the ages of 70 and 104 years ( M = 81 years, SD = 7) participated in our study after screening out delirious patients. We observed a test-retest reliability of the serious game (as assessed by correlation r -values) between 0.5 and 0.8 across adjacent sessions. Conclusion: The game-based assessment for cognitive screening has relatively strong test-retest reliability and little evidence of practice effects among elderly emergency patients, and may be a useful supplement to existing cognitive assessment methods.

Association between use of a health information exchange system and hospital admissions.

PubMed

Vest, J R; Kern, L M; Campion, T R; Silver, M D; Kaushal, R

2014-01-01

Relevant patient information is frequently difficult to obtain in emergency department (ED) visits. Improved provider access to previously inaccessible patient information may improve the quality of care and reduce hospital admissions. Health information exchange (HIE) systems enable access to longitudinal, community-wide patient information at the point of care. However, the ability of HIE to avert admissions is not well demonstrated. We sought to determine if HIE system usage is correlated with a reduction in admissions via the ED. We identified 15,645 adults from New York State with an ED visit during a 6-month period, all of whom consented to have their information accessible in the HIE system, and were continuously enrolled in two area health plans. Using claims we determined if the ED encounter resulted in an admission. We used the HIE's system log files to determine usage during the encounter. We determined the association between HIE system use and the likelihood of admission to the hospital from the ED and potential cost savings. The HIE system was accessed during 2.4% of encounters. The odds of an admission were 30% lower when the system was accessed after controlling for confounding (odds ratio = 0.70; 95%C I= 0.52, 0.95). The annual savings in the sample was $357,000. These findings suggest that the use of an HIE system may reduce hospitalizations from the ED with resultant cost savings. This is an important outcome given the substantial financial investment in interventions designed to improve provider access to patient information in the US.

Unhealthy alcohol use in older adults: Association with readmissions and emergency department use in the 30 days after hospital discharge☆

PubMed Central

Chavez, Laura J.; Liu, Chuan-Fen; Tefft, Nathan; Hebert, Paul L; Clark, Brendan J.; Rubinsky, Anna D.; Lapham, Gwen T.; Bradley, Katharine A.

2016-01-01

Background Unhealthy alcohol use could impair recovery of older patients after medical or surgical hospitalizations. However, no prior research has evaluated whether older patients who screen positive for unhealthy alcohol use are at increased risk of readmissions or emergency department (ED) visits within 30 days after discharge. This study examined the association between AUDIT-C alcohol screening results and 30-day readmissions or ED visits. Methods Veterans Affairs (VA) patients age 65 years or older, were eligible if they were hospitalized for a medical or surgical condition (2/1/2009–10/1/2011) and had an AUDIT-C score documented in their VA electronic medical record in the year before they were hospitalized. VA and Medicare data identified VA or non-VA index hospitalizations, readmissions, and ED visits. Primary analyses adjusted for demographics, comorbid conditions, and past-year health care utilization. Results Among 579,330 hospitalized patients, 13.7% were readmitted and 12.0% visited an ED within 30 days of discharge. In primary analyses, high-risk drinking (n = 7167) and nondrinking (n =357,086) were associated with increased probability of readmission (13.8%, 95% CI 13.0–14.6%; and 14.2%, 95% CI 14.1–14.3%, respectively), relative to low-risk drinking (12.9%; 95% CI 12.7–13.0%). Only nondrinkers had increased risk for ED visits. Conclusions Alcohol screening results indicating high-risk drinking that were available in medical records were modestly associated with risk for 30-day readmissions and were not associated with risk for ED visits. PMID:26644137

Association Between Use of a Health Information Exchange System and Hospital Admissions

PubMed Central

Vest, J.R.; Kern, L.M.; Campion, T.R.; Silver, M.D.; Kaushal, R.

2014-01-01

Summary Objective Relevant patient information is frequently difficult to obtain in emergency department (ED) visits. Improved provider access to previously inaccessible patient information may improve the quality of care and reduce hospital admissions. Health information exchange (HIE) systems enable access to longitudinal, community-wide patient information at the point of care. However, the ability of HIE to avert admissions is not well demonstrated. We sought to determine if HIE system usage is correlated with a reduction in admissions via the ED. Methods We identified 15,645 adults from New York State with an ED visit during a 6-month period, all of whom consented to have their information accessible in the HIE system, and were continuously enrolled in two area health plans. Using claims we determined if the ED encounter resulted in an admission. We used the HIE’s system log files to determine usage during the encounter. We determined the association between HIE system use and the likelihood of admission to the hospital from the ED and potential cost savings. Results The HIE system was accessed during 2.4% of encounters. The odds of an admission were 30% lower when the system was accessed after controlling for confounding (odds ratio = 0.70; 95%C I= 0.52, 0.95). The annual savings in the sample was $357,000. Conclusion These findings suggest that the use of an HIE system may reduce hospitalizations from the ED with resultant cost savings. This is an important outcome given the substantial financial investment in interventions designed to improve provider access to patient information in the US. PMID:24734135

Management of Adults With Acute Migraine in the Emergency Department: The American Headache Society Evidence Assessment of Parenteral Pharmacotherapies.

PubMed

Orr, Serena L; Friedman, Benjamin W; Christie, Suzanne; Minen, Mia T; Bamford, Cynthia; Kelley, Nancy E; Tepper, Deborah

2016-06-01

To provide evidence-based treatment recommendations for adults with acute migraine who require treatment with injectable medication in an emergency department (ED). We addressed two clinically relevant questions: (1) Which injectable medications should be considered first-line treatment for adults who present to an ED with acute migraine? (2) Do parenteral corticosteroids prevent recurrence of migraine in adults discharged from an ED? The American Headache Society convened an expert panel of authors who defined a search strategy and then performed a search of Medline, Embase, the Cochrane database and clinical trial registries from inception through 2015. Identified articles were rated using the American Academy of Neurology's risk of bias tool. For each medication, the expert panel determined likelihood of efficacy. Recommendations were created accounting for efficacy, adverse events, availability of alternate therapies, and principles of medication action. The search identified 68 unique randomized controlled trials utilizing 28 injectable medications. Of these, 19 were rated class 1 (low risk of bias), 21 were rated class 2 (higher risk of bias), and 28 were rated class 3 (highest risk of bias). Metoclopramide, prochlorperazine, and sumatriptan each had multiple class 1 studies supporting acute efficacy, as did dexamethasone for prevention of headache recurrence. All other medications had lower levels of evidence. Intravenous metoclopramide and prochlorperazine, and subcutaneous sumatriptan should be offered to eligible adults who present to an ED with acute migraine (Should offer-Level B). Dexamethasone should be offered to these patients to prevent recurrence of headache (Should offer-Level B). Because of lack of evidence demonstrating efficacy and concern about sub-acute or long-term sequelae, injectable morphine and hydromorphone are best avoided as first-line therapy (May avoid-Level C). © 2016 American Headache Society.

Pharmacist's impact on acute pain management during trauma resuscitation.

PubMed

Montgomery, Kayla; Hall, A Brad; Keriazes, Georgia

2015-01-01

The timely administration of analgesics is crucial to the comprehensive management of trauma patients. When an emergency department (ED) pharmacist participates in trauma resuscitation, the pharmacist acts as a medication resource for trauma team members and facilitates the timely administration of analgesics. This study measured the impact of a pharmacist on time to first analgesic dose administered during trauma resuscitation. All adult (>18 years) patients who presented to this level II trauma center via activation of the trauma response system between January 1, 2009, and May 31, 2013, were screened for eligibility. For inclusion, patients must have received intravenous fentanyl, morphine, or hydromorphone in the trauma bay. The time to medication administration was defined as the elapsed time from ED arrival to administration of first analgesic. There were 1328 trauma response system activations during the study period; of which 340 patients were included. The most common analgesic administered was fentanyl (62% in both groups). When a pharmacist was participating, the mean time to first analgesic administered was decreased (17 vs 21 minutes; P = .03). Among the 78% of patients with documented pain scores, the overall mean reduction in pain scores from ED arrival to ED discharge was similar between the 2 groups. There was a 2.4 point reduction with a pharmacist versus 2.7 without a pharmacist, using a 0 to 10 numeric pain rating scale. The participation of a clinical pharmacist during trauma resuscitation significantly decreased the time to first analgesic administration in trauma patients. The results of this study supplement the literature supporting the integration of clinical ED pharmacists on trauma teams.

Characteristics features and factors influencing early death in Acute promyelocytic leukemia; Experience from United Arab Emirates (UAE).

PubMed

Hassan, Inaam Bashir; Zaabi, Mariam R Al; Alam, Arif; Hashim, Mohammed Jawad; Tallman, Martin S; Kristensen, Jorgen

2017-07-01

Although acute promyelocytic leukemia (APL) is a curable hematologic malignancy, early death (ED) remains a significant cause of treatment failure especially in developing countries. In a retrospective data analysis of 67 adult APL patients diagnosed in United Arab Emirates we report an ED rate of 11.9% which is comparable to that reported from more developed countries. We identified the following parameters at presentation as significant predictor of increased ED: Age >40 years (P = 0.015), fever (P = 0.030), WBC count >20 × 10 9 /L (P = 0.010), the breakpoints other than bcr1 (P = 0.043) and fibrinogen level <1.5 g/L (P = 0.025). Delay in ATRA administration beyond 24 h from admission and fibrinogen <150 mg/dL were also significant predictors of ED, but only among high-risk patients (P = 0.035 and P = 0.033, respectively). WBC count >10 × 10 9 /L and expression of HLA-DR (P = 0.018) or CD2 (P = 0.017) were significant predictors for differentiation syndrome (DS) which was found to be a predictor of ED (P = 0.002). Reducing the APL related ED rate in centers with limited resources is feasible provided early initiation of ATRA administration and early correction of coagulopathy in high-risk patients in addition to prompt treatment of DS. To our knowledge this is the first report from the Arabian Gulf describing ED in APL.

Outcomes following trauma laparotomy for hypotensive trauma patients: a UK military and civilian perspective.

PubMed

Marsden, Max; Carden, Rich; Navaratne, Lalin; Smith, Iain M; Penn-Barwell, Jowan G; Kraven, Luke M; Brohi, Karim; Tai, Nigel R M; Bowley, Douglas M

2018-05-25

The management of trauma patients has changed radically in the last decade and studies have shown overall improvements in survival. However, reduction in mortality for the many may obscure a lack of progress in some high-risk patients. We sought to examine the outcomes for hypotensive patients requiring laparotomy in UK military and civilian cohorts. We undertook a review of two prospectively maintained trauma databases; the UK Joint Theatre Trauma Registry (JTTR) for the military cohort (4th February 2003 to 21st September 2014), and the trauma registry of the Royal London Hospital MTC (1st January 2012 to 1st January 2017) for civilian patients. Adults undergoing trauma laparotomy within 90 minutes of arrival at the Emergency Department (ED) were included. Hypotension was present on arrival at the ED in 155/761 (20.4%) military patients. Mortality was higher in hypotensive casualties 25.8% vs 9.7% normotensive casualties (p<0.001). Hypotension was present on arrival at the ED in 63/176 (35.7%) civilian patients. Mortality was higher in hypotensive patients 47.6% vs 12.4% normotensive patients (p<0.001). In both cohorts of hypotensive patients neither the average injury severity, the prehospital time, the ED arrival SBP, nor mortality rate changed significantly during the study period. Despite improvements in survival after trauma for patients overall, the mortality for patients undergoing laparotomy who arrive at the Emergency Department with hypotension has not changed and appears stubbornly resistant to all efforts. Specific enquiry and research should continue to be directed at this high-risk group of patients. IV; Observational Cohort Study.

Association of the Ottawa Aggressive Protocol with rapid discharge of emergency department patients with recent-onset atrial fibrillation or flutter.

PubMed

Stiell, Ian G; Clement, Catherine M; Perry, Jeffrey J; Vaillancourt, Christian; Symington, Cheryl; Dickinson, Garth; Birnie, David; Green, Martin S

2010-05-01

There is no consensus on the optimal management of recent-onset episodes of atrial fibrillation or flutter. The approach to these conditions is particularly relevant in the current era of emergency department (ED) overcrowding. We sought to examine the effectiveness and safety of the Ottawa Aggressive Protocol to perform rapid cardioversion and discharge patients with these arrhythmias. This cohort study enrolled consecutive patient visits to an adult university hospital ED for recent-onset atrial fibrillation or flutter managed with the Ottawa Aggressive Protocol. The protocol includes intravenous chemical cardioversion, electrical cardioversion if necessary and discharge home from the ED. A total of 660 patient visits were included, 95.2% involving atrial fibrillation and 4.9% involving atrial flutter. The mean age of patients enrolled was 64.5 years. In total, 96.8% were discharged home and, of those, 93.3% were in sinus rhythm. All patients were initially administered intravenous procainamide, with a 58.3% conversion rate. A total of 243 patients underwent subsequent electrical cardioversion with a 91.7% success rate. Adverse events occurred in 7.6% of cases: hypotension 6.7%, bradycardia 0.3% and 7-day relapse 8.6%. There were no cases of torsades de pointes, stroke or death. The median lengths of stay in the ED were as follows: 4.9 hours overall, 3.9 hours for those undergoing conversion with procainamide and 6.5 hours for those requiring electrical conversion. This is the largest study to date to evaluate the Ottawa Aggressive Protocol, a unique approach to cardioversion for ED patients with recent-onset episodes of atrial fibrillation and flutter. Our data demonstrate that the Ottawa Aggressive Protocol is effective, safe and rapid, and has the potential to significantly reduce hospital admissions and expedite ED care.

Impact of relative contraindications to home management in emergency department patients with low-risk pulmonary embolism.

PubMed

Vinson, David R; Drenten, Carrieann E; Huang, Jie; Morley, J Eileen; Anderson, Megan L; Reed, Mary E; Nishijima, Daniel K; Liu, Vincent

2015-05-01

Studies of adults presenting to the emergency department (ED) with acute pulmonary embolism (PE) suggest that those who are low risk on the PE Severity Index (classes I and II) can be managed safely without hospitalization. However, the impact of relative contraindications to home management on outcomes has not been described. To compare 5-day and 30-day adverse event rates among low-risk ED patients with acute PE without and with outpatient ineligibility criteria. We conducted a retrospective multicenter cohort study of adults presenting to the ED with acute low-risk PE between 2010 and 2012. We evaluated the association between outpatient treatment eligibility criteria based on a comprehensive list of relative contraindications and 5-day adverse events and 30-day outcomes, including major hemorrhage, recurrent venous thromboembolism, and all-cause mortality. Of 423 adults with acute low-risk PE, 271 (64.1%) had no relative contraindications to outpatient treatment (outpatient eligible), whereas 152 (35.9%) had at least one contraindication (outpatient ineligible). Relative contraindications were categorized as PE-related factors (n = 112; 26.5%), comorbid illness (n = 42; 9.9%), and psychosocial barriers (n = 19; 4.5%). There were no 5-day events in the outpatient-eligible group (95% upper confidence limit, 1.7%) and two events (1.3%; 95% confidence interval [CI], 0.1-5.0%) in the outpatient-ineligible group (P = 0.13). At 30 days, there were five events (two recurrent venous thromboemboli and three major bleeding events) in the outpatient-eligible group (1.8%; 95% CI, 0.7-4.4%) compared with nine in the ineligible group (5.9%; 95% CI, 2.7-10.9%; P < 0.05). This difference remained significant when controlling for PE severity class. Nearly two-thirds of adults presenting to the ED with low-risk PE were potentially eligible for outpatient therapy. Relative contraindications to outpatient management were associated with an increased frequency of adverse events at 30 days among adults with low-risk PE.

Physical activity and exercise dependence during inpatient treatment of longstanding eating disorders: an exploratory study of excessive and non-excessive exercisers.

PubMed

Bratland-Sanda, Solfrid; Sundgot-Borgen, Jorunn; Rø, Øyvind; Rosenvinge, Jan H; Hoffart, Asle; Martinsen, Egil W

2010-04-01

To describe changes in physical activity (PA) and exercise dependence score during treatment of eating disorders (ED), and to explore correlations among changes in PA, exercise motivation, exercise dependence score and ED psychopathology in excessive and non-excessive exercisers. Thirty-eight adult females receiving inpatient treatment for anorexia nervosa, bulimia nervosa or ED not otherwise specified participated in this prospective study. Assessments included accelerometer assessed PA, Exercise Dependence Scale, Reasons for Exercise Inventory, ED Examination, and ED Inventory. Amount of PA was significantly reduced in non-excessive exercisers during treatment, in excessive exercisers there was a trend towards reduced amount of PA from admission to discharge. In excessive exercisers, reduced ED psychopathology was correlated with reduction in exercise dependence score and perceived importance of exercise to regulate negative affects, but not with importance of exercise for weight/appearance. These associations were not found in non-excessive exercisers. Excessive exercise is an important issue in longstanding ED, and the excessive exercising patients need help to develop alternative strategies to regulate negative affects.

Antidepressive and BDNF effects of enriched environment treatment across ages in mice lacking BDNF expression through promoter IV

PubMed Central

Jha, S; Dong, B E; Xue, Y; Delotterie, D F; Vail, M G; Sakata, K

2016-01-01

Reduced promoter IV-driven expression of brain-derived neurotrophic factor (BDNF) is implicated in stress and major depression. We previously reported that defective promoter IV (KIV) caused depression-like behavior in young adult mice, which was reversed more effectively by enriched environment treatment (EET) than antidepressants. The effects of promoter IV-BDNF deficiency and EET over the life stages remain unknown. Since early-life development (ED) involves dynamic epigenetic processes, we hypothesized that EET during ED would provide maximum antidepressive effects that would persist later in life due to enhanced, long-lasting BDNF induction. We tested this hypothesis by determining EET effects across three life stages: ED (0–2 months), young adult (2–4 months), and old adult (12–14 months). KIV mice at all life stages showed depression-like behavior in the open-field and tail-suspension tests compared with wild-type mice. Two months of EET reduced depression-like behavior in ED and young adult, but not old adult mice, with the largest effect in ED KIV mice. This effect lasted for 1 month after discontinuance of EET only in ED mice. BDNF protein induction by EET in the hippocampus and frontal cortex was also the largest in ED mice and persisted only in the hippocampus of ED KIV mice after discontinuance of EET. No gender-specific effects were observed. The results suggest that defective promoter IV causes depression-like behavior, regardless of age and gender, and that EET during ED is particularly beneficial to individuals with promoter IV-BDNF deficiency, while additional treatment may be needed for older adults. PMID:27648918

Feasibility Testing of an Emergency Department Screening Tool To Identify Older Adults Appropriate for Palliative Care Consultation.

PubMed

Ouchi, Kei; Block, Susan D; Schonberg, Mara A; Jamieson, Emily S; Aaronson, Emily L; Pallin, Daniel J; Tulsky, James A; Schuur, Jeremiah D

2017-01-01

Seriously ill older adults in the emergency department (ED) may benefit from palliative care referral, yet little is known about how to identify these patients. To assess the performance and determine the acceptability of a content-validated palliative care screening tool. We surveyed Emergency Medicine (EM) attending physicians at the end of their shifts using the screening tool and asked them to retrospectively apply it to all patients ≥65 years whom they had cared for. We conducted the survey for three consecutive weeks in October 2015. EM attending physicians at an urban, university-affiliated ED. Patient characteristics, acceptability rating, and time per patient screened. We approached 38 attending physicians to apply the screening tool for 69 eligible shifts. Physicians agreed to participate during 55 shifts (80%) and screened 207 patients. On 14 shifts (20%), physicians declined to participate. Mean age of the screened patients was 75 years, 51% were male, and 45% had at least one life-limiting illness. Overall, 67 patients (32%) screened positive for palliative care needs. Seventy percent of physicians (n = 33) found the screening tool acceptable to use and the average time of completion was 1.8 minutes per patient screened. A rapid screen of older adults for palliative care needs was acceptable to a majority of EM physicians and identified a significant number of patients who may benefit from palliative care referral. Further research is needed to improve acceptability and determine the appropriate care pathway for patients with palliative care needs.

Physician Risk Tolerance and Head Computed Tomography Use for Patients with Isolated Headaches.

PubMed

Huang, Yi-Syun; Syue, Yuan-Jhen; Yen, Yung-Lin; Wu, Chien-Hung; Ho, Yu-Ni; Cheng, Fu-Jen

2016-11-01

Headaches are one of the most common afflictions in adults and reasons for emergency department (ED) visits. We sought to determine the association between physician risk tolerance and head computed tomography (CT) use in patients with headaches in the ED. We performed a retrospective study of patients with nontraumatic isolated headaches in the ED and then administered two instruments (Risk-Taking subscale [RTS] of the Jackson Personality Index and a Malpractice Fear Scale [MFS]) to attending physicians who had evaluated these patients and made decisions regarding head CT scans. Outcomes were head CT use during ED evaluation and hospital admission. A hierarchical logistic regression was used to determine the effect of risk scales on head CT use. Of the 1328 patients with headaches, 521 (39.2%) received brain CTs and 83 (6.9%) were admitted; 33 (2.5%) patients received a final diagnosis that the central nervous system was the origin of the disease. Among the 17 emergency physicians (EPs), the median of the MFS and RTS was 23 (interquartile range [IQR] 19-25) and 21 (IQR 20-23), respectively. EPs who were relatively risk-averse and those who possessed a higher level of malpractice fear were not more likely to order brain CTs for patients with isolated headaches. Individual EP risk tolerance, as measured by RTS, and malpractice concerns, measured by MFS, were not predictive of CT use in patients with isolated headaches. Copyright © 2016 Elsevier Inc. All rights reserved.

An unusual presentation of a chronic ingested foreign body in an adult.

PubMed

Kropf, Jesse A H; Jeanmonod, Rebecca; Yen, David M

2013-01-01

Sore throat is a common complaint for patients presenting to the emergency department (ED). Although most are caused by viral and bacterial sources, an ingested foreign body must be considered in the right patient population. Retained foreign bodies occur in both children and adults. In children, the objects are usually non-food items, whereas adults are more likely to have impacted food boluses. Typically, patients present acutely, and chronic foreign bodies are rare, especially in adults. We use an unusual presentation of a retained foreign body in a previously undiagnosed Zenker diverticulum to review ingested foreign bodies and Zenker diverticuli. We report the case of an 82-year-old woman who presented to the ED with a chief complaint of 12 h of worsening pharyngitis and odynophagia. She reported she had a capsule endoscopy performed approximately 4 months earlier during which the device had malfunctioned and no images were transmitted from beyond the esophagus. A soft tissue film of the neck showed the endoscopic capsule retained at the level of the clavicles. Esophagogastroduodenoscopy demonstrated a previously undiagnosed Zenker diverticulum containing the endoscope capsule. This was subsequently removed with laryngoscopy. Complaints related to sore throat commonly have a simple explanation. Recurrent symptoms and a physical examination inconsistent with common explanations require the differential to be broadened and less common causes considered. Copyright © 2013 Elsevier Inc. All rights reserved.

Paid sick leave is associated with fewer ED visits among US private sector working adults.

PubMed

Bhuyan, Soumitra S; Wang, Yang; Bhatt, Jay; Dismuke, S Edward; Carlton, Erik L; Gentry, Dan; LaGrange, Chad; Chang, Cyril F

2016-05-01

The United States (US) is the only developed country that does not guarantee short-term or longer-term paid sick leave. This study used a multiyear nationally representative database to examine the association between availability of paid sick leave and frequency of emergency department (ED) use among US private sector employees. We used the National Health Interview Survey data (2012-2014). The final study sample consists of 42,460 US adults between 18 and 64years of age and working in nongovernmental private sector. Our results suggest that availability of paid sick leave is significantly associated with lower likelihood of ED use, for both moderate (1-3 times/year) and repeated users (4 or more times/year). After controlling for confounding factors, respondents with paid sick leave are 14% less likely to be moderate ED users (adjusted odds ratio, 0.86; 95% CI, 0.79-0.93) and 32% less likely to be repeated ED users (adjusted odds ratio, 0.68; 95% CI, 0.50-0.91). Although expansion of health insurance coverage under the Affordable Care Act has not been shown to reduce utilization of high cost health care services such as the ED, our study suggests other factors such as the availability of paid sick leave may do so, by allowing patients to seek care through other more cost-effective mechanisms (eg, primary care providers). To reduce ED utilization, health policymakers should consider alternative reforms including paid sick leave. Copyright © 2016 Elsevier Inc. All rights reserved.

Perceived social support among adults seeking care for acute respiratory tract infections in US EDs.

PubMed

Levin, Sara K; Metlay, Joshua P; Maselli, Judith H; Kersey, Ayanna S; Camargo, Carlos A; Gonzales, Ralph

2009-06-01

Emergency departments (EDs) provide a disproportionate amount of care to disenfranchised and vulnerable populations. We examined social support levels among a diverse population of adults seeking ED care for acute respiratory tract infections. A convenience sample of adults seeking care in 1 of 15 US EDs was telephone interviewed 1 to 6 weeks postvisit. The Multidimensional Scale of Perceived Social Support (7-point Likert) assessed social support across 3 domains: friends, family, and significant others. Higher scores indicate higher support. Of 1104 subjects enrolled, 704 (64%) completed the follow-up interview. Factor analysis yielded 3 factors. Mean social support score was 5.54 (SD 1.04). Female sex, greater household income, and better health status were independently associated with higher levels of social support. Social support levels among adults seeking care in the ED for acute respiratory tract infections are similar to general population cohorts, suggesting that social support is not a strong determinant of health care seeking in EDs.

Clinical and molecular characterization of 40 patients with classic Ehlers–Danlos syndrome: identification of 18 COL5A1 and 2 COL5A2 novel mutations

PubMed Central

2013-01-01

Background Classic Ehlers–Danlos syndrome (cEDS) is a rare autosomal dominant connective tissue disorder that is primarily characterized by skin hyperextensibility, abnormal wound healing/atrophic scars, and joint hypermobility. A recent study demonstrated that more than 90% of patients who satisfy all of these major criteria harbor a type V collagen (COLLV) defect. Methods This cohort included 40 patients with cEDS who were clinically diagnosed according to the Villefranche nosology. The flowchart that was adopted for mutation detection consisted of sequencing the COL5A1 gene and, if no mutation was detected, COL5A2 analysis. In the negative patients the presence of large genomic rearrangements in COL5A1 was investigated using MLPA, and positive results were confirmed via SNP-array analysis. Results We report the clinical and molecular characterization of 40 patients from 28 families, consisting of 14 pediatric patients and 26 adults. A family history of cEDS was present in 9 patients. The majority of the patients fulfilled all the major diagnostic criteria for cEDS; atrophic scars were absent in 2 females, skin hyperextensibility was not detected in a male and joint hypermobility was negative in 8 patients (20% of the entire cohort). Wide inter- and intra-familial phenotypic heterogeneity was observed. We identified causal mutations with a detection rate of approximately 93%. In 25/28 probands, COL5A1 or COL5A2 mutations were detected. Twenty-one mutations were in the COL5A1 gene, 18 of which were novel (2 recurrent). Of these, 16 mutations led to nonsense-mediated mRNA decay (NMD) and to COLLV haploinsufficiency and 5 mutations were structural. Two novel COL5A2 splice mutations were detected in patients with the most severe phenotypes. The known p. (Arg312Cys) mutation in the COL1A1 gene was identified in one patient with vascular-like cEDS. Conclusions Our findings highlight that the three major criteria for cEDS are useful and sufficient for cEDS clinical diagnosis in the large majority of the patients. The borderline patients for whom these criteria fail can be diagnosed when minor signs of connective tissue diseases and family history are present and when genetic testing reveals a defect in COLLV. Our data also confirm that COL5A1 and COL5A2 are the major, if not the only, genes involved in cEDS. PMID:23587214

A retrospective study of emergency department potassium disturbances: severity, treatment, and outcomes.

PubMed

Singer, Adam J; Thode, Henry C; Peacock, W Frank

2017-06-01

Disturbances in potassium (K) levels are relatively common and may be associated with significant morbidity and mortality; however, treatments vary. Our purpose was to determine the incidence, treatments, and outcomes associated with hyperkalemia and hypokalemia in emergency department (ED) patients. We performed a structured, retrospective review of electronic medical records of consecutive adult ED patients with K measured while in the ED. Demographic, clinical, and laboratory data as well as treatments, disposition, and in-hospital complications were collected. Univariate and multivariate analyses, presented as adjusted odds ratios, were used to compare outcomes by K levels. Of 100,260 visits in 2014, an ED K level was ordered in 48,827 (49%). A total of 1,738 patients (3.6%) were excluded because of sample hemolysis. The K was low (<3.5 mEq/L) in 5.5%, normal (3.5 to 5.0 mEq/L) in 90.9%, and elevated (>5.0 mEq/L) in 3.6% of patients. Patients with hyperkalemia were older (64 vs. 49 years, P<0.001) and more likely male (58% vs. 40%, P<0.001). Treatment for hyperkalemia varied greatly. After adjusting for confounders, both hyperkalemia and hypokalemia were associated with inpatient hospitalization and death. At least one medication was used to manage hyperkalemia in 11.5% of patients with a K of 5.1 to 5.4 mEq/L, 36.4% of those with a K 5.5 to 6 mEq/L and 77.0% of the cohort with K >6 mEq/L. Hyperkalemia or hypokalemia occur in 1 of 11 ED patients and are associated with inpatient admission and mortality. Treatment of hyperkalemia varies greatly suggesting the need for evidence-based treatment guidelines.

Hemodynamic effects of nitroglycerin ointment in emergency department patients.

PubMed

Mumma, Bryn E; Dhingra, Kapil R; Kurlinkus, Charley; Diercks, Deborah B

2014-08-01

Nitroglycerin ointment is commonly used in the treatment of emergency department (ED) patients with suspected acute heart failure (AHF) or suspected acute coronary syndrome (ACS), but its hemodynamic effects in this population are not well described. Our objective was to assess the effect of nitroglycerin ointment on mean arterial pressure (MAP) and systemic vascular resistance (SVR) in ED patients receiving nitroglycerin. We hypothesized that nitroglycerin ointment would result in a reduction of MAP and SVR in the acute treatment of patients. We conducted a prospective, observational pilot study in a convenience sample of adult patients from a single ED who were treated with nitroglycerin ointment. Impedance cardiography was used to measure MAP, SVR, cardiac output (CO), stroke volume (SV), and thoracic fluid content (TFC) at baseline and at 30, 60, and 120 min after application of nitroglycerin ointment. Mixed effects regression models with random slope and random intercept were used to analyze changes in hemodynamic parameters from baseline to 30, 60, and 120 min after adjusting for age, sex, and final ED diagnosis of AHF. Sixty-four subjects with mean age of 55 years (interquartile range, 48-67 years) were enrolled; 59% were male. In the adjusted analysis, MAP and TFC decreased after application of nitroglycerin ointment (p=0.001 and p=0.043, respectively). Cardiac index, CO, SVR, and SV showed no change (p=0.113, p=0.085, p=0.570, and p=0.076, respectively) over time. Among ED patients who are treated with nitroglycerin ointment, MAP and TFC decrease over time. However, other hemodynamic parameters do not change after application of nitroglycerin ointment in these patients. Copyright © 2014 Elsevier Inc. All rights reserved.

Hemodynamic Effects of Nitroglycerin Ointment in Emergency Department Patients

PubMed Central

Mumma, Bryn E.; Dhingra, Kapil R.; Kurlinkus, Charley; Diercks, Deborah B.

2014-01-01

Background Nitroglycerin ointment is commonly used in the treatment of emergency department (ED) patients with suspected acute heart failure (AHF) or suspected acute coronary syndrome (ACS), but its hemodynamic effects in this population are not well described. Objectives Our objective was to assess effect of nitroglycerin ointment on mean arterial pressure (MAP) and systemic vascular resistance (SVR) in ED patients receiving nitroglycerin. We hypothesized that nitroglycerin ointment would result in a reduction of MAP and SVR in the acute treatment of patients. Methods We conducted a prospective, observational pilot study in a convenience sample of adult patients from a single ED who were treated with nitroglycerin ointment. Impedance cardiography was used to measure MAP, SVR, cardiac output (CO), stroke volume (SV), and thoracic fluid content (TFC) at baseline and at 30, 60, and 120 minutes following application of nitroglycerin ointment. Mixed effects regression models with random slope and random intercept were used to analyze changes in hemodynamic parameters from baseline to 30, 60, and 120 minutes after adjusting for age, sex, and final ED diagnosis of AHF. Results Sixty-four subjects with mean age 55 years (IQR 48-67) were enrolled; 59% were male. In the adjusted analysis, MAP and TFC decreased following application of nitroglycerin ointment (p=0.001 and p=0.043, respectively). CI, CO, SVR, and SV showed no change (p=0.113, p=0.085, p=0.570, and p=0.076, respectively) over time. Conclusions Among ED patients who are treated with nitroglycerin ointment, MAP and TFC decrease over time. However, other hemodynamic parameters do not change following application of nitroglycerin ointment in these patients. PMID:24698507

Feasibility of Non-Mydriatic Ocular Fundus Photography in the Emergency Department: Phase I of the FOTO-ED Study

PubMed Central

Bruce, Beau B.; Lamirel, Cédric; Biousse, Valérie; Ward, Antionette; Heilpern, Katherine L.; Newman, Nancy J.; Wright, David W.

2011-01-01

Objectives Examination of the ocular fundus is imperative in many acute medical and neurologic conditions, but direct ophthalmoscopy by non-ophthalmologists is underutilized, poorly performed, and difficult without pharmacologic pupillary dilation. The objective was to examine the feasibility of non-mydriatic fundus photography as a clinical alternative to direct ophthalmoscopy by emergency physicians (EPs). Methods Adult patients presenting to the emergency department (ED) with headache, acute focal neurologic deficit, diastolic blood pressure ≥ 120 mmHg, or acute visual change had ocular fundus photographs taken by nurse practitioners using a non-mydriatic fundus camera. Photographs were reviewed by a neuro-ophthalmologist within 24 hours for findings relevant to acute ED patient care. Nurse practitioners and patients rated ease, comfort, and speed of non-mydriatic fundus photography on a 10-point Likert scale (10 best). Timing of visit and photography were recorded by automated electronic systems. Results Three hundred fifty patients were enrolled. There were 1,734 photographs taken during 230 nurse practitioner shifts. Eighty-three percent of the 350 patients had at least one eye with a high quality photograph, while only 3% of patients had no photographs of diagnostic value. Mean ratings were ≥ 8.7 (standard deviation [SD] ≤ 1.9) for all measures. The median photography session lasted 1.9 minutes (interquartile range [IQR] 1.3 to 2.9 minutes), typically accounting for less that 0.5% of the patient’s total ED visit. Conclusions Non-mydriatic fundus photography taken by nurse practitioners is a feasible alternative to direct ophthalmoscopy in the ED. It is performed well by non-physician staff, is well-received by staff and patients, and requires a trivial amount of time to perform. PMID:21906202

Drug treatment of patients with insomnia and excessive daytime sleepiness: pharmacokinetic considerations.

PubMed

Nishino, S; Mignot, E

1999-10-01

Insomnia and excessive daytime sleepiness (EDS) are frequently observed conditions in the general public. A national survey in the USA in 1979 indicated that 35% of American adults experience insomnia in the course of a year. The prevalence of EDS varies depending on the survey (0.3 to 13.3%), but a recent study stated that 2.4% of individuals reported that they continually fell asleep at work. These problems are often long term and negatively affect the individuals' quality of life. People with these sleep problems often have difficulties maintaining high levels of productivity at work or pursuing their daily activities; individuals with insomnia lack the feeling of being rested or refreshed in the morning and EDS is unavoidable in most cases. Behavioural therapy has been shown to be effective for many people affected with insomnia and EDS. However, pharmacological treatments using hypnosedatives and central nervous system (CNS) stimulants are usually necessary, and effective, for those with more severe cases. These compounds have thus been widely prescribed in clinical practice (e.g., 2.6% of all adults surveyed used medically prescribed hypnosedatives and 4.5% used over-the-counter drugs to promote sleep). The onset and duration of action of these hypnosedatives and CNS stimulant drugs are important factors to be considered when prescribing these compounds. These factors primarily depend on physicochemical properties (lipid solubility and protein binding), as well as the pharmacokinetic profile (absorption, distribution, elimination and clearance) of the compounds. Significant differences in profile exist amongst hypnosedatives and CNS stimulants, and these differences may account for the observed variations in clinical action and adverse effects during and after treatment. In this review, we will introduce recently obtained knowledge of the pharmacokinetics of hypnosedatives and CNS stimulants and their applications for patients affected with insomnia and EDS.

Invasive Mechanical Ventilation in California Over 2000-2009: Implications for Emergency Medicine.

PubMed

Mudumbai, Seshadri C; Barr, Juli; Scott, Jennifer; Mariano, Edward R; Bertaccini, Edward; Nguyen, Hieu; Memtsoudis, Stavros G; Cason, Brian; Phibbs, Ciaran S; Wagner, Todd

2015-09-01

Patients who require invasive mechanical ventilation (IMV) often represent a sequence of care between the emergency department (ED) and intensive care unit (ICU). Despite being the most populous state, little information exists to define patterns of IMV use within the state of California. We examined data from the masked Patient Discharge Database of California's Office of Statewide Health Planning and Development from 2000-2009. Adult patients who received IMV during their stay were identified using the International Classification of Diseases 9th Revision and Clinical Modification procedure codes (96.70, 96.71, 96.72). Patients were divided into age strata (18-34 yr, 35-64 yr, and >65 yr). Using descriptive statistics and regression analyses, for IMV discharges during the study period, we quantified the number of ED vs. non-ED based admissions; changes in patient characteristics and clinical outcome; evaluated the marginal costs for IMV; determined predictors for prolonged acute mechanical ventilation (PAMV, i.e. IMV>96 hr); and projected the number of IMV discharges and ED-based admissions by year 2020. There were 696,634 IMV discharges available for analysis. From 2000-2009, IMV discharges increased by 2.8%/year: n=60,933 (293/100,000 persons) in 2000 to n=79,868 (328/100,000 persons) in 2009. While ED-based admissions grew by 3.8%/year, non-ED-based admissions remained stable (0%). During 2000-2009, fastest growth was noted for 1) the 35-64 year age strata; 2) Hispanics; 3) patients with non-Medicare public insurance; and 4) patients requiring PAMV. Average total patient cost-adjusted charges per hospital discharge increased by 29% from 2000 (from $42,528 to $60,215 in 2014 dollars) along with increases in the number of patients discharged to home and skilled nursing facilities. Higher marginal costs were noted for younger patients (ages 18-34 yr), non-whites, and publicly insured patients. Some of the strongest predictors for PAMV were age 35-64 years (OR=1.12; 95% CI [1.09-1.14], p<0.05); non-Whites; and non-Medicare public insurance. Our models suggest that by 2020, IMV discharges will grow to n=153,153 (377 IMV discharges/100,000 persons) with 99,095 admitted through the ED. Based on sustained growth over the past decade, by the year 2020, we project a further increase to 153,153 IMV discharges with 99,095 admitted through the ED. Given limited ICU bed capacities, ongoing increases in the number and type of IMV patients have the potential to adversely affect California EDs that often admit patients to ICUs.

Implementing routine blood-borne virus testing for HCV, HBV and HIV at a London Emergency Department - uncovering the iceberg?

PubMed

Parry, S; Bundle, N; Ullah, S; Foster, G R; Ahmad, K; Tong, C Y W; Balasegaram, S; Orkin, C

2018-06-01

UK guidelines recommend routine HIV testing in high prevalence emergency departments (ED) and targeted testing for HBV and HCV. The 'Going Viral' campaign implemented opt-out blood-borne virus (BBV) testing in adults in a high prevalence ED, to assess seroprevalence, uptake, linkage to care (LTC) rates and staff time taken to achieve LTC. Diagnosis status (new/known/unknown), current engagement in care, and severity of disease was established. LTC was defined as patient informed plus ⩾1 clinic visit. A total of 6211/24 981 ED attendees were tested (uptake 25%); 257 (4.1%) were BBV positive (15 co-infected), 84 (33%) required LTC. 100/147 (68%) HCV positives were viraemic; 44 (30%) required LTC (13 new, 16 disengaged). 26/54 (48%) HBV required LTC (seven new, 11 disengaged). 16/71 (23%) HIV required LTC (10 new, five disengaged). 26/84 (31%) patients requiring LTC had advanced disease (CD4 1, Fibroscan F3/F4 or liver cancer), including five with AIDS-defining conditions and three hepatocellular carcinomas. There were five BBV-related deaths. BBV prevalence was high (4.1%); most were HCV (2.4%). HIV patients were more successfully and quickly LTC than HBV or HCV patients. ED testing was valuable as one-third of those requiring LTC (new, disengaged or unknown status patients) had advanced disease.

Pediatric psychiatric emergency department visits during a full moon.

PubMed

Kamat, Shyama; Maniaci, Vincenzo; Linares, Marc Yves-Rene; Lozano, Juan M

2014-12-01

This study aimed to verify the hypothesis that the lunar cycle influences the number of pediatric psychiatric emergency department (ED) visits. Pediatric psychiatric ED visits between 2009 and 2011 were obtained retrospectively. Patients aged between 4 and 21 years presenting to Miami Children's Hospital ED with a primary psychiatric complaint were included in the study. Patients with a concomitant psychiatric problem and a secondary medical condition were excluded. The number of psychiatric visits was retrieved for the full moon dates, control dates as well as the day before and after the full moon when the moon appears full to the naked eye (full moon effect). A comparison was made using the 2-sample independent t test. Between 2009 and 2011, 36 dates were considered as the true full moon dates and 108 dates as the "full moon effect." A total of 559 patients were included in the study. The 2-sample independent t tests were performed between the actual full moon date and control dates, as well as between the "full moon effect" dates and control dates. Our results failed to show a statistical significance when comparing the number of pediatric psychiatric patients presenting to a children's hospital ED during a full moon and a non-full moon date. Our study's results are in agreement with those involving adult patients. The full moon does not affect psychiatric visits in a children's hospital.

Biodegradable stent or balloon dilatation for benign oesophageal stricture: pilot randomised controlled trial.

PubMed

Dhar, Anjan; Close, Helen; Viswanath, Yirupaiahgari K; Rees, Colin J; Hancock, Helen C; Dwarakanath, A Deepak; Maier, Rebecca H; Wilson, Douglas; Mason, James M

2014-12-28

To undertake a randomised pilot study comparing biodegradable stents and endoscopic dilatation in patients with strictures. This British multi-site study recruited seventeen symptomatic adult patients with refractory strictures. Patients were randomised using a multicentre, blinded assessor design, comparing a biodegradable stent (BS) with endoscopic dilatation (ED). The primary endpoint was the average dysphagia score during the first 6 mo. Secondary endpoints included repeat endoscopic procedures, quality of life, and adverse events. Secondary analysis included follow-up to 12 mo. Sensitivity analyses explored alternative estimation methods for dysphagia and multiple imputation of missing values. Nonparametric tests were used. Although both groups improved, the average dysphagia scores for patients receiving stents were higher after 6 mo: BS-ED 1.17 (95%CI: 0.63-1.78) P = 0.029. The finding was robust under different estimation methods. Use of additional endoscopic procedures and quality of life (QALY) estimates were similar for BS and ED patients at 6 and 12 mo. Concomitant use of gastrointestinal prescribed medication was greater in the stent group (BS 5.1, ED 2.0 prescriptions; P < 0.001), as were related adverse events (BS 1.4, ED 0.0 events; P = 0.024). Groups were comparable at baseline and findings were statistically significant but numbers were small due to under-recruitment. The oesophageal tract has somatic sensitivity and the process of the stent dissolving, possibly unevenly, might promote discomfort or reflux. Stenting was associated with greater dysphagia, co-medication and adverse events. Rigorously conducted and adequately powered trials are needed before widespread adoption of this technology.

Biodegradable stent or balloon dilatation for benign oesophageal stricture: Pilot randomised controlled trial

PubMed Central

Dhar, Anjan; Close, Helen; Viswanath, Yirupaiahgari K; Rees, Colin J; Hancock, Helen C; Dwarakanath, A Deepak; Maier, Rebecca H; Wilson, Douglas; Mason, James M

2014-01-01

AIM: To undertake a randomised pilot study comparing biodegradable stents and endoscopic dilatation in patients with strictures. METHODS: This British multi-site study recruited seventeen symptomatic adult patients with refractory strictures. Patients were randomised using a multicentre, blinded assessor design, comparing a biodegradable stent (BS) with endoscopic dilatation (ED). The primary endpoint was the average dysphagia score during the first 6 mo. Secondary endpoints included repeat endoscopic procedures, quality of life, and adverse events. Secondary analysis included follow-up to 12 mo. Sensitivity analyses explored alternative estimation methods for dysphagia and multiple imputation of missing values. Nonparametric tests were used. RESULTS: Although both groups improved, the average dysphagia scores for patients receiving stents were higher after 6 mo: BS-ED 1.17 (95%CI: 0.63-1.78) P = 0.029. The finding was robust under different estimation methods. Use of additional endoscopic procedures and quality of life (QALY) estimates were similar for BS and ED patients at 6 and 12 mo. Concomitant use of gastrointestinal prescribed medication was greater in the stent group (BS 5.1, ED 2.0 prescriptions; P < 0.001), as were related adverse events (BS 1.4, ED 0.0 events; P = 0.024). Groups were comparable at baseline and findings were statistically significant but numbers were small due to under-recruitment. The oesophageal tract has somatic sensitivity and the process of the stent dissolving, possibly unevenly, might promote discomfort or reflux. CONCLUSION: Stenting was associated with greater dysphagia, co-medication and adverse events. Rigorously conducted and adequately powered trials are needed before widespread adoption of this technology. PMID:25561787

Myotonic dystrophy type 1, daytime sleepiness and REM sleep dysregulation.

PubMed

Dauvilliers, Yves A; Laberge, Luc

2012-12-01

Myotonic dystrophy type 1 (DM1), or Steinert's disease, is the most common adult-onset form of muscular dystrophy. DM1 also constitutes the neuromuscular condition with the most significant sleep disorders including excessive daytime sleepiness (EDS), central and obstructive sleep apneas, restless legs syndrome (RLS), periodic leg movements in wake (PLMW) and periodic leg movements in sleep (PLMS) as well as nocturnal and diurnal rapid eye movement (REM) sleep dysregulation. EDS is the most frequent non-muscular complaint in DM1, being present in about 70-80% of patients. Different phenotypes of sleep-related problems may mimic several sleep disorders, including idiopathic hypersomnia, narcolepsy without cataplexy, sleep apnea syndrome, and periodic leg movement disorder. Subjective and objective daytime sleepiness may be associated with the degree of muscular impairment. However, available evidence suggests that DM1-related EDS is primarily caused by a central dysfunction of sleep regulation rather than by sleep fragmentation, sleep-related respiratory events or periodic leg movements. EDS also tends to persist despite successful treatment of sleep-disordered breathing in DM1 patients. As EDS clearly impacts on physical and social functioning of DM1 patients, studies are needed to identify the best appropriate tools to identify hypersomnia, and clarify the indications for polysomnography (PSG) and multiple sleep latency test (MSLT) in DM1. In addition, further structured trials of assisted nocturnal ventilation and randomized trials of central nervous system (CNS) stimulant drugs in large samples of DM1 patients are required to optimally treat patients affected by this progressive, incurable condition. Copyright © 2012 Elsevier Ltd. All rights reserved.

Should adrenaline be used in patients with hemodynamically stable anaphylaxis? Incident case control study nested within a retrospective cohort study.

PubMed

Ko, Byuk Sung; Kim, Ji Yeon; Seo, Dong-Woo; Kim, Won Young; Lee, Jae Ho; Sheikh, Aziz; Bates, David W

2016-02-03

Although adrenaline (epinephrine) is a cornerstone of initial anaphylaxis treatment, it is not often used. We sought to assess whether use of adrenaline in hemodynamically stable patients with anaphylaxis could prevent the development of hypotension. We conducted a retrospective cohort study of 761 adult patients with anaphylaxis presenting to the emergency department (ED) of a tertiary care hospital over a 10-year period. We divided the patients into two groups according to the occurrence of hypotension and compared demographic characteristics, clinical features, treatments and outcomes. Of the 340 patients with anaphylaxis who were normotensive at first presentation, 40 patients experienced hypotension during their ED stay. The ED stay of the hypotension group was significantly longer than that of patients who did not experience hypotension (496 min vs 253 min, P = 0.000). Adrenaline use in hemodynamically stable anaphylaxis patient was independently associated with a lower risk of developing in-hospital occurrence of hypotension: OR, 0.254 [95% CI, 0.091-0.706]. Adrenaline use in hemodynamically stable anaphylaxis patients was associated with a reduced risk of developing in-hospital occurrence of hypotension. Adverse events induced by adrenaline were rare when the intramuscular route was used.

Should adrenaline be used in patients with hemodynamically stable anaphylaxis? Incident case control study nested within a retrospective cohort study

PubMed Central

Ko, Byuk Sung; Kim, Ji Yeon; Seo, Dong-Woo; Kim, Won Young; Lee, Jae Ho; Sheikh, Aziz; Bates, David W.

2016-01-01

Although adrenaline (epinephrine) is a cornerstone of initial anaphylaxis treatment, it is not often used. We sought to assess whether use of adrenaline in hemodynamically stable patients with anaphylaxis could prevent the development of hypotension. We conducted a retrospective cohort study of 761 adult patients with anaphylaxis presenting to the emergency department (ED) of a tertiary care hospital over a 10-year period. We divided the patients into two groups according to the occurrence of hypotension and compared demographic characteristics, clinical features, treatments and outcomes. Of the 340 patients with anaphylaxis who were normotensive at first presentation, 40 patients experienced hypotension during their ED stay. The ED stay of the hypotension group was significantly longer than that of patients who did not experience hypotension (496 min vs 253 min, P = 0.000). Adrenaline use in hemodynamically stable anaphylaxis patient was independently associated with a lower risk of developing in-hospital occurrence of hypotension: OR, 0.254 [95% CI, 0.091–0.706]. Adrenaline use in hemodynamically stable anaphylaxis patients was associated with a reduced risk of developing in-hospital occurrence of hypotension. Adverse events induced by adrenaline were rare when the intramuscular route was used. PMID:26837822

Eating disorder psychopathology, brain structure, neuropsychological correlates and risk mechanisms in very preterm young adults.

PubMed

Micali, Nadia; Kothari, Radha; Nam, Kie Woo; Gioroukou, Elena; Walshe, Muriel; Allin, Matthew; Rifkin, Larry; Murray, Robin M; Nosarti, Chiara

2015-03-01

This study investigates the prevalence of eating disorder (ED) psychopathology, neuropsychological function, structural brain correlates and risk mechanisms in a prospective cohort of very preterm (VPT) young adults. We assessed ED psychopathology and neuropsychological correlates in 143 cohort individuals born at <33 weeks of gestation. Structural brain correlates and risk factors at birth, in childhood and adolescence, were investigated using prospectively collected data throughout childhood/adolescence. VPT-born individuals had high levels of ED psychopathology at age 21 years. Executive function did not correlate with ED symptomatology. VPT adults presenting with ED psychopathology had smaller grey matter volume at age 14/15 years in the left posterior cerebellum and smaller white matter volume in the fusiform gyrus bilaterally, compared with VPT adults with no ED psychopathology. Caesarean delivery predicted engaging in compensatory behaviours, and severe eating difficulty at age 14 years predicted ED symptomatology in young adulthood. VPT individuals are at risk for ED symptomatology, with evidence of associated structural alterations in posterior brain regions. Further prospective studies are needed to clarify the pathways that lead from perinatal/obstetric complications to ED and relevant neurobiological mechanisms. © 2015 The Authors. European Eating Disorders Review published by John Wiley &Sons, Ltd. © 2015 The Authors. European Eating Disorders Review published by John Wiley & Sons, Ltd.

A Population-Based Cohort Study Evaluating Outcomes and Costs for Syncope Presentations to the Emergency Department.

PubMed

Sandhu, Roopinder K; Tran, Dat T; Sheldon, Robert S; Kaul, Padma

2018-02-01

This study sought to examine outcomes and costs of patients with syncope admitted and discharged from the emergency department (ED). ED visits for syncope are common, yet the impact on health care utilization is relatively unknown. A total of 51,831 consecutive patients presented to the ED with a primary diagnosis of syncope (International Classification of Diseases-9 code 780.2 and International Classification of Diseases-10 code R55) in Alberta, Canada from 2006 to 2014. Outcomes included 30-day syncope ED and hospital readmissions; 30-day and 1-year mortality; and annual inpatient, outpatient, physician, and drug costs, cumulative. Of adults presenting to the ED, 6.6% were hospitalized and discharged with a primary diagnosis of syncope (Cohort 1), 8.7% were hospitalized and discharged with a primary diagnosis other than syncope (Cohort 2), and 84.7% were discharged home with a syncope diagnosis (Cohort 3). The 30-day ED revisits for syncope varied from 1.2% (Cohort 2) to 2.4% (Cohort 1) (p < 0.001), and readmission rates were <1% among cohorts. Short- and long-term mortality rates were highest for Cohort 2 and lowest for Cohort 3 (30-day mortality: Cohort 1 of 1.2%, Cohort 2 of 5.2%, Cohort 3 of 0.4%; p < 0.001) (1-year mortality: Cohort 1 of 9.2%, Cohort 2 of 17.7%, Cohort 3 of 3.0%; p < 0.001). Total cost of syncope presentations was $530.6 million (Cohort 1: $75.3 million; $29,519/patient, Cohort 2: $138.1 million; $42,042/patient, Cohort 3: $317.3 million; $9,963/patient; p<0.001). Most patients with syncope presenting to the ED were discharged and had a favorable prognosis but overall costs were high compared with patients hospitalized. Further research is needed for cost-saving strategies across all cohorts. Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Addressing Unmet Need for HIV Testing in Emergency Care Settings: A Role for Computer-facilitated Rapid HIV Testing?

PubMed Central

Kurth, Ann E.; Severynen, Anneleen; Spielberg, Freya

2014-01-01

HIV testing in emergency departments (EDs) remains underutilized. We evaluated a computer tool to facilitate rapid HIV testing in an urban ED. Randomly assigned non-acute adult ED patients to computer tool (‘CARE’) and rapid HIV testing before standard visit (n=258) or to standard visit (n=259) with chart access. Assessed intervention acceptability and compared noted HIV risks. Participants were 56% non-white, 58% male; median age 37 years. In the CARE arm nearly all (251/258) completed the session and received HIV results; 4 declined test consent. HIV risks were reported by 54% of users and there was one confirmed HIV-positive and 2 false-positives (seroprevalence 0.4%, 95% CI 0.01–2.2%). Half (55%) preferred computerized, over face-to-face, counseling for future HIV testing. In standard arm, one HIV test and 2 referrals for testing occurred. Computer-facilitated HIV testing appears acceptable to ED patients. Future research should assess cost-effectiveness compared with staff-delivered approaches. PMID:23837807

Concussion - what to ask your doctor - adult

MedlinePlus

... Adult brain injury - what to ask your doctor; Traumatic brain injury - what to ask the doctor ... Begaz T. Traumatic brain injury (adult). In: Adams JG, ed. Emergency Medicine . 2nd ed. Philadelphia, PA: Elsevier Saunders; 2013:chap 73. Giza CC, ...

A Patient-Centered Emergency Department Management Strategy for Sickle-Cell Disease Super-Utilizers.

PubMed

Simpson, Grant G; Hahn, Hallie R; Powel, Alex A; Leverence, Robert R; Morris, Linda A; Thompson, Lara G; Zumberg, Marc S; Borde, Deepa J; Tyndall, Joseph A; Shuster, Jonathan J; Yealy, Donald M; Allen, Brandon R

2017-04-01

A subpopulation of sickle-cell disease patients, termed super-utilizers, presents frequently to emergency departments (EDs) for vaso-occlusive events and may consume disproportionate resources without broader health benefit. To address the healthcare needs of this vulnerable patient population, we piloted a multidisciplinary intervention seeking to create and use individualized patient care plans that alter utilization through coordinated care. Our goals were to assess feasibility primarily, and to assess resource use secondarily. We evaluated the effects of a single-site interventional study targeted at a population of adult sickle-cell disease super-utilizers using a pre- and post-implementation design. The pre-intervention period was 06/01/13 to 12/31/13 (seven months) and the post-intervention period was 01/01/14 to 02/28/15 (14 months). Our approach included patient-specific best practice advisories (BPA); an ED management protocol; and formation of a "medical home" for these patients. For 10 subjects targeted initially we developed and implemented coordinated care plans; after deployment, we observed a tendency toward reduction in ED and inpatient utilization across all measured indices. Between the annualized pre- and post-implementation periods we found the following: ED visits decreased by 16.5 visits/pt-yr (95% confidence interval [CI] [-1.32-34.2]); ED length of state (LOS) decreased by 115.3 hours/pt-yr (95% CI [-82.9-313.5]); in-patient admissions decreased by 4.20 admissions/pt-yr (95% CI [-1.73-10.1]); in-patient LOS decreased by 35.8 hours/pt-yr (95% CI [-74.9-146.7]); and visits where the patient left before treatment were reduced by an annualized total of 13.7 visits. We observed no patient mortality in our 10 subjects, and no patient required admission to the intensive care unit 72 hours following discharge. This effort suggests that a targeted approach is both feasible and potentially effective, laying a foundation for broader study.

Timing of intubation and ventilator-associated pneumonia following injury.

PubMed

Evans, Heather L; Zonies, David H; Warner, Keir J; Bulger, Eileen M; Sharar, Sam R; Maier, Ronald V; Cuschieri, Joseph

2010-11-01

In an emergency medical system with established rapid-sequence intubation protocols, prehospital (PH) intubation of patients with trauma is not associated with a higher rate of ventilator-associated pneumonia (VAP) than emergency department (ED) intubation. Retrospective observational cohort. Level I trauma center. Adult patients with trauma intubated in a PH or an ED setting from July 1, 2007, through July 31, 2008. Diagnosis of VAP by means of bronchoscopic alveolar lavage or clinical assessment when bronchoscopic alveolar lavage was impossible. Secondary outcomes included time to VAP, length of hospitalization, and in-hospital mortality. Of 572 patients, 412 (72.0%) underwent PH intubation. The ED group was older than the PH group (mean ages, 46.4 vs 39.1 years; P < .001) and had a higher incidence of blunt injury (142 [88.8%] vs 322 [78.2%]; P = .002). The mean (SD) lowest recorded ED systolic blood pressure was lower in the ED group (102.8 [1.9] vs 111.4 [1.2] mm Hg; P < .001), despite similar mean injury severity scores in both groups (27.2 [0.7] vs 27.0 [1.1]; P = .94). There was no difference in the mean rate of VAP (30 [18.8%] vs 71 [17.2%]; P = .66) or mean time to diagnosis (8.1 [1.2] vs 7.8 [1.0] days; P = .89). Logistic regression analysis identified history of drug abuse, lowest recorded ED systolic blood pressure, and injury severity score as 3 independent factors predictive of VAP. Prehospital intubation of patients with trauma is not associated with higher risk of VAP. Further investigation of intubation factors and the incidence and timing of aspiration is required to identify potentially modifiable factors to prevent VAP.

Eating-related Psychopathology and Food Addiction in Adolescent Psychiatric Inpatients.

PubMed

Albayrak, Özgür; Föcker, Manuel; Kliewer, Josephine; Esber, Simon; Peters, Triinu; de Zwaan, Martina; Hebebrand, Johannes

2017-05-01

Our aims were to investigate the relationship between food addiction and mental disorders including eating disorders (ED), eating-related psychopathology and body mass index-standard deviation score in a sample of adolescent psychiatric inpatients. Food addiction was assessed with the Yale Food Addiction Scale (YFAS). Eating-related psychopathology was measured with the Three-Factor Eating Questionnaire (TFEQ). Psychiatric diagnoses were assessed according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. The sample consisted of n = 242 adolescent psychiatric inpatients, of which n = 37 (15.3%) met criteria for an ED. Multiple regression analysis was used to examine the association between YFAS symptom count, TFEQ scales and ED controlling for age and gender. Food addiction frequency was 16.5%, and the mean YFAS symptom count was 2.39 (SD: 1.60). In patients with food addiction, TFEQ scale scores were significantly higher than patients without food addiction. Frequency of ED was 42.9% in patients with and 9.9% in patients without food addiction. The TFEQ subscales disinhibition and hunger as well as diagnosis of ED were associated with YFAS symptom count. Food addiction in adolescent psychiatric inpatients occurs with rates higher than those seen in community samples of children, adolescents and adults. Food addiction might be associated with eating styles related to susceptibility to hunger and feelings of loss of control. The implications of high-YFAS scores in restricting-type anorexia nervosa warrant further investigations to explore which and how the respective items are interpreted in this ED subgroup. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

Efficacy of emergency department-based interventions designed to reduce repeat visits and other adverse outcomes for older patients after discharge: A systematic review.

PubMed

Karam, Grace; Radden, Zoe; Berall, Laura E; Cheng, Catherine; Gruneir, Andrea

2015-09-01

There is an urgent need for effective geriatric interventions to meet the health service demands of the growing older population. In this paper, we systematically review and update existing literature on interventions within emergency departments (ED) targeted towards reducing ED re-visits, hospitalizations, nursing home admissions and deaths in older patients after initial ED discharge. Databases Medline, CINAHL, Embase and Web of Science were searched to identify all articles published up to June 2012 that focused on older adults in the ED, included a comparison group, and reported quantitative results in four primary outcomes: ED re-visits, hospitalizations, nursing home admissions and death after initial ED discharge. Of the 2826 titles screened, just nine studies met our inclusion criteria. The studies varied in their design and outcome measurements such that results could not be combined. Two trends surfaced: (i) more intensive interventions more frequently resulted in reduced adverse outcomes than did simple referral intervention types; and (ii) among the lowest intensity, referral-based interventions, studies that used a validated prediction tool to identify high-risk patients more frequently reported improved outcomes than those that did not use such a tool. Of the few studies that met the inclusion criteria, there was a lack of consistency and clarity in study designs and evaluative outcomes. Despite this, more intensive interventions that followed patients beyond a referral and the use of a clinical risk prediction tool appeared to be associated with improved outcomes. The dearth of rigorous evaluations with standardized methodologies precludes further recommendations. © 2015 The Authors. Geriatrics & Gerontology International published by Wiley Publishing Asia Pty Ltd on behalf of Japan Geriatrics Society.

Efficacy of emergency department‐based interventions designed to reduce repeat visits and other adverse outcomes for older patients after discharge: A systematic review

PubMed Central

Karam, Grace; Radden, Zoe; Berall, Laura E; Cheng, Catherine

2015-01-01

Aim There is an urgent need for effective geriatric interventions to meet the health service demands of the growing older population. In this paper, we systematically review and update existing literature on interventions within emergency departments (ED) targeted towards reducing ED re‐visits, hospitalizations, nursing home admissions and deaths in older patients after initial ED discharge. Methods Databases Medline, CINAHL, Embase and Web of Science were searched to identify all articles published up to June 2012 that focused on older adults in the ED, included a comparison group, and reported quantitative results in four primary outcomes: ED re‐visits, hospitalizations, nursing home admissions and death after initial ED discharge. Results Of the 2826 titles screened, just nine studies met our inclusion criteria. The studies varied in their design and outcome measurements such that results could not be combined. Two trends surfaced: (i) more intensive interventions more frequently resulted in reduced adverse outcomes than did simple referral intervention types; and (ii) among the lowest intensity, referral‐based interventions, studies that used a validated prediction tool to identify high‐risk patients more frequently reported improved outcomes than those that did not use such a tool. Conclusion Of the few studies that met the inclusion criteria, there was a lack of consistency and clarity in study designs and evaluative outcomes. Despite this, more intensive interventions that followed patients beyond a referral and the use of a clinical risk prediction tool appeared to be associated with improved outcomes. The dearth of rigorous evaluations with standardized methodologies precludes further recommendations. Geriatr Gerontol Int 2015; 15: 1107–1117. PMID:26171554

All purulence is local – epidemiology and management of skin and soft tissue infections in three urban emergency departments

PubMed Central

2013-01-01

Background Skin and soft tissue infection (SSTIs) are commonly treated in emergency departments (EDs). While the precise role of antibiotics in treating SSTIs remains unclear, most SSTI patients receive empiric antibiotics, often targeted toward methicillin-resistant Staphylococcus aureus (MRSA). The goal of this study was to assess the efficiency with which ED clinicians targeted empiric therapy against MRSA, and to identify factors that may allow ED clinicians to safely target antibiotic use. Methods We performed a retrospective analysis of patient visits for community-acquired SSTIs to three urban, academic EDs in one northeastern US city during the first quarter of 2010. We examined microbiologic patterns among cultured SSTIs, and relationships between clinical and demographic factors and management of SSTIs. Results Antibiotics were prescribed to 86.1% of all patients. Though S. aureus (60% MRSA) was the most common pathogen cultured, antibiotic susceptibility differed between adult and pediatric patients. Susceptibility of S. aureus from ED SSTIs differed from published local antibiograms, with greater trimethoprim resistance and less fluoroquinolone resistance than seen in S. aureus from all hospital sources. Empiric antibiotics covered the resultant pathogen in 85.3% of cases, though coverage was frequently broader than necessary. Conclusions Though S. aureus remained the predominant pathogen in community-acquired SSTIs, ED clinicians did not accurately target therapy toward the causative pathogen. Incomplete local epidemiologic data may contribute to this degree of discordance. Future efforts should seek to identify when antibiotic use can be narrowed or withheld. Local, disease-specific antibiotic resistance patterns should be publicized with the goal of improving antibiotic stewardship. PMID:24359038

Current variability of clinical practice management of pediatric diabetic ketoacidosis in Illinois pediatric emergency departments.

PubMed

Barrios, Ellen K; Hageman, Joseph; Lyons, Evelyn; Janies, Kathryn; Leonard, Daniel; Duck, Stephen; Fuchs, Susan

2012-12-01

This study aimed to investigate the management of pediatric patients with diabetic ketoacidosis (DKA) presenting to emergency departments (EDs) participating in the Illinois Emergency Medical Services for Children (EMSC) Facility Recognition program. In 2010, Illinois EMSC conducted a survey (including case scenarios) and medical record review regarding management of pediatric patients with DKA. Data were submitted by 116 EDs. Survey response rate was 94%. Only 34% of EDs had a documented DKA guideline/policy; 37% reported that they did not have hospital adult or pediatric endocrinology services. Case scenarios identified a high percentage of respondents given an intravenous (IV) isotonic sodium chloride solution of 10 to 20 mL/kg during the first hour. However 17% to 21% would use an alternative choice such as administering initial IV solution of 0.45 sodium chloride, initiating an insulin drip before fluids, or waiting for more laboratory results before giving fluids or insulin. A total of 532 medical record reviews were submitted. In 87% of records, patients received an initial IV isotonic sodium chloride solution within the first hour. In 74%, patients received IV insulin infusion/drip (0.1 U/kg/h) after the initial fluid bolus. Of the patients, 51% were transferred to another facility; 22% were admitted to an intensive care unit. Best ED practice management of pediatric DKA includes establishing a specific guideline/protocol and ensuring access to a pediatric endocrinologist. Both were identified as improvement areas in this project. Illinois EMSC has developed an educational module and provided direct feedback to all participating EDs, to improve their management of pediatric patients with DKA.

Comparative Analgesic Efficacy of Oxycodone/Acetaminophen vs Codeine/Acetaminophen for Short-Term Pain Management Following ED Discharge.

PubMed

Chang, Andrew K; Bijur, Polly E; Lupow, Jason B; Gallagher, E John

2015-12-01

To test the hypothesis that oxycodone/acetaminophen provides analgesia superior to codeine/acetaminophen following emergency department (ED) discharge. Prospective, randomized, double-blind, trial. Adult inner city ED. ED patients with acute extremity pain who were discharged home. Patients randomized to oxycodone/acetaminophen (5 mg/325 mg) or codeine/acetaminophen (30 mg/300 mg). The primary outcome, obtained via telephone one day after ED discharge, was the between-group difference in improvement in numerical rating scale (NRS) pain scores over a 2-hour period following the most recent ingestion of study drug. Secondary outcomes included proportion of patients with >50% pain reduction, side-effect profile, and patient satisfaction. Two hundred and forty patients were enrolled. Mean baseline NRS scores were 7.9 in both groups. Mean decrease over 2 hours was 4.5 NRS units in the oxycodone/acetaminophen group vs 4.2 NRS units in the codeine/acetaminophen group, for a clinically and statistically nonsignificant difference of 0.2 NRS units (95% CI -0.4-0.9 NRS units). Similarly, 66% vs 61% achieved >50% pain relief for a nonsignificant difference of 5% (95% CI -8% to 17%). Side-effect profile and patient satisfaction were similar. Our hypothesis that oxycodone/acetaminophen provides analgesia superior to codeine/acetaminophen was rejected. Although pain within each group was reduced by more than half, the between-group difference was not significant. Pending independent validation, these unexpected findings suggest that codeine/acetaminophen, a Schedule III agent, may be a clinically reasonable outpatient opioid alternative to oxycodone/acetaminophen, a more tightly restricted Schedule II agent thought to be more prone to misuse. Wiley Periodicals, Inc.

DOE Office of Scientific and Technical Information (OSTI.GOV)

Wang, C; Nguyen, G; Chung, Y

Purpose: Ureteroscopy involves fluoroscopy which potentially results in considerable amount of radiation dose to the patient. Purpose of this study was two-fold: (a) to develop the effective dose computational model for obese and non-obese patients undergoing left and right ureteroscopy, and (b) to evaluate the utility of a commercial Monte Carlo software for dose assessment in ureteroscopy. Methods: Organ dose measurements were performed on an adult male anthropomorphic phantom, representing the non-obese patients, with 20 high-sensitivity MOSFET detectors and two 0.18cc ionization chambers placed in selected organs. Fat-equivalent paddings were placed around the abdominal region to simulate for obese patients.more » Effective dose (ED) was calculated using ICRP 103 tissue weighting factors and normalized to the effective dose rate in miliSivert per second (mSv/s). In addition, a commercial Monte Carlo (MC) dose estimation program was used to estimate ED for the non-obese model, with table attenuation correction applied to simulate clinical procedure. Results: For the equipment and protocols involved in this study, the MOSFETderived ED rates for the obese patient model (‘Left’: 0.0092±0.0004 mSv/s; ‘Right’: 0.0086±0.0004 mSv/s) was found to be more than twice as much as that to the non-obese patient model (‘Left’: 0.0041±0.0003 mSv/s; ‘Right’: 0.0036±0.0007 mSv/s). The MC-derived ED rates for the non-obese patient model (‘Left’: 0.0041 mSv/s; ‘Right’: 0.0036 mSv/s; with statistical uncertainty of 1%) showed a good agreement with the MOSFET method. Conclusion: The significant difference in ED rate between the obese and non-obese patient models shows the limitation of directly applying commercial softwares for obese patients and leading to considerable underestimation of ED. Although commercial softwares offer a convenient means of dose estimation, but the utility may be limited to standard-man geometry as the software does not account for table attenuation, obese patient geometry, and differences between the anthropomorphic phantom and MC mathematical phantom.« less

Patient perspectives on communication with the medical team: pilot study using the Communication Assessment Tool-Team (CAT-T).

PubMed

Mercer, Laura Min; Tanabe, Paula; Pang, Peter S; Gisondi, Michael A; Courtney, D Mark; Engel, Kirsten G; Donlan, Sarah M; Adams, James G; Makoul, Gregory

2008-11-01

Effective communication is an essential aspect of high-quality patient care and a core competency for physicians. To date, assessment of communication skills in team-based settings has not been well established. We sought to tailor a psychometrically validated instrument, the Communication Assessment Tool, for use in Team settings (CAT-T), and test the feasibility of collecting patient perspectives of communication with medical teams in the emergency department (ED). A prospective, cross-sectional study in an academic, tertiary, urban, Level 1 trauma center using the CAT-T, a 15-item instrument. Items were answered via a 5-point scale, with 5 = excellent. All adult ED patients (> or = 18 y/o) were eligible if the following exclusion criteria did not apply: primary psychiatric issues, critically ill, physiologically unstable, non-English speaking, or under arrest. 81 patients were enrolled (mean age: 44, S.D. = 17; 44% male). Highest ratings were for treating the patient with respect (69% excellent), paying attention to the patient (69% excellent), and showing care and concern (69% excellent). Lowest ratings were for greeting the patient appropriately (54%), encouraging the patient to ask questions (54%), showing interest in the patient's ideas about his or her health (53% excellent), and involving the patient in decisions as much as he or she wanted (53% excellent). Although this pilot study has several methodological limitations, it demonstrates a signal that patient assessment of communication with the medical team is feasible and offers important feedback. Results indicate the need to improve communication in the ED. In the ED, focusing on the medical team rather then individual caregivers may more accurately reflect patients' experience.

Improving emergency care pathways: an action research approach.

PubMed

Endacott, Ruth; Cooper, Simon; Sheaff, Rod; Padmore, Jacqueline; Blakely, Gillian

2011-03-01

Clinicians and managers across specialities are under pressure to review treatment and referral pathways to enable evidence-based practice, improve patient flow and provide a seamless service. This study outlines the processes and outcomes of an action research study conducted to reduce inappropriate attendances and unplanned pressures on Emergency Department (ED) staff in an English hospital during 2006-2008. Action research, comprising three action/reflection cycles conducted with participants, was used. Data were collected using retrospective patient record review (n=35,200) interviews with staff members (n=28), observation of patient pathways (n=38 patients) and measurement of team climate (n=31) with literature reviews also informing each cycle of data collection. ED attendance and hospital emergency admission data were largely similar to the national picture with regards to time/day of attendance and seasonal variation. However, in the 'adult majors' subgroup, mean attendance on a Monday was significantly higher than the rest of the week (p<0.001) and 36% were self-referrals. Observation data revealed that patients were informally assessed by reception staff and directed to majors or minors; this practice was replaced by reinstatement of triage. Patients identified as 'inappropriate' were managed inconsistently, irrespective of department workload. ED attendance decreased as the project progressed and the number of attendees resulting in hospital admission rose slightly. Study data suggest that inappropriate attendances decreased; however, data collection exposed gaps in the existing management information systems and inconsistencies in working practices in the ED. Action research can have a practical value besides contributing to knowledge.

Patterns of Emergency Department Use Among Long-Stay Nursing Home Residents With Differing Levels of Dementia Severity.

PubMed

LaMantia, Michael A; Lane, Kathleen A; Tu, Wanzhu; Carnahan, Jennifer L; Messina, Frank; Unroe, Kathleen T

2016-06-01

To describe emergency department (ED) utilization among long-stay nursing home residents with different levels of dementia severity. Retrospective cohort study. Public Health System. A total of 4491 older adults (age 65 years and older) who were long-stay nursing home residents. Patient demographics, dementia severity, comorbidities, ED visits, ED disposition decisions, and discharge diagnoses. Forty-seven percent of all long-stay nursing home residents experienced at least 1 transfer to the ED over the course of a year. At their first ED transfer, 36.4% of the participants were admitted to the hospital, whereas 63.1% of those who visited the ED were not. The median time to first ED visit for the participants with advanced stage dementia was 258 days, whereas it was 250 days for the participants with early to moderate stage dementia and 202 days for the participants with no dementia (P = .0034). Multivariate proportional hazard modeling showed that age, race, number of comorbidities, number of hospitalizations in the year prior, and do not resuscitate status all significantly influenced participants' time to first ED visit (P < .05 for all). After accounting for these effects, dementia severity (P = .66), years in nursing home before qualification (P = .46), and gender (P = .36) lost their significance. This study confirms high rates of transfer of long-stay nursing home residents, with nearly one-half of the participants experiencing at least 1 ED visit over the course of a year. Although dementia severity is not a predictor of time to ED use in our analyses, other factors that influence ED use are readily identifiable. Nursing home providers should be aware of these factors when developing strategies that meet patient care goals and avoid transfer from the nursing home to the ED. Copyright © 2016 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.

Redesigned geriatric emergency care may have helped reduce admissions of older adults to intensive care units.

PubMed

Grudzen, Corita; Richardson, Lynne D; Baumlin, Kevin M; Winkel, Gary; Davila, Carine; Ng, Kristen; Hwang, Ula

2015-05-01

Charged with transforming geriatric emergency care by applying palliative care principles, a process improvement team at New York City's Mount Sinai Medical Center developed the GEDI WISE (Geriatric Emergency Department Innovations in Care through Workforce, Informatics, and Structural Enhancements) model. The model introduced workforce enhancements for emergency department (ED) and adjunct staff, including role redefinition, retraining, and education in palliative care principles. Existing ED triage nurses screened patients ages sixty-five and older to identify those at high risk of ED revisit and hospital readmission. Once fully trained, these nurses screened all but 6 percent of ED visitors meeting the screening criteria. Newly hired ED nurse practitioners identified high-risk patients suitable for and desiring palliative and hospice care, then expedited referrals. Between January 2011 and May 2013 the percentage of geriatric ED admissions to the intensive care unit fell significantly, from 2.3 percent to 0.9 percent, generating an estimated savings of more than $3 million to Medicare. The decline in these admissions cannot be confidently attributed to the GEDI WISE program because other geriatric care innovations were implemented during the study period. GEDI WISE programs are now running at Mount Sinai and two partner sites, and their potential to affect the quality and value of geriatric emergency care continues to be examined. Project HOPE—The People-to-People Health Foundation, Inc.

Risk for Clinically Relevant Adverse Cardiac Events in Patients With Chest Pain at Hospital Admission.

PubMed

Weinstock, Michael B; Weingart, Scott; Orth, Frank; VanFossen, Douglas; Kaide, Colin; Anderson, Judy; Newman, David H

2015-07-01

Patients with potentially ischemic chest pain are commonly admitted to the hospital or observed after a negative evaluation in the emergency department (ED) owing to concern about adverse events. Previous studies have looked at 30-day mortality, but no current large studies have examined the most important information regarding ED disposition: the short-term risk for a clinically relevant adverse cardiac event (including inpatient ST-segment elevation myocardial infarction, life-threatening arrhythmia, cardiac or respiratory arrest, or death). To determine the incidence of clinically relevant adverse cardiac events in patients hospitalized for chest pain with 2 troponin-negative findings, nonconcerning initial ED vital signs, and nonischemic, interpretable electrocardiographic findings. We conducted a blinded data review of 45,416 encounters obtained from a prospectively collected database enrolling adult patients admitted or observed with the following inclusion criteria: (1) primary presenting symptom of chest pain, chest tightness, chest burning, or chest pressure and (2) negative findings for serial biomarkers. Data were collected and analyzed from July 1, 2008, through June 30, 2013, from the EDs of 3 community teaching institutions with an aggregate census of more than 1 million visits. We analyzed data extracted by hypothesis-blinded abstractors. The primary outcome was a composite of life-threatening arrhythmia, inpatient ST-segment elevation myocardial infarction, cardiac or respiratory arrest, or death during hospitalization. Of the 45,416 encounters, 11,230 met criteria for inclusion. Mean patient age was 58.0 years. Of the 11 230 encounters, 44.83% of patients arrived by ambulance and 55.00% of patients were women. Relevant history included hypertension in 46.00%, diabetes mellitus in 19.72%, and myocardial infarction in 13.16%. The primary end point occurred in 20 of the 11 230 patients (0.18% [95% CI, 0.11%-0.27%]). After excluding patients with abnormal vital signs, electrocardiographic ischemia, left bundle branch block, or a pacemaker rhythm, we identified a primary end point event in 4 of 7266 patients (0.06% [95% CI, 0.02%-0.14%]). Of these events, 2 were noncardiac and 2 were possibly iatrogenic. In adult patients with chest pain admitted with 2 negative findings for serial biomarkers, nonconcerning vital signs, and nonischemic electrocardiographic findings, short-term clinically relevant adverse cardiac events were rare and commonly iatrogenic, suggesting that routine inpatient admission may not be a beneficial strategy for this group.

Emergency Department Presentations for Injuries in Older Adults Independently Known to be Victims of Elder Abuse

PubMed Central

Rosen, Tony; Bloemen, Elizabeth M.; LoFaso, Veronica M.; Clark, Sunday; Flomenbaum, Neal; Lachs, Mark S.

2015-01-01

Background Elder abuse is under-recognized by Emergency Department (ED) providers, largely due to challenges distinguishing between abuse and accidental trauma. Objective To describe patterns and circumstances surrounding elder abuse-related and potentially abuse-related injuries in ED patients independently known to be physical elder abuse victims. Methods ED utilization of community-dwelling victims of physical elder abuse in New Haven, CT from 1981-1994 was analyzed previously. Cases were identified using Elderly Protective Services data matched to ED records. 66 ED visits were judged to have high probability of being related to elder abuse and 244 of indeterminate probability. We re-examined these visits to assess whether they occurred due to injury. We identified and analyzed in detail 31 injury-associated ED visits from 26 patients with high probability of being related to elder abuse and 108 visits from 57 patients with intermediate probability and accidental injury. Results Abuse-related injuries were most common on upper extremities (45% of visits) and lower extremities (32%), with injuries on head or neck noted in 13 visits (42%). Bruising was observed in 39% of visits, most commonly on upper extremities. 42% of purportedly accidental injuries had suspicious characteristics, with the most common suspicious circumstance being injury occurring >1 day prior to presentation and the most common suspicious injury pattern being maxillofacial injuries. Conclusion Victims of physical elder abuse commonly have injuries on upper extremities, head, and neck. Suspicious circumstances and injury patterns may be identified and are commonly present when victims of physical elder abuse present with purportedly accidental injuries. PMID:26810019

Hyperthyroidism

MedlinePlus

... Larsen PR, Kronenberg HM, eds. Williams Textbook of Endocrinology . 13th ed. Philadelphia, PA: Elsevier; 2016:chap 12. ... Groot LJ, de Kretser DM, et al, eds. Endocrinology: Adult and Pediatric . 7th ed. Philadelphia, PA: Elsevier ...

Osteomalacia

MedlinePlus

... Larsen PR, Kronenberg HM, eds. Williams Textbook of Endocrinology . 13th ed. Philadelphia, PA: Elsevier; 2016:chap 28. ... Groot LJ, de Kretser DM, et al, eds. Endocrinology: Adult and Pediatric . 7th ed. Philadelphia, PA: Elsevier ...

Mittelschmerz

MedlinePlus

... Little M, eds. Textbook of Adult Emergency Medicine . 4th ed. Philadelphia, PA: Elsevier Churchill Livingstone; 2015:626- ... abdomen. In: Goldbloom RB, eds. Pediatric Clinical Skills . 4th ed. Philadelphia, PA: Elsevier Saunders; 2011:chap 12. ...

Nocturnal emergency department visits, duration of symptoms and risk of hospitalisation among adults with asthma exacerbations: a multicentre observational study.

PubMed

Yasuda, Hideto; Hagiwara, Yusuke; Watase, Hiroko; Hasegawa, Kohei

2016-08-12

We sought to compare the characteristics of patients with asthma presenting to the emergency department (ED) during the night-time with those of patients presenting at other times of the day, and to determine whether the time of ED presentation is associated with the risk of hospitalisation. A multicentre chart review study of 23 EDs across Japan. Patients aged 18-54 years with a history of physician-diagnosed asthma, presented to the ED between January 2009 and December 2011 OUTCOME MEASURES: The outcome of interest was hospitalisation, including admissions to an observation unit, inpatient unit and intensive care unit. Among the 1354 patients (30.1% in the night-time group vs 69.9% in the other time group) included in this study, the median age was 34 years and ∼40% were male. Overall 145 patients (10.7%) were hospitalised. Patients in the night-time group were more likely to have a shorter duration of symptoms (≤3 hours) before ED presentation than those in the other time group (25.9% in night-time vs 13.4% in other times; p<0.001). In contrast, there were no significant differences in respiratory rate, initial peak expiratory flow or ED asthma treatment between the two groups (p>0.05). Similarly, the risk of hospitalisation did not differ between the two groups (11.3% in night-time vs 10.5% in other times; p=0.65). In a multivariable model adjusting for potential confounders, the risk of hospitalisation in the night-time group was not statistically different from the other time group (OR, 1.10; 95% CI 0.74 to 1.61; p=0.63). This multicentre study in Japan demonstrated no significant difference in the risk of hospitalisations according to the time of ED presentation. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Contingent Valuation Analysis of an Otolaryngology and Ophthalmology Emergency Department: The Value of Acute Specialty Care.

PubMed

Naunheim, Matthew R; Kozin, Elliot D; Sethi, Rosh K; Ota, H G; Gray, Stacey T; Shrime, Mark G

2017-03-01

Specialty emergency departments (EDs) provide a unique mechanism of health care delivery, but the value that they add to the medical system is not known. Evaluation of patient preferences to determine value can have a direct impact on resource allocation and direct-to-specialist care. To assess the feasibility of contingent valuation (CV) methodology using a willingness-to-pay (WTP) survey to evaluate specialty emergency services, in the context of an ophthalmology- and otolaryngology-specific ED. Contingent valuation analysis of a standalone otolaryngology and ophthalmology ED. Participants were English-speaking adults presenting to a dedicated otolaryngology and ophthalmology ED. The WTP questions were assessed using a payment card format, with reference to an alternative modality of treatment (ie, general ED), and were analyzed with multivariate regression. Validated WTP survey administered from October 14, 2014, through October 1, 2015. Sociodemographic data, level of distress, referral data, income, and WTP. A total of 327 of 423 (77.3%) ED patients responded to the WTP survey, with 116 ophthalmology and 211 otolaryngology patients included (52.3% female; mean [range] age, 46 [18-90] years). The most common reason for seeking care at this facility was a reputation for specialty care for both ear, nose, and throat (80 [37.9%]) and ophthalmology (43 [37.1%]). Mean WTP for specialty-specific ED services was $377 for ophthalmology patients, and $321 for otolaryngology patients ($340 overall; 95% CI, $294 to $386), without significant difference between groups (absolute difference, $56; 95% CI, $-156 to $43). Self-reported level of distress was higher among ear, nose, and throat vs ophthalmology patients (absolute difference, 0.47 on a Likert scale of 1-7; 95% CI, 0.10 to 0.84). Neither level of distress, income, nor demographic characteristics influenced WTP, but patients with higher estimates of total visit cost were more likely to have higher WTP (β coefficient, 0.27; SE, 0.05; adjusted R2 = 0.17 for model). Patients with eye and ear, nose, and throat complaints place a mean explicit value on specialty emergency services of $340 per visit, relative to general emergency care. Ultimately, CV data using WTP methodology are useful in valuing patient preferences in monetary terms and can help inform state-wide resource allocation and the availability of direct-to-specialist care.

Ethics seminars: a best-practice approach to navigating the against-medical-advice discharge.

PubMed

Clark, Mark A; Abbott, Jean T; Adyanthaya, Tara

2014-09-01

Patients who sign out or choose to leave the emergency department (ED) against medical advice (AMA) present important challenges. The current approach to the complex legal, ethical, and medical challenges that arise when adult patients decline medical care in the ED would benefit from a systematic best-practice strategy to maximize patient care outcomes, minimize legal risk, and reach the optimal ethical standard for this at-risk population. Professional responsibilities generated during an AMA encounter include determination of patient decision-making capacity, balancing protection of patient autonomy with prevention of harm, providing the best alternatives for patients who decline some or all of the proposed plan, negotiating to encourage patients to stay, planning for subsequent care, and documenting what transpired. We present two cases that illustrate key insights into a best-practice approach for emergency physicians (EPs) to address problems arising when patients want or need to leave the ED prior to completion of their care. We propose a practical, systematic framework, "AIMED" (assess, investigate, mitigate, explain, and document), that can be consistently applied in situations where patients consider leaving or do leave before their evaluations and urgent treatment are complete. Our goal is to maximize patient outcomes, minimize legal risk, and encourage a consistent and ethical approach to these vulnerable patients. © 2014 by the Society for Academic Emergency Medicine.

Thyroid ultrasound

MedlinePlus

... imaging. In: Jameson JL, De Groot LJ, eds. Endocrinology: Adult and Pediatric . 7th ed. Philadelphia, PA: Elsevier ... Larsen PR, Kronenberg HM, eds. Williams Textbook of Endocrinology . 13th ed. Philadelphia, PA: Elsevier; 2016:chap 11. ...

Cataract - adult

MedlinePlus

... JA, Vander JF, eds. Ophthalmology Secrets in Color . 4th ed. Philadelphia, PA: Elsevier; 2015:chap 21. Wevill ... cataract. In: Yanoff M, Duker JS, eds. Ophthalmology . 4th ed. Philadelphia, PA: Elsevier Saunders; 2014:chap 5. ...

Summertime Acute Heat Illness in U.S. Emergency Departments from 2006 through 2010: Analysis of a Nationally Representative Sample

PubMed Central

Saha, Shubhayu; Luber, George

2014-01-01

Background: Patients with acute heat illness present primarily to emergency departments (EDs), yet little is known regarding these visits. Objective: We aimed to describe acute heat illness visits to U.S. EDs from 2006 through 2010 and identify factors associated with hospital admission or with death in the ED. Methods: We extracted ED case-level data from the Nationwide Emergency Department Sample (NEDS) for 2006–2010, defining cases as ED visits from May through September with any heat illness diagnosis (ICD-9-CM 992.0–992.9). We correlated visit rates and temperature anomalies, analyzed demographics and ED disposition, identified risk factors for adverse outcomes, and examined ED case fatality rates (CFR). Results: There were 326,497 (95% CI: 308,372, 344,658) cases, with 287,875 (88.2%) treated and released, 38,392 (11.8%) admitted, and 230 (0.07%) died in the ED. Heat illness diagnoses were first-listed in 68%. 74.7% had heat exhaustion, 5.4% heat stroke. Visit rates were highly correlated with annual temperature anomalies (Pearson correlation coefficient 0.882, p = 0.005). Treat-and-release rates were highest for younger adults (26.2/100,000/year), whereas hospitalization and death-in-the-ED rates were highest for older adults (6.7 and 0.03/100,000/year, respectively); all rates were highest in rural areas. Heat stroke had an ED CFR of 99.4/10,000 (95% CI: 78.7, 120.1) visits and was diagnosed in 77.0% of deaths. Adjusted odds of hospital admission or death in the ED were higher among elders, males, urban and low-income residents, and those with chronic conditions. Conclusions: Heat illness presented to the ED frequently, with highest rates in rural areas. Case definitions should include all diagnoses. Visit rates were correlated with temperature anomalies. Heat stroke had a high ED CFR. Males, elders, and the chronically ill were at greatest risk of admission or death in the ED. Chronic disease burden exponentially increased this risk. Citation: Hess JJ, Saha S, Luber G. 2014. Summertime acute heat illness in U.S. emergency departments from 2006 through 2010: analysis of a nationally representative sample. Environ Health Perspect 122:1209–1215; http://dx.doi.org/10.1289/ehp.1306796 PMID:24937159

City housing atmospheric pollutant impact on emergency visit for asthma: A classification and regression tree approach.

PubMed

Mazenq, Julie; Dubus, Jean-Christophe; Gaudart, Jean; Charpin, Denis; Viudes, Gilles; Noel, Guilhem

2017-11-01

Particulate matter, nitrogen dioxide (NO 2 ) and ozone are recognized as the three pollutants that most significantly affect human health. Asthma is a multifactorial disease. However, the place of residence has rarely been investigated. We compared the impact of air pollution, measured near patients' homes, on emergency department (ED) visits for asthma or trauma (controls) within the Provence-Alpes-Côte-d'Azur region. Variables were selected using classification and regression trees on asthmatic and control population, 3-99 years, visiting ED from January 1 to December 31, 2013. Then in a nested case control study, randomization was based on the day of ED visit and on defined age groups. Pollution, meteorological, pollens and viral data measured that day were linked to the patient's ZIP code. A total of 794,884 visits were reported including 6250 for asthma and 278,192 for trauma. Factors associated with an excess risk of emergency visit for asthma included short-term exposure to NO 2 , female gender, high viral load and a combination of low temperature and high humidity. Short-term exposures to high NO 2 concentrations, as assessed close to the homes of the patients, were significantly associated with asthma-related ED visits in children and adults. Copyright © 2017 Elsevier Ltd. All rights reserved.

Type 1 diabetes

MedlinePlus

... Larsen PR, Kronenberg HM, eds. Williams Textbook of Endocrinology . 13th ed. Philadelphia, PA: Elsevier; 2016:chap 32. ... Groot LJ, de Kretser DM, et al, eds. Endocrinology: Adult and Pediatric . 7th ed. Philadelphia, PA: Elsevier ...

Calcitonin blood test

MedlinePlus

... Larsen PR, Kronenberg HM, eds. Williams Textbook of Endocrinology . 13th ed. Philadelphia, PA: Elsevier; 2016:chap 28. ... Groot LJ, de Kretser DM, et al, eds. Endocrinology: Adult and Pediatric . 7th ed. Philadelphia, PA: Elsevier ...

Type 2 diabetes

MedlinePlus

... Groot LJ, de Kretser DM, et al, eds. Endocrinology: Adult and Pediatric. 7th ed. Philadelphia, PA: Elsevier ... Larsen PR, Kronenberg HM, eds. Williams Textbook of Endocrinology . 13th ed. Philadelphia, PA: Elsevier; 2016:chap 31. ...

Radioactive iodine uptake

MedlinePlus

... Larsen PR, Kronenberg HM, eds. Williams Textbook of Endocrinology . 13th ed. Philadelphia, PA: Elsevier; 2016:chap 11. ... Groot LJ, de Kretser DM, et al, eds. Endocrinology: Adult and Pediatric . 7th ed. Philadelphia, PA: Elsevier ...

T4 test

MedlinePlus

... Larsen PR, et al, eds. Williams Textbook of Endocrinology . 12th ed. Philadelphia, PA: Elsevier Saunders; 2011:chap ... testing. In: Jameson JL, De Groot LJ, eds. Endocrinology: Adult and Pediatric . 7th ed. Philadelphia, PA: Elsevier ...

Antithyroid microsomal antibody

MedlinePlus

... Larsen PR, et al, eds. Williams Textbook of Endocrinology . 12th ed. Philadelphia, PA: Elsevier; 2016:chap 11. ... testing. In: Jameson JL, De Groot LJ, eds. Endocrinology: Adult and Pediatric . 7th ed. Philadelphia, PA: Elsevier ...

TBG - blood test

MedlinePlus

... Larsen PR, Kronenberg HM, eds. Williams Textbook of Endocrinology . 13th ed. Philadelphia, PA: Elsevier; 2016:chap 11. ... Groot LJ, de Kretser DM, et al, eds. Endocrinology: Adult and Pediatric . 7th ed. Philadelphia, PA: Elsevier ...

T3 test

MedlinePlus

... Larsen PR, Kronenberg HM, eds. Williams Textbook of Endocrinology . 13th ed. Philadelphia, PA: Elsevier; 2016:chap 11. ... Groot LJ, de Kretser DM, et al, eds. Endocrinology: Adult and Pediatric . 7th ed. Philadelphia, PA: Elsevier ...

Intrauterine devices (IUD)

MedlinePlus

... Groot LJ, de Kretser DM, et al, eds. Endocrinology: Adult and Pediatric . 7th ed. Philadelphia, PA: Elsevier ... Strauss JF, Barbieri RL, eds. Yen & Jaffe's Reproductive Endocrinology . 7th ed. Philadelphia, PA: Elsevier Saunders; 2014:chap ...

Utility of brief questionnaires of health-related quality of life (Airways Questionnaire 20 and Clinical COPD Questionnaire) to predict exacerbations in patients with asthma and COPD

PubMed Central

2013-01-01

Background There is some evidence that quality of life measured by long disease-specific questionnaires may predict exacerbations in asthma and COPD, however brief quality of life tools, such as the Airways Questionnaire 20 (AQ20) or the Clinical COPD Questionnaire (CCQ), have not yet been evaluated as predictors of hospital exacerbations. Objectives To determine the ability of brief specific health-related quality of life (HRQoL) questionnaires (AQ20 and CCQ) to predict emergency department visits (ED) and hospitalizations in patients with asthma and COPD, and to compare them to longer disease-specific questionnaires, such as the St George´s Respiratory Questionnaire (SGRQ), the Chronic Respiratory Disease Questionnaire (CRQ) and the Asthma Quality of Life Questionnaire (AQLQ). Methods We conducted a two-year prospective cohort study of 208 adult patients (108 asthma, 100 COPD). Baseline sociodemographic, clinical, functional and psychological variables were assessed. All patients completed the AQ20 and the SGRQ. COPD patients also completed the CCQ and the CRQ, while asthmatic patients completed the AQLQ. We registered all exacerbations that required ED or hospitalizations in the follow-up period. Differences between groups (zero ED visits or hospitalizations versus ≥ 1 ED visits or hospitalizations) were tested with Pearson´s X2 or Fisher´s exact test for categorical variables, ANOVA for normally distributed continuous variables, and Mann–Whitney U test for non-normally distributed variables. Logistic regression analyses were performed to estimate the predictive ability of each HRQoL questionnaire. Results In the first year of follow-up, the AQ20 scores predicted both ED visits (OR: 1.19; p = .004; AUC 0.723) and hospitalizations (OR: 1.21; p = .04; AUC 0.759) for asthma patients, and the CCQ emerged as independent predictor of ED visits in COPD patients (OR: 1.06; p = .036; AUC 0.651), after adjusting for sociodemographic, clinical, and psychological variables. Among the longer disease-specific questionnaires, only the AQLQ emerged as predictor of ED visits in asthma patients (OR: 0.9; p = .002; AUC 0.727). In the second year of follow-up, none of HRQoL questionnaires predicted exacerbations. Conclusions AQ20 predicts exacerbations in asthma and CCQ predicts ED visits in COPD in the first year of follow-up. Their predictive ability is similar to or even higher than that of longer disease-specific questionnaires. PMID:23706146

The accuracy of pulse oximetry in emergency department patients with severe sepsis and septic shock: a retrospective cohort study.

PubMed

Wilson, Ben J; Cowan, Hamish J; Lord, Jason A; Zuege, Dan J; Zygun, David A

2010-05-05

Pulse oximetry is routinely used to continuously and noninvasively monitor arterial oxygen saturation (SaO2) in critically ill patients. Although pulse oximeter oxygen saturation (SpO2) has been studied in several patient populations, including the critically ill, its accuracy has never been studied in emergency department (ED) patients with severe sepsis and septic shock. Sepsis results in characteristic microcirculatory derangements that could theoretically affect pulse oximeter accuracy. The purposes of the present study were twofold: 1) to determine the accuracy of pulse oximetry relative to SaO2 obtained from ABG in ED patients with severe sepsis and septic shock, and 2) to assess the impact of specific physiologic factors on this accuracy. This analysis consisted of a retrospective cohort of 88 consecutive ED patients with severe sepsis who had a simultaneous arterial blood gas and an SpO2 value recorded. Adult ICU patients that were admitted from any Calgary Health Region adult ED with a pre-specified, sepsis-related admission diagnosis between October 1, 2005 and September 30, 2006, were identified. Accuracy (SpO2 - SaO2) was analyzed by the method of Bland and Altman. The effects of hypoxemia, acidosis, hyperlactatemia, anemia, and the use of vasoactive drugs on bias were determined. The cohort consisted of 88 subjects, with a mean age of 57 years (19 - 89). The mean difference (SpO2 - SaO2) was 2.75% and the standard deviation of the differences was 3.1%. Subgroup analysis demonstrated that hypoxemia (SaO2 < 90) significantly affected pulse oximeter accuracy. The mean difference was 4.9% in hypoxemic patients and 1.89% in non-hypoxemic patients (p < 0.004). In 50% (11/22) of cases in which SpO2 was in the 90-93% range the SaO2 was <90%. Though pulse oximeter accuracy was not affected by acidoisis, hyperlactatementa, anemia or vasoactive drugs, these factors worsened precision. Pulse oximetry overestimates ABG-determined SaO2 by a mean of 2.75% in emergency department patients with severe sepsis and septic shock. This overestimation is exacerbated by the presence of hypoxemia. When SaO2 needs to be determined with a high degree of accuracy arterial blood gases are recommended.

Effectiveness of Implementing Evidence-based Interventions to Reduce C-spine Image Ordering in the Emergency Department: A Systematic Review.

PubMed

Desai, Shashwat; Liu, Chaocheng; Kirkland, Scott W; Krebs, Lynette D; Keto-Lambert, Diana; Rowe, Brian H

2018-06-01

Appropriate use of imaging for adult patients with cervical spine (C-spine) injuries in the emergency department (ED) is a longstanding issue. Guidance for C-spine ordering exists; however, the effectiveness of the decision support implementation in the ED is not well studied. This systematic review examines the implementation and effectiveness of evidence-based interventions aimed at reducing C-spine imaging in adults presenting to the ED with neck trauma. Six electronic databases and the gray literature were searched. Comparative intervention studies were eligible for inclusion. Two independent reviewers screened for study eligibility, study quality, and extracted data. The change in imaging was reported using individual odds ratios (ORs) with 95% confidence intervals (CIs) using random effects. A total of 990 unique citations were screened for relevance of which six before-after studies and one randomized controlled trial were included. None of the studies were assessed as high quality. Interventions consisted primarily of locally developed guidelines or established clinical decision rules such as the NEXUS or the Canadian C-spine rule. Overall, implementation of interventions aimed at reducing C-spine image ordering resulted in a statistically significant reduction in imaging (OR = 0.69, 95% CI = 0.51-0.93); however, heterogeneity was high (I 2  = 82%). Subgroup analysis revealed no differences between studies that specified enrolling alert and stable patients compared to unspecified trauma (p = 0.81) or between studies employing multifaceted versus nonmultifaceted interventions (p = 0.66). While studies generally provided details on implementation strategies (e.g., teaching sessions, pocket cards, posters, computerized decision support) the effectiveness of these implementation strategies were frequently not reported. There is moderate evidence regarding the effectiveness of interventions to reduce C-spine image ordering in adult patients seen in the ED with neck trauma. Given the national and international focus on improving appropriateness and reducing unnecessary C-spine imaging through campaigns such as Choosing Wisely, additional interventional research in this field is warranted. © 2017 by the Society for Academic Emergency Medicine.

Methoxyflurane Analgesia in Adult Patients in the Emergency Department: A Subgroup Analysis of a Randomized, Double-blind, Placebo-controlled Study (STOP!).

PubMed

Coffey, Frank; Dissmann, Patrick; Mirza, Kazim; Lomax, Mark

2016-11-01

Acute pain remains highly prevalent in the Emergency Department (ED) setting. This double-blind, randomized, placebo-controlled UK study investigated the efficacy and safety of low-dose methoxyflurane analgesia for the treatment of acute pain in the ED in the adult population of the STOP! trial. Patients presenting to the ED requiring analgesia for acute pain (pain score of 4-7 on the Numerical Rating Scale) due to minor trauma were randomized in a 1:1 ratio to receive methoxyflurane (up to 6 mL) or placebo (normal saline), both via a Penthrox ® (Medical Developments International Limited, Scoresby, Australia) inhaler. Rescue medication (paracetamol/opioids) was available immediately upon request. Change from baseline in visual analog scale (VAS) pain intensity was the primary endpoint. 300 adult and adolescent patients were randomized; data are presented for the adult subgroup (N = 204). Mean baseline VAS pain score was ~66 mm in both groups. The mean change from baseline to 5, 10, 15 and 20 min was greater for methoxyflurane (-20.7, -27.4, -33.3 and -34.8 mm, respectively) than placebo (-8.0, -11.1, -12.3 and -15.2 mm, respectively). The primary analysis showed a highly significant treatment effect overall across all four time points (-17.4 mm; 95% confidence interval: -22.3 to -12.5 mm; p < 0.0001). Median time to first pain relief was 5 min with methoxyflurane [versus 20 min with placebo; (hazard ratio: 2.32; 95% CI: 1.63, 3.30; p < 0.0001)]; 79.4% of methoxyflurane-treated patients experienced pain relief within 1-10 inhalations. 22.8% of placebo-treated patients requested rescue medication within 20 min compared with 2.0% of methoxyflurane-treated patients (p = 0.0003). Methoxyflurane treatment was rated 'Excellent', 'Very Good' or 'Good' by 77.6% of patients, 74.5% of physicians and 72.5% of nurses. Treatment-related adverse events (mostly dizziness/headache) were reported by 42.2% of patients receiving methoxyflurane and 14.9% of patients receiving placebo; none caused withdrawal and the majority were mild and transient. The results of this study support the evidence from previous trials that low-dose methoxyflurane administered via the Penthrox inhaler is a well-tolerated, efficacious and rapid-acting analgesic. Medical Developments International (MDI) Limited and Mundipharma Research GmbH & Co.KG. Clinicaltrials.gov identifier: NCT01420159, EudraCT number: 2011-000338-12.

The Benefits and Risks of Energy Drinks in Young Adults and Military Service Members.

PubMed

Manchester, Julianne; Eshel, Inbal; Marion, Donald W

2017-07-01

Energy drinks (EDs) have become an integral part of the young adult, athletic, and military culture. Many athletes are convinced that EDs enhance performance, and service members as well as college students frequently use EDs as stimulants to counter sleep deprivation, or to improve academic performance. However, concerns have been raised by some military leaders about potential adverse effects of EDs. A needs assessment survey of a convenience sample of military health care providers was conducted and identified EDs as a top knowledge need for those providers working in the area of traumatic brain injury (TBI). The instrument demonstrated high interitem consistency (Cronbach's α > .80). To further explore the state of knowledge on EDs, and to prompt further discussion of ED use and how it may related to military treatment protocols and supporting educational products, we conducted a literature review of English language publications listed in the National Library of Medicine using the search term "energy drinks" and published during the last 5 years to determine what is known about EDs in terms of their potential benefits and health risks. The active ingredients in most EDs are caffeine, and to a lesser extent taurine and sugars. Several reports suggest that the combination of these ingredients is more active than the caffeine alone. Despite the positive attributes of EDs, there are increasing reports of serious and potentially life-threatening side effects. Most recently there also has been a dramatic increase in the use of ED/alcohol combination drinks, and there are preliminary studies that suggest important adverse effects with this combination. A 2013 National Institutes of Health expert workshop concluded that more clinical studies are needed to clearly define the health risks associated with ED use. The needs assessment points to a desire for more ED knowledge of health providers working with TBI patients. A few key themes emerged from the exploratory literature review that can be taken into consideration when educating health providers and delivering knowledge-based resources. Adverse effects of EDs are most closely associated with the dose of caffeine consumed. In general, the combination of ED with alcohol should be avoided because the ED can mask the level of intoxication, and the combination may be associated with increased risk-taking behavior. Overall, the risks and benefits of EDs remain controversial and good-quality long-term clinical trials are needed to inform policymaking, regulation, and the development of prevention and treatment resources. Reprint & Copyright © 2017 Association of Military Surgeons of the U.S.

Panic Disorder in Patients Presenting to the Emergency Department With Chest Pain: Prevalence and Presenting Symptoms.

PubMed

Greenslade, Jaimi H; Hawkins, Tracey; Parsonage, William; Cullen, Louise

2017-12-01

Patients with panic disorder experience symptoms such as palpitations, chest pain, dizziness, and breathlessness. Consequently, they may attend the Emergency Department (ED) to be assessed for possible emergency medical conditions. Recognition of panic disorder within the ED is low. We sought to establish the prevalence of panic disorder in patients presenting for ED investigation of potential acute coronary syndrome. We also sought to characterise the cohort of patients with panic disorder in terms of presenting symptoms, risk factors, medical history and major adverse cardiac events (MACE). This was an observational study of 338 adult patients presenting to the Emergency Department of a tertiary hospital in Australia. Research nurses collected clinical data using a customised case report form. The outcome was panic disorder, assessed using the Mini International Neuropsychiatric Interview. The average age of participants was 50.2 years and 37.9% were female. Thirty-day MACE occurred in 7.7% of the cohort. The clinical diagnosis of panic disorder was made in 5.6% (95% CI: 3.4-8.6%) of patients. Compared to patients without panic disorder, patients with panic disorder were slightly more likely to report that their pain felt heavy (48.9% and 73.7% respectively, p=0.04). All other reported symptoms were similar in the two groups. The prevalence of panic disorder was low in patients presenting to an Australian ED with chest pain. Clinical signs or symptoms that are routinely collected as part of the chest pain workup cannot be used to distinguish patients with and without panic disorder. Copyright © 2017 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). All rights reserved.

Deciding about an IUD

MedlinePlus

... Groot LJ, de Krester DM, et al, eds. Endocrinology: Adult and Pediatric . 7th ed. Philadelphia, PA: Elsevier ... Strauss JF, Barbieri RL, eds. Yen & Jaffe's Reproductive Endocrinology . 7th ed. Philadelphia, PA: Elsevier Saunders; 2014:chap ...

T3RU test

MedlinePlus

... Larsen PR, Kronenberg HM, eds. Williams Textbook of Endocrinology . 13th ed. Philadelphia, PA: Elsevier; 2016:chap 11. ... Groot LJ, de Kretser DM, et al, eds. Endocrinology: Adult and Pediatric . 7th ed. Philadelphia, PA: Elsevier ...

Type 2 diabetes - self-care

MedlinePlus

... Larsen PR, Kronenberg HM, eds. Williams Textbook of Endocrinology . 13th ed. Philadelphia, PA: Elsevier; 2016:chap 33. ... Groot LJ, de Kretser DM, et al, eds. Endocrinology: Adult and Pediatric . 7th ed. Philadelphia, PA: Elsevier ...

ACTH (cosyntropin) stimulation test

MedlinePlus

... Groot LJ, de Kretser DM, et al, eds. Endocrinology: Adult and Pediatric . 7th ed. Philadelphia, PA: Elsevier ... Larsen PR, Kronenberg HM, eds. Williams Textbook of Endocrinology . 13th ed. Philadelphia, PA: Elsevier; 2016:chap 15. ...

Women and sexual problems

MedlinePlus

... Larsen PR, Kronenberg HM, eds. Williams Textbook of Endocrinology . 13th ed. Philadelphia, PA: Elsevier; 2016:chap 20. ... Groot LJ, de Kretser DM, et al, eds. Endocrinology: Adult and Pediatric . 7th ed. Philadelphia, PA: Elsevier ...

What causes bone loss?

MedlinePlus

... Larsen PR, Kronenberg HM, eds. Williams Textbook of Endocrinology . 13th ed. Philadelphia, PA: Elsevier; 2016:chap 29. ... Groot LJ, de Kretser DM, et al, eds. Endocrinology: Adult and Pediatric . 7th ed. Philadelphia, PA: Elsevier ...

Chronic thyroiditis (Hashimoto disease)

MedlinePlus

... Groot LJ, de Kretser DM, et al, eds. Endocrinology: Adult and Pediatric . 7th ed. Philadelphia, PA: Elsevier ... Larsen PR, Kronenberg HM, eds. Williams Textbook of Endocrinology . 13th ed. Philadelphia, PA: Elsevier; 2016:chap 13. ...

Periactin overdose

MedlinePlus

... Brown A, Little M, eds. Textbook of Adult Emergency Medicine . 4th ed. Philadelphia, PA: Elsevier Churchill Livingstone; 2015: ... Hockberger RS, Walls RM, et al, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice . 8th ed. Philadelphia, PA: ...

Effects of Education and Health Literacy on Postoperative Hospital Visits in Bariatric Surgery.

PubMed

Mahoney, Stephen T; Tawfik-Sexton, Dahlia; Strassle, Paula D; Farrell, Timothy M; Duke, Meredith C

2018-04-02

Hospital readmissions following bariatric surgery are high and it is necessary to identify modifiable risk factors to minimize this postoperative cost. We hypothesize that lower levels of education and health literacy are associated with increased risks of nonadherence, thus leading to increased emergency department (ED) visits and preventable readmissions postoperatively. Bariatric surgery patients presenting between October 2015 and December 2016 were administered a preoperative questionnaire that measured education level and the Rapid Estimate of Adult Literacy in Medicine-Short Form (REALM-SF) health literacy test. The rates of postoperative ED visits and readmissions were across education levels (≤12th grade versus >12th grade) and health literacy scores (≤8th grade versus high school level). A composite "hospital visit" outcome was also assessed. Ninety-five patients were enrolled; 23 had ≤12th grade level education and 7 scored ≤8th grade on the REALM-SF. Patients with ≤12th grade education were significantly more likely to have a hospital visit after surgery, compared with patients with >12th grade education (incidence rate ratio [IRR] 3.06, P = .008). No significant difference in ED visits, readmission, or hospital visits was seen when stratified by REALM-SF health literacy score. Lower level of education was associated with more than threefold increased risk of postoperative ED visits and readmission in our center's bariatric surgery patients. A patient's education level is a low-cost means to identify patients who are at risk for postoperative hospital visits, and who may benefit from enhanced educational efforts or more intensive postoperative follow-up.

Epidemiology of otologic diagnoses in United States emergency departments.

PubMed

Kozin, Elliott D; Sethi, Rosh K V; Remenschneider, Aaron K; Kaplan, Alyson B; Del Portal, Daniel A; Gray, Stacey T; Shrime, Mark G; Lee, Daniel J

2015-08-01

Otologic complaints may place a significant burden on emergency departments (EDs) in the United States; however, few studies have comprehensively examined this discrete patient population. We aimed to identify utilization of EDs by patients with primary otologic complaints. Retrospective analysis of the Nationwide Emergency Department Sample (NEDS) from 2009 through 2011. The NEDS database was queried for patient encounters with a primary otologic diagnosis based on International Classification of Diseases, Ninth Revision codes (380-389). Weighted estimates for demographics, diagnostic characteristics, socioeconomic status, and trends over time were extracted. Predictors of mortality and admission were determined by multivariable logistic regression. A weighted total of 8,611,282 visits between 2009 and 2011 were attributed to otologic diagnoses, representing 2.21% of all ED visits. Stratified by patient age, otologic diagnoses encompassed 1.01% and 6.79% of all adult and pediatric ED visits, respectively. The majority of patients were treated and released (98.17%). The average age of patients presenting with an otologic complaint was 17.9 years (standard error = 0.23). Overall, 62.7% of patients who presented with an otologic complaint were 0 to 17 years old. The most common diagnoses among all age groups included otitis media not otherwise specified (NOS) (60.6%), infected otitis externa NOS (11.8%), and otalgia NOS (6.8%). We provide a comprehensive overview of otologic complaints that are an overlooked diagnostic category in public health research. NEDS data demonstrate a significant number of visits related to otologic complaints, especially in the pediatric population, that are nonemergent. 4 © 2015 The American Laryngological, Rhinological and Otological Society, Inc.

Comparison between Canadian Triage and Acuity Scale and Taiwan Triage System in emergency departments.

PubMed

Ng, Chip-Jin; Hsu, Kuang-Hung; Kuan, Jen-Tze; Chiu, Te-Fa; Chen, Wei-Kong; Lin, Hung-Jung; Bullard, Michael J; Chen, Jih-Chang

2010-11-01

Since the implementation of National Health Insurance in Taiwan, Emergency Department (ED) volume has progressively increased, and the current triage system is insufficient and needs modification. This study compared the prioritization and resource utilization differences between the four-level Taiwan Triage System (TTS) and the standardized five-level Canadian Triage and Acuity Scale (CTAS) among ED patients. This was a prospective observational study. All adult ED patients who presented to three different medical centers during the study period were included. Patients were independently triaged by the duty triage nurse using TTS, and a single trained research nurse using CTAS with a computer support software system. Hospitalization, length of stay (LOS), and medical resource consumption were analyzed by comparing TTS and CTAS by acuity levels. There was significant disparity in patient prioritization between TTS and CTAS among the 1851 enrolled patients. With TTS, 7.8%, 46.1%, 45.9% and 0.2% were assigned to levels 1, 2, 3, and 4, respectively. With CTAS, 3.5%, 24.4%, 44.3%, 22.4% and 5.5% were assigned to levels 1, 2, 3, 4, and 5, respectively. The hospitalization rate, LOS, and medical resource consumption differed significantly between the two triage systems and correlated better with CTAS. CTAS provided better discrimination for ED patient triage, and also showed greater validity when predicting hospitalization, LOS, and medical resource consumption. An accurate five-level triage scale appeared superior in predicting patient acuity and resource utilization. Copyright © 2010 Formosan Medical Association & Elsevier. Published by Elsevier B.V. All rights reserved.

Test-Retest Reliability of a Serious Game for Delirium Screening in the Emergency Department

PubMed Central

Tong, Tiffany; Chignell, Mark; Tierney, Mary C.; Lee, Jacques S.

2016-01-01

Introduction: Cognitive screening in settings such as emergency departments (ED) is frequently carried out using paper-and-pencil tests that require administration by trained staff. These assessments often compete with other clinical duties and thus may not be routinely administered in these busy settings. Literature has shown that the presence of cognitive impairments such as dementia and delirium are often missed in older ED patients. Failure to recognize delirium can have devastating consequences including increased mortality (Kakuma et al., 2003). Given the demands on emergency staff, an automated cognitive test to screen for delirium onset could be a valuable tool to support delirium prevention and management. In earlier research we examined the concurrent validity of a serious game, and carried out an initial assessment of its potential as a delirium screening tool (Tong et al., 2016). In this paper, we examine the test-retest reliability of the game, as it is an important criterion in a cognitive test for detecting risk of delirium onset. Objective: To demonstrate the test-retest reliability of the screening tool over time in a clinical sample of older emergency patients. A secondary objective is to assess whether there are practice effects that might make game performance unstable over repeated presentations. Materials and Methods: Adults over the age of 70 were recruited from a hospital ED. Each patient played our serious game in an initial session soon after they arrived in the ED, and in follow up sessions conducted at 8-h intervals (for each participant there were up to five follow up sessions, depending on how long the person stayed in the ED). Results: A total of 114 adults (61 females, 53 males) between the ages of 70 and 104 years (M = 81 years, SD = 7) participated in our study after screening out delirious patients. We observed a test-retest reliability of the serious game (as assessed by correlation r-values) between 0.5 and 0.8 across adjacent sessions. Conclusion: The game-based assessment for cognitive screening has relatively strong test-retest reliability and little evidence of practice effects among elderly emergency patients, and may be a useful supplement to existing cognitive assessment methods. PMID:27872590

Skin - clammy

MedlinePlus

... Adult Emergency Medicine . 4th ed. Philadelphia, PA: Elsevier Churchill Livingstone; 2015:chap 2. Brown A. Resuscitation. In: ... Adult Emergency Medicine . 4th ed. Philadelphia, PA: Elsevier Churchill Livingstone; 2015:chap 1. Jones AE, Kline JA. ...

Older adults who persistently present to the emergency department with severe, non-severe, and indeterminate episode patterns.

PubMed

Kaskie, Brian; Obrizan, Maksym; Jones, Michael P; Bentler, Suzanne; Weigel, Paula; Hockenberry, Jason; Wallace, Robert B; Ohsfeldt, Robert L; Rosenthal, Gary E; Wolinsky, Fredric D

2011-10-21

It is well known that older adults figure prominently in the use of emergency departments (ED) across the United States. Previous research has differentiated ED visits by levels of clinical severity and found health status and other individual characteristics distinguished severe from non-severe visits. In this research, we classified older adults into population groups that persistently present with severe, non-severe, or indeterminate patterns of ED episodes. We then contrasted the three groups using a comprehensive set of covariates. Using a unique dataset linking individual characteristics with Medicare claims for calendar years 1991-2007, we identified patterns of ED use among the large, nationally representative AHEAD sample consisting of 5,510 older adults. We then classified one group of older adults who persistently presented to the ED with clinically severe episodes and another group who persistently presented to the ED with non-severe episodes. These two groups were contrasted using logistic regression, and then contrasted against a third group with a persistent pattern of ED episodes with indeterminate levels of severity using multinomial logistic regression. Variable selection was based on Andersen's behavioral model of health services use and featured clinical status, demographic and socioeconomic characteristics, health behaviors, health service use patterns, local health care supply, and other contextual effects. We identified 948 individuals (17.2% of the entire sample) who presented a pattern in which their ED episodes were typically defined as severe and 1,076 individuals (19.5%) who typically presented with non-severe episodes. Individuals who persistently presented to the ED with severe episodes were more likely to be older (AOR 1.52), men (AOR 1.28), current smokers (AOR 1.60), experience diabetes (AOR (AOR 1.80), heart disease (AOR 1.70), hypertension (AOR 1.32) and have a greater amount of morbidity (AOR 1.48) than those who persistently presented to the ED with non-severe episodes. When contrasted with 1,177 individuals with a persistent pattern of indeterminate severity ED use, persons with severe patterns were older (AOR 1.36), more likely to be obese (AOR 1.36), and experience heart disease (AOR 1.49) and hypertension (AOR 1.36) while persons with non-severe patterns were less likely to smoke (AOR 0.63) and have diabetes (AOR 0.67) or lung disease (AOR 0.58). We distinguished three large, readily identifiable groups of older adults which figure prominently in the use of EDs across the United States. Our results suggest that one group affects the general capacity of the ED to provide care as they persistently present with severe episodes requiring urgent staff attention and greater resource allocation. Another group persistently presents with non-severe episodes and creates a considerable share of the excess demand for ED care. Future research should determine how chronic disease management programs and varied co-payment obligations might impact the use of the ED by these two large and distinct groups of older adults with consistent ED use patterns.

Health Literacy among Parents of Pediatric Patients

PubMed Central

Tran, T. Paul; Robinson, Laura M.; Keebler, John R.; Walker, Richard A.; Wadman, Michael C.

2008-01-01

Background Health literacy is an important predictor of healthcare outcomes, but research on this topic has largely been absent from the emergency medicine literature. Objective We measured the prevalence of health literacy in parents or guardians of pediatric patients seen in the emergency department (ED). Methods This was an observational study conducted in a Midwestern urban, university-based, tertiary, Level 1 trauma center ED with 33,000 visits/year. Using convenience sampling during a three-month period, English-speaking parents or guardians of pediatric patients (< 19 yrs.) were asked to complete the short version of the Test of Functional Health Literacy for Adults (s-TOFHLA). Parents/guardians were excluded if they had uncorrected visual impairment, required an interpreter, had altered mental status, or if the patients they accompanied were the subjects of a medical or trauma activation. Results Of the 188 parents or guardians approached, six did not consent or withdrew, one was excluded, leaving 181 (96.3%) in the study. Of these, 19 (10.5%) had either “marginal” or “inadequate” health literacy, while 162 (89.5%, 95% CI: 84.1%, 93.6%) had “adequate” health literacy. Conclusion A large majority (89.5%) of English-speaking parents or guardians of pediatric patients evaluated in the ED have adequate health literacy. This data may prompt ED professionals to adjust their communication styles in the evaluation of children. Future multi-center studies are needed to confirm the findings in this pilot study. PMID:19561727

Erectile Dysfunction in the Older Adult Male.

PubMed

Mola, Joanna R

2015-01-01

Erectile dysfunction (ED) in the older adult male is a significant problem affecting more than 75% of men over 70 years of age in the United States. Older men have an increased likelihood of developing ED due to chronic disease, comorbid conditions, and age-related changes. Research has demonstrated that while the prevalence and severity of ED increases with age, sexual desire often remains unchanged. This article discusses the clinical picture of ED, including relevant pathophysiology, clinical presentation, and evaluation and treatment options.

Take a Multidisciplinary, Team-based Approach on Elder Abuse.

PubMed

2016-07-01

While EDs are well positioned to identify incidents of elder abuse, providers often miss the opportunity. Experts say providers find only one in every 24 cases, and that the pendulum must swing toward over-detection. Investigators acknowledge elder abuse is difficult to confirm, given that disease processes can explain some of the signs. Further, older adults are often reluctant to report abuse because they fear they will be removed from their homes or separated from their caregivers. Given the complexity involved with addressing the issue, investigators recommend EDs establish a multidisciplinary approach to the problem. Providing great care to a victim of elder abuse requires time and setting up a circumstance whereby one can actually communicate with the patient reliably and alone. While most states require providers to report suspected cases of elder abuse to Adult Protective Services, there is little evidence this requirement has incentivized more reports in the same way a similar requirement has prompted providers to report cases of suspected child abuse. Investigators advise ED leaders to train and empower every member of their team to identify potential signs of elder abuse.

Original sound compositions reduce anxiety in emergency department patients: a randomised controlled trial.

PubMed

Weiland, Tracey J; Jelinek, George A; Macarow, Keely E; Samartzis, Philip; Brown, David M; Grierson, Elizabeth M; Winter, Craig

2011-12-19

To determine whether emergency department (ED) patients' self-rated levels of anxiety are affected by exposure to purpose-designed music or sound compositions with and without the audio frequencies of embedded binaural beat. Randomised controlled trial in an ED between 1 February 2010 and 14 April 2010 among a convenience sample of adult patients who were rated as category 3 on the Australasian Triage Scale. All interventions involved listening to soundtracks of 20 minutes' duration that were purpose-designed by composers and sound-recording artists. Participants were allocated at random to one of five groups: headphones and iPod only, no soundtrack (control group); reconstructed ambient noise simulating an ED but free of clear verbalisations; electroacoustic musical composition; composed non-musical soundtracks derived from audio field recordings obtained from natural and constructed settings; sound composition of audio field recordings with embedded binaural beat. All soundtracks were presented on an iPod through headphones. Patients and researchers were blinded to allocation until interventions were administered. State-trait anxiety was self-assessed before the intervention and state anxiety was self-assessed again 20 minutes after the provision of the soundtrack. Spielberger State-Trait Anxiety Inventory. Of 291 patients assessed for eligibility, 170 patients completed the pre-intervention anxiety self-assessment and 169 completed the post-intervention assessment. Significant decreases (all P < 0.001) in anxiety level were observed among patients exposed to the electroacoustic musical composition (pre-intervention mean, 39; post-intervention mean, 34), audio field recordings (42; 35) or audio field recordings with embedded bianaural beats (43; 37) when compared with those allocated to receive simulated ED ambient noise (40; 41) or headphones only (44; 44). In moderately anxious ED patients, state anxiety was reduced by 10%-15% following exposure to purpose-designed sound interventions. Australian New Zealand Clinical Trials Registry ACTRN 12608000444381.

Choking - adult or child over 1 year

MedlinePlus

... Hockberger RS, Walls RM, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice . 8th ed. Philadelphia, PA: Elsevier ... Hockberger RS, Walls RM, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice . 8th ed. Philadelphia, PA: Elsevier ...

Changes in insurance status and emergency department visits after the 2008 economic downturn.

PubMed

Watts, Susan H; David Bryan, E; Tarwater, Patrick M

2015-01-01

As the U.S. economy began its downward trend in 2008, many citizens lost their jobs and, ultimately, their employer-sponsored health care insurance. The expectation was that many of the newly uninsured would turn to emergency departments (EDs) for their health care. This study was undertaken to determine, first, if changes in the insurance status of the general population were reflected in the ED insurance payer mix and, second, whether there was evidence of an increased reliance on the ED as a continuing source of health care for any payer group(s). This was a retrospective observational study using public data files from the National Hospital Ambulatory Medical Care Survey for Emergency Departments for years 2006 through 2010 (2008 ± 2 years). Changes in the relative proportions of ED visits funded annually by private insurance, Medicaid, Medicare, and self-pay (uninsured) were analyzed using a logistic model. Poisson regression was used to compare trends in the rates of ED visits for each payer type (i.e., number of ED visits per 100 persons with each insurance type). A linear spline term was used to determine if there was a change in each risk estimate after 2008 compared to the risk estimate before 2008. Before 2008, the odds of an ED visit being funded by private insurance increased by 4% per year (odds ratio [OR] = 1.04, 95% confidence interval [CI] = 0.98 to 1.10; p = 0.15), but after 2008 the odds reversed, decreasing by nearly 10% per year (OR = 0.91, 95% CI = 0.85 to 0.97; p = 0.02). Medicaid-funded visits demonstrated opposite trends with a small decreasing trend of 2% per year before 2008 (OR = 0.98, 95% CI = 0.92 to 1.04; p = 0.52), followed by a significantly increasing trend of 20% per year after 2008 (OR = 1.20, 95% CI = 1.12 to 1.27; p = 0.001). The growth in Medicaid-funded ED visits was attributable to increased numbers of visits by both pediatric (<18 years old) and non-elderly adult (19 to 64 years old) patients. For both Medicaid and private insurance visits, the change in trend in 2008 was statistically significant (p < 0.001 and p = 0.004, respectively). Self-pay visits were fairly steady before 2008 and then increased by about 5% per year after 2008, but this was not statistically significant (OR = 1.05, 95% CI = 0.96 to 1.14; p = 0.46), nor was the change in trend (p = 0.29). The results for Medicare-funded visits were also small and not statistically significant. There was also evidence of increased reliance on the ED by Medicaid-funded patients based on the comparison of ED visit rates. After 2008, the incidence rate ratio (IRR) for Medicaid-funded visits increased by 10% per year (IRR = 1.10, 95% CI = 1.10 to 1.10; p < 0.001) while the IRR for the other three payer groups changed about 1% per year (IRR = 0.99, 95% CI = 0.99 to 0.099; p < 0.001), indicating an increasing utilization of the ED by patients with Medicaid-funded care. After 2008, Medicaid patients were more dependent on ED services than uninsured, Medicare, or privately insured patients. Medicaid patients made up an increasing proportion of ED patients, and the rate of usage of ED services by all ages of Medicaid patients was significantly greater than that of the other three payer groups. © 2014 by the Society for Academic Emergency Medicine.

Diagnostic performance of a biomarker panel as a negative predictor for acute appendicitis in adult ED patients with abdominal pain.

PubMed

Huckins, David S; Copeland, Karen; Self, Wesley; Vance, Cheryl; Hendry, Phyllis; Borg, Keith; Gogain, Joseph

2017-03-01

Evaluate the diagnostic accuracy of the APPY1TM biomarker panel, previously described for use in pediatric patients, for identifying adult ED patients with abdominal pain who are at low risk of acute appendicitis. This study prospectively enrolled subjects >18years of age presenting to seven U.S. emergency departments with <72hours of abdominal pain suggesting possible acute appendicitis. The APPY1 panel was performed on blood samples drawn from each patient at the time of initial evaluation and results were correlated with the final diagnosis either positive or negative for acute appendicitis. 431 patients were enrolled with 422 completing all aspects of the study. The APPY1 biomarker panel exhibited a sensitivity of 97.5% (95% CI, 91.3-99.3%), a negative predictive value of 98.4% (95% CI, 94.4-99.6%), a negative likelihood ratio of 0.07 (95% CI, 0.02-0.27), with a specificity of 36.5% (95% CI, 31.6-41.8%) for acute appendicitis. The panel correctly identified 125 of 342 (36.6%) patients who did not have appendicitis with 2 (2.5%) false negatives. The CT utilization rate in this population was 72.7% (307/422). Of 307 CT scans, 232 were done for patients who did not have appendicitis and 79 (34%) of these patients were correctly identified as negative with "low risk" biomarker panel results, representing 26% (79/307) of all CT scans performed. This biomarker panel exhibited high sensitivity and negative predictive value for acute appendicitis in this prospective adult cohort, thereby potentially reducing the dependence on CT for the evaluation of possible acute appendicitis. Copyright © 2016 Elsevier Inc. All rights reserved.

Longitudinal trends in the treatment of abdominal pain in an academic emergency department.

PubMed

Cinar, Orhan; Jay, Loni; Fosnocht, David; Carey, Jessica; Rogers, LeGrand; Carey, Adrienne; Horne, Benjamin; Madsen, Troy

2013-09-01

Abdominal pain is a top chief complaint of patients presenting to Emergency Departments (ED). Historically, uncertainty surrounded correct management. Evidence has shown adequate analgesia does not obscure the diagnosis, making it the standard of care. We sought to evaluate trends in treatment of abdominal pain in an academic ED during a 10-year period. We prospectively evaluated a convenience sample of patients in an urban academic tertiary care hospital ED from September 2000 through April 2010. Adult patients presenting with a chief complaint of abdominal pain were included in this study. Analgesic administration rates and times, pain scores, and patient satisfaction at discharge were analyzed to evaluate trends by year. There were 2,646 patients presenting with abdominal pain who were enrolled during the study period. Rates of analgesic administration generally increased each year from 39.9% in 2000 to 65.5% in 2010 (p value for trend <0.001). Similarly, time to analgesic administration generally decreased by year, from 116 min in 2000 to 81 min in 2009 (p < 0.001). There was no improvement in mean pain scores at discharge by year (p = 0.27) and 48% of patients during the 10-year period still reported moderate to severe pain at discharge. Patient satisfaction with pain treatment increased from a score of 7.1 to 9.0 during the study period (p < 0.005), following the trend of increase in analgesic administration. In patients presenting to the ED with abdominal pain, analgesia administration increased and time to medication decreased during the 10-year period. Despite overall improvements in satisfaction, significant numbers of patients presenting with abdominal pain still reported moderate to severe pain at discharge. Copyright © 2013 Elsevier Inc. All rights reserved.

Cognitive assessment of older adults at the acute care interface: the informant history.

PubMed

Dyer, Adam H; Nabeel, Shamis; Briggs, Robert; O'Neill, Desmond; Kennelly, Sean P

2016-05-01

An informant history is critical in the complete cognitive assessments of older adults, but has never been formally assessed. A convenience sample of older adults aged ≥70 years were assessed using cognitive screeners for delirium (confusion assessment method-intensive care unit) and dementia (standardised Mini Mental State Examination and AD8) in a tertiary referral emergency department (ED). A total of 220/270 (81.5%) adults were included in the study (mean age 78.8±6.16; 49.1% male). Informant histories, obtained in almost two-thirds (61.1%, 66/108) of patients where desired, revealed a cognitive pattern suggestive of previously undiagnosed dementia in 39.4% (26/66). Most informants were relatives/friends (93.9%, 62/66) and were rated very good/excellent in contribution to care (96.9%, 64/66) and ability to provide useful information (93.9%, 62/66). The acute environment was also rated suitable to brief informant interviewing (mean duration <6 min) in terms of privacy (8.4±1.6/10) and accessibility (8.5±1.47/10). Following a review of the attending ED physician's notes, an informant history (either obtained/desired/refused) was only documented in 5.6% of cases. The informant history represents a much underused tool in the cognitive assessment of older adults presenting to the ED. The main barrier to informant interviewing in the ED environment appears to be informant availability. Where available, the informant history is easy to extract and provides invaluable information to the assessing physician. The acute care environment is suitable to brief informant interviews using readily available frameworks (AD8). However, the informant history is rarely obtained in this context, and further emphasis on undergraduate and postgraduate medical curricula is warranted. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Emergency department visits by pediatric patients for poisoning by prescription opioids.

PubMed

Tadros, Allison; Layman, Shelley M; Davis, Stephen M; Bozeman, Rachel; Davidov, Danielle M

2016-09-01

Prescription medication abuse is an increasingly recognized problem in the United States. As more opioids are being prescribed and abused by adults, there is an increased risk of both accidental and intentional exposure to children and adolescents. The impact of pediatric exposures to prescription pain pills has not been well studied. We sought to evaluate emergency department (ED) visits for poisoning by prescription opioids in pediatric patients. This retrospective study looked at clinical and demographic data from the Nationwide Emergency Department Sample (NEDS) from 2006 to 2012. There were 21,928 pediatric ED visits for prescription opioid poisonings and more than half were unintentional. There was a bimodal age distribution of patients, with slightly more than half occurring in females. The majority of patients were discharged from the ED. More visits in the younger age group (0-5 years) were unintentional, while the majority of visits in the adolescent age group (15-17 years) were intentional. Mean charge per discharge was $1,840 and $14,235 for admissions and surmounted to over $81 million in total charges. Poisonings by prescription opioids largely impact both young children and adolescents. These findings can be used to help target this population for future preventive efforts.

Temperament and risk for exercise dependence: results of a pilot study in female patients with eating disorders compared to elite athletes.

PubMed

Müller, Astrid; Claes, Laurence; Wos, Katharina; Kerling, Arno; Wünsch-Leiteritz, Wally; Cook, Brian; de Zwaan, Martina

2015-01-01

The present pilot study investigated the relationship between temperament and the risk for exercise dependence (EXD). A total of 32 female patients with eating disorders (potentially at risk for secondary EXD) and 29 female elite athletes without eating disturbances (potentially at risk for primary EXD) answered the Eating Disorder Examination-Questionnaire (EDE-Q), the Exercise Dependence Scale-German version (EDS-G), the Behavioral Inhibition System/Behavioral Activation System (BIS/BAS) scales, and the effortful control subscale of the Adult Temperament Questionnaire (ATQ-EC). There were significant positive correlations of the EDS-G with the BIS in women with an eating disorder and with the BAS in elite athletes. No significant association was found between the EDS-G and effortful control. The results indicate that the risk for EXD is associated with avoidance tendencies in women with eating disorders and with approach tendencies in elite athletes. Implications for secondary and primary EXD are discussed. © 2015 S. Karger AG, Basel.

Prosthetic hip dislocations: is relocation in the emergency department by emergency medicine staff better?

PubMed

Lawrey, Emma; Jones, Peter; Mitchell, Robin

2012-04-01

Prosthetic hip dislocation is common. This study compares prosthetic hip relocations attempted within the ED by emergency doctors and those under orthopaedic care in the ED or operating theatre (OT). Retrospective cohort study of patients presenting to Auckland City Hospital Adult Emergency Department with prosthetic hip dislocations between 1 January 2003 and 14 April 2008. Primary outcomes were proportion of successful relocation attempts and length of hospital stay. Secondary outcomes were: time to relocation, complications, post-procedural advice, representation rate and long-term outcomes for first-time dislocations. There were 410 eligible presentations during the study period. Emergency medicine (EM) was successful in 254/323 attempts (79%, 95% confidence interval [CI] 74-83). Orthopaedics were successful in 25/35 reductions in the ED (71%, 95% CI 55-84) and 49/51 OT attempts (96%, 95% CI 86-100), P = 0.004 for location OT versus ED. Median times to discharge were 8.8 h for EM, 28.3 h for orthopaedics in the ED and 81 h for orthopaedics in the OT, P < 0.001 for EM versus orthopaedics. Mechanical complications of procedures and early redislocations were infrequent. Complication of sedation were more often seen in OT compared to ED (23/47 [49%, 95% CI 35-63]vs 37/318 [12%, 95% CI 9-16]). There was no difference between EM and orthopaedics in the proportion of hips successfully relocated or complications in the ED; however, EM patients were discharged much sooner, with important resource implications. Procedures carried out in the OT were more successful than in the ED but resulted in prolonged hospital stays and were associated with more complications. © 2012 The Authors. EMA © 2012 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

Impact of season, weekends and bank holidays on emergency department transfers of nursing home residents.

PubMed

Fan, C W; Keating, T; Brazil, E; Power, D; Duggan, J

2016-08-01

For urgent, unexpected clinical events, nursing home (NH) residents are transferred to the acute hospital emergency department (ED). A previous study showed that a third of transfers occurred during working hours. Our aims were to profile a one-year NH transfers to the ED and to examine the re-presentation, patient-oriented outcome and the impact of season, weekends and bank holidays on NH transfers. All NH transfers from a catchment to an ED over one year were identified using electronic patient record. Age, gender, reason for presentation, patient-oriented outcome and date and time of presentation were recorded. Representation and the interval between transfers were calculated. Number of transfers was calculated for season, weekdays/weekends and bank holidays. Student t test, Chi-square statistics and one-way ANOVA were used. Significance was set at 0.05. There were 802 transfers from 465 NH residents over a year; 501 (62.5 %) resulted in admissions, 189 (40.6 %) residents represent to the service and 80 episodes occurred within a fortnight of the last attendance. The highest transfers occurred in May (2.81 patients/day), during working hours and on Wednesdays and Thursdays (>2.5 transfers/day). 'Unwell adult' and 'falls' were the two commonest reasons for presentation. Our study showed that NH transfers occurred mainly within working hours and during weekdays. Insights into the transfer pattern and the reasons for NH patients to utilise ED will facilitate improved design and operation of the department by creating care pathways for these patients.

Assault by battery: battery-related injury in the head and neck.

PubMed

Svider, Peter F; Johnson, Andrew P; Folbe, Adam J; Carron, Michael A; Eloy, Jean Anderson; Zuliani, Giancarlo

2014-10-01

To estimate nationwide incidence of emergency department (ED) visits for battery-related injury (BRI) occurring in the head and neck, and analyze demographic and anatomic-specific trends. The National Electronic Injury Surveillance System (NEISS) was searched for BRI in the head and neck, with analysis for incidence, anatomic site, age and gender, and specific diagnoses. There were an estimated 18,803 head and neck BRI ED visits from 2003 to 2012. A total of 65.8% of patients were male. A total of 92.8% of patients were treated/examined and then released, and 4.7% of patients were admitted. A plurality (34.2%) of patients had BRI related to nose injures, and this represented the youngest cohort (median: 3 years old). The vast majority of ear and nose diagnoses were "foreign bodies"; two-thirds of mouth injuries were related to burns, whereas lacerations predominated in the face and head. Nearly half of ED visits involved patients between 2 and 5 years of age. A total of 45.2% of cases involving patients ≥ 65 years of age were related to hearing aid batteries as foreign bodies. BRI in the head and neck results in a significant amount of ED visits. Mechanisms of injury vary by age and anatomic location, but a considerable male predilection exists. Whereas pediatric patients are primarily affected, particularly patients between 2 to 5 years of age, injuries do occur among adults. Importantly, the prevalence of dislodged hearing-aid batteries in the elderly necessitates comprehensive patient education to increase awareness and counseling regarding this complication. Awareness of demographic and anatomic-specific trends reported in this analysis may be an invaluable adjunct for history-taking and clinical examination. © 2014 The American Laryngological, Rhinological and Otological Society, Inc.

Comparison of drug administration logistics between prothrombin complex concentrates and plasma in the emergency department.

PubMed

Alarfaj, Sumaiah J; Jarrell, Daniel H; Patanwala, Asad E

2018-03-24

Prothrombin complex concentrate (PCC) is used as an alternative to fresh frozen plasma (FFP) for emergency bleeding. The primary objective of this study was to compare the time from order to start of administration between 3-factor PCC (PCC3), 4-factor (PCC4), and FFP in the emergency department (ED). The secondary objective was to evaluate the effect of an ED pharmacist on time to administration of PCCs. This was a single center three-arm retrospective cohort study. Adult patients in the ED with bleeding were included. The primary outcome measure was the time from order to administration, which was compared between PCC3, PCC4, and FFP. The time from order to administration was also compared when the ED pharmacist was involved versus not involved in the care of patients receiving PCC. There were 90 patients included in the study cohort (30 in each group). The median age was 69years (IQR 57-82years), and 57% (n=52) were male. The median time from order to administration was 36min (IQR 20-58min) for PCC3, 34min (IQR 18-48min) for PCC4, and 92min (IQR 63-133) for FFP (PCC3 versus PCC4, p=0.429; PCC3 versus FFP, p<0.001; PCC4 versus FFP, p<0.001). The median time from order to administration was significantly decreased when the ED pharmacist was involved (24min [IQR 15-35min] versus 42min [IQR 32-59min], p<0.001). Time from order to administration is faster with PCC than FFP. ED pharmacist involvement decreases the time from order to administration of PCC. Copyright © 2018. Published by Elsevier Inc.

Emergency Department Presentations for Injuries in Older Adults Independently Known to be Victims of Elder Abuse.

PubMed

Rosen, Tony; Bloemen, Elizabeth M; LoFaso, Veronica M; Clark, Sunday; Flomenbaum, Neal E; Lachs, Mark S

2016-03-01

Elder abuse is under-recognized by emergency department (ED) providers, largely due to challenges distinguishing between abuse and accidental trauma. To describe patterns and circumstances surrounding elder abuse-related and potentially abuse-related injuries in ED patients independently known to be physical elder abuse victims. ED utilization of community-dwelling victims of physical elder abuse in New Haven, CT from 1981-1994 was analyzed previously. Cases were identified using Elderly Protective Services data matched to ED records. Sixty-six ED visits were judged to have high probability of being related to elder abuse and 244 were of indeterminate probability. We re-examined these visits to assess whether they occurred due to injury. We identified and analyzed in detail 31 injury-associated ED visits from 26 patients with high probability of being related to elder abuse and 108 visits from 57 patients with intermediate probability and accidental injury. Abuse-related injuries were most common on upper extremities (45% of visits) and lower extremities (32%), with injuries on head or neck noted in 13 visits (42%). Bruising was observed in 39% of visits, most commonly on upper extremities. Forty-two percent of purportedly accidental injuries had suspicious characteristics, with the most common suspicious circumstance being injury occurring more than 1 day prior to presentation, and the most common suspicious injury pattern being maxillofacial injuries. Victims of physical elder abuse commonly have injuries on the upper extremities, head, and neck. Suspicious circumstances and injury patterns may be identified and are commonly present when victims of physical elder abuse present with purportedly accidental injuries. Copyright © 2016 Elsevier Inc. All rights reserved.

Clinically significant differences in the visual analog pain scale in acute vasoocclusive sickle cell crisis.

PubMed

Lopez, Bernard L; Flenders, Pamela; Davis-Moon, Linda; Corbin, Theodore; Ballas, Samir K

2007-01-01

This study sought to determine the minimum clinically significant change in the visual analog scale (VAS) during the Emergency Department (ED) treatment of adult vasoocclusive sickle cell crisis (VOC). Sickle cell anemia patients presenting to the ED with their typical VOC pain had a 100 mm VAS administered prior to each of up to three standard analgesic injections administered as part of a treatment protocol. At each assessment, subjects were asked to describe their pain as "much better," a "little better," "the same," "a little worse," or "much worse." The change in the VAS (DeltaVAS) between assessments was measured. The main outcome of the measurement was change in the VAS associated with a description of a change in pain of "a little less" or "a little more." Seventy four subjects presented with initially high pain scores [VAS = 79.47 mm, 95% confidence interval (CI) = 75.99 to 82.95 mm]. In the "little better/little worse" combined group, the DeltaVAS was 13.5 mm (95% CI = 11.25 cm to 15.74 cm). A change in the 100 mm VAS of 13.5 mm is the minimum clinically significant change during ED treatment of VOC. A DeltaVAS <13.5 mm may not be clinically important. This finding may assist the clinician in the assessment of pain improvement for adult sickle cell patients with VOC.

The unsafe haven: Eating disorders as attachment relationships.

PubMed

Forsén Mantilla, Emma; Clinton, David; Birgegård, Andreas

2018-05-21

Some patients with eating disorders (EDs) seem to experience their illness as an entity, a symbolic other to whom they relate, and which may influence both symptom levels and self-image. Extending previous research, this study investigated whether the patient-ED relationship has attachment qualities. Structural Analysis of Social Behaviour was used to operationalize the patient-ED relationship, and the Attachment Style Questionnaire was used to measure attachment. We examined ED patients' (N = 148) relationship with their ED, attachment behaviour, symptoms, and self-image. Attachment dimensions of Confidence, Anxious/ambivalence, and Avoidance were found to be significantly correlated with aspects of the patient-ED relationship. Introjection (i.e., whether ED actions were incorporated into patients' self-image) was investigated by examining the match between self-image profiles and the actions of patients' EDs. A double mediation model was tested in which ED control/emancipation and patients' Self-blame mediated the effect of attachment security on ED symptoms. Attachment insecurity was associated with greater ED control and patient submission. In 28.5% of patients, there was a high degree of correlation between self-image and ED action profile. Data supported the mediation model. Attachment processes appear to be associated with the manner in which ED patients relate to their disorder, at least in some cases. Attempts to maintain psychological proximity to the ED as an introjected attachment figure may help to explain treatment resistance and ambivalence about change. This perspective may be useful in treatment. Attachment behaviours are associated with the patient-ED relationship, in which attachment insecurity is correlated with greater eating disorder control and patient submission. Some patients seem to incorporate the actions of the ED in their self-image, suggesting the presence of introjection. The patient-ED relationship may help explain patients' anxiety and ambivalence about change, seen from an attachment perspective. In treatment, it may be important to explore alternative safe havens and secure bases to the ED, such as interpersonal relationships and activities. © 2018 The British Psychological Society.

Plantar and Pedal Puncture Wounds in Children: A Case Series Study From a Single Level I Trauma Center.

PubMed

Volk, Angela; Zebda, Mohamed; Abdelgawad, Amr A

2017-11-01

The purpose of this study was to describe our experience in treatment of pediatric patient presenting with pedal puncture wound to our level I trauma center and describe our results for the need for hospitalization and/or surgery for these patients. Children and adolescents 18 years and younger presenting with pedal puncture wounds from September 2009 to December of 2013 were retrospectively studied. Exclusion criteria included adult patients, wounds related to animal bites, lacerations associated with a motor vehicle collision or all-terrain vehicle accidents, gunshot wounds, degloving injuries, or injuries resulting in complex lacerations to the foot. A total of 147 children presented to emergency department (ED) with a pedal puncture wound. Average age was 9.8 years. Prophylactic antibiotic therapy was administered in 107 cases (72.8%). Fifteen patients (10%) were treated with intravenous or intramuscular antibiotics in the ED or after hospital admission, 81 patients (55%) were treated with oral medications (prescribed for them to be taken after discharge), and 35 patients (24%) received topical antibiotic treatment. Of the 147 patients included in the study, 9 patients (6%) required the need for hospitalization. Two patients were admitted for parenteral antibiotic treatment only, and 7 patients required formal surgical debridement in the operating room in addition to parenteral antibiotic therapy. The majority of pediatric patients with pedal puncture wounds were treated in the ED with only a small percentage of patients requiring admission for either parenteral antibiotic treatment or formal surgical debridement.

An Analysis of the Relationship Between the Heat Index and Arrivals in the Emergency Department

PubMed Central

Levy, Matthew; Broccoli, Morgan; Cole, Gai; Jenkins, J Lee; Klein, Eili Y.

2015-01-01

Background: Heatwaves are one of the most deadly weather-related events in the United States and account for more deaths annually than hurricanes, tornadoes, floods, and earthquakes combined. However, there are few statistically rigorous studies of the effect of heatwaves on emergency department (ED) arrivals. A better understanding of this relationship can help hospitals plan better and provide better care for patients during these types of events. Methods: A retrospective review of all ED patient arrivals that occurred from April 15 through August 15 for the years 2008 through 2013 was performed. Daily patient arrival data were combined with weather data (temperature and humidity) to examine the potential relationships between the heat index and ED arrivals as well as the length of time patients spend in the ED using generalized additive models. In particular the effect the 2012 heat wave that swept across the United States, and which was hypothesized to increase arrivals was examined. Results: While there was no relationship found between the heat index and arrivals on a single day, a non-linear relationship was found between the mean three-day heat index and the number of daily arrivals. As the mean three-day heat index initially increased, the number of arrivals significantly declined. However, as the heat index continued to increase, the number of arrivals increased. It was estimated that there was approximately a 2% increase in arrivals when the mean heat index for three days approached 100°F. This relationship was strongest for adults aged 18-64, as well as for patients arriving with lower acuity. Additionally, a positive relationship was noted between the mean three-day heat index and the length of stay (LOS) for patients in the ED, but no relationship was found for the time from which a patient was first seen to when a disposition decision was made. No significant relationship was found for the effect of the 2012 heat wave on ED arrivals, though it did have an effect on patient LOS. Conclusion: A single hot day has only a limited effect on ED arrivals, but continued hot weather has a cumulative effect. When the heat index is high (~90°F) for a number of days in a row, this curtails peoples activities, but if the heat index is very hot (~100°F) this likely results in an exacerbation of underlying conditions as well as heat-related events that drives an increase in ED arrivals. Periods of high heat also affects the length of stay of patients either by complicating care or by making it more difficult to discharge patients. PMID:26579329

Impact of a Community Dental Access Program on Emergency Dental Admissions in Rural Maryland.

PubMed

Rowland, Sandi; Leider, Jonathon P; Davidson, Clare; Brady, Joanne; Knudson, Alana

2016-12-01

To characterize the expansion of a community dental access program (CDP) in rural Maryland providing urgent dental care to low-income individuals, as well as the CDP's impact on dental-related visits to a regional emergency department (ED). We used de-identified CDP and ED claims data to construct a data set of weekly counts of CDP visits and dental-related ED visits among Maryland adults. A time series model examined the association over time between visits to the CDP and ED visits for fiscal years (FYs) 2011 through 2015. The CDP served approximately 1600 unique clients across 2700 visits during FYs 2011 through 2015. The model suggested that if the CDP had not provided services during that time period, about 670 more dental-related visits to the ED would have occurred, resulting in $215 000 more in charges. Effective ED dental diversion programs can result in substantial cost savings to taxpayers, and more appropriate and cost-effective care for the patient. Community dental access programs may be a viable way to patch the dental safety net in rural communities while holistic solutions are developed.

Impact of a Community Dental Access Program on Emergency Dental Admissions in Rural Maryland

PubMed Central

Rowland, Sandi; Davidson, Clare; Brady, Joanne; Knudson, Alana

2016-01-01

Objectives. To characterize the expansion of a community dental access program (CDP) in rural Maryland providing urgent dental care to low-income individuals, as well as the CDP’s impact on dental-related visits to a regional emergency department (ED). Methods. We used de-identified CDP and ED claims data to construct a data set of weekly counts of CDP visits and dental-related ED visits among Maryland adults. A time series model examined the association over time between visits to the CDP and ED visits for fiscal years (FYs) 2011 through 2015. Results. The CDP served approximately 1600 unique clients across 2700 visits during FYs 2011 through 2015. The model suggested that if the CDP had not provided services during that time period, about 670 more dental-related visits to the ED would have occurred, resulting in $215 000 more in charges. Conclusions. Effective ED dental diversion programs can result in substantial cost savings to taxpayers, and more appropriate and cost-effective care for the patient. Policy Implications. Community dental access programs may be a viable way to patch the dental safety net in rural communities while holistic solutions are developed. PMID:27736218

The effect of spinal cord level on sexual function in the spina bifida population.

PubMed

Lee, N G; Andrews, E; Rosoklija, I; Logvinenko, T; Johnson, E K; Oates, R D; Estrada, C R

2015-06-01

Sexual dysfunction and infertility are prevalent in the spina bifida (SB) population; however, the mechanism of how they affect a person with spina bifida is poorly understood. Additionally, the management of children with spina bifida becomes more difficult as they exit from pediatric institutes. The present study sought to evaluate sexual health (using validated questionnaires) and fertility in adults with spina bifida and to correlate spinal cord level and ambulatory status with degree of sexual function. After institutional board review approval, 199 adult patients with SB, aged 18 and older and who were followed in one pediatric institution, were identified. Patients who were non-English speaking, cognitively and/or developmentally delayed, or unable to be contacted were excluded. Surveys regarding demographics, sexual health and infertility were mailed to the patients and administered in the clinic with the option to opt-out of the survey. Survey questions regarding sexual health were constructed using validated questionnaires: Female Sexual Function Index (FSFI) for females, and International Index of Erectile Function (IIEF) and Sexual Health Inventory for Men (SHIM) for males. Sexual dysfunction scores were correlated to the patients' spinal level and ambulatory status. Of the 121 eligible patients, 45 replied, with a response rate of 39%. For females, using a cut-off value of 26.5 for FSFI scoring, 25 out of 28 (89%) had sexual dysfunction. No association was seen between spinal level or ambulatory status and overall FSFI, satisfaction, or desire scores. For males, 10 out of 17 (59%) had severe erectile dysfunction (ED), and one out of 17 (6%) had no ED. No association was seen between ambulatory status and sexual function scores for the males. However, SHIM, satisfaction, and ED scores were higher in males with lower spinal lesions. People with spina bifida of both genders tended to have more severe dysfunction compared to those with sexual dysfunction of other etiologies, except with similar sexual desire scores. Regarding questions on fertility, no participant attempted to have children; thus, there was no infertility reported. Few studies have been conducted on sexual health and fertility in adults with SB. Three studies have utilized validated questionnaires and found varying degrees of sexual dysfunction in this subset of patients; however, only one study found sexual activity to be more likely in patients with more caudal levels of neurologic impairment. The present study also showed that SHIM, satisfaction, and ED scores were higher in males with lower spinal lesions. Limitations to this study primarily included the small sample size and low survey response rate. Limited information is known about adults with SB, and sexual function and fertility. While expressing sexual desire, adults with SB appear to experience high rates of sexual dysfunction. Fertility rates were inadequately assessed; this was possibly due to the high rate of sexual dysfunction. Sexual health in the SB population is an important component of the myriad of urologic care issues for these people. Due to the disparity in their care after reaching adulthood, it is prudent to follow these patients and understand their pathophysiology as they continue to mature through life. Copyright © 2015 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.

Lack of efficacy in a randomised trial of a brief intervention to reduce drug use and increase drug treatment services utilisation among adult emergency department patients over a 12-month period.

PubMed

Merchant, Roland C; Zhang, Zhongli; Zhang, Zihao; Liu, Tao; Baird, Janette R

2018-05-01

Assess the 12-month efficacy of a brief intervention (BI) on reducing drug use and increasing drug treatment services utilisation among adult emergency department (ED) patients. This randomised, controlled trial enrolled 18-64-year-old ED patients needing a drug use intervention. Treatment arm participants received a tailored BI while control arm participants only completed the study questionnaires. Self-reported past 3-month drug use and engagement in drug treatment services were compared by study arm at 3-month intervals over 1 year. Multiple imputations were performed to overcome loss-to-follow-up. Of the 1030 participants, follow-up completion ranged 55%-64% over the four follow-ups. At 12 months, the two study arms were similar in regards to mean: (1) proportion reporting any drug use (treatment: 67.1% (61.6 to 72.6), control: 74.4% (69.4 to 79.4)); (2) drug use frequency on a five-point scale (treatment: 3.7 (3.3 to 4.2), control: 4.6 (4.0 to 5.2)); (3) total days of drug use (treatment: 28.3 (23.2 to 33.4), control: 33.4 (28.5 to 38.2)); (4) most number of times drugs used/day (treatment: 4.6 (3.6 to 5.5), control: 6.1 (4.8 to 7.3)) and (5) typical number of times drugs used/day (treatment: 3.3 (2.5 to 4.1), control: 5.1 (3.9 to 6.2)). Utilisation of drug treatment services also was similar by study arm. In multivariable regression analyses, patients who were homeless or had higher drug use at baseline continued to have greater drug use in follow-up. Among adult ED patients requiring a drug use intervention, this BI did not decrease drug use or increase drug treatment services utilisation over a 12-month period more than the control condition. NCT01124591; Pre-trial. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Increased risk of osteoporosis in patients with erectile dysfunction

PubMed Central

Wu, Chieh-Hsin; Lu, Ying-Yi; Chai, Chee-Yin; Su, Yu-Feng; Tsai, Tai-Hsin; Tsai, Feng-Ji; Lin, Chih-Lung

2016-01-01

Abstract In this study, we aimed to investigate the risk of osteoporosis in patients with erectile dysfunction (ED) by analyzing data from the Taiwan National Health Insurance Research Database (NHIRD). From the Taiwan NHIRD, we analyzed data on 4460 patients aged ≥40 years diagnosed with ED between 1996 and 2010. In total, 17,480 age-matched patients without ED in a 1:4 ratio were randomly selected as the non-ED group. The relationship between ED and the risk of osteoporosis was estimated using Cox proportional hazard regression models. During the follow-up period, 264 patients with ED (5.92%) and 651 patients without ED (3.65%) developed osteoporosis. The overall incidence of osteoporosis was 3.04-fold higher in the ED group than in the non-ED group (9.74 vs 2.47 per 1000 person-years) after controlling for covariates. Compared with patients without ED, patients with psychogenic and organic ED were 3.19- and 3.03-fold more likely to develop osteoporosis. Our results indicate that patients with a history of ED, particularly younger men, had a high risk of osteoporosis. Patients with ED should be examined for bone mineral density, and men with osteoporosis should be evaluated for ED. PMID:27368024

Energy Density, Energy Intake, and Body Weight Regulation in Adults12345

PubMed Central

Karl, J. Philip; Roberts, Susan B.

2014-01-01

The role of dietary energy density (ED) in the regulation of energy intake (EI) is controversial. Methodologically, there is also debate about whether beverages should be included in dietary ED calculations. To address these issues, studies examining the effects of ED on EI or body weight in nonelderly adults were reviewed. Different approaches to calculating dietary ED do not appear to alter the direction of reported relations between ED and body weight. Evidence that lowering dietary ED reduces EI in short-term studies is convincing, but there are currently insufficient data to determine long-term effectiveness for weight loss. The review also identified key barriers to progress in understanding the role of ED in energy regulation, in particular the absence of a standard definition of ED, and the lack of data from multiple long-term clinical trials examining the effectiveness of low-ED diet recommendations for preventing both primary weight gain and weight regain in nonobese individuals. Long-term clinical trials designed to examine the impact of dietary ED on energy regulation, and including multiple ED calculation methods within the same study, are still needed to determine the importance of ED in the regulation of EI and body weight. PMID:25398750

Rural Patients with Severe Sepsis or Septic Shock who Bypass Rural Hospitals have Increased Mortality: An Instrumental Variables Approach

PubMed Central

Mohr, Nicholas M.; Harland, Karisa K.; Shane, Dan M.; Ahmed, Azeemuddin; Fuller, Brian M.; Ward, Marcia M.; Torner, James C.

2016-01-01

Objective To identify factors associated with rural sepsis patients’ bypassing rural emergency departments (EDs) to seek emergency care in larger hospitals, and to measure the association between rural hospital bypass and sepsis survival. Design, Setting, and Patients Cohort study of adults treated in EDs of a rural Midwestern state with severe sepsis or septic shock between 2005 and 2014, using administrative claims data. Patients residing ≥ 20 miles from a top-decile sepsis volume hospital and < 20 miles from a local hospital were included. Interventions Patients bypassing local rural hospitals to seek care in larger hospitals. Measurements and Main Results A total of 13,461 patients were included, and only 5.4% (n = 731) bypassed a rural hospital for their ED care. Patients who initially chose a top-decile sepsis volume hospital were younger (64.7 vs. 72.7 y, p<0.001) and were more likely to have commercial insurance (19.6% vs. 10.6%, p<0.001) than those who were seen initially at a local rural hospital. They were also more likely to have significant medical comorbidities, such as liver failure (9.9% vs 4.2%, p<0.001), metastatic cancer (5.9% vs 3.2%, p<0.001), and diabetes with complications (25.2% vs. 21.6%, p=0.024). Using an instrumental variables approach, rural hospital bypass was associated with a 5.6% increase (95%CI 2.2 – 8.9%) in mortality. Conclusions Most rural patients with sepsis seek care in local EDs, but demographic and disease-oriented factors are associated with rural hospital bypass. Rural hospital bypass is independently associated with increased mortality. PMID:27611977

HD-tDCS in refractory lateral frontal lobe epilepsy patients.

PubMed

Karvigh, Sanaz Ahmadi; Motamedi, Mahmoud; Arzani, Mahsa; Roshan, Javad Hasan Nia

2017-04-01

To evaluate the anticonvulsant effect of the novel high definition transcranial direct current stimulation (HD-tDCS) method on patients with refractory lateral frontal lobe epilepsy. The effects of HD-tDCS on working memory were also examined. 10 adult patients with intractable lateral frontal lobe epilepsy were studied. A central cathode electrode was placed on the epileptogenic zone according to LTM, and 20-min sessions of 2mA HD-tDCS were applied for 10 consecutive days. The primary endpoint was to make changes in the epileptiform discharges (EDs) during a 1-h EEG. Moreover, the seizure frequency based on seizure diary and neuropsychiatric parameters was evaluated. All patients tolerated HD-tDCS stimulation course without any adverse reaction. The frequency of EDs increased immediately and one month after the stimulation course by an average of 6.4% and 1.2%, respectively. However, these changes in the EDs frequency were not statistically significant (p-value >0.05). The mean seizure frequency changes showed decrement by an average of 17.9% immediately, and increment by an average of 38.1% one month after the HD-tDCS. These changes were not significant statistically (p-value >0.05). One patient experienced exacerbation of seizures during the stimulations hence dropped out of the study. Attention and working memory improved significantly immediately and one month after the HD-tDCS in all patients. Changes of EDs and mean seizure frequency caused by HD-tDCS were not statistically significant for the whole group; however, this method could improve the patients' working memory scores. Copyright © 2017 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.

Diazepam and Meclizine Are Equally Effective in the Treatment of Vertigo: An Emergency Department Randomized Double-Blind Placebo-Controlled Trial.

PubMed

Shih, Richard D; Walsh, Brian; Eskin, Barnet; Allegra, John; Fiesseler, Frederick W; Salo, Dave; Silverman, Michael

2017-01-01

Vertigo is a debilitating disease that is commonly encountered in the emergency department (ED). Diazepam and meclizine are oral medications that are commonly used to alleviate symptoms. We sought to determine whether meclizine or diazepam is superior in the treatment of patients with peripheral vertigo in the ED. We performed a double-blind clinical trial at a suburban, teaching ED. We randomized a convenience sample of adult patients with acute peripheral vertigo (APV) to diazepam 5 mg or meclizine 25 mg orally. Demographic and historical features were recorded on a standardized data form. Patients recorded their initial level (t0) of vertigo on a 100-mm visual analog scale (VAS) and after 30 min (t30) and 60 min (t60). The primary outcome parameter was the mean change in VAS score from t0 to t60. Differences between groups and 95% confidence intervals were calculated. Our a priori power calculation estimated that a sample size of 20 patients in each group was required to have an 80% power to detect a difference of 20 mm between treatment groups. There were 20 patients in the diazepam group and 20 in the meclizine group. The two groups were similar with respect to patient demographics and presenting signs and symptoms. At t60, the mean improvements in the diazepam and meclizine groups were 36 and 40, respectively (difference -4; 95% confidence interval -20 to 12; p = 0.60). We found no difference between oral diazepam and oral meclizine for the treatment of ED patients with acute peripheral vertigo. Copyright © 2016 Elsevier Inc. All rights reserved.

Emergency Department Use among Adults with Autism Spectrum Disorders (ASD)

ERIC Educational Resources Information Center

Vohra, Rini; Madhavan, Suresh; Sambamoorthi, Usha

2016-01-01

A cross-sectional analyses using Nationwide Emergency Department Sample (2006-2011) was conducted to examine the trends, type of ED visits, and mean total ED charges for adults aged 22-64 years with and without ASD (matched 1:3). Around 0.4% ED visits (n = 25,527) were associated with any ASD and rates of such visits more than doubled from 2006 to…

Emergency Department Sickle Cell Assessment of Needs and Strengths (ED-SCANS), a Focus Group and Decision Support Tool Development Project

PubMed Central

Tanabe, Paula; Reddin, Christopher; Thornton, Victoria L.; Todd, Knox H.; Wun, Ted; Lyons, John S.

2010-01-01

Objectives A decision support tool may guide emergency clinicians in recognizing assessment, analgesic and overall management, and health service delivery needs for patients with sickle cell disease (SCD) in the emergency department (ED). We aimed to identify data and process elements important in making decisions regarding evaluation and management of adult patients in the ED with painful episodes of sickle cell disease. Methods Qualitative methods using a series of focus groups and grounded theory were used. Eligible participants included adult clients with SCD, and emergency physicians and nurses with a minimum of one year of experience providing care to patients with SCD in the ED. Patients were recruited in conjunction with annual SCD meetings, and providers included clinicians who were and were not affiliated with sickle cell centers. Groups were conducted until saturation was reached, and included a total of two patient groups, three physician groups, and two nurse groups. Focus groups were held in New York, Durham, Chicago, New Orleans, and Denver. Clinician participants were asked the following three questions to guide the discussion: 1) what information would be important to know about patients with SCD in the ED setting to effectively care for them and help you identify patient analgesic, treatment, and referral needs? 2) what treatment decisions would you make with this information? and 3) what characteristics would a decision support tool need to have to make it meaningful and useful? Client participants were asked the same questions with re-wording to reflect what they believed providers should know to provide the best care, and what they should do with the information. All focus groups were audio taped and transcribed. The constant comparative method was used to analyze the data. Two coders independently coded participant responses and identified focal themes based on the key questions. An investigator and assistant independently reviewed the transcripts and met until the final coding structure was determined. Results Forty-seven individuals participated (14 persons with SCD, 16 physicians, and 17 nurses) in a total of seven different groups. Two major themes emerged: acute management and health care utilization. Major sub-themes included the following: physiologic findings, diagnostics, assessment and treatment of acute painful episodes, and disposition. The most common minor sub-themes that emerged included past medical history, presence of a medical home (physician or clinic), individualized analgesic treatment plan for treatment of painful episodes, history of present illness, medical home follow-up available, patient reported analgesic treatment that works, and availability of analgesic prescription at discharge. Additional important elements in treatment of acute pain episodes included the use of a standard analgesic protocol, need for fluids and non-pharmacologic interventions, and the assessment of typicality of pain presentation. The patients' interpretation of the need for hospital admission also ranked high. Conclusions Participants identified several areas that are important in the assessment, management, and disposition decisions that may help guide best practices for SCD patients in the ED setting. PMID:20670322

Delineation of Ehlers-Danlos syndrome phenotype due to the c.934C>T, p.(Arg312Cys) mutation in COL1A1: Report on a three-generation family without cardiovascular events, and literature review.

PubMed

Colombi, Marina; Dordoni, Chiara; Venturini, Marina; Zanca, Arianna; Calzavara-Pinton, Piergiacomo; Ritelli, Marco

2017-02-01

Classical Ehlers-Danlos syndrome (cEDS) is a rare connective tissue disorder primarily characterized by hyperextensible skin, defective wound healing, abnormal scars, easy bruising, and generalized joint hypermobility; arterial dissections are rarely observed. Mutations in COL5A1 and COL5A2 encoding type V collagen account for more than 90% of the patients so far characterized. In addition, cEDS phenotype was reported in a small number of patients carrying the c.934C>T mutation in COL1A1 that results in an uncommon substitution of a non-glycine residue in one Gly-Xaa-Yaa repeat of the pro-α1(I)-chain p.(Arg312Cys), which leads to disturbed collagen fibrillogenesis due to delayed removal of the type I procollagen N-propeptide. This specific mutation has been associated with propensity to arterial rupture in early adulthood; indeed, in literature the individuals harboring this mutation are also referred to as "(classic) vascular-like" EDS patients. Herein, we describe a three-generation cEDS family with six adults carrying the p.(Arg312Cys) substitution, which show a variable and prevalent cutaneous involvement without any major vascular event. These data, together with those available in literature, suggest that vascular events are not a diagnostic handle to differentiate patients with the p.(Arg312Cys) COL1A1 mutation from those with COL5A1 and COL5A2 defects, and highlight that during the diagnostic process the presence of at least the p.(Arg312Cys) substitution in COL1A1 should be investigated in cEDS patients without type V collagen mutations. Nevertheless, for these patients, as well as for those affected with cEDS, a periodical vascular surveillance should be carried out together with cardiovascular risk factors monitoring. © 2016 Wiley Periodicals, Inc. © 2016 Wiley Periodicals, Inc.

Temporal Trends in Epinephrine Dispensing and Allergy/Immunology Follow-up Among Emergency Department Anaphylaxis Patients in the United States, 2005-2014.

PubMed

Motosue, Megan S; Bellolio, M Fernanda; Van Houten, Holly K; Shah, Nilay D; Bellamkonda, Venkatesh R; Nestler, David M; Campbell, Ronna L

Anaphylaxis is a potentially life-threatening allergic reaction; measures including prescription of an epinephrine autoinjector (EAI) and allergy/immunology (A/I) follow-up may prevent future morbidity. The objective of this study was to evaluate trends in outpatient management of anaphylaxis by studying EAI dispensing and A/I follow-up among patients seen in the emergency department (ED) for anaphylaxis from 2005 through 2014. We analyzed administrative claims data from the OptumLabs Data Warehouse database using an expanded International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code algorithm. The study cohort comprised 18,279 patients with a mean age of 39 years; 58% were female, and 86% were discharged from an ED. Within 1 year after discharge, 46% had filled an EAI prescription and 29% had A/I follow-up. Overall, from 2005 to 2014, annual rates of filled EAI prescriptions and A/I follow-up did not change. Among children (aged <18 years), rates increased for filled EAI prescriptions (16.1% increase; P = .02 for trend) and A/I follow-up (18.8% increase; P = .048 for trend). Rates decreased for A/I follow-up among adults (15.4% decrease; P = .002 for trend). Overall rates of filled EAI prescriptions were highest in those with venom-induced (73.9 per 100 ED visits) and food-induced anaphylaxis (69.4 per 100 ED visits); the lowest rates were among those with medication-related anaphylaxis (18.2 per 100 ED visits). Over the past decade, rates of EAI dispensing and A/I follow-up after an ED visit for anaphylaxis have remained low, suggesting that patients may not be prepared to manage future episodes. Copyright © 2017 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.

Hyperthyroidism and erectile dysfunction: a population-based case-control study.

PubMed

Keller, J; Chen, Y-K; Lin, H-C

2012-01-01

Dysthyroidism has been highlighted as a common endocrine disorder associated with erectile dysfunction (ED); however, to date, no large-scale population-based study has investigated the association between hyperthyroidism and ED. This case-control study aimed to explore the association between ED and hyperthyroidism using a population-based data set. In total, 6310 adult patients who received new diagnoses of ED were recruited as cases together with 18 930 matched enrollees with no history of ED who served as controls. Conditional logistic regressions were conducted to explore the association between ED and having been previously diagnosed with hyperthyroidism. In total, 569 (2.3%) of the 25 240 sampled subjects had been diagnosed with hyperthyroidism before the index date; hyperthyroidism was found in 207 (3.3%) cases and 362 (1.90%) controls. After adjusting for potential confounding factors, the odds ratio (OR) of prior hyperthyroidism among cases was 1.64 (95% confidence interval=1.37-1.96, P<0.001) than that of controls. No association was detected between prior hyperthyroidism and ED for the 18-30, 30-39 and >70 age groups. Subjects aged between 60 and 69 years had the highest ORs for prior hyperthyroidism among cases when compared to controls (OR=1.84; 95% confidence interval=1.20-2.84; P<0.001). Our study further confirms the existence of an association between ED and prior hyperthyroidism.

Cavernosal arterial insufficiency is a major component of erectile dysfunction in some recipients of high-dose chemotherapy/chemo-radiotherapy for haematological malignancies.

PubMed

Chatterjee, R; Andrews, H O; McGarrigle, H H; Kottaridis, P D; Lees, W R; Mackinnon, S; Ralph, D J; Goldstone, A H

2000-06-01

We studied 24 male patients aged 26-62 years (median 41) prospectively presenting over a 5 year period with clinical features of hypogonadism and erectile dysfunction (ED), who had been treated with autologous or allogeneic bone marrow/stem cell transplant for a variety of haematological malignancies and had received either high-dose chemotherapy or high-dose chemotherapy combined with total body irradiation (TBI). Ten healthy adult controls (aged 35-50 years) were also studied. Erectile dysfunction (ED) was assessed clinically and by colour flow Doppler studies of the cavernosal vessels. Testicular function was assessed by testicular volume including orchidometry, FSH, LH and testosterone measurements. Libido and ejaculatory function were also recorded. Patients had severe hypogonadism as evidenced by low mean testicular volume (7.0 +/- 2.4 ml vs 20 +/- 2.0 ml; P < 0.001), elevated gonadotrophins (FSH = 18.54 +/- 7.61 vs 5 IU/l (P < 0.001); LH = 8.02 +/- 2.89 vs 3. 9 IU/l (P < 0.001)) and low normal mean testosterone levels (16.4 nmol/l +/- 9.1 vs 22.4 nmol/l (P < 0.5)). Cavernosal arterial insufficiency was found in 11/14 of TBI-treated and in 3/10 HDC-treated patients, indicative of vasculogenic damage to corpora cavernosal vessels. Patients were given a therapeutic trial with testosterone replacement therapy (TRT). Those who had diminished libido had a marked improvement in their symptoms but the effect of TRT on ED was equivocal. In conclusion, this is the first report to show vasculogenic insufficiency in patients with haematological malignancies treated by BMT. Although hypogonadism can account for diminished libido, arteriogenic insufficiency is likely to be an important factor accounting for ED in these patients, especially those treated by TBI. We recommend a comprehensive assessment including endocrine profile and colour flow Doppler study in formulating the best management plan in recipients of high-dose therapy presenting after transplant with ED.

Baseline Characteristics and Outcomes of Older Adults Seeking Care in Ambulatory Urgent Care Clinics.

PubMed

Reyes, Bernardo J; Lopez, Javier M; Galindo, Diana J; Briceno, Maria; Ouslander, Joseph G

2017-12-01

To determine the most common clinical conditions associated with older adults visiting Urgent care centers (UCCs) and the potential need for further resource use. Cross-sectional retrospective study. Nonprofit academic medical center with campuses and multiple satellite offices in Ohio and Florida. Individuals aged 55 and older who visited UCCs between August 2014 and March 2015 (N = 9,445; average age 63.1 ± 10.1, 64% female). Of those, 2,445 had at least one encounter within the same healthcare system within 30 days after the index visit and were included in our final analysis. 30-day ED visits and hospitalizations. Of the 2,445 patients, 578 (23.6%) visited the emergency department (ED) or were hospitalized, 974 (39.8%) returned to the UCC, and 895 (63.4%) visited their primary care physician's office. A significantly higher proportion (38.4%, n = 68/177) of individuals aged 85 and older visited the ED or were hospitalized within 30 days (P < .010) than of those younger than 65 (20.0%, n = 273/1,367). Diabetes mellitus (odds ratio (OR) = 1.73, 95% confidence interval (CI) = 1.40-2.15, P < .001), coronary artery disease or cerebrovascular disease (OR = 2.45 CI 1.95-3.09, P < .001), chronic obstructive pulmonary disorder or asthma (OR = 1.57, 95% CI = 1.23-2.01, P < .001), polypharmacy (OR = 1.45, 95% CI = 1.18-1.78, P = .004), and cognitive impairment (OR = 2.74, 95% CI = 1.74-4.31, P < .010) were associated with higher rates of ED visits or hospitalizations within 30 days of the UCC visit. Older adults (especially those aged ≥85) and those with conditions such as polypharmacy and dementia are at higher risk of being hospitalized or visit the ED after seeking care at UCCs than younger adults and those without these conditions. © 2017, Copyright the Authors Journal compilation © 2017, The American Geriatrics Society.

Risk factors for admission at three urban emergency departments in England: a cross-sectional analysis of attendances over 1 month.

PubMed

Ismail, Sharif A; Pope, Ian; Bloom, Benjamin; Catalao, Raquel; Green, Emilie; Longbottom, Rebecca E; Jansen, Gwyneth; McCoy, David; Harris, Tim

2017-06-22

To investigate factors associated with unscheduled admission following presentation to emergency departments (EDs) at three hospitals in England. Cross-sectional analysis of attendance data for patients from three urban EDs in England: a large teaching hospital and major trauma centre (site 1) and two district general hospitals (sites 2 and 3). Variables included patient age, gender, ethnicity, deprivation score, arrival date and time, arrival by ambulance or otherwise, a variety of ED workload measures, inpatient bed occupancy rates and admission outcome. Coding inconsistencies in routine ED data used for this study meant that diagnosis could not be included. The primary outcome for the study was unscheduled admission. All adults aged 16 and older attending the three inner London EDs in December 2013. Data on 19 734 unique patient attendances were gathered. Outcome data were available for 19 721 attendances (>99%), of whom 6263 (32%) were admitted to hospital. Site 1 was set as the baseline site for analysis of admission risk. Risk of admission was significantly greater at sites 2 and 3 (adjusted OR (AOR) relative to site 1 for site 2 was 1.89, 95% CI 1.74 to 2.05, p<0.001) and for patients of black or black British ethnicity (AOR 1.29, 1.16 to 1.44, p<0.001). Deprivation was strongly associated with admission. Analysis of departmental and hospital-wide workload pressures gave conflicting results, but proximity to the "4-hour target" (a rule that limits patient stays in EDs to 4 hours in the National Health Service in England) emerged as a strong driver for admission in this analysis (AOR 3.61, 95% CI 3.30 to 3.95, p<0.001). This study found statistically significant variations in odds of admission between hospital sites when adjusting for various patient demographic and presentation factors, suggesting important variations in ED-level and clinician-level behaviour relating to admission decisions. The 4-hour target is a strong driver for emergency admission. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

An Integrated Computerized Triage System in the Emergency Department

PubMed Central

Aronsky, Dominik; Jones, Ian; Raines, Bill; Hemphill, Robin; Mayberry, Scott R; Luther, Melissa A; Slusser, Ted

2008-01-01

Emergency department (ED) triage is a fast-paced process that prioritizes the allocation of limited health care resources to patients in greatest need. This paper describes the experiences with an integrated, computerized triage application. The system exchanges information with other information systems, including the ED patient tracking board, the longitudinal electronic medical record, the computerized provider order entry, and the medication reconciliation application. The application includes decision support capabilities such as assessing the patient’s acuity level, age-dependent alerts for vital signs, and clinical reminders. The browser-based system utilizes the institution’s controlled vocabulary, improves data completeness and quality, such as compliance with capturing required data elements and screening questions, initiates clinical processes, such as pneumococcal vaccination ordering, and reminders to start clinical pathways, issues alerts for clinical trial eligibility, and facilitates various reporting needs. The system has supported the triage documentation of >290,000 pediatric and adult patients. PMID:18999190

A new model to study sleep deprivation-induced seizure.

PubMed

Lucey, Brendan P; Leahy, Averi; Rosas, Regine; Shaw, Paul J

2015-05-01

A relationship between sleep and seizures is well-described in both humans and rodent animal models; however, the mechanism underlying this relationship is unknown. Using Drosophila melanogaster mutants with seizure phenotypes, we demonstrate that seizure activity can be modified by sleep deprivation. Seizure activity was evaluated in an adult bang-sensitive seizure mutant, stress sensitive B (sesB(9ed4)), and in an adult temperature sensitive seizure mutant seizure (sei(ts1)) under baseline and following 12 h of sleep deprivation. The long-term effect of sleep deprivation on young, immature sesB(9ed4) flies was also assessed. Laboratory. Drosophila melanogaster. Sleep deprivation. Sleep deprivation increased seizure susceptibility in adult sesB(9ed4)/+ and sei(ts1) mutant flies. Sleep deprivation also increased seizure susceptibility when sesB was disrupted using RNAi. The effect of sleep deprivation on seizure activity was reduced when sesB(9ed4)/+ flies were given the anti-seizure drug, valproic acid. In contrast to adult flies, sleep deprivation during early fly development resulted in chronic seizure susceptibility when sesB(9ed4)/+ became adults. These findings show that Drosophila is a model organism for investigating the relationship between sleep and seizure activity. © 2015 Associated Professional Sleep Societies, LLC.

Comparison of patient centeredness of visits to emergency departments, physicians, and dentists for dental problems and injuries.

PubMed

Cohen, Leonard A; Bonito, Arthur J; Eicheldinger, Celia; Manski, Richard J; Macek, Mark D; Edwards, Robert R; Khanna, Niharika

2010-01-01

Patient-centered care has a positive impact on patient health status. This report compares patient assessments of patient centeredness during treatment in hospital emergency departments (EDs) and physician and dentist offices for dental problems and injuries. Participants included low-income White, Black, and Hispanic adults who had experienced a dental problem or injury during the previous 12 months and who visited an emergency department, physician, or dentist for treatment. A stratified random sample of Maryland households participated in a cross-sectional telephone survey. Interviews were completed with 94.8% (401/423) of eligible individuals. Multivariable logistic regression analyses were performed. The measure of predictive power, the pseudo-R2s, calculated for the logistic regression models ranged from 12% to 18% for the analyses of responses to the measures of patient centeredness (satisfaction with treatment, careful listening, thorough explaining, spending enough time, and treated with courtesy and respect). EDs were less likely than dentists to treat patients with great courtesy and respect. Further research is needed to identify factors that support patient-centered care.

Geriatric Screening Tools to Select Older Adults Susceptible for Direct Transfer From the Emergency Department to Subacute Intermediate-Care Hospitalization.

PubMed

Inzitari, Marco; Gual, Neus; Roig, Thaïs; Colprim, Daniel; Pérez-Bocanegra, Carmen; San-José, Antonio; Jimenez, Xavier

2015-10-01

Early transfer to intermediate-care hospitals, low-tech but with geriatric expertise, represents an alternative to conventional acute hospitalization for selected older adults visiting emergency departments (EDs). We evaluated if simple screening tools predict discharge destination in patients included in this pathway. Cohort study, including patients transferred from ED to the intermediate-care hospital Parc Sanitari Pere Virgili, Barcelona, during 14 months (2012-2013) for exacerbated chronic diseases. At admission, we collected demographics, comprehensive geriatric assessment, and 3 screening tools (Identification of Seniors at Risk [ISAR], SilverCode, and Walter indicator). Discharge destination different from usual living situation (combined death and transfer to acute hospitals or long-term nursing care) versus return to previous situation (home or nursing home). Of 265 patients (mean age ± SD = 85.3 ± 7.5, 69% women, 58% with acute respiratory infections, 38% with dementia), 80.8% returned to previous living situation after 14.1 ± 6.5 days (mean ± SD). In multivariable Cox proportional hazard models, ISAR >3 points (hazard ratio [HR] 2.06, 95% confidence interval [95% CI] 1.16-3.66) and >1 pressure ulcers (HR 2.09, 95% CI 1.11-3.93), but also continuous ISAR, and, in subanalyses, Walter indicator, increased the risk of negative outcomes. Using ROC curves, ISAR showed the best prediction among other variables, although predictive value was poor (AUC = 0.62 (0.53-0.71) for ISAR >3 and AUC = 0.65 (0.57-0.74) for continuous ISAR). ISAR and SilverCode showed fair prediction of acute hospital readmissions. Among geriatric screening tools, ISAR was independently associated with discharge destination in older adults transferred from ED to intermediate care. Predictive validity was poor. Further research on selection of candidates for alternatives to conventional hospitalization is needed. Copyright © 2015 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.

Marked reduction in length of stay for patients with psychiatric emergencies after implementation of a comanagement model.

PubMed

Polevoi, Steven K; Jewel Shim, J; McCulloch, Charles E; Grimes, Barbara; Govindarajan, Prasanthi

2013-04-01

Patients with psychiatric emergencies often spend excessive time in an emergency department (ED) due to limited inpatient psychiatric bed capacity. The objective was to compare traditional resident consultation with a new model (comanagement) to reduce length of stay (LOS) for patients with psychiatric emergencies. The costs of this model were compared to those of standard care. This was a before-and-after study conducted in the ED of an urban academic medical center without an inpatient psychiatry unit from January 1, 2007, through December 31, 2009. Subjects were all adult patients seen by ED clinicians and determined to be a danger to self or others or gravely disabled. At baseline, psychiatry residents evaluated patients and made therapeutic recommendations after consultation with faculty. The comanagement model was fully implemented in September 2008. In this model, psychiatrists directly ordered pharmacotherapy, regularly monitored effects, and intensified efforts toward appropriate disposition. Additionally, increased attending-level involvement expedited focused evaluation and disposition of patients. An interrupted time series analysis was used to study the effects of this intervention on LOS for all psychiatric patients transferred for inpatient psychiatric care. Secondary outcomes included mean number of hours on ambulance diversion per month and the mean number of patients who left without being seen (LWBS) from the ED. A total of 1,884 patient visits were considered. Compared to the preintervention phase, median LOS for patients transferred for inpatient psychiatric care decreased by about 22% (p < 0.0005, 95% confidence interval [CI] = 15% to 28%) in the postintervention phase. Ambulance diversion hours increased by about 40 hours per month (p = 0.008, 95% CI = 11 to 69 hours) and the mean number of patients who LWBS decreased by about 26 per month (p = 0.106; 95% CI = -60 to 5.9 visits per month) in the postintervention phase. A comanagement model was associated with a marked reduction in the LOS for this patient population. © 2013 by the Society for Academic Emergency Medicine.

The association of emergency department administration of sodium bicarbonate after out of hospital cardiac arrest with outcomes.

PubMed

Chen, Yi-Chuan; Hung, Ming-Szu; Liu, Chia-Yen; Hsiao, Cheng-Ting; Yang, Yao-Hsu

2018-03-05

Sodium bicarbonate administration is mostly restricted to in-hospital use in Taiwan. This study was conducted to investigate the effect of sodium bicarbonate on outcomes among patients with out-of-hospital cardiac arrest (OHCA). This population-based study used a 16-year database to analyze the association between sodium bicarbonate administration for resuscitation in the emergency department (ED) and outcomes. All adult patients with OHCA were identified through diagnostic and procedure codes. The primary outcome was survival to hospital admission and secondary outcome was the rate of death within the first 30days of incidence of cardiac arrest. Cox proportional-hazards regression, logistic regression, and propensity analyses were conducted. Among 5589 total OHCA patients, 15.1% (844) had survival to hospital admission. For all patients, a positive association was noted between sodium bicarbonate administration during resuscitation in the ED and survival to hospital admission (adjusted odds ratio [OR]: 4.47; 95% confidence interval [CI]: 3.82-5.22, p<0.001). In propensity-matched patients, a positive association was also noted (adjusted OR, 4.61; 95% CI: 3.90-5.46, p<0.001). Among patients with OHCA in Taiwan, administration of sodium bicarbonate during ED resuscitation was significantly associated with an increased rate of survival to hospital admission. Copyright © 2018. Published by Elsevier Inc.

Adverse outcomes in older adults attending emergency departments: a systematic review and meta-analysis of the Identification of Seniors At Risk (ISAR) screening tool.

PubMed

Galvin, Rose; Gilleit, Yannick; Wallace, Emma; Cousins, Gráinne; Bolmer, Manon; Rainer, Timothy; Smith, Susan M; Fahey, Tom

2017-03-01

older adults are frequent users of emergency services and demonstrate high rates of adverse outcomes following emergency care. to perform a systematic review and meta-analysis of the Identification of Seniors At Risk (ISAR) screening tool, to determine its predictive value in identifying adults ≥65 years at risk of functional decline, unplanned emergency department (ED) readmission, emergency hospitalisation or death within 180 days after index ED visit/hospitalisation. a systematic literature search was conducted in PubMed, EMBASE, CINAHL, EBSCO and the Cochrane Library to identify validation and impact analysis studies of the ISAR tool. A pre-specified ISAR score of ≥2 (maximum score 6 points) was used to identify patients at high risk of adverse outcomes. A bivariate random effects model generated pooled estimates of sensitivity and specificity. Statistical heterogeneity was explored and methodological quality was assessed using validated criteria. thirty-two validation studies (n = 12,939) are included. At ≥2, the pooled sensitivity of the ISAR for predicting ED return, emergency hospitalisation and mortality at 6 months is 0.80 (95% confidence interval (CI) 0.70-0.87), 0.82 (95% CI 0.74-0.88) and 0.87 (95% CI 0.75-0.94), respectively, with a pooled specificity of 0.31 (95% CI 0.24-0.38), 0.32 (95% CI 0.24-0.41) and 0.35 (95% CI 0.26-0.44). Similar values are demonstrated at 30 and 90 days. Three heterogeneous impact analysis studies examined the clinical implementation of the ISAR and reported mixed findings across patient and process outcomes. the ISAR has modest predictive accuracy and may serve as a decision-making adjunct when determining which older adults can be safely discharged. © The Author 2016. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For Permissions, please email: journals.permissions@oup.com

TRANSFER FROM PEDIATRIC TO ADULT ENDOCRINOLOGY.

PubMed

Jones, Marybeth R; Robbins, Brett W; Augustine, Marilyn; Doyle, Jackie; Mack-Fogg, Jean; Jones, Heather; White, Patience H

2017-07-01

Adult and pediatric endocrinologists share responsibility for the transition of youth with type 1 diabetes from pediatric to adult healthcare. This study aimed to increase successful transfers to adult care in subspecialty practices by establishing a systematic health care transition (HCT) process. Providers from the adult and pediatric endocrinology divisions at the University of Rochester Medical Center met monthly to customize and integrate the Six Core Elements (6CEs) of HCT into clinical workflows. Young adult patients with type 1 diabetes having an outpatient visit during a 34-month pre-post intervention period were eligible (N = 371). Retrospective chart review was performed on patients receiving referrals to adult endocrinology (n = 75) to obtain (1) the proportion of patients explicitly tracked during transfer from the pediatric to adult endocrinology practice, (2) the providers' documentation of the use of the 6CEs, and (3) the patients' diabetes control and healthcare utilization during the transition period. The percent of eligible patients with type 1 diabetes who were explicitly tracked in their transfer more than doubled compared to baseline (11% vs. 27% of eligible patients; P<.01). Pediatric providers started to use transition readiness assessments and create medical summaries, and adult providers increased closed-loop communication with pediatric providers after a patient's first adult visit. Glycemic control and healthcare utilization remained stable. Successful implementation of the 6CEs into pediatric and adult subspecialty practices can result in improvements of planned transfers of pediatric patients with type 1 diabetes to adult subspecialty providers. 6CEs = six core elements; AYA = adolescent and young adult; DKA = diabetic ketoacidosis; ED = emergency department; HbA1c = hemoglobin A1c; HCT = health care transition.

Successful Tobacco Dependence Treatment in Low-Income Emergency Department Patients: A Randomized Trial.

PubMed

Bernstein, Steven L; D'Onofrio, Gail; Rosner, June; O'Malley, Stephanie; Makuch, Robert; Busch, Susan; Pantalon, Michael V; Toll, Benjamin

2015-08-01

Tobacco use is common among emergency department (ED) patients, many of whom have low income. Our objective is to study the efficacy of an intervention incorporating motivational interviewing, nicotine replacement, and quitline referral for adult smokers in an ED. This was a 2-arm randomized clinical trial conducted from October 2010 to December 2012 in a northeastern urban US ED with 90,000 visits per year. Eligible subjects were aged 18 years or older, smoked, and were self-pay or had Medicaid insurance. Intervention subjects received a motivational interview by a trained research assistant, 6 weeks' worth of nicotine patches and gum initiated in the ED, a faxed referral to the state smokers' quitline, a booster call, and a brochure. Control subjects received the brochure, which provided quitline information. The primary outcome was biochemically confirmed tobacco abstinence at 3 months. Secondary endpoints included quitline use. Of 778 enrolled subjects, 774 (99.5%) were alive at 3 months. The prevalence of biochemically confirmed abstinence was 12.2% (47/386) in the intervention arm versus 4.9% (19/388) in the control arm, for a difference in quit rates of 7.3% (95% confidence interval 3.2% to 11.5%). In multivariable logistic modeling controlling for age, sex, and race or ethnicity, study subjects remained more likely to be abstinent than controls (odds ratio 2.72; 95% confidence interval 1.55 to 4.75). An intensive intervention improved tobacco abstinence rates in low-income ED smokers. Because approximately 20 million smokers, many of whom have low income, visit US EDs annually, these results suggest that ED-initiated treatment may be an effective technique to treat this group of smokers. Copyright © 2015 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Osteitis fibrosa

MedlinePlus

... LJ, de Kretser DM, et al, eds. Endocrinology: Adult and Pediatric . 7th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap 63. Thakker RV. The parathyroid glands, hypercalcemia and hypocalcemia. In: Goldman L, Schafer AI, eds. Goldman's Cecil ...

Burden of uncontrolled epilepsy in patients requiring an emergency room visit or hospitalization.

PubMed

Manjunath, Ranjani; Paradis, Pierre Emmanuel; Parisé, Hélène; Lafeuille, Marie-Hélène; Bowers, Brian; Duh, Mei Sheng; Lefebvre, Patrick; Faught, Edward

2012-10-30

To quantify the clinical and economic burden of uncontrolled epilepsy in patients requiring emergency department (ED) visit or hospitalization. Health insurance claims from a 5-state Medicaid database (1997Q1-2009Q2) and 55 self-insured US companies ("employer," 1999Q1 and 2008Q4) were analyzed. Adult patients with epilepsy receiving antiepileptic drugs (AED) were selected. Using a retrospective matched-cohort design, patients were categorized into cohorts of "uncontrolled" (≥ 2 changes in AED therapy, then ≥ 1 epilepsy-related ED visit/hospitalization within 1 year) and "well-controlled" (no AED change, no epilepsy-related ED visit/hospitalization) epilepsy. Matched cohorts were compared for health care resource utilization and costs using multivariate conditional regression models and nonparametric methods. From 110,312 (Medicaid) and 36,529 (employer) eligible patients, 3,454 and 602 with uncontrolled epilepsy were matched 1:1 to patients with well-controlled epilepsy, respectively. In both populations, uncontrolled epilepsy cohorts presented about 2 times more fractures and head injuries (all p values < 0.0001) and higher health care resource utilization (ranges of adjusted incidence rate ratios [IRRs] [all-cause utilization]: AEDs = 1.8-1.9, non-AEDs = 1.3-1.5, hospitalizations = 5.4-6.7, length of hospital stays = 7.3-7.7, ED visits = 3.7-5.0, outpatient visits = 1.4-1.7, neurologist visits = 2.3-3.1; all p values < 0.0001) than well-controlled groups. Total direct health care costs were higher in patients with uncontrolled epilepsy (adjusted cost difference [95% confidence interval (CI)] Medicaid = $12,258 [$10,482-$14,083]; employer = $14,582 [$12,019-$17,097]) vs well-controlled patients. Privately insured employees with uncontrolled epilepsy lost 2.5 times more work days, with associated indirect costs of $2,857 (95% CI $1,042-$4,581). Uncontrolled epilepsy in patients requiring ED visit or hospitalization was associated with significantly greater health care resource utilization and increased direct and indirect costs compared to well-controlled epilepsy in both publicly and privately insured settings.

Collaborative Care from the Emergency Department for Injured Patients with Prescription Drug Misuse: An Open Feasibility Study

PubMed Central

Whiteside, Lauren K.; Darnell, Doyanne; Jackson, Karlee; Wang, Jin; Russo, Joan; Donovan, Dennis M.; Zatzick, Douglas F.

2018-01-01

Collaborative Care is a comprehensive longitudinal care management strategy. The purpose of this pilot effectiveness-implementation hybrid study was to determine the feasibility of a Collaborative Care intervention initiated from the Emergency Department and proceeding longitudinally for six months for injured patients with prescription drug misuse (PDM). Adult patients presenting to an urban ED with an injury were screened for eligibility from 2/2015-8/2015. Eligible participants with a positive screen for PDM were enrolled in the ‘ED-LINC’ intervention which included the following elements: 1) active care coordination and linkage, 2) medication safety and utilization of opioid guidelines 3) longitudinal care management and 4) utilization of Electronic Medical Record (EMR) innovations such as the statewide Emergency Department Information Exchange (EDIE) and statewide prescription monitoring program information for assessment and follow-up. Baseline characteristics of the sample were assessed and regression models were used to evaluate longitudinal trajectories of risk for PDM. A total of 36 participants (56% of patients approached) had PDM and 30 participants were enrolled. Of those enrolled, 37% had prescription stimulant misuse, 20% with prescription sedative misuse and 97% had prescription opioid misuse. Follow-up rates at all time points were ≥ 83%. Baseline levels of comorbidity were high; 57% endorsed recent heroin use and 70% endorsed symptoms consistent with major depression. Over 50% had five or more statewide ED visits and 53% had used three or more different ED‘s in the past year. On average, participants received a total of 85 minutes of ED-LINC over six months with 90% of participants receiving all four intervention elements. All patients had care coordinated with new or existing primary care providers (PCP’s) and 23% were linked to a new PCP. A majority of patients (≥ 80%) reported receiving high quality, desired intervention services. There was no significant change in PDM over time. Collaborative Care initiated from the ED is feasible and acceptable to patients with trauma and PDM. Future directions could include effectiveness-implementation hybrid trials to study implementation barriers and strategies as well as patient-level outcomes of this intervention for this complex patient population. PMID:29021110

The emergency department prediction of disposition (EPOD) study.

PubMed

Vaghasiya, Milan R; Murphy, Margaret; O'Flynn, Daniel; Shetty, Amith

2014-11-01

Emergency departments (ED) continue to evolve models of care and streaming as interventions to tackle the effects of access block and overcrowding. Tertiary ED may be able to design patient-flow based on predicted dispositions in the department. Segregating discharge-stream patients may help develop patient-flows within the department, which is less affected by availability of beds in a hospital. We aim to determine if triage nurses and ED doctors can predict disposition outcomes early in the patient journey and thus lead to successful streaming of patients in the ED. During this study, triage nurses and ED doctors anonymously predicted disposition outcomes for patients presenting to triage after their brief assessments. Patient disposition at the 24-h post ED presentation was considered as the actual outcome and compared against predicted outcomes. Triage nurses were able to predict actual discharges of 445 patients out of 490 patients with a positive predictive value (PPV) of 90.8% (95% CI 87.8-93.2%). ED registrars were able to predict actual discharges of 85 patients out of 93 patients with PPV of 91.4% (95% CI 83.3-95.9%). ED consultants were able to predict actual discharges of 111 patients out of 118 patients with PPV 94.1% (95% CI 87.7-97.4%). PPVs for admission among ED consultants, ED registrars and Triage nurses were 59.7%, 54.4% and 48.5% respectively. Triage nurses, ED consultants and ED registrars are able to predict a patient's discharge disposition at triage with high levels of confidence. Triage nurses, ED consultants, and ED registrars can predict patients who are likely to be admitted with equal ability. This data may be used to develop specific admission and discharge streams based on early decision-making in EDs by triage nurses, ED registrars or ED consultants. Crown Copyright © 2014. Published by Elsevier Ltd. All rights reserved.

The role of charity care and primary care physician assignment on ED use in homeless patients.

PubMed

Wang, Hao; Nejtek, Vicki A; Zieger, Dawn; Robinson, Richard D; Schrader, Chet D; Phariss, Chase; Ku, Jocelyn; Zenarosa, Nestor R

2015-08-01

Homeless patients are a vulnerable population with a higher incidence of using the emergency department (ED) for noncrisis care. Multiple charity programs target their outreach toward improving the health of homeless patients, but few data are available on the effectiveness of reducing ED recidivism. The aim of this study is to determine whether inappropriate ED use for nonemergency care may be reduced by providing charity insurance and assigning homeless patients to a primary care physician (PCP) in an outpatient clinic setting. A retrospective medical records review of homeless patients presenting to the ED and receiving treatment between July 2013 and June 2014 was completed. Appropriate vs inappropriate use of the ED was determined using the New York University ED Algorithm. The association between patients with charity care coverage, PCP assignment status, and appropriate vs inappropriate ED use was analyzed and compared. Following New York University ED Algorithm standards, 76% of all ED visits were deemed inappropriate with approximately 77% of homeless patients receiving charity care and 74% of patients with no insurance seeking noncrisis health care in the ED (P=.112). About 50% of inappropriate ED visits and 43.84% of appropriate ED visits occurred in patients with a PCP assignment (P=.019). Both charity care homeless patients and those without insurance coverage tend to use the ED for noncrisis care resulting in high rates of inappropriate ED use. Simply providing charity care and/or PCP assignment does not seem to sufficiently reduce inappropriate ED use in homeless patients. Copyright © 2015 The Authors. Published by Elsevier Inc. All rights reserved.

Increased hospital and emergency department utilization by individuals with recent criminal justice involvement: results of a national survey.

PubMed

Frank, Joseph W; Linder, Jeffrey A; Becker, William C; Fiellin, David A; Wang, Emily A

2014-09-01

Individuals involved with the criminal justice system have increased health needs and poor access to primary care. To examine hospital and emergency department (ED) utilization and related costs by individuals with recent criminal justice involvement. Cross-sectional survey. Non-institutionalized, civilian U.S. adult participants (n = 154,356) of the National Survey on Drug Use and Health (2008-2011). Estimated proportion of adults who reported past year 1) hospitalization or 2) ED utilization according to past year criminal justice involvement, defined as 1) parole or probation, 2) arrest without subsequent correctional supervision, or 3) no criminal justice involvement; estimated annual expenditures using unlinked data from the Medical Expenditure Panel Survey. An estimated 5.7 million adults reported parole or probation and an additional 3.9 million adults reported an arrest in the past year. Adults with recent parole or probation and those with a recent arrest, compared with the general population, had higher rates of hospitalization (12.3 %, 14.3 %, 10.5 %; P < 0.001) and higher rates of ED utilization (39.3 %, 47.2 %, 26.9 %; P < 0.001). Recent parole or probation was an independent predictor of hospitalization (adjusted odds ratio [AOR], 1.21; 95 % confidence interval [CI], 1.02-1.44) and ED utilization (AOR, 1.35; 95 % CI, 1.12-1.63); Recent arrest was an independent predictor of hospitalization (AOR, 1.26; 95 % CI, 1.08-1.47) and ED utilization (AOR, 1.81; 95 % CI, 1.53-2.15). Individuals with recent criminal justice involvement make up 4.2 % of the U.S. adult population, yet account for an estimated 7.2 % of hospital expenditures and 8.5 % of ED expenditures. Recent criminal justice involvement is associated with increased hospital and ED utilization and costs. The criminal justice system may offer an important point of contact for efforts to improve the healthcare utilization patterns of a large and vulnerable population.

Emergency Department Visits by Pediatric Patients for Poisoning by Prescription Opioids

PubMed Central

Tadros, Allison; Layman, Shelley M.; Davis, Stephen M.; Bozeman, Rachel; Davidov, Danielle M.

2016-01-01

Background Prescription medication abuse is an increasingly recognized problem in the United States. As more opioids are being prescribed and abused by adults, there is an increased risk of both accidental and intentional exposure to children and adolescents. The impact of pediatric exposures to prescription pain pills has not been well studied. Objectives We sought to evaluate emergency department (ED) visits for poisoning by prescription opioids in pediatric patients. Methods This retrospective study looked at clinical and demographic data from the Nationwide Emergency Department Sample (NEDS) from 2006 – 2012. Results There were 21,928 pediatric ED visits for prescription opioid poisonings and more than half were unintentional. There was a bimodal age distribution of patients with slightly more than half occurring in females. The majority of patients were discharged from the ED. More visits in the younger age group (0–5 years) were unintentional while the majority of visits in the adolescent age group (15–17 years) were intentional. Mean charge per discharge was $1,840 and $14,235 for admissions and surmounted to over $81 million in total charges. Conclusion Poisonings by prescription opioids largely impact both young children and adolescents. These findings can be used to help target this population for future preventive efforts. PMID:27398815

Comparison of associated features and drug treatment between co-occurring unipolar and bipolar disorders in depressed eating disorder patients.

PubMed

Tseng, Mei-Chih Meg; Chang, Chin-Hao; Liao, Shih-Cheng; Chen, Hsi-Chung

2017-02-27

To examine the differences of associated characteristics and prescription drug use between co-occurring unipolar and bipolar disorders in patients with eating disorders (EDs). Patients with EDs and major depressive episode (MDE) were recruited from psychiatric outpatient clinics. They were interviewed and completed self-administered measures assessing eating and general psychopathology. The prescribed drugs at the index outpatient visit were recorded. Clinical characteristics and prescription drugs of groups with major depressive disorder (ED-MDD), MDE with lifetime mania (ED-BP I), and MDE with lifetime hypomania (ED-BP II) were compared. Continuous variables between groups were compared using generalized linear regression with adjustments of age, gender, and ED subtype for pair-wise comparisons. Multivariate logistic regression with adjustments of age, gender, and ED subtype was employed to estimate adjusted odds ratios with 95% confidence intervals between groups. Two hundred and twenty-seven patients with EDs had a current MDE. Among them, 17.2% and 24.2% experienced associated manic and hypomanic episodes, respectively. Bipolar I and II patients displayed significantly poorer weight regulation, more severe impulsivity and emotional lability, and higher rates of co-occurring alcohol use disorders than ED-MDD patients. ED-BP I patients were found to have the lowest IQ, poorest working memory, and the most severe depression, suicidality and functional impairment among all patients. Patients with ED-BP II shared affect and behavioral dysregulations with ED-BP I, but had less severe degrees of cognitive and functional impairments than ED-BP I. Patients with ED-BP I were significantly less likely than those in the ED-MDD and ED-BP II groups to be on antidepressant monotherapy, but a great rate (27%) of ED-BP I individuals taking antidepressant monotherapy had potential risk of mood switch during the course of treatment. Our study identified discriminative features of bipolar I and II disorders from MDD among a group of depressed ED patients. We suggest that the associated mania, hypomania, and mood lability are predictors of clinical severity and should be identified from ED patients presented with depressive features. Accurate diagnosis of bipolar disorders may have implications for pharmacotherapy in patients with EDs.

Sarcopenia and post-hospital outcomes in older adults: A longitudinal study.

PubMed

Pérez-Zepeda, Mario Ulises; Sgaravatti, Aldo; Dent, Elsa

Sarcopenia poses a significant problem for older adults, yet very little is known about this medical condition in the hospital setting. The aims of this hospital-based study were to determine: (i) the prevalence of sarcopenia; (ii) factors associated with sarcopenia; and (iii) the association of sarcopenia with adverse clinical outcomes post-hospitalisation. This is a longitudinal analysis of consecutive patients aged ≥70 years admitted to a Geriatric Management and Evaluation Unit (GEMU) ward. Sarcopenia was classified using the European Working Group on Sarcopenia in Older People (EWGSOP) algorithm, which included: handgrip strength, gait speed, and muscle mass using Bioelectrical Impedance Analysis (BIA). Outcomes were assessed at 12-months post-hospital discharge, and included both mortality and admission to a hospital Emergency Department (ED). Kaplan-Meier methods were used to estimate survival, with Cox proportion hazard models then applied. All regression analyses controlled for age, sex, and co-morbidity. 172 patients (72% female) with a mean (SD) age of 85.2 (6.4) years were included. Sarcopenia was present in 69 (40.1%) of patients. Patients with sarcopenia were twice as likely to die in the 12-months post-hospitalisation (HR, 95% CI=2.23, 1.15-4.34), but did not have an increased likelihood of ED admission. Sarcopenia showed an independent association with 12-month post-hospital mortality in older adults. With the new recognition of sarcopenia as a medical condition with its own unique ICD-10-CM code, awareness and diagnosis of sarcopenia in clinical settings is paramount. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Association Between Hearing Aid Use and Health Care Use and Cost Among Older Adults With Hearing Loss.

PubMed

Mahmoudi, Elham; Zazove, Philip; Meade, Michelle; McKee, Michael M

2018-04-26

Hearing loss (HL) is common among older adults and is associated with poorer health and impeded communication. Hearing aids (HAs), while helpful in addressing some of the outcomes of HL, are not covered by Medicare. To determine whether HA use is associated with health care costs and utilization in older adults. This retrospective cohort study used nationally representative 2013-2014 Medical Expenditure Panel Survey data to evaluate the use of HAs among 1336 adults aged 65 years or older with HL. An inverse propensity score weighting was applied to adjust for potential selection bias between older adults with and without HAs, all of whom reported having HL. The mean treatment outcomes of HA use on health care utilization and costs were estimated. Encounter with the US health care system. (1) Total health care, Medicare, and out-of-pocket spending; (2) any emergency department (ED), inpatient, and office visit; and (3) number of ED visits, nights in hospital, and office visits. Of the 1336 individuals included in the study, 574 (43.0%) were women; mean (SD) age was 77 (7) years. Adults without HAs (n = 734) were less educated, had lower income, and were more likely to be from minority subpopulations. The mean treatment outcomes of using HAs per participant were (1) higher total annual health care spending by $1125 (95% CI, $1114 to $1137) and higher out-of-pocket spending by $325 (95% CI, $322 to $326) but lower Medicare spending by $71 (95% CI, -$81 to -$62); (2) lower probability of any ED visit by 2 percentage points (PPs) (24% vs 26%; 95% CI, -2% to -2%) and lower probability of any hospitalization by 2 PPs (20% vs 22%; 95% CI, -3% to -1%) but higher probability of any office visit by 4 PPs (96% vs 92%; 95% CI, 4% to 4%); and (3) 1.40 more office visits (95% CI, 1.39 to 1.41) but 0.46 (5%) fewer number of hospital nights (95% CI, -0.47 to -0.44), with no association with the number of ED visits, if any (95% CI, 0.01 to 0). This study demonstrates the beneficial outcomes of use of HAs in reducing the probability of any ED visits and any hospitalizations and in reducing the number of nights in the hospital. Although use of HAs reduced total Medicare costs, it significantly increased total and out-of-pocket health care spending. This information may have implications for Medicare regarding covering HAs for patients with HL.

C-reactive protein testing does not decrease antibiotic use for acute cough illness when compared to a clinical algorithm.

PubMed

Gonzales, Ralph; Aagaard, Eva M; Camargo, Carlos A; Ma, O John; Plautz, Mark; Maselli, Judith H; McCulloch, Charles E; Levin, Sara K; Metlay, Joshua P

2011-07-01

Antibiotics are commonly overused in adults seeking emergency department (ED) care for acute cough illness. To evaluate the effect of a point-of-care C-reactive protein (CRP) blood test on antibiotic treatment of acute cough illness in adults. A randomized controlled trial was conducted in a single urban ED in the United States. The participants were adults (age ≥ 18 years) seeking care for acute cough illness (≤ 21 days duration); 139 participants were enrolled, and 131 completed the ED visit. Between November 2005 and March 2006, study participants had attached to their medical charts a clinical algorithm with recommendations for chest X-ray study or antibiotic treatment. For CRP-tested patients, recommendations were based on the same algorithm plus the CRP level. There was no difference in antibiotic use between CRP-tested and control participants (37% [95% confidence interval (CI) 29-45%] vs. 31% [95% CI 23-39%], respectively; p = 0.46) or chest X-ray use (52% [95% CI 43-61%] vs. 48% [95% CI 39-57%], respectively; p = 0.67). Among CRP-tested participants, those with normal CRP levels received antibiotics much less frequently than those with indeterminate CRP levels (20% [95% CI 7-33%] vs. 50% [95% CI 32-68%], respectively; p = 0.01). Point-of-care CRP testing does not seem to provide any additional value beyond a point-of-care clinical decision support for reducing antibiotic use in adults with acute cough illness. Copyright © 2011 Elsevier Inc. All rights reserved.

The Use of Ketamine for Acute Treatment of Pain: A Randomized, Double-Blind, Placebo-Controlled Trial.

PubMed

Sin, Billy; Tatunchak, Tamara; Paryavi, Mohammad; Olivo, Maria; Mian, Usman; Ruiz, Josel; Shah, Bupendra; de Souza, Sylvie

2017-05-01

Pain is one of the most common reasons for emergency department (ED) visits in the United States. Ketamine is a sedative with N-methyl-D-aspartate (NMDA) receptor antagonism. Recent literature has suggested that the use of subdissociative dose ketamine (SDDK) may be safe and effective for acute pain. The objective of our study was to evaluate ketamine in subdissociative doses as an adjunct for acute pain in the ED. This was a single-center, prospective, randomized, double-blind, placebo-controlled trial that evaluated the use of SDDK in adult patients who presented to the ED with acute pain. Patients received ketamine 0.3 mg/kg via intravenous piggyback over 15 min or placebo. Morphine 0.1 mg/kg intravenous push was administered with the study interventions. The primary outcome was the patient's pain score 15 min after initiation of the intervention. Secondary outcomes included adverse events, consumption of rescue analgesia, patient's length of stay, and patient satisfaction with treatment. Thirty patients were enrolled in each group. Median pain scores in patients who received ketamine were lower than in controls at 15 min (3.5 [interquartile range {IQR} 1.0-7.3 vs. 6.0 [IQR 4.0-9.0], respectively; p = 0.018). No serious adverse events occurred. No difference was detected in the amount of rescue analgesia used or in length of stay. Patients who received ketamine reported a higher mean satisfaction score with their pain management (8.57 [standard deviation {SD} 2.1]) than patients who received placebo (6.05 [SD 2.6]; p = 0.01). When used as an adjunct, SDDK administered at 0.3 mg/kg over 15 min resulted in safe and effective analgesia for ≤30 min in patients who presented with acute pain in the ED. Copyright © 2017 Elsevier Inc. All rights reserved.

Past-year Prescription Drug Monitoring Program Opioid Prescriptions and Self-reported Opioid Use in an Emergency Department Population With Opioid Use Disorder.

PubMed

Hawk, Kathryn; D'Onofrio, Gail; Fiellin, David A; Chawarski, Marek C; O'Connor, Patrick G; Owens, Patricia H; Pantalon, Michael V; Bernstein, Steven L

2017-11-22

Despite increasing reliance on prescription drug monitoring programs (PDMPs) as a response to the opioid epidemic, the relationship between aberrant drug-related behaviors captured by the PDMP and opioid use disorder is incompletely understood. How PDMP data should guide emergency department (ED) assessment has not been studied. The objective was to evaluate a relationship between PDMP opioid prescription records and self-reported nonmedical opioid use of prescription opioids in a cohort of opioid-dependent ED patients enrolled in a treatment trial. PDMP opioid prescription records during 1 year prior to study enrollment on 329 adults meeting Diagnostic and Statistical Manual IV criteria for opioid dependence entering a randomized clinical trial in a large, urban ED were cross-tabulated with data on 30-day nonmedical prescription opioid use self-report. The association among these two types of data was assessed by the Goodman and Kruskal's gamma; a logistic regression was used to explore characteristics of participants who had PDMP record of opioid prescriptions. During 1 year prior to study enrollment, 118 of 329 (36%) patients had at least one opioid prescription (range = 1-51) in our states' PDMP. Patients who reported ≥15 of 30 days of nonmedical prescription opioid use were more likely to have at least four PDMP opioid prescriptions (20/38; 53%) than patients reporting 1 to 14 days (14/38, 37%) or zero days of nonmedical prescription opioid use (4/38, 11%; p = 0.002). Female sex and having health insurance were significantly more represented in the PDMP (p < 0.05 for both). PDMPs may be helpful in identifying patients with certain aberrant drug-related behavior, but are unable to detect many patients with opioid use disorder. The majority of ED patients with opioid use disorder were not captured by the PDMP, highlighting the importance of using additional methods such as screening and clinical history to identify opioid use disorders in ED patients and the limitations of PDMPs to detect opioid use disorders. © 2017 by the Society for Academic Emergency Medicine.

Comparison of bedside screening methods for frailty assessment in older adult trauma patients in the emergency department.

PubMed

Shah, Sachita P; Penn, Kevin; Kaplan, Stephen J; Vrablik, Michael; Jablonowski, Karl; Pham, Tam N; Reed, May J

2018-04-14

Frailty is linked to poor outcomes in older patients. We prospectively compared the utility of the picture-based Clinical Frailty Scale (CFS9), clinical assessments, and ultrasound muscle measurements against the reference FRAIL scale in older adult trauma patients in the emergency department (ED). We recruited a convenience sample of adults 65 yrs. or older with blunt trauma and injury severity scores <9. We queried subjects (or surrogates) on the FRAIL scale, and compared this to: physician-based and subject/surrogate-based CFS9; mid-upper arm circumference (MUAC) and grip strength; and ultrasound (US) measures of muscle thickness (limbs and abdominal wall). We derived optimal diagnostic thresholds and calculated performance metrics for each comparison using sensitivity, specificity, predictive values, and area under receiver operating characteristic curves (AUROC). Fifteen of 65 patients were frail by FRAIL scale (23%). CFS9 performed well when assessed by subject/surrogate (AUROC 0.91 [95% CI 0.84-0.98] or physician (AUROC 0.77 [95% CI 0.63-0.91]. Optimal thresholds for both physician and subject/surrogate were CFS9 of 4 or greater. If both physician and subject/surrogate provided scores <4, sensitivity and negative predictive value were 90.0% (54.1-99.5%) and 95.0% (73.1-99.7%). Grip strength and MUAC were not predictors. US measures that combined biceps and quadriceps thickness showed an AUROC of 0.75 compared to the reference standard. The ED needs rapid, validated tools to screen for frailty. The CFS9 has excellent negative predictive value in ruling out frailty. Ultrasound of combined biceps and quadriceps has modest concordance as an alternative in trauma patients who cannot provide a history. Copyright © 2017 Elsevier Inc. All rights reserved.

Diagnostic accuracy of a screening electronic alert tool for severe sepsis and septic shock in the emergency department.

PubMed

Alsolamy, Sami; Al Salamah, Majid; Al Thagafi, Majed; Al-Dorzi, Hasan M; Marini, Abdellatif M; Aljerian, Nawfal; Al-Enezi, Farhan; Al-Hunaidi, Fatimah; Mahmoud, Ahmed M; Alamry, Ahmed; Arabi, Yaseen M

2014-12-05

Early recognition of severe sepsis and septic shock is challenging. The aim of this study was to determine the diagnostic accuracy of an electronic alert system in detecting severe sepsis or septic shock among emergency department (ED) patients. An electronic sepsis alert system was developed as a part of a quality-improvement project for severe sepsis and septic shock. The system screened all adult ED patients for a combination of systemic inflammatory response syndrome and organ dysfunction criteria (hypotension, hypoxemia or lactic acidosis). This study included all patients older than 14 years who presented to the ED of a tertiary care academic medical center from Oct. 1, 2012 to Jan. 31, 2013. As a comparator, emergency medicine physicians or the critical care physician identified the patients with severe sepsis or septic shock. In the ED, vital signs were manually entered into the hospital electronic heath record every hour in the critical care area and every two hours in other areas. We also calculated the time from the alert to the intensive care unit (ICU) referral. Of the 49,838 patients who presented to the ED, 222 (0.4%) were identified to have severe sepsis or septic shock. The electronic sepsis alert had a sensitivity of 93.18% (95% CI, 88.78% - 96.00%), specificity of 98.44 (95% CI, 98.33% - 98.55%), positive predictive value of 20.98% (95% CI, 18.50% - 23.70%) and negative predictive value of 99.97% (95% CI, 99.95% - 99.98%) for severe sepsis and septic shock. The alert preceded ICU referral by a median of 4.02 hours (Q1 - Q3: 1.25-8.55). Our study shows that electronic sepsis alert tool has high sensitivity and specificity in recognizing severe sepsis and septic shock, which may improve early recognition and management.

"Let Me Tell You About My…" Provider Self-Disclosure in the Emergency Department Builds Patient Rapport.

PubMed

Zink, Korie L; Perry, Marcia; London, Kory; Floto, Olivia; Bassin, Benjamin; Burkhardt, John; Santen, Sally A

2017-01-01

As patients become increasingly involved in their medical care, physician-patient communication gains importance. A previous study showed that physician self-disclosure (SD) of personal information by primary care providers decreased patient rating of the provider communication skills. The objective of this study was to explore the incidence and impact of emergency department (ED) provider self-disclosure on patients' rating of provider communication skills. A survey was administered to 520 adult patients or parents of pediatric patients in a large tertiary care ED during the summer of 2014. The instrument asked patients whether the provider self-disclosed and subsequently asked patients to rate providers' communication skills. We compared patients' ratings of communication measurements between encounters where self-disclosure occurred to those where it did not. Patients reported provider SD in 18.9% of interactions. Provider SD was associated with more positive patient perception of provider communication skills (p<0.05), more positive ratings of provider rapport (p<0.05) and higher satisfaction with provider communication (p<0.05). Patients who noted SD scored their providers' communication skills as "excellent" (63.4%) compared to patients without self-disclosure (47.1%). Patients reported that they would like to hear about their providers' experiences with a similar chief complaint (64.4% of patients), their providers' education (49%), family (33%), personal life (21%) or an injury/ailment unlike their own (18%). Patients responded that providers self-disclose to make patients comfortable/at ease and to build rapport. Provider self-disclosure in the ED is common and is associated with higher ratings of provider communication, rapport, and patient satisfaction.

Erectile Dysfunction Among Patients on Methadone Maintenance Therapy and Its Association With Quality of Life.

PubMed

Teoh, Joni Bing Fei; Yee, Anne; Danaee, Mahmoud; Ng, Chong Guan; Sulaiman, Ahmad Hatim Bin

Erectile dysfunction (ED) is a problem commonly encountered by patients on methadone maintenance therapy (MMT). This study aimed to assess the prevalence of ED among this group of patients along with its risk factors and association with quality of life (QOL). Male patients on MMT in a tertiary hospital in Malaysia were included in the study. A total of 134 patients with sexual partners were assessed for ED using the International Index of Erectile Function. Patients were assessed for substance use using Opiate Treatment Index (OTI) and depression using the Malay version of the self-rated Montgomery-Asberg Depression Rating Scale (MADRS-BM). QOL was evaluated using World Health Organisation Quality of Life (WHOQOL)-BREF. The prevalence of ED among patients on MMT was 67%, with 26.1% having mild ED, 30.4% having mild-to-moderate ED, 7.0% having moderate ED, and 17.2% having severe ED. Patients with depression were 4 times more likely to have ED compared with patients without depression, whereas increasing age significantly correlated with the severity of ED. Having ED predicted a poorer QOL in the social relationships domain. Depression is highly associated with ED, which negatively influences the social aspect of QOL among patients on methadone maintenance therapy.

Red blood cell distribution width and haemoglobin are associated with hospital admission in patients with acute allergic reactions.

PubMed

Lippi, Giuseppe; Buonocore, Ruggero; Picanza, Alessandra; Schirosa, Fabio; Cervellin, Gianfranco

2016-01-01

Red blood cell distribution width (RDW) is significantly associated with a variety of human disorders. This study aimed to investigate whether RDW value at admission may predict the need of hospitalisation in patients presenting to the emergency department (ED) with acute allergic reactions. The study population consisted of adult patients (aged > 17) admitted to the ED for acute allergic reactions. One hundred and thirty-two subjects were included, 12 of whom (9%) required hospital admission for severity of symptoms. Patients who needed hospital admission displayed significantly lower values of haemoglobin and significantly higher values of RDW-coefficient of variation (RDW-CV). In multivariate analysis, haemoglobin and RDW-CV were found to be independent predictors of hospital admission. The area under the curve (AUC), sensitivity and specificity for predicting hospital admission were 0.72, 0.88 and 0.42 for haemoglobin and 0.73, 0.88 and 0.50 for RDW-CV, respectively. The combination of these tests (both positive) was characterised by 0.76 AUC, 0.83 sensitivity, 0.67 specificity, 0.96 negative predictive value and 0.30 positive predictive. The results of this study suggest that two common and inexpensive parameters such as haemoglobin and RDW are independent predictors of hospital admission in patients presenting to the ED with acute allergic reactions.

Effectiveness of Interventions to Decrease Image Ordering for Low Back Pain Presentations in the Emergency Department: A Systematic Review.

PubMed

Liu, Chaocheng; Desai, Shashwat; Krebs, Lynette D; Kirkland, Scott W; Keto-Lambert, Diana; Rowe, Brian H

2018-01-08

Low back pain (LBP) is an extremely frequent reason for patients to present to an emergency department (ED). Despite evidence against the utility of imaging, simple and advanced imaging (i.e., computed tomography [CT], magnetic resonance imaging) for patients with LBP has become increasingly frequent in the ED. The objective of this review was to identify and examine the effectiveness of interventions aimed at reducing image ordering in the ED for LBP patients. A protocol was developed a priori, following the PRISMA guidelines, and registered with PROSPERO. Six bibliographic databases (including MEDLINE, EMBASE, EBM Reviews, SCOPUS, CINAHL, and Dissertation Abstracts) and the gray literature were searched. Comparative studies assessing interventions that targeted image ordering in the ED for adult patients with LBP were eligible for inclusion. Two reviewers independently screened study eligibility and completed data extraction. Study quality was completed independently by two reviewers using the before-after quality assessment checklist, with a third-party mediator resolving any differences. Due to a limited number of studies and significant heterogeneity, only a descriptive analysis was performed. The search yielded 603 unique citations of which a total of five before-after studies were included. Quality assessment identified potential biases relating to comparability between the pre- and postintervention groups, reliable assessment of outcomes, and an overall lack of information on the intervention (i.e., time point, description, intervention data collection). The type of interventions utilized included clinical decision support tools, clinical practice guidelines, a knowledge translation initiative, and multidisciplinary protocols. Overall, four studies reported a decrease in the relative percentage change in imaging in a specific image modality (22.7%-47.4%) following implementation of the interventions; however, one study reported a 35% increase in patient referrals to radiography, while another study reported a subsequent 15.4% increase in referrals to CT and myelography after implementing an intervention which reduced referrals for simple radiography. While imaging of LBP has been identified as a key area of imaging overuse (e.g., Choosing Wisely recommendation), evidence on interventions to reduce image ordering for ED patients with LBP is sparse. There is some evidence to suggest that interventions can reduce the use of simple imaging in LBP in the ED; however, a shift in imaging modality has also been demonstrated. Additional studies employing higher-quality methods and measuring intervention fidelity are strongly recommended to further explore the potential of ED-based interventions to reduce image ordering for this patient population. © 2018 by the Society for Academic Emergency Medicine.

Feasibility of web-based self-triage by parents of children with influenza-like illness: a cautionary tale.

PubMed

Anhang Price, Rebecca; Fagbuyi, Daniel; Harris, Racine; Hanfling, Dan; Place, Frederick; Taylor, Todd B; Kellermann, Arthur L

2013-02-01

Self-triage using web-based decision support could be a useful way to encourage appropriate care-seeking behavior and reduce health system surge in epidemics. However, the feasibility and safety of this strategy have not previously been evaluated. To assess the usability and safety of Strategy for Off-site Rapid Triage (SORT) for Kids, a web-based decision support tool designed to translate clinical guidance developed by the Centers for Disease Control and Prevention to help parents and adult caregivers determine if a child with influenza-like illness requires immediate care in an emergency department (ED). Prospective pilot validation study conducted between February 8 and April 30, 2012. Staff who abstracted medical records and made follow-up calls were blinded to the SORT algorithm's assessment of the child's level of risk. Two pediatric emergency departments in the National Capital Region. Convenience sample of 294 parents and adult caregivers who were at least 18 years of age; able to read and speak English; and the parent or legal guardian of a child 18 years or younger presenting to 1 of 2 EDs with signs and symptoms meeting Centers for Disease Control and Prevention criteria for influenza-like illness. Completion of the SORT for Kids survey. Caregiver ratings of the website's usability and the sensitivity of the underlying algorithm for identifying children who required immediate ED management of influenza-like illness, defined as receipt of 1 or more of 5 essential clinical services. Ninety percent of participants reported that the website was "very easy" to understand and use. Ratings did not differ by respondent race, ethnicity, or educational attainment. Of the 15 patients whose initial ED visit met explicit criteria for clinical necessity, the Centers for Disease Control and Prevention algorithm classified 14 as high risk, resulting in an overall sensitivity of 93.3% (exact 95% CI, 68.1%-99.8%). Specificity of the algorithm was poor. This pilot study suggests that web-based decision support to help parents and adult caregivers self-triage children with influenza-like illness is feasible. However, prospective refinement of the clinical algorithm is needed to improve its specificity without compromising patient safety.

Feasibility of an ED-to-Home Intervention to Engage Patients: A Mixed-Methods Investigation.

PubMed

Schumacher, Jessica R; Lutz, Barbara J; Hall, Allyson G; Pines, Jesse M; Jones, Andrea L; Hendry, Phyllis; Kalynych, Colleen; Carden, Donna L

2017-06-01

Older, chronically ill patients with limited health literacy are often under-engaged in managing their health and turn to the emergency department (ED) for healthcare needs. We tested the impact of an ED-initiated coaching intervention on patient engagement and follow-up doctor visits in this high-risk population. We also explored patients' care-seeking decisions. We conducted a mixed-methods study including a randomized controlled trial and in-depth interviews in two EDs in northern Florida. Participants were chronically ill older ED patients with limited health literacy and Medicare as a payer source. Patients were assigned to an evidence-based coaching intervention (n= 35) or usual post-ED care (n= 34). Qualitative interviews (n=9) explored patients' reasons for ED use. We assessed average between-group differences in patient engagement over time with the Patient Activation Measure (PAM) tool, using logistic regression and a difference-in-difference approach. Between-group differences in follow-up doctor visits were determined. We analyzed qualitative data using open coding and thematic analysis. PAM scores fell in both groups after the ED visit but fell significantly more in "usual care" (average decline -4.64) than "intervention" participants (average decline -2.77) (β=1.87, p=0.043). There were no between-group differences in doctor visits. Patients described well-informed reasons for ED visits including onset and severity of symptoms, lack of timely provider access, and immediate and comprehensive ED care. The coaching intervention significantly reduced declines in patient engagement observed after usual post-ED care. Patients reported well-informed reasons for ED use and will likely continue to make ED visits unless strategies, such as ED-initiated coaching, are implemented to help vulnerable patients better manage their health and healthcare.

Rapid Rule-out of Acute Myocardial Infarction With a Single High-Sensitivity Cardiac Troponin T Measurement Below the Limit of Detection: A Collaborative Meta-analysis.

PubMed

Pickering, John W; Than, Martin P; Cullen, Louise; Aldous, Sally; Ter Avest, Ewoud; Body, Richard; Carlton, Edward W; Collinson, Paul; Dupuy, Anne Marie; Ekelund, Ulf; Eggers, Kai M; Florkowski, Christopher M; Freund, Yonathan; George, Peter; Goodacre, Steve; Greenslade, Jaimi H; Jaffe, Allan S; Lord, Sarah J; Mokhtari, Arash; Mueller, Christian; Munro, Andrew; Mustapha, Sebbane; Parsonage, William; Peacock, W Frank; Pemberton, Christopher; Richards, A Mark; Sanchis, Juan; Staub, Lukas P; Troughton, Richard; Twerenbold, Raphael; Wildi, Karin; Young, Joanna

2017-05-16

High-sensitivity assays for cardiac troponin T (hs-cTnT) are sometimes used to rapidly rule out acute myocardial infarction (AMI). To estimate the ability of a single hs-cTnT concentration below the limit of detection (<0.005 µg/L) and a nonischemic electrocardiogram (ECG) to rule out AMI in adults presenting to the emergency department (ED) with chest pain. EMBASE and MEDLINE without language restrictions (1 January 2008 to 14 December 2016). Cohort studies involving adults presenting to the ED with possible acute coronary syndrome in whom an ECG and hs-cTnT measurements were obtained and AMI outcomes adjudicated during initial hospitalization. Investigators of studies provided data on the number of low-risk patients (no new ischemia on ECG and hs-cTnT measurements <0.005 µg/L) and the number who had AMI during hospitalization (primary outcome) or a major adverse cardiac event (MACE) or death within 30 days (secondary outcomes), by risk classification (low or not low risk). Two independent epidemiologists rated risk of bias of studies. Of 9241 patients in 11 cohort studies, 2825 (30.6%) were classified as low risk. Fourteen (0.5%) low-risk patients had AMI. Sensitivity of the risk classification for AMI ranged from 87.5% to 100% in individual studies. Pooled estimated sensitivity was 98.7% (95% CI, 96.6% to 99.5%). Sensitivity for 30-day MACEs ranged from 87.9% to 100%; pooled sensitivity was 98.0% (CI, 94.7% to 99.3%). No low-risk patients died. Few studies, variation in timing and methods of reference standard troponin tests, and heterogeneity of risk and prevalence of AMI across studies. A single hs-cTnT concentration below the limit of detection in combination with a nonischemic ECG may successfully rule out AMI in patients presenting to EDs with possible emergency acute coronary syndrome. Emergency Care Foundation.

Septic acute kidney injury patients in emergency department: The risk factors and its correlation to serum lactate.

PubMed

Hsu, Yin-Chou; Hsu, Chih-Wei

2018-05-15

Acute kidney injury (AKI) is a common complication in septic patients, imposing a heavy burden of illness in terms of morbidity and mortality. Serum lactate is a widely used marker predicting the severity of sepsis. A paucity of research has investigated septic AKI in emergency departments (EDs) and its correlation with initial serum lactate level. This study aimed at identifying risk factors for septic AKI and clarifying the link between initial serum lactate level and septic AKI in ED patients. A retrospective cohort study was conducted at a single tertiary referral medical center. The medical records of all adult ED patients with measurement of serum lactate and creatinine between January 2012 and December 2016 were reviewed. A total of 696 septic patients were stratified into AKI and non-AKI groups according to Acute Kidney Injury Network (AKIN) criteria for further statistical analysis. Ninety-nine septic patients (14.2%) had AKI, with AKIN-I, AKIN-II, and AKIN-III in 71.7%, 11.1%, and 17.2% of patients, respectively. Compared with the non-AKI group, the AKI group had a significantly higher mortality rate (71.7% vs. 21.3%, p < 0.001). Independent risk factors for septic AKI included liver disease (adjusted odds ratio [AOR] = 2.02, 95% confidence interval [CI] = 1.16-3.52), diabetes mellitus (AOR = 1.73, 95% CI = 1.11-2.69), chronic kidney disease (AOR = 1.68, 95% CI = 1.06-2.66), and initial serum lactate (AOR = 1.08, 95% CI = 1.02-1.14). Patients with septic AKI had an overwhelmingly higher mortality rate. The comorbidities of liver disease, diabetes mellitus, and chronic kidney disease were correlated with septic AKI and in combination with an elevated initial serum lactate level had predictive regarding AKI and further mortality in ED septic patients. Copyright © 2018 Elsevier Inc. All rights reserved.

Alcohol-related presentations to the Royal Perth Hospital Emergency Department: A prospective study.

PubMed

McLay, Stuart Vb; MacDonald, Ellen; Fatovich, Daniel M

2017-10-01

To quantify and describe alcohol-related presentations to our ED, as part of the binational Alcohol Harm in Emergency Departments study. A prospective observational study at Royal Perth Hospital of every patient attending ED for the 168-h period commencing 08.00 hours Monday 1 December 2014. Patient presentations were classified as alcohol-related (alcohol-positive) using predefined criteria. These patients were compared to alcohol-negative patients on a range of demographic and clinical descriptors. Two hundred and thirteen (15.2%) of 1403 patients screened were alcohol-positive. Compared with alcohol-negative patients, alcohol-positive patients were more likely to be male (148/213, 69.5% vs 636/1190, 53.4%, P < 0.001) and younger (mean 38 years vs 48 years, P < 0.001). They were more likely to arrive in police custody (OR 3.7, 95% CI 1.3-9.5, P = 0.005), and be admitted to the State Adult Major Trauma Unit (OR 4.2, 95% CI 2.1-8.3, P < 0.001). Forty-two (19.7%) of 213 patients had injuries suspected to be caused by an alcohol-affected third party. The ED length of stay and admission rate were not significantly different between the groups. 15.2% of patient presentations over the study week were alcohol-related. These patients were more likely to present with injury; one in five having injuries suspected to be caused by a third party affected by alcohol. This is a significant public health problem. © 2017 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

'Registrar in charge shifts': learning how to run a busy emergency department.

PubMed

Craig, Simon; Dowling, Jonathan

2013-04-01

In Australasia, emergency registrars usually gain experience 'running' an ED overnight - without supervision. This paper describes the introduction of FACEM-supervised daytime 'registrar in charge' (RIC) shifts into a tertiary adult ED over a 6 month period. Each registrar was allocated at least one RIC shift during their 13 week ED term. Structured questionnaires gathered data regarding the educational impact of the shifts, any adverse effects on departmental function, changes to work practices, and perceptions of teaching and learning. Data were analysed using thematic analysis. During the study period, 16 senior ED registrars were rostered for 26 RIC shifts. Questionnaires were completed by 16/16 registrars and 13/16 emergency physicians. The RIC shifts were viewed positively by the emergency registrars - 93% reported useful feedback, felt that the shifts provided a good insight into their workplace behaviour, and that they should be rolled out across other departments. FACEMs were also positive in their evaluation, and reported little negative impact on departmental function. Major themes identified by both registrars and emergency physicians included communication skills, knowledge and experience, delegation, professionalism and organisational skills. Additional themes that were more prominent in FACEM responses included multitasking, dealing with interruptions, managing patient flow and being aware of the whole department. RIC shifts are a feasible and acceptable method to teach running the floor in the ED. Further study should assess impact on patient outcomes. © 2013 The Authors. EMA © 2013 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

Triage sepsis alert and sepsis protocol lower times to fluids and antibiotics in the ED.

PubMed

Hayden, Geoffrey E; Tuuri, Rachel E; Scott, Rachel; Losek, Joseph D; Blackshaw, Aaron M; Schoenling, Andrew J; Nietert, Paul J; Hall, Greg A

2016-01-01

Early identification of sepsis in the emergency department (ED), followed by adequate fluid hydration and appropriate antibiotics, improves patient outcomes. We sought to measure the impact of a sepsis workup and treatment protocol (SWAT) that included an electronic health record (EHR)-based triage sepsis alert, direct communication, mobilization of resources, and standardized order sets. We conducted a retrospective, quasiexperimental study of adult ED patients admitted with suspected sepsis, severe sepsis, or septic shock. We defined a preimplementation (pre-SWAT) group and a postimplementation (post-SWAT) group and further broke these down into SWAT A (septic shock) and SWAT B (sepsis with normal systolic blood pressure). We performed extensive data comparisons in the pre-SWAT and post-SWAT groups, including demographics, systemic inflammatory response syndrome criteria, time to intravenous fluids bolus, time to antibiotics, length-of-stay times, and mortality rates. There were 108 patients in the pre-SWAT group and 130 patients in the post-SWAT group. The mean time to bolus was 31 minutes less in the postimplementation group, 51 vs 82 minutes (95% confidence interval, 15-46; P value < .01). The mean time to antibiotics was 59 minutes less in the postimplementation group, 81 vs 139 minutes (95% confidence interval, 44-74; P value < .01). Segmented regression modeling did not identify secular trends in these outcomes. There was no significant difference in mortality rates. An EHR-based triage sepsis alert and SWAT protocol led to a significant reduction in the time to intravenous fluids and time to antibiotics in ED patients admitted with suspected sepsis, severe sepsis, and septic shock. Copyright © 2015 Elsevier Inc. All rights reserved.

Night sleep electroencephalogram power spectral analysis in excessive daytime sleepiness disorders.

PubMed

Reimão, R

1991-06-01

A group of 53 patients (40 males, 13 females) with mean age of 49 years, ranging from 30 to 70 years, was evaluated in the following excessive daytime sleepiness (EDS) disorders: obstructive sleep apnea syndrome (B4a), periodic movements in sleep (B5a), affective disorder (B2a), functional psychiatric non affective disorder (B2b). We considered all adult patients referred to the Center sequentially with no other distinctions but these three criteria: (a) EDS was the main complaint; (b) right handed; (c) not using psychotropic drugs for two weeks prior to the all-night polysomnography. EEG (C3/A1, C4/A2) samples from 2 to 10 minutes of each stage of the first REM cycle were chosen. The data was recorded simultaneously in magnetic tape and then fed into a computer for power spectral analysis. The percentage of power (PP) in each band calculated in relation to the total EEG power was determined of subsequent sections of 20.4 s for the following frequency bands: delta, theta, alpha and beta. The PP in all EDS patients sample had a tendency to decrease progressively from the slowest to the fastest frequency bands, in every sleep stage. PP distribution in the delta range increased progressively from stage 1 to stage 4; stage REM levels were close to stage 2 levels. In an EDS patients interhemispheric coherence was high in every band and sleep stage. B4a patients sample PP had a tendency to decrease progressively from the slowest to the fastest frequency bands, in every sleep stage; PP distribution in the delta range increased progressively from stage 1 to stage 4; stage REM levels were between stage 1 and stage 2 levels.(ABSTRACT TRUNCATED AT 250 WORDS)

Streaming primary urgent care: a prospective approach.

PubMed

Bickerton, Jane; Davies, Jacqueline; Davies, Helen; Apau, Daniel; Procter, Susan

2012-04-01

To identify the appropriate service provider attendees of emergency departments (EDs) and walk-in centres (WiCs) in North East London and to match this to local service provision and patient choice. An anonymous patient survey and a retrospective analysis of a random sample of patient records were performed. A nurse consultant, general practitioner (GP) and pharmacist used the presenting complaints in the patients' records to independently stream the patient to primary care services, non-National Health Services or ED. Statistical analysis of level of agreement was undertaken. A stakeholder focus group reviewed the results. Adult health consumers attending ED and urgent care services in North East London. The health user survey identified younger rather than older users (mean age of 35.6 years--SD 15.5), where 50% had not seen a health professional about their concern, with over 40% unable to obtain a convenient or emergency appointment with their GP. Over a third of the attendees were already receiving treatment and over 40% of these saw their complaint as an emergency. Over half of respondents expected to see a doctor, one-quarter expected to see a nurse and only 1% expected to see a pharmacist across both services, although WiCs are nurse-led services. More respondents expected a prescription from a visit to a WiC, whereas in the ED a third of respondents sought health advice or reassurance. A number of unscheduled care strategies are, or have just been, developed with the emphasis on moving demand into community-based services. Plurality of services provides service users with a range of alternative access points but can cause duplication of services and repeat attendance. Managing continued increase in emergency and unscheduled care is a challenge. The uncertainties in prospective decision making could be used to inform service development and delivery.

A systematic review and qualitative analysis to inform the development of a new emergency department-based geriatric case management model.

PubMed

Sinha, Samir K; Bessman, Edward S; Flomenbaum, Neal; Leff, Bruce

2011-06-01

We inform the future development of a new geriatric emergency management practice model. We perform a systematic review of the existing evidence for emergency department (ED)-based case management models designed to improve the health, social, and health service utilization outcomes for noninstitutionalized older patients within the context of an index ED visit. This was a systematic review of English-language articles indexed in MEDLINE and CINAHL (1966 to 2010), describing ED-based case management models for older adults. Bibliographies of the retrieved articles were reviewed to identify additional references. A systematic qualitative case study analytic approach was used to identify the core operational components and outcome measures of the described clinical interventions. The authors of the included studies were also invited to verify our interpretations of their work. The determined patterns of component adherence were then used to postulate the relative importance and effect of the presence or absence of a particular component in influencing the overall effectiveness of their respective interventions. Eighteen of 352 studies (reported in 20 articles) met study criteria. Qualitative analyses identified 28 outcome measures and 8 distinct model characteristic components that included having an evidence-based practice model, nursing clinical involvement or leadership, high-risk screening processes, focused geriatric assessments, the initiation of care and disposition planning in the ED, interprofessional and capacity-building work practices, post-ED discharge follow-up with patients, and evaluation and monitoring processes. Of the 15 positive study results, 6 had all 8 characteristic components and 9 were found to be lacking at least 1 component. Two studies with positive results lacked 2 characteristic components and none lacked more than 2 components. Of the 3 studies with negative results demonstrating no positive effects based on any outcome tested, one lacked 2, one lacked 3, and one lacked 4 of the 8 model components. Successful models of ED-based case management models for older adults share certain key characteristics. This study builds on the emerging literature in this area and leverages the differences in these models and their associated outcomes to support the development of an evidence-based normative and effective geriatric emergency management practice model designed to address the special care needs and thereby improve the health and health service utilization outcomes of older patients. Copyright © 2010 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.

Intoxication-Related AmED (Alcohol Mixed with Energy Drink) Expectancies Scale: Initial Development and Validation

PubMed Central

Miller, Kathleen E.; Dermen, Kurt H.; Lucke, Joseph F.

2017-01-01

BACKGROUND Young adult use of alcohol mixed with energy drinks (AmEDs) has been linked with elevated risks for a constellation of problem behaviors. These risks may be conditioned by expectancies regarding the effects of caffeine in conjunction with alcohol consumption. The aim of this study was to describe the construction and psychometric evaluation of the Intoxication-Related AmED Expectancies Scale (AmED_EXPI), 15 self-report items measuring beliefs about how the experience of AmED intoxication differs from the experience of noncaffeinated alcohol (NCA) intoxication. METHODS Scale development and testing were conducted using data from a U.S. national sample of 3,105 adolescents and emerging adults aged 13–25. Exploratory and confirmatory factor analyses were conducted to evaluate the factor structure and establish factor invariance across gender, age, and prior experience with AmED use. Cross-sectional and longitudinal analyses examining correlates of AmED use were used to assess construct and predictive validity. RESULTS In confirmatory factor analyses, fit indices for the hypothesized four-factor structure (i.e., Intoxication Management [IM], Alertness [AL], Sociability [SO], and Jitters [JT]) revealed a moderately good fit to the data. Together, these factors accounted for 75.3% of total variance. The factor structure was stable across male/female, teen/young adult, and AmED experience/no experience subgroups. The resultant unit-weighted subscales showed strong internal consistency and satisfactory convergent validity. Baseline scores on the IM, SO, and JT subscales predicted changes in AmED use over a subsequent three-month period. CONCLUSIONS The AmED_EXPI appears to be a reliable and valid tool for measuring expectancies about the effects of caffeine during alcohol intoxication. PMID:28421613

Aromatherapy Versus Oral Ondansetron for Antiemetic Therapy Among Adult Emergency Department Patients: A Randomized Controlled Trial.

PubMed

April, Michael D; Oliver, Joshua J; Davis, William T; Ong, David; Simon, Erica M; Ng, Patrick C; Hunter, Curtis J

2018-02-17

We compare aromatherapy with inhaled isopropyl alcohol versus oral ondansetron for treating nausea among emergency department (ED) patients not requiring immediate intravenous access. In a randomized, blinded, placebo-controlled trial, we enrolled a convenience sample of adults presenting to an urban tertiary care ED with chief complaints including nausea or vomiting. We randomized subjects to 1 of 3 arms: inhaled isopropyl alcohol and 4 mg oral ondansetron, inhaled isopropyl alcohol and oral placebo, and inhaled saline solution placebo and 4 mg oral ondansetron. The primary outcome was mean nausea reduction measured by a 0- to 100-mm visual analog scale from enrollment to 30 minutes postintervention. Secondary outcomes included receipt of rescue antiemetic medications and adverse events. We enrolled 122 subjects, of whom 120 (98.3%) completed the study. Of randomized subjects, 40 received inhaled isopropyl alcohol and oral ondansetron, 41 received inhaled isopropyl alcohol and oral placebo, and 41 received inhaled saline solution placebo and oral ondansetron. The mean decrease in nausea visual analog scale score in each arm was 30 mm (95% confidence interval [CI] 22 to 37 mm), 32 mm (95% CI 25 to 39 mm), and 9 mm (95% CI 5 to 14 mm), respectively. The proportions of subjects who received rescue antiemetic therapy in each arm were 27.5% (95% CI 14.6% to 43.9%), 25.0% (95% CI 12.7% to 41.2%), and 45.0% (95% CI 29.3% to 61.5%), respectively. There were no adverse events. Among ED patients with acute nausea and not requiring immediate intravenous access, aromatherapy with or without oral ondansetron provides greater nausea relief than oral ondansetron alone. Copyright © 2018 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Evaluation of the effectiveness of peer pressure to change disposition decisions and patient throughput by emergency physician.

PubMed

Wu, Kuan-Han; Cheng, Fu-Jen; Li, Chao-Jui; Cheng, Hsien-Hung; Lee, Wen-Huei; Lee, Chi-Wei

2013-03-01

The aim of this study was to develop a strategy for imposing peer pressure on emergency physicians to discharge patients and to evaluate patient throughput before and after intervention. A before-and-after study was conducted in a medical center with more than 120 000 annual emergency department (ED) visits. All nontraumatic adult patients who presented to the ED between 7:30 and 11:30 am Wednesday to Sunday were reviewed. We created a "team norm" imposed peer-pressure effect by announcing the patient discharge rate of each emergency physician through monthly e-mail reminders. Emergency department length of stay (LOS) and 8-hour (the end of shift) and final disposition of patients before (June 1, 2011-September 30, 2011) and after (October 1, 2011-January 30, 2012) intervention were compared. Patients enrolled before and after intervention totaled 3305 and 2945. No differences existed for age, sex, or average number of patient visits per shift. The 8-hour discharge rate increased significantly for all patients (53.5% vs 48.2%, P < .001), particularly for triage level III patients (odds ratio, 1.3; 95% confidence interval, 1.09-1.38) after intervention and without corresponding differences in the final disposition (P = .165) or admission rate (33.7% vs 31.6%, P = .079). Patients with a final discharge disposition had a shorter LOS (median, 140.4 min vs 158.3 min; P < .001) after intervention. The intervention strategy used peer pressure to enhance patient flow and throughput. More patients were discharged at the end of shifts, particularly triage level III patients. The ED LOS for patients whose final disposition was discharge decreased significantly. Copyright © 2013 Elsevier Inc. All rights reserved.

Admission time to hospital: a varying standard for a critical definition for admissions to an intensive care unit from the emergency department.

PubMed

Nanayakkara, Shane; Weiss, Heike; Bailey, Michael; van Lint, Allison; Cameron, Peter; Pilcher, David

2014-11-01

Time spent in the emergency department (ED) before admission to hospital is often considered an important key performance indicator (KPI). Throughout Australia and New Zealand, there is no standard definition of 'time of admission' for patients admitted through the ED. By using data submitted to the Australian and New Zealand Intensive Care Society Adult Patient Database, the aim was to determine the differing methods used to define hospital admission time and assess how these impact on the calculation of time spent in the ED before admission to an intensive care unit (ICU). Between March and December of 2010, 61 hospitals were contacted directly. Decision methods for determining time of admission to the ED were matched to 67,787 patient records. Univariate and multivariate analyses were conducted to assess the relationship between decision method and the reported time spent in the ED. Four mechanisms of recording time of admission were identified, with time of triage being the most common (28/61 hospitals). Reported median time spent in the ED varied from 2.5 (IQR 0.83-5.35) to 5.1 h (2.82-8.68), depending on the decision method. After adjusting for illness severity, hospital type and location, decision method remained a significant factor in determining measurement of ED length of stay. Different methods are used in Australia and New Zealand to define admission time to hospital. Professional bodies, hospitals and jurisdictions should ensure standardisation of definitions for appropriate interpretation of KPIs as well as for the interpretation of studies assessing the impact of admission time to ICU from the ED. WHAT IS KNOWN ABOUT THE TOPIC?: There are standards for the maximum time spent in the ED internationally, but these standards vary greatly across Australia. The definition of such a standard is critically important not only to patient care, but also in the assessment of hospital outcomes. Key performance indicators rely on quality data to improve decision-making. WHAT DOES THIS PAPER ADD?: This paper quantifies the variability of times measured and analyses why the variability exists. It also discusses the impact of this variability on assessment of outcomes and provides suggestions to improve standardisation. WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS?: This paper provides a clearer view on standards regarding length of stay in the ICU, highlighting the importance of key performance indicators, as well as the quality of data that underlies them. This will lead to significant changes in the way we standardise and interpret data regarding length of stay.

Factors associated with ambulatory care sensitive emergency department visits for South Carolina Medicaid members with intellectual disability.

PubMed

McDermott, S; Royer, J; Mann, J R; Armour, B S

2018-03-01

Ambulatory care sensitive conditions (ACSCs) can be seen as failure of access or management in primary care settings. Identifying factors associated with ACSCs for individuals with an Intellectual Disability (ID) provide insight into potential interventions. To assess the association between emergency department (ED) ACSC visits and a number of demographic and health characteristics of South Carolina Medicaid members with ID. A retrospective cohort of adults with ID was followed from 2001 to 2011. Using ICD-9-CM codes, four ID subgroups, totalling 14 650 members, were studied. There were 106 919 ED visits, with 21 214 visits (19.8%) classified as ACSC. Of those, 82.9% were treated and released from EDs with costs averaging $578 per visit. People with mild and unspecified ID averaged greater than one ED visit per member year. Those with Down syndrome and other genetic cause ID had the lowest rates of ED visits but the highest percentage of ACSC ED visits that resulted in inpatient hospitalisation (26.6% vs. an average of 16.8% for other subgroups). When compared with other residential types, those residing at home with no health support services had the highest ED visit rate and were most likely to be discharged back to the community following an ED visit (85.2%). Adults residing in a nursing home had lower rates of ED visits but were most likely to be admitted to the hospital (38.9%) following an ED visit. Epilepsy and convulsions were the leading cause (29.6%) of ACSC ED visits across all subgroups and residential settings. Prevention of ACSC ED visits may be possible by targeting adults with ID who live at home without health support services. © 2017 MENCAP and International Association of the Scientific Study of Intellectual and Developmental Disabilities and John Wiley & Sons Ltd.

Comparison of balance assessment modalities in emergency department elders: a pilot cross-sectional observational study.

PubMed

Caterino, Jeffrey M; Karaman, Rowan; Arora, Vinay; Martin, Jacqueline L; Hiestand, Brian C

2009-09-28

More than one-third of US adults 65 and over fall every year. These falls may cause serious injury including substantial long-term morbidity (due declines in activities of daily living) and death. The emergency department (ED) visit represents an opportunity for identifying high risk elders and potentially instituting falls-related interventions. The unique characteristic of the ED environment and patient population necessitate that risk-assessment modalities be validated in this specific setting. In order to better identify elders at risk of falls, we examined the relationship between patient-provided history of falling and two testing modalities (a balance plate system and the timed up-and-go [TUG] test) in elder emergency department (ED) patients. We conducted a cross-sectional observational study of patients > or = 60 years old being discharged from the ED. Patient history of falls in the past week, month, 6 months, and year was obtained. Balance plate center of pressure excursion (COP) measurements and TUG testing times were recorded. COP was recorded under four conditions: normal stability eyes open (NSEO) and closed (NSEC), and perturbed stability eyes open and closed. Correlation between TUG and COP scores was measured. Univariate logistic regression was used to identify the relationship between patient-provided falls history and the two testing modalities. Proportions, likelihood ratios, and receiver-operating-characteristic (ROC) curves for prediction of previous falls were reported. Fifty-three subjects were enrolled, 11% had fallen in the previous week and 42% in the previous year. There was no correlation between TUG and any balance plate measurements. In logistic regression, neither testing modality was associated with prior history of falls (p > 0.05 for all time periods). Balance plate NSEO and NSEC testing cutoffs could be identified which were 83% sensitive and had a negative likelihood ratio (LR-) of 0.3 for falls in the past week. TUG testing was not useful for falls in the past week, but performed best for more distant falls in the past month, 6 months, or year. TUG cutoffs with sensitivity over 80% and LR(-) of 0.17-0.32 could be identified for these time periods. Over 40% of community-dwelling elder ED patients report a fall within the past year. Balance plate and TUG testing were feasibly conducted in an ED setting. There is no relationship between scores on balance plate and TUG testing in these patients. In regression analysis, neither modality was significantly associated with patient provided history of falls. These modalities should not be adopted for screening purposes in elders in the ED setting without validation in future studies or as part of multi-factorial risk assessment.

Emergency Department Visits for Drug-Related Suicide Attempts Involving Antidepressants by Adolescents and Young Adults: 2004 to 2008. The DAWN Report

ERIC Educational Resources Information Center

Substance Abuse and Mental Health Services Administration, 2011

2011-01-01

In 2008, adolescents made 23,124 visits to the emergency department (ED) for drug-related suicide attempts, and young adults made 38,036 such visits; of these visits, 23.0 percent (5,312 visits) among adolescents and 17.6 percent (6,700 visits) among young adults involved antidepressants. Among ED visits for suicide attempts involving…

Feasibility of an ED-to-Home Intervention to Engage Patients: A Mixed-Methods Investigation

PubMed Central

Schumacher, Jessica R.; Lutz, Barbara J.; Hall, Allyson G.; Pines, Jesse M.; Jones, Andrea L.; Hendry, Phyllis; Kalynych, Colleen; Carden, Donna L.

2017-01-01

Introduction Older, chronically ill patients with limited health literacy are often under-engaged in managing their health and turn to the emergency department (ED) for healthcare needs. We tested the impact of an ED-initiated coaching intervention on patient engagement and follow-up doctor visits in this high-risk population. We also explored patients’ care-seeking decisions. Methods We conducted a mixed-methods study including a randomized controlled trial and in-depth interviews in two EDs in northern Florida. Participants were chronically ill older ED patients with limited health literacy and Medicare as a payer source. Patients were assigned to an evidence-based coaching intervention (n= 35) or usual post-ED care (n= 34). Qualitative interviews (n=9) explored patients’ reasons for ED use. We assessed average between-group differences in patient engagement over time with the Patient Activation Measure (PAM) tool, using logistic regression and a difference-in-difference approach. Between-group differences in follow-up doctor visits were determined. We analyzed qualitative data using open coding and thematic analysis. Results PAM scores fell in both groups after the ED visit but fell significantly more in “usual care” (average decline −4.64) than “intervention” participants (average decline −2.77) (β=1.87, p=0.043). There were no between-group differences in doctor visits. Patients described well-informed reasons for ED visits including onset and severity of symptoms, lack of timely provider access, and immediate and comprehensive ED care. Conclusion The coaching intervention significantly reduced declines in patient engagement observed after usual post-ED care. Patients reported well-informed reasons for ED use and will likely continue to make ED visits unless strategies, such as ED-initiated coaching, are implemented to help vulnerable patients better manage their health and healthcare. PMID:28611897

A statewide teleradiology system reduces radiation exposure and charges in transferred trauma patients.

PubMed

Watson, Justin J J; Moren, Alexis; Diggs, Brian; Houser, Ben; Eastes, Lynn; Brand, Dawn; Bilyeu, Pamela; Schreiber, Martin; Kiraly, Laszlo

2016-05-01

Trauma transfer patients routinely undergo repeat imaging because of inefficiencies within the radiology system. In 2009, the virtual private network (VPN) telemedicine system was adopted throughout Oregon allowing virtual image transfer between hospitals. The startup cost was a nominal $3,000 per hospital. A retrospective review from 2007 to 2012 included 400 randomly selected adult trauma transfer patients based on a power analysis (200 pre/200 post). The primary outcome evaluated was reduction in repeat computed tomography (CT) scans. Secondary outcomes included cost savings, emergency department (ED) length of stay (LOS), and spared radiation. All data were analyzed using Mann-Whitney U and chi-square tests. P less than .05 indicated significance. Spared radiation was calculated as a weighted average per body region, and savings was calculated using charges obtained from Oregon Health and Science University radiology current procedural terminology codes. Four-hundred patients were included. Injury Severity Score, age, ED and overall LOS, mortality, trauma type, and gender were not statistically different between groups. The percentage of patients with repeat CT scans decreased after VPN implementation: CT abdomen (13.2% vs 2.8%, P < .01) and cervical spine (34.4% vs 18.2%, P < .01). Post-VPN, the total charges saved in 2012 for trauma transfer patients was $333,500, whereas the average radiation dose spared per person was 1.8 mSV. Length of stay in the ED for patients with Injury Severity Score less than 15 transferring to the ICU was decreased (P < .05). Implementation of a statewide teleradiology network resulted in fewer total repeat CT scans, significant savings, decrease in radiation exposure, and decreased LOS in the ED for patients with less complex injuries. The potential for health care savings by widespread adoption of a VPN is significant. Copyright © 2016 Elsevier Inc. All rights reserved.

Analysis of testosterone effects on sonic hedgehog signaling in juvenile, adolescent and adult sprague dawley rat penis.

PubMed

Bond, Christopher W; Angeloni, Nicholas L; Podlasek, Carol A

2010-03-01

Smooth muscle apoptosis is a major contributing factor to erectile dysfunction (ED) development in prostatectomy and diabetic patients and animal models. A critical regulator of penile smooth muscle and apoptosis is Sonic hedgehog (SHH). The SHH protein is decreased in ED models and SHH treatment of cavernous nerve (CN) injured rats prevents smooth muscle apoptosis. A close association between androgen deficiency and ED has been suggested in the literature, but few studies have examined the molecular effects on penile smooth muscle and on known signaling mechanisms that regulate morphology. Aim. Examine testosterone and SHH interaction in eugonadal adult, adolescent and juvenile rats by performing castration studies and treatment with supraphysiological testosterone. The eugonadal adult Sprague Dawley rats were either treated with testosterone for 7 or 14 days (N = 14) or were castrated for 4 or 7 days (N = 12). The juvenile rats were treated with testosterone for 8 days (N = 7). The adolescent rats were castrated and sacrificed at P88 (N = 8). The control rats had empty vehicle (N = 22) or sham surgery (N = 20). The active form of SHH protein and mRNA were quantified by semi-quantitative immunohistochemical analysis and real-time reverse transcriptase polymerase chain reaction (RT-PCR). Testosterone treatment did not alter SHH signaling in juvenile rats. Shh mRNA increased 3.2-fold and SHH protein increased 1.2-fold in rats castrated during puberty. In adult rats, castration decreased Shh mRNA 3.2-fold but did not alter SHH protein. Testosterone supplement in adult rats increased Shh mRNA 2.3-fold and decreased SHH protein 1.3-fold. SHH signaling is independent of testosterone in normal juvenile rats and is sensitive to testosterone during adolescence, while testosterone supplement in the adult adversely impacts SHH signaling in a very similar manner to that observed with CN injury.

Descriptive study of prescriptions for opioids from a suburban academic emergency department before New York's I-STOP Act.

PubMed

Ung, Lyncean; Dvorkin, Ronald; Sattler, Steven; Yens, David

2015-01-01

Controlled prescription opioid use is perceived as a national problem attributed to all specialties. Our objective was to provide a descriptive analysis of prescriptions written for controlled opioids from a database of emergency department (ED) visits prior to the enactment of the I-STOP law, which requires New York prescribers to consult the Prescription Monitoring Program (PMP) prior to prescribing Schedule II, III, and IV controlled substances for prescriptions of greater than five days duration. We conducted a retrospective medical record review of patients 21 years of age and older, who presented to the ED between July 1, 2011 - June 30, 2012 and were given a prescription for a controlled opioid. Our primary purpose was to characterize each prescription as to the type of controlled substance, the quantity dispensed, and the duration of the prescription. We also looked at outliers, those patients who received prescriptions for longer than five days. A total of 9,502 prescriptions were written for opioids out of a total 63,143 prescriptions for 69,500 adult patients. Twenty-six (0.27%) of the prescriptions for controlled opioids were written for greater than five days. Most prescriptions were for five days or less (99.7%, 95% CI [99.6 to 99.8%]). The vast majority of opioid prescriptions in our ED prior to the I-STOP legislature were limited to a five-day or less supply. These new regulations were meant to reduce the ED's contribution to the rise of opioid related morbidity. This study suggests that the emergency physicians' usual prescribing practices were negligibly limited by the new restrictive regulations. The ED may not be primarily contributing to the increase in opioid-related overdoses and death. The effect of the I-STOP regulation on future prescribing patterns in the ED remains to be determined.

High Utilizers of Emergency Health Services in a Population-Based Cohort of Homeless Adults

PubMed Central

Chambers, Catharine; Chiu, Shirley; Katic, Marko; Kiss, Alex; Redelmeier, Donald A.; Levinson, Wendy

2013-01-01

Objectives. We identified predictors of emergency department (ED) use among a population-based prospective cohort of homeless adults in Toronto, Ontario. Methods. We assessed ED visit rates using administrative data from the Institute for Clinical Evaluative Sciences (2005–2009). We then used logistic regression to identify predictors of ED use. Frequent users were defined as participants with rates in the top decile (≥ 4.7 visits per person-year). Results. Among 1165 homeless adults, 892 (77%) had at least 1 ED visit during the study. The average rate of ED visits was 2.0 visits per person-year, whereas frequent users averaged 12.1 visits per person-year. Frequent users accounted for 10% of the sample but contributed more than 60% of visits. Predictors of frequent use in adjusted analyses included birth in Canada, higher monthly income, lower health status, perceived unmet mental health needs, and perceived external health locus of control from powerful others; being accompanied by a partner or dependent children had a protective effect on frequent use. Conclusions. Among homeless adults with universal health insurance, a small subgroup accounted for the majority of visits to emergency services. Frequent use was driven by multiple predisposing, enabling, and need factors. PMID:24148033

Utility of common bile duct measurement in ED point of care ultrasound: A prospective study.

PubMed

Lahham, Shadi; Becker, Brent A; Gari, Abdulatif; Bunch, Steven; Alvarado, Maili; Anderson, Craig L; Viquez, Eric; Spann, Sophia C; Fox, John C

2018-06-01

Measurement of the common bile duct (CBD) is considered a fundamental component of biliary point-of-care ultrasound (POCUS), but can be technically challenging. The primary objective of this study was to determine whether CBD diameter contributes to the diagnosis of complicated biliary pathology in emergency department (ED) patients with normal laboratory values and no abnormal biliary POCUS findings aside from cholelithiasis. We performed a prospective, observational study of adult ED patients undergoing POCUS of the right upper quadrant (RUQ) and serum laboratory studies for suspected biliary pathology. The primary outcome was complicated biliary pathology occurring in the setting of normal laboratory values and a POCUS demonstrating the absence of gallbladder wall thickening (GWT), pericholecystic fluid (PCF) and sonographic Murphy's sign (SMS). The association between CBD dilation and complicated biliary pathology was assessed using logistic regression to control for other factors, including laboratory findings, cholelithiasis and other sonographic abnormalities. A total of 158 patients were included in the study. 76 (48.1%) received non-biliary diagnoses and 82 (51.9%) were diagnosed with biliary pathology. Complicated biliary pathology was diagnosed in 39 patients. Sensitivity of CBD dilation for complicated biliary pathology was 23.7% and specificity was 77.9%. Of patients diagnosed with biliary pathology, none had isolated CBD dilatation. In the absence of abnormal laboratory values and GWT, PCF or SMS on POCUS, obtaining a CBD measurement is unlikely to contribute to the evaluation of this patient population. Copyright © 2017 Elsevier Inc. All rights reserved.

Emergency Department Length of Stay: Accuracy of Patient Estimates

PubMed Central

Parker, Brendan T.; Marco, Catherine

2014-01-01

Introduction Managing a patient’s expectations in the emergency department (ED) environment is challenging. Previous studies have identified several factors associated with ED patient satisfaction. Lengthy wait times have shown to be associated with dissatisfaction with ED care. Understanding that patients are inaccurate at their estimation of wait time, which could lead to lower satisfaction, provides administrators possible points of intervention to help improve accuracy of estimation and possibly satisfaction with the ED. This study was undertaken to examine the accuracy of patient estimates of time periods in an ED and identify factors associated with accuracy. Method In this prospective convenience sample survey at UTMC ED, we collected data between March and July 2012. Outcome measures included duration of each phase of ED care and patient estimates of these time periods. Results Among 309 participants, the majority underestimated the total length of stay (LOS) in the ED (median difference −7 minutes (IQR −29-12)). There was significant variability in ED LOS (median 155 minutes (IQR 75–240)). No significant associations were identified between accuracy of time estimates and gender, age, race, or insurance status. Participants with longer ED LOS demonstrated lower patient satisfaction scores (p<0.001). Conclusion Patients demonstrated inaccurate time estimates of ED treatment times, including total LOS. Patients with longer ED LOS had lower patient satisfaction scores. PMID:24672606

Malnutrition among Cognitively Intact, non-Critically Ill Older Adults in the Emergency Department

PubMed Central

Pereira, Greg F.; Bulik, Cynthia M.; Weaver, Mark A.; Holland, Wesley C.; Platts-Mills, Timothy F.

2014-01-01

Objectives We estimate the prevalence of malnutrition among older patients presenting to an emergency department (ED) in the southeastern United States and identify subgroups at increased risk. Methods We conducted a cross-sectional study with random time block sampling of cognitively intact patients aged 65 years and older. Nutrition was assessed using the Mini Nutritional Assessment Short-Form (0–14 scale) with malnutrition defined as a score of 7 or less and at-risk for malnutrition defined as a score of 8–11. The presence of depressive symptoms was defined as a Center for Epidemiological Studies Depression-10 score of 4 or more (0–10 scale). Results Among 138 older adults, 16% (95% Confidence Interval [CI], 10%–22%) were malnourished and 60% (95% CI, 52%–69%) were either malnourished or at-risk for malnutrition. Seventeen of the 22 malnourished patients (77%) denied previously being diagnosed with malnutrition. The prevalence of malnutrition was not appreciably different between males and females, across levels of patient education, or between those living in urban and rural areas. However, the prevalence of malnutrition was higher among patients with depressive symptoms 52%, those residing in assisted living 50%, those with difficulty eating 38%, and those reporting difficulty buying groceries 33%. Conclusion Among a random sample of cognitively intact older ED patients, more than half were malnourished or at-risk for malnutrition, and the majority of malnourished patients had not previously been diagnosed. Higher rates of malnutrition among those with depression, difficulty eating, and difficulty buying groceries suggest the need to explore multifaceted interventions. PMID:25129819

Symptom burden predicts hospitalization independent of comorbidity in community-dwelling older adults.

PubMed

Salanitro, Amanda H; Hovater, Martha; Hearld, Kristine R; Roth, David L; Sawyer, Patricia; Locher, Julie L; Bodner, Eric; Brown, Cynthia J; Allman, Richard M; Ritchie, Christine S

2012-09-01

To determine whether cumulative symptom burden predicts hospitalization or emergency department (ED) visits in a cohort of older adults. Prospective, observational study with a baseline in-home assessment of symptom burden. Central Alabama. Nine hundred eighty community-dwelling adults aged 65 and older (mean 75.3 ± 6.7) recruited from a random sample of Medicare beneficiaries stratified according to sex, race, and urban/rural residence. Symptom burden score (range 0-10). One point was given for each symptom reported: shortness of breath, tiredness or fatigue, problems with balance or dizziness, leg weakness, poor appetite, pain, stiffness, constipation, anxiety, and loss of interest in activities. Dependent variables were hospitalizations and ED visits, assessed every 6 months during the 8.5-year follow-up period. Using Cox proportional hazards models, time from the baseline in-home assessment to the first hospitalization and first hospitalization or ED visit was determined. During the 8.5-year follow-up period, 545 (55.6%) participants were hospitalized or had an ED visit. Participants with greater symptom burden had higher risk of hospitalization (hazard ratio (HR) = 1.09, 95% confidence interval (CI) = 1.05-1.14) and hospitalization or ED visit (HR = 1.10, 95% CI = 1.06-1.14) than those with lower scores. Participants living in rural areas had significantly lower risk of hospitalization (HR = 0.83, 95% CI = 0.69-0.99) and hospitalization or ED visit (HR = 0.80, 95% CI = 0.70-0.95) than individuals in urban areas, independent of symptom burden and comorbidity. Greater symptom burden was associated with higher risk of hospitalization and ED visits in community-dwelling older adults. Healthcare providers treating older adults should consider symptom burden to be an additional risk factor for subsequent hospital utilization. © 2012, Copyright the Authors Journal compilation © 2012, The American Geriatrics Society.

Symptom Burden Predicts Hospitalization Independent of Comorbidity in Community-Dwelling Older Adults

PubMed Central

Salanitro, Amanda H.; Hovater, Martha; Hearld, Kristine Ria; Roth, David L.; Sawyer, Patricia; Locher, Julie L.; Bodner, Eric; Brown, Cynthia J.; Allman, Richard M.; Ritchie, Christine S.

2012-01-01

OBJECTIVES To determine if cumulative symptom burden predicted hospitalizations or emergency department (ED) visits in a cohort of older adults. DESIGN Prospective, observational study with a baseline in-home assessment of symptom burden. SETTING Central Alabama. PARTICIPANTS 980 community-dwelling adults age 65 years or older recruited from a random sample of Medicare beneficiaries, stratified by sex, race, and urban/rural residence. MEASUREMENTS Symptom burden score (range 0–10). One point was added to the score for each symptom reported: shortness of breath, tiredness/fatigue, problems with balance/dizziness, leg weakness, poor appetite, pain, stiffness, constipation, anxiety, and loss of interest in activities. Dependent variables: Hospitalizations and ED visits assessed every 6 months during the 8.5 year follow-up period. Using Cox proportional hazard models, we determined time from the baseline in-home assessment to the first hospitalization and first hospitalization or ED visit. RESULTS During the 8.5 year follow up period, 545 (55.6%) participants were hospitalized or had an ED visit. The participants’ mean age was 75.3 years ± 6.7. Compared to those with lower scores, participants with greater symptom burden had higher risk of hospitalization (hazard ratio (HR)=1.09, 95% confidence interval=1.05–1.14) and hospitalization or ED visit (HR=1.10, 95% CI=1.06–1.14). Participants living in rural areas had significantly lower risk of hospitalization (HR=0.83, 95% CI= 0.69–0.99) and hospitalization or ED visit (HR=0.80, 95% CI=0.70–0.95) compared to individuals in urban areas, independent of symptom burden and comorbidity. CONCLUSION Greater symptom burden was associated with higher risk of hospitalization and ED visits in community-dwelling older adults. Health care providers treating older adults should consider symptom burden as an additional risk factor for subsequent hospital utilization. PMID:22985139

The ED use and non-urgent visits of elderly patients.

PubMed

Gulacti, Umut; Lok, Ugur; Celik, Murat; Aktas, Nurettin; Polat, Haci

2016-12-01

To evaluate the use of the emergency department (ED) by elderly patients, their non-urgent visits and the prevalence of main disease for ED visits. This cross-sectional study was conducted on patients aged 65 years and over who visited the ED of a tertiary care university hospital in Turkey between January 2015 and January 2016 retrospectively. A total of 36,369 elderly patients who visited the ED were included in the study. The rate of ED visits by elderly patients was higher than their representation within the general population (p < 0.001). While the rate of elderly patients visiting polyclinics was 15.8%, the rate of elderly patients visiting the ED was 24.3% (p < 0.001). For both genders, the rates of ED visits for patients between 65 and 74 years old was higher than for other elderly age groups (p < 0.001). The prevalence of upper respiratory tract infection (URTI) was the highest within the elderly population (17.5%, CI: 17.1-17.9). The proportion of ED visits for non-urgent conditions was 23.4%. Most of the ED visits were during the non-business hours (51.1%), and they were highest in the winter season (25.9%) and in January (10.2%). The hospitalization rate was 9.4%, and 37.9% of hospitalized patients were admitted to intensive care units. The proportion of ED visits by elderly patients was higher than their representation within the general population. Elderly patients often visited the ED instead of a polyclinic. The rate of inappropriate ED use by elderly patients in this hospital was higher than in other countries.

A comparative study of South Asian and non-Asian referrals to an eating disorders service in Leicester, UK.

PubMed

Abbas, S; Damani, S; Malik, I; Button, E; Aldridge, S; Palmer, R L

2010-01-01

Literature on eating disorders (EDs) among South Asian people in Britain is limited. In an extension of an earlier study, referrals to the Leicester Adult Eating Disorders Service were examined between 1991 and 2005. All South-Asians presenting to the service were compared on age, gender and diagnosis with non-Asians. Female Asian patients diagnosed as bulimia nervosa and ED not otherwise specified were compared on a larger number of variables with the same number of non-Asian patients matched for diagnosis. As there were only six Asian patients with anorexia nervosa they were excluded from this comparison. Only 4.5% of female patients were Asian, as opposed to 13.8% of the local young female population in the most recent UK census. Overall, Asian women were significantly younger than the non-Asians but did not differ significantly with regard to clinical features or treatment variables. Asians are under-represented amongst women presenting to the service. The explanation for this remains uncertain. Overall, Asian sufferers who reach secondary specialist services closely resemble non-Asian patients.

100 midlife women with eating disorders: a phenomenological analysis of etiology.

PubMed

Kally, Zina; Cumella, Edward J

2008-10-01

This study analyzed eating disorder (ED) etiological factors for 100 midlife women ED inpatients, grouped by ED onset age: < 40 and > or = 40 years. Interpretative Phenomenological Analysis classified ED etiological influences into background contributors, immediate triggers, or sustainers. Family-of-origin issues, predominantly parental maltreatment, emerged as important background contributors, but not immediate ED triggers, regardless of onset age. Body image issues were also major background contributors regardless of onset age and further served as immediate ED triggers for many of the younger-onset patients, but not the older-onset patients. Family-of-choice and health issues were unimportant for younger-onset patients but were important ED contributors and triggers for older-onset patients. Emergent etiological differences suggest differential assessment and treatment needs for midlife ED patients based on ED onset age.

Comorbid Parkinson's disease, falls and fractures in the 2010 National Emergency Department Sample

PubMed Central

Beydoun, Hind A.; Beydoun, May A.; Mishra, Nishant K.; Rostant, Ola S.; Zonderman, Alan B.; Eid, Shaker M.

2017-01-01

Introduction Parkinson's disease (PD) is a progressive, neurodegenerative disorder of multifactorial etiology affecting ~1% of older adults. Research focused on linking PD to falls and bone fractures has been limited in Emergency Department (ED) settings, where most injuries are identified. We assessed whether injured U.S. ED admissions with PD diagnoses were more likely to exhibit comorbid fall- or non-fall related bone fractures and whether a PD diagnosis with a concomitant fall or bone fracture is linked to worse prognosis. Methods We performed secondary analyses of 2010 Healthcare Utilization Project National ED Sample from 4,253,987 admissions to U.S. EDs linked to injured elderly patients. ED discharges with ICD-9-CM code (332.0) were identified as PD and those with ICD-9-CM code (800.0–829.0) were used to define bone fracture location. Linear and logistic regression models were constructed to estimate slopes (B) and odds ratios (OR) with 95% confidence intervals (CI). Results PD admissions had 28% increased adjusted prevalence of bone fracture. Non-fall injuries showed stronger relationship between PD and bone fracture (ORadj = 1.33, 95% CI: 1.22–1.45) than fall injuries (ORadj = 1.06, 95% CI: 1.01–1.10). PD had the strongest impact on hospitalization length when bone fracture and fall co-occurred, and total charges were directly associated with PD only for fall injuries. Finally, PD status was not related to in-hospital death in this population. Conclusions Among injured U.S. ED elderly patient visits, those with PD had higher bone fracture prevalence and more resource utilization especially among fall-related injuries. No association of PD with in-hospital death was noted. PMID:27887896

Prevalence of alcohol related attendance at an inner city emergency department and its impact: a dual prospective and retrospective cohort study

PubMed Central

Parkinson, Kathryn; Newbury-Birch, Dorothy; Phillipson, Angela; Hindmarch, Paul; Kaner, Eileen; Stamp, Elaine; Vale, Luke; Wright, John; Connolly, Jim

2016-01-01

Background Alcohol related hospital attendances are a potentially avoidable burden on emergency departments (EDs). Understanding the number and type of patients attending EDs with alcohol intoxication is important in estimating the workload and cost implications. We used best practice from previous studies to establish the prevalence of adult alcohol related ED attendances and estimate the costs of clinical management and subsequent health service use. Methods The setting was a large inner city ED in northeast England, UK. Data were collected via (i) retrospective review of hospital records for all ED attendances for four pre-specified weeks in 2010/2011 to identify alcohol related cases along with 12 months of follow-up of the care episode and (ii) prospective 24/7 assessment via breath alcohol concentration testing of patients presenting to the ED in the corresponding weeks in 2012/2013. Results The prevalence rates of alcohol related attendances were 12% and 15% for the retrospective and prospective cohorts, respectively. Prospectively, the rates ranged widely from 4% to 60% across week days, rising to over 70% at weekends. Younger males attending in the early morning hours at weekends made up the largest proportion of alcohol related attendances. The mean cost per attendance was £249 (SD £1064); the mean total cost for those admitted was £851 (SD £2549). The most common reasons for attending were trauma related injuries followed by psychiatric problems. Conclusions Alcohol related attendances are a major and avoidable burden on emergency care. However, targeted interventions at weekends and early morning hours could capture the majority of cases and help prevent future re-attendance. PMID:26698364

Persistent pain after motor vehicle collision: comparative effectiveness of opioids vs nonsteroidal antiinflammatory drugs prescribed from the emergency department-a propensity matched analysis.

PubMed

Beaudoin, Francesca L; Gutman, Roee; Merchant, Roland C; Clark, Melissa A; Swor, Robert A; Jones, Jeffrey S; Lee, David C; Peak, David A; Domeier, Robert M; Rathlev, Niels K; McLean, Samuel A

2017-02-01

Each year millions of Americans present to the emergency department (ED) for care after a motor vehicle collision (MVC); the majority (>90%) are discharged to home after evaluation. Acute musculoskeletal pain is the norm in this population, and such patients are typically discharged to home with prescriptions for oral opioid analgesics or nonsteroidal antiinflammatory drugs (NSAIDs). The influence of acute pain management on subsequent pain outcomes in this common ED population is unknown. We evaluated the effect of opioid analgesics vs NSAIDs initiated from the ED on the presence of moderate to severe musculoskeletal pain and ongoing opioid use at 6 weeks in a large cohort of adult ED patients presenting to the ED after MVC (n = 948). The effect of opioids vs NSAIDs was evaluated using an innovative quasi-experimental design method using propensity scores to account for covariate imbalances between the 2 treatment groups. No difference in risk for moderate to severe musculoskeletal pain at 6 weeks was observed between those discharged with opioid analgesics vs NSAIDs (risk difference = 7.2% [95% confidence interval: -5.2% to 19.5%]). However, at follow-up participants prescribed opioids were more likely than those prescribed NSAIDs to report use of prescription opioids medications at week 6 (risk difference = 17.5% [95% confidence interval: 5.8%-29.3%]). These results suggest that analgesic choice at ED discharge does not influence the development of persistent moderate to severe musculoskeletal pain 6 weeks after an MVC, but may result in continued use of prescription opioids. Supported by NIAMS R01AR056328 and AHRQ 5K12HS022998.

Randomized clinical trial of an intravenous hydromorphone titration protocol versus usual care for management of acute pain in older emergency department patients.

PubMed

Chang, Andrew K; Bijur, Polly E; Davitt, Michelle; Gallagher, E John

2013-09-01

Opioid titration is an effective strategy for treating pain; however, titration is generally impractical in the busy emergency department (ED) setting. Our objective was to test a rapid, two-step, hydromorphone titration protocol against usual care in older patients presenting to the ED with acute severe pain. This was a prospective, randomized clinical trial of patients 65 years of age and older presenting to an adult, urban, academic ED with acute severe pain. The study was registered at http://www.clinicaltrials.gov (NCT01429285). Patients randomized to the hydromorphone titration protocol initially received 0.5 mg intravenous hydromorphone. Patients randomized to usual care received any dose of any intravenous opioid. At 15 min, patients in both groups were asked, 'Do you want more pain medication?' Patients in the hydromorphone titration group who answered 'yes' received a second dose of 0.5 mg intravenous hydromorphone. Patients in the usual care group who answered 'yes' had their ED attending physician notified, who then could administer any (or no) additional medication. The primary efficacy outcome was satisfactory analgesia defined a priori as the patient declining additional analgesia at least once when asked at 15 or 60 min after administration of the initial opioid. Dose was calculated in morphine equivalent units (MEU: 1 mg hydromorphone = 7 mg morphine). The need for naloxone to reverse adverse opioid effects was the primary safety outcome. 83.0 % of 153 patients in the hydromorphone titration group achieved satisfactory analgesia compared with 82.5 % of 166 patients in the usual care group (p = 0.91). Patients in the hydromorphone titration group received lower mean initial doses of opioids at baseline than patients in the usual care group (3.5 MEU vs. 4.7 MEU, respectively; p ≤ 0.001) and lower total opioids through 60 min (5.3 MEU vs. 6.0 MEU; p = 0.03). No patient needed naloxone. Low-dose titration of intravenous hydromorphone in increments of 0.5 mg provides comparable analgesia to usual care with less opioid over 60 min.

Patient nonadherence to filling discharge medication prescriptions from the emergency department: Barriers and clinical implications.

PubMed

Farris, Brian; Shakowski, Courtney; Mueller, Scott W; Phong, Suzanne; Kiser, Tyree H; Jacknin, Gabrielle

2018-03-01

Barriers to and clinical implications of patient nonadherence to filling discharge medication prescriptions from the emergency department (ED) were evaluated. This was a retrospective, observational analysis of patients discharged from the ED from April 2013 through May 2015 with medication prescriptions. Patients age 18-89 years who were seen in the ED and did not retrieve discharge medication prescriptions from the onsite, 24-hour ED discharge pharmacy were included in this study. Patients who did not pick up prescriptions were called and asked about barriers to prescription filling. These charts were then retrospectively reviewed and categorized. The primary study outcome was the frequency of nonadherence to filling discharge medications prescribed during the ED visit at the ED outpatient pharmacy. Secondary outcomes included identifying barriers to medication adherence, the rate of return ED visits within 30 days of ED discharge, and the rate of 30-day hospital admissions. Associations between patient and medication variables and the rates of return ED visits within 30 days of discharge and 30-day hospital admissions were analyzed. Of the 4,444 patients discharged from the ED with a prescription to be filled at the satellite pharmacy, 510 were nonadherent. Of these patients, 505 had complete chart information available for evaluation. A large proportion of nonadherent patients revisited the ED within 30 days of ED discharge. Multivariate logistic regression found payer class, ethnicity, and sex were independently associated with return ED visits. The majority of patients who received a prescription during an ED visit filled their discharge medications. Sex, ethnicity, and payer class were independently associated with nonadherence. Copyright © 2018 by the American Society of Health-System Pharmacists, Inc. All rights reserved.

Results from a large multinational clinical trial (guardian™1) using prophylactic treatment with turoctocog alfa in adolescent and adult patients with severe haemophilia A: safety and efficacy.

PubMed

Lentz, S R; Misgav, M; Ozelo, M; Salek, S Z; Veljkovic, D; Recht, M; Cerqueira, M; Tiede, A; Brand, B; Mancuso, M E; Seremetis, S; Lindblom, A; Martinowitz, U

2013-09-01

Recombinant factor VIII (rFVIII) products provide a safe and efficacious replacement therapy for prophylaxis and treatment of bleeding episodes in patients with severe haemophilia A. This multinational, open-label, non-controlled trial investigated the safety and efficacy of turoctocog alfa, a new rFVIII product. The primary objective was to evaluate safety. A total of 150 patients (24 adolescents and 126 adults) with severe haemophilia A (FVIII activity ≤ 1%), with at least 150 exposure days (EDs) to any FVIII product and no history of inhibitors were enrolled, and 146 patients (97%) completed the trial. All patients received prophylaxis with turoctocog alfa for approximately 6 months and had a mean of 85 EDs during the trial. None of the patients developed FVIII inhibitors, there were no indications of early FVIII inhibitor development and no safety concerns were identified. A total of 225 adverse events were reported in 100 (67%) patients, with the most common being events associated with dosing procedures, headaches, and nasopharyngitis. A total of 499 bleeding episodes were reported during the trial, the majority (89%) were controlled with 1-2 infusions of turoctocog alfa. Based on patient reports, the success rate (defined as 'excellent' or 'good' haemostatic response) for treatment of bleeding episodes was 81%. The overall median annualized bleeding rate was 3.7 (interquartile range: 8.7) bleeds/patient/year. In conclusion, turoctocog alfa provides a new, safe and effective alternative for prophylaxis and treatment of bleeding episodes in patients with haemophilia A. © 2013 John Wiley & Sons Ltd.

X-ray radiation and development inhibition of Helicoverpa armigera Hübner (Lepidoptera: Noctuidae)

NASA Astrophysics Data System (ADS)

Kim, Junheon; Jung, Soon-Oh; Jang, Sin Ae; Kim, Jeongmin; Park, Chung Gyoo

2015-10-01

Effect of X-ray radiation on the development inhibition was evaluated for all stages of the life cycle of Helicoverpa armigera to determine a radiation dose for potential quarantine treatment against the insect. ED99 values for inhibition of hatching, pupation, and adult emergence from irradiated eggs were 413, 210, and 154 Gy, respectively. ED99 values for inhibition of pupation and adult emergence from irradiated larvae were 221 and 167 Gy, respectively. Pupa was the most tolerant to X-ray radiation. ED99 value for inhibition of adult emergence from irradiated pupae was as high as 2310 Gy, whereas that for inhibition of F1 egg hatching was only 66 Gy. ED99 value for inhibition of hatching of F1 eggs which were laid by irradiated adults was estimated to 194 Gy. X-ray irradiation against H. armigera is recommended as an alternative method to methyl bromide fumigation for phytosanitary treatments during quarantine. X-ray radiation dose of 200 Gy is proposed as a potential quarantine treatment dose for H. armigera eggs and larvae.

Preventing avoidable incidents leading to a presentation to the emergency department (ED) by older adults with cognitive impairment: protocol for a scoping review.

PubMed

Provencher, Véronique; Généreux, Mélissa; Gagnon-Roy, Mireille; Veillette, Nathalie; Egan, Mary; Sirois, Marie-Josée; Lacasse, Francis; Rose, Kathy; Stocco, Stéphanie

2016-02-12

Older adults with cognitive impairment represent a large portion (21-42%) of people (65+) who consult at an emergency department (ED). Because this sub-group is at higher risk for hospitalisation and mortality following an ED visit, awareness about 'avoidable' incidents should be increased in order to prevent presentations to the ED due to such incidents. This study aims to synthetise the actual knowledge related to 'avoidable' incidents (ie, traumatic injuries, poisoning and other consequences of external causes) (WHO, 2016) leading to ED presentations in older people with cognitive impairment. A scoping review will be performed. Scientific and grey literature (1996-2016) will be searched using a combination of key words pertaining to avoidable incidents, ED presentations, older adults and cognitive impairment. A variety of databases (MEDLINE, CINAHL, Ageline, SCOPUS, ProQuest Dissertations/theses, EBM Reviews, Healthstar), online library catalogues, governmental websites and published statistics will be examined. Included sources will pertain to community-dwelling older adults presenting to the ED as a result of an avoidable incident, with the main focus on those with cognitive impairment. Data (eg, type, frequency, severity, circumstances of incidents, preventive measures) will be extracted and analysed using a thematic chart and content analysis. This scoping review will provide a picture of the actual knowledge on the subject and identify knowledge gaps in existing literature to be filled by future primary researches. Findings will help stakeholders to develop programmes in order to promote safe and healthy environments and behaviours aimed at reducing avoidable incidents in seniors, especially those with cognitive impairment. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Preventing avoidable incidents leading to a presentation to the emergency department (ED) by older adults with cognitive impairment: protocol for a scoping review

PubMed Central

Provencher, Véronique; Généreux, Mélissa; Gagnon-Roy, Mireille; Veillette, Nathalie; Egan, Mary; Sirois, Marie-Josée; Lacasse, Francis; Rose, Kathy; Stocco, Stéphanie

2016-01-01

Introduction Older adults with cognitive impairment represent a large portion (21–42%) of people (65+) who consult at an emergency department (ED). Because this sub-group is at higher risk for hospitalisation and mortality following an ED visit, awareness about ‘avoidable’ incidents should be increased in order to prevent presentations to the ED due to such incidents. This study aims to synthetise the actual knowledge related to ‘avoidable’ incidents (ie, traumatic injuries, poisoning and other consequences of external causes) (WHO, 2016) leading to ED presentations in older people with cognitive impairment. Methodology and analysis A scoping review will be performed. Scientific and grey literature (1996–2016) will be searched using a combination of key words pertaining to avoidable incidents, ED presentations, older adults and cognitive impairment. A variety of databases (MEDLINE, CINAHL, Ageline, SCOPUS, ProQuest Dissertations/theses, EBM Reviews, Healthstar), online library catalogues, governmental websites and published statistics will be examined. Included sources will pertain to community-dwelling older adults presenting to the ED as a result of an avoidable incident, with the main focus on those with cognitive impairment. Data (eg, type, frequency, severity, circumstances of incidents, preventive measures) will be extracted and analysed using a thematic chart and content analysis. Discussion and dissemination This scoping review will provide a picture of the actual knowledge on the subject and identify knowledge gaps in existing literature to be filled by future primary researches. Findings will help stakeholders to develop programmes in order to promote safe and healthy environments and behaviours aimed at reducing avoidable incidents in seniors, especially those with cognitive impairment. PMID:26873049

Care and Respect for Elders in Emergencies program: a preliminary report of a volunteer approach to enhance care in the emergency department.

PubMed

Sanon, Martine; Baumlin, Kevin M; Kaplan, Shari Sirkin; Grudzen, Corita R

2014-02-01

Older adults who present to an emergency department (ED) generally have more-complex medical conditions with complicated care needs and are at high risk for preventable adverse outcomes during their ED visit. The Care and Respect for Elders with Emergencies (CARE) volunteer initiative is a geriatric-focused volunteer program developed to help prevent avoidable complications such as falls, delirium and use of restraints, and functional decline in vulnerable elders in the ED. The CARE program consists of bedside volunteer interventions ranging from conversation to various short activities designed to engage and reorient high-risk, older, unaccompanied individuals in the ED. This article describes the development and characteristics of the CARE program, the services provided, the experiences of the elderly patients and their volunteers, and the growth of the program over time. CARE volunteers provide elders with the additional attention needed in an often chaotic, unfamiliar environment by enhancing their care, improving satisfaction, and preventing potential decline. © 2014, Copyright the Authors Journal compilation © 2014, The American Geriatrics Society.

Nonurgent patients in emergency departments: rational or irresponsible consumers? Perceptions of professionals and patients.

PubMed

Durand, Anne-Claire; Palazzolo, Sylvie; Tanti-Hardouin, Nicolas; Gerbeaux, Patrick; Sambuc, Roland; Gentile, Stéphanie

2012-09-25

For several decades, overcrowding in emergency departments (EDs) has been intensifying due to the increased number of patients seeking care in EDs. Demand growth is partly due to misuse of EDs by patients who seek care for nonurgent problems. This study explores the reasons why people with nonurgent complaints choose to come to EDs, and how ED health professionals perceive the phenomenon of "nonurgency". Semi-structured interviews were conducted in 10 EDs with 87 nonurgent patients and 34 health professionals. Interviews of patients revealed three themes: (1) fulfilled health care needs, (2) barriers to primary care providers (PCPs), and (3) convenience. Patients chose EDs as discerning health consumers: they preferred EDs because they had difficulties obtaining a rapid appointment. Access to technical facilities in EDs spares the patient from being overwhelmed with appointments with various specialists. Four themes were identified from the interviews of health professionals: (1) the problem of defining a nonurgent visit, (2) explanations for patients' use of EDs for nonurgent complaints, (3) consequences of nonurgent visits, and (4) solutions to counter this tendency. Studies on the underlying reasons patients opt for the ED, as well as on their decision-making process, are lacking. The present study highlighted discrepancies between the perceptions of ED patients and those of health professionals, with a special focus on patient behaviour. To explain the use of ED, health professionals based themselves on the acuity and urgency of medical problems, while patients focused on rational reasons to initiate care in the ED (accessibility to health care resources, and the context in which the medical problem occurred). In spite of some limitations due to the slightly outdated nature of our data, as well as the difficulty of categorizing nonurgent situations, our findings show the importance of conducting a detailed analysis of the demand for health care. Understanding it is crucial, as it is the main determining factor in the utilization of health care resources, and provides promising insights into the phenomenon of ED usage increase. For reforms to be successful, the process of decision-making for unscheduled patients will have to be thoroughly investigated.

A New Model to Study Sleep Deprivation-Induced Seizure

PubMed Central

Lucey, Brendan P.; Leahy, Averi; Rosas, Regine; Shaw, Paul J.

2015-01-01

Background and Study Objectives: A relationship between sleep and seizures is well-described in both humans and rodent animal models; however, the mechanism underlying this relationship is unknown. Using Drosophila melanogaster mutants with seizure phenotypes, we demonstrate that seizure activity can be modified by sleep deprivation. Design: Seizure activity was evaluated in an adult bang-sensitive seizure mutant, stress sensitive B (sesB9ed4), and in an adult temperature sensitive seizure mutant seizure (seits1) under baseline and following 12 h of sleep deprivation. The long-term effect of sleep deprivation on young, immature sesB9ed4 flies was also assessed. Setting: Laboratory. Participants: Drosophila melanogaster. Interventions: Sleep deprivation. Measurements and Results: Sleep deprivation increased seizure susceptibility in adult sesB9ed4/+ and seits1 mutant flies. Sleep deprivation also increased seizure susceptibility when sesB was disrupted using RNAi. The effect of sleep deprivation on seizure activity was reduced when sesB9ed4/+ flies were given the anti-seizure drug, valproic acid. In contrast to adult flies, sleep deprivation during early fly development resulted in chronic seizure susceptibility when sesB9ed4/+ became adults. Conclusions: These findings show that Drosophila is a model organism for investigating the relationship between sleep and seizure activity. Citation: Lucey BP, Leahy A, Rosas R, Shaw PJ. A new model to study sleep deprivation-induced seizure. SLEEP 2015;38(5):777–785. PMID:25515102

The impact of short prehospital times on trauma center performance benchmarking: An ecologic study.

PubMed

Byrne, James P; Mann, N Clay; Hoeft, Christopher J; Buick, Jason; Karanicolas, Paul; Rizoli, Sandro; Hunt, John P; Nathens, Avery B

2016-04-01

Emergency medical service (EMS) prehospital times vary between regions, yet the impact of local prehospital times on trauma center (TC) performance is unknown. To inform external benchmarking efforts, we explored the impact of EMS prehospital times on the risk-adjusted rate of emergency department (ED) death and overall hospital mortality at urban TCs across the United States. We used a novel ecologic study design, linking EMS data from the National EMS Information System to TCs participating in the American College of Surgeons' Trauma Quality Improvement Program (TQIP) by destination zip code. This approach provided EMS times for populations of injured patients transported to TQIP centers. We defined the exposure of interest as the 90th percentile total prehospital time (PHT) for each TC. TCs were then stratified by PHT quartile. Analyses were limited to adult patients with severe blunt or penetrating trauma, transported directly by land to urban TQIP centers. Random-intercept multilevel modeling was used to evaluate the risk-adjusted relationship between PHT quartile and the outcomes of ED death and overall hospital mortality. During the study period, 119,740 patients met inclusion criteria at 113 TCs. ED death occurred in 1% of patients, and overall mortality was 7.2%. Across all centers, the median PHT was 61 minutes (interquartile range, 53-71 minutes). After risk adjustment, TCs in regions with the shortest quartile of PHTs (<53 minutes) had significantly greater odds of ED death compared with those with the longest PHTs (odds ratio, 2.00; 95% confidence interval, 1.43-2.78). However, there was no association between PHT and overall TC mortality. At urban TCs, local EMS prehospital times are a significant predictor of ED death. However, no relationship exists between prehospital time and overall TC risk-adjusted mortality. Therefore, there is no evidence for the inclusion of EMS prehospital time in external benchmarking analyses.

Implementation of an Emergency Department Sepsis Bundle and System Redesign: A Process Improvement Initiative.

PubMed

McColl, Tamara; Gatien, Mathieu; Calder, Lisa; Yadav, Krishan; Tam, Ryan; Ong, Melody; Taljaard, Monica; Stiell, Ian

2017-03-01

In 2008-2009, the Canadian Institute for Health Information reported over 30,000 cases of sepsis hospitalizations in Canada, an increase of almost 4,000 from 2005. Mortality rates from severe sepsis and septic shock continue to remain greater than 30% in Canada and are significantly higher than other critical conditions treated in the emergency department (ED). Our group formed a multidisciplinary sepsis committee, conducted an ED process of care analysis, and developed a quality improvement protocol. The objective of this study was to evaluate the effects of this sepsis management bundle on patient mortality. This before and after study was conducted in two large Canadian tertiary care EDs and included adult patients with suspected severe infection that met at least two systemic inflammatory response syndrome (SIRS) criteria. We studied the implementation of a sepsis bundle including triage flagging, RN medical directive, education campaign, and a modified sepsis protocol. The primary outcomes were 30-day all-cause mortality and sepsis protocol use. We included a total of 167 and 185 patients in the pre- and post-intervention analysis, respectively. Compared to the pre-intervention group, mortality was significantly lower in the post-intervention group (30.7% versus 17.3%; absolute difference, 13.4%; 95% CI 9.8-17.0; p=0.006). There was also a higher rate of sepsis protocol use in the post-intervention group (20.3% versus 80.5%, absolute difference 60.2%; 95% CI 55.1-65.3; p<0.001). Additionally, we found shorter time-intervals from triage to MD assessment, fluid resuscitation, and antibiotic administration as well as lower rates of vasopressor requirements and ICU admission. Interpretation The implementation of our multidisciplinary ED sepsis bundle, including improved early identification and protocolized medical care, was associated with improved time to achieve key therapeutic interventions and a reduction in 30-day mortality. Similar low-cost initiatives could be implemented in other EDs to potentially improve outcomes for this high-risk group of patients.

Arsenic trioxide at conventional dosage does not aggravate hemorrhage in the first-line treatment of adult acute promyelocytic leukemia.

PubMed

Cui, Wen; Wang, Jin; Nie, Rui-Min; Zhao, Ling-Ling; Gao, Meng-Qing; Zhu, Hong-Ming; Chen, Li; Hu, Jiong; Li, Jun-Min; Shen, Zhi-Xiang; Wang, Zhen-Yi; Chen, Sai-Juan; Chen, Zhu; Wang, Kan-Kan; Xi, Xiao-Dong; Mi, Jian-Qing

2018-04-01

The arsenic trioxide (ATO) plus all-trans retinoic acid (ATRA) therapy has demonstrated a tremendous success in the first-line treatment of acute promyelocytic leukemia (APL). Actually, early death (ED) is currently thought as a major challenge in APL. ATO has been reported to inhibit platelet function in vitro, and whether it increases the ED rate by exacerbating the hemorrhagic symptoms remains to be investigated. Effects of ATO on platelet aggregation and adhesion were evaluated in vitro and in thirty-two complete remission (CR) and four newly diagnosed APL patients. Furthermore, concentrations of plasma total arsenic were monitored in APL patients via ICP-MS. The inhibition of platelet function, either aggregation or adhesion, did occur in vitro when the concentration of ATO reached 2 μmol/L. However, in CR APL patients receiving ATO with normal platelet count, the platelets responded normally when being activated and so did those in the newly diagnosed patients with thrombocytopenia. Our data further showed that the conventional dosage of ATO reached a plasma concentration substantially below the required concentration to inhibit platelets. In the first-line treatment of APL, the use of ATO is safe and effective and does not compromise the hemostatic potential that may eventually increase ED rate. © 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Emergency department triage scales and their components: a systematic review of the scientific evidence.

PubMed

Farrohknia, Nasim; Castrén, Maaret; Ehrenberg, Anna; Lind, Lars; Oredsson, Sven; Jonsson, Håkan; Asplund, Kjell; Göransson, Katarina E

2011-06-30

Emergency department (ED) triage is used to identify patients' level of urgency and treat them based on their triage level. The global advancement of triage scales in the past two decades has generated considerable research on the validity and reliability of these scales. This systematic review aims to investigate the scientific evidence for published ED triage scales. The following questions are addressed: 1. Does assessment of individual vital signs or chief complaints affect mortality during the hospital stay or within 30 days after arrival at the ED?2. What is the level of agreement between clinicians' triage decisions compared to each other or to a gold standard for each scale (reliability)? 3. How valid is each triage scale in predicting hospitalization and hospital mortality? A systematic search of the international literature published from 1966 through March 31, 2009 explored the British Nursing Index, Business Source Premier, CINAHL, Cochrane Library, EMBASE, and PubMed. Inclusion was limited to controlled studies of adult patients (≥ 15 years) visiting EDs for somatic reasons. Outcome variables were death in ED or hospital and need for hospitalization (validity). Methodological quality and clinical relevance of each study were rated as high, medium, or low. The results from the studies that met the inclusion criteria and quality standards were synthesized applying the internationally developed GRADE system. Each conclusion was then assessed as having strong, moderately strong, limited, or insufficient scientific evidence. If studies were not available, this was also noted.We found ED triage scales to be supported, at best, by limited and often insufficient evidence.The ability of the individual vital signs included in the different scales to predict outcome is seldom, if at all, studied in the ED setting. The scientific evidence to assess interrater agreement (reliability) was limited for one triage scale and insufficient or lacking for all other scales. Two of the scales yielded limited scientific evidence, and one scale yielded insufficient evidence, on which to assess the risk of early death or hospitalization in patients assigned to the two lowest triage levels on a 5-level scale (validity).

Emergency Department Triage Scales and Their Components: A Systematic Review of the Scientific Evidence

PubMed Central

2011-01-01

Emergency department (ED) triage is used to identify patients' level of urgency and treat them based on their triage level. The global advancement of triage scales in the past two decades has generated considerable research on the validity and reliability of these scales. This systematic review aims to investigate the scientific evidence for published ED triage scales. The following questions are addressed: 1. Does assessment of individual vital signs or chief complaints affect mortality during the hospital stay or within 30 days after arrival at the ED? 2. What is the level of agreement between clinicians' triage decisions compared to each other or to a gold standard for each scale (reliability)? 3. How valid is each triage scale in predicting hospitalization and hospital mortality? A systematic search of the international literature published from 1966 through March 31, 2009 explored the British Nursing Index, Business Source Premier, CINAHL, Cochrane Library, EMBASE, and PubMed. Inclusion was limited to controlled studies of adult patients (≥15 years) visiting EDs for somatic reasons. Outcome variables were death in ED or hospital and need for hospitalization (validity). Methodological quality and clinical relevance of each study were rated as high, medium, or low. The results from the studies that met the inclusion criteria and quality standards were synthesized applying the internationally developed GRADE system. Each conclusion was then assessed as having strong, moderately strong, limited, or insufficient scientific evidence. If studies were not available, this was also noted. We found ED triage scales to be supported, at best, by limited and often insufficient evidence. The ability of the individual vital signs included in the different scales to predict outcome is seldom, if at all, studied in the ED setting. The scientific evidence to assess interrater agreement (reliability) was limited for one triage scale and insufficient or lacking for all other scales. Two of the scales yielded limited scientific evidence, and one scale yielded insufficient evidence, on which to assess the risk of early death or hospitalization in patients assigned to the two lowest triage levels on a 5-level scale (validity). PMID:21718476

Alcohol Mixed with Energy Drink Use as an Event-Level Predictor of Physical and Verbal Aggression in Bar Conflicts.

PubMed

Miller, Kathleen E; Quigley, Brian M; Eliseo-Arras, Rebecca K; Ball, Natalie J

2016-01-01

Young adult use of alcohol mixed with caffeinated energy drinks (AmEDs) has been globally linked with increased odds of interpersonal aggression, compared with the use of alcohol alone. However, no prior research has linked these behaviors at the event level in bar drinking situations. The present study assessed whether AmED use is associated with the perpetration of verbal and physical aggression in bar conflicts at the event level. In Fall 2014, a community sample of 175 young adult AmED users (55% female) completed a web survey describing a recent conflict experienced while drinking in a bar. Use of both AmED and non-AmED alcoholic drinks in the incident were assessed, allowing calculation of our main predictor variable, the proportion of AmEDs consumed (AmED/total drinks consumed). To measure perpetration of aggression, participants reported on the occurrence of 6 verbal and 6 physical acts during the bar conflict incident. Linear regression analyses showed that the proportion of AmEDs consumed predicted scores for perpetration of both verbal aggression (β = 0.16, p < 0.05) and physical aggression (β = 0.19, p < 0.01) after controlling for gender, age, sensation-seeking and aggressive personality traits, aggressive alcohol expectancies, aggressogenic physical and social bar environments, and total number of drinks. Results of this study suggest that in alcohol-related bar conflicts, higher levels of young adult AmED use are associated with higher levels of aggression perpetration than alcohol use alone and that the elevated risk is not attributable to individual differences between AmED users and nonusers or to contextual differences in bar drinking settings. While future research is needed to identify motivations, dosages, and sequencing issues associated with AmED use, these beverages should be considered a potential risk factor in the escalation of aggressive bar conflicts. Copyright © 2016 by the Research Society on Alcoholism.

Simulation-based multidisciplinary team training decreases time to critical operations for trauma patients.

PubMed

Murphy, Margaret; Curtis, Kate; Lam, Mary K; Palmer, Cameron S; Hsu, Jeremy; McCloughen, Andrea

2018-05-01

Simulation has been promoted as a platform for training trauma teams. However, it is not clear if this training has an impact on health service delivery and patient outcomes. This study evaluates the association between implementation of a simulation based multidisciplinary trauma team training program at a metropolitan trauma centre and subsequent patient outcomes. This was a retrospective review of trauma registry data collected at an 850-bed Level 1 Adult Trauma Centre in Sydney, Australia. Two concurrent four-year periods, before and after implementation of a simulation based multidisciplinary trauma team training program were compared for differences in time to critical operations, Emergency Department (ED) length of stay (LOS) and patient mortality. There were 2389 major trauma patients admitted to the hospital during the study, 1116 in the four years preceding trauma team training (the PREgroup) and 1273 in the subsequent 4 years (the POST group). There were no differences between the groups with respect to gender, body region injured, incidence of polytrauma, and pattern of arrival to ED. The POST group was older (median age 54 versus 43 years, p < 0.001) and had a higher incidence of falls and assaults (p < 0.001). There was a reduction in time to critical operation, from 2.63 h (IQR 1.23-5.12) in the PRE-group to 0.55 h (IQR 0.22-1.27) in the POST-group, p < 0.001. The overall ED LOS increased, and there was no reduction in mortality. Post-hoc analysis found LOS in ED was reduced in the cohort requiring critical operations, p < 0.001. The implementation of trauma team training was associated with a reduction in time to critical operation while overall ED length of stay increased. Simulation is promoted as a platform for training teams; but the complexity of trauma care challenges efforts to demonstrate direct links between multidisciplinary team training and improved outcomes. There remain considerable gaps in knowledge as to how team training impacts health service delivery and patient outcomes. Retrospective comparative therapeutic/care management study, Level III evidence. Crown Copyright © 2018. Published by Elsevier Ltd. All rights reserved.

Predictors and Outcomes of Revisits in Older Adults Discharged from the Emergency Department.

PubMed

de Gelder, Jelle; Lucke, Jacinta A; de Groot, Bas; Fogteloo, Anne J; Anten, Sander; Heringhaus, Christian; Dekkers, Olaf M; Blauw, Gerard J; Mooijaart, Simon P

2018-04-01

To study predictors of emergency department (ED) revisits and the association between ED revisits and 90-day functional decline or mortality. Multicenter cohort study. One academic and two regional Dutch hospitals. Older adults discharged from the ED (N=1,093). At baseline, data on demographic characteristics, illness severity, and geriatric parameters (cognition, functional capacity) were collected. All participants were prospectively followed for an unplanned revisit within 30 days and for functional decline and mortality 90 days after the initial visit. The median age was 79 (interquartile range 74-84), and 114 participants (10.4%) had an ED revisit within 30 days of discharge. Age (hazard ratio (HR)=0.96, 95% confidence interval (CI)=0.92-0.99), male sex (HR=1.61, 95% CI=1.05-2.45), polypharmacy (HR=2.06, 95% CI=1.34-3.16), and cognitive impairment (HR=1.71, 95% CI=1.02-2.88) were independent predictors of a 30-day ED revisit. The area under the receiver operating characteristic curve to predict an ED revisit was 0.65 (95% CI=0.60-0.70). In a propensity score-matched analysis, individuals with an ED revisit were at higher risk (odds ratio=1.99 95% CI=1.06-3.71) of functional decline or mortality. Age, male sex, polypharmacy, and cognitive impairment were independent predictors of a 30-day ED revisit, but no useful clinical prediction model could be developed. However, an early ED revisit is a strong new predictor of adverse outcomes in older adults. © 2018 The Authors. The Journal of the American Geriatrics Society published by Wiley Periodicals, Inc. on behalf of The American Geriatrics Society.

Intoxication-Related Alcohol Mixed with Energy Drink Expectancies Scale: Initial Development and Validation.

PubMed

Miller, Kathleen E; Dermen, Kurt H; Lucke, Joseph F

2017-06-01

Young adult use of alcohol mixed with energy drinks (AmEDs) has been linked with elevated risks of a constellation of problem behaviors. These risks may be conditioned by expectancies regarding the effects of caffeine in conjunction with alcohol consumption. The aim of this study was to describe the construction and psychometric evaluation of the Intoxication-Related AmED Expectancies Scale (AmED_EXPI), 15 self-report items measuring beliefs about how the experience of AmED intoxication differs from the experience of noncaffeinated alcohol (NCA) intoxication. Scale development and testing were conducted using data from a U.S. national sample of 3,105 adolescents and emerging adults aged 13 to 25. Exploratory and confirmatory factor analyses were conducted to evaluate the factor structure and establish factor invariance across gender, age, and prior experience with AmED use. Cross-sectional and longitudinal analyses examining correlates of AmED use were used to assess construct and predictive validity. In confirmatory factor analyses, fit indices for the hypothesized 4-factor structure (i.e., Intoxication Management [IM], Alertness [AL], Sociability [SO], and Jitters [JT]) revealed a moderately good fit to the data. Together, these factors accounted for 75.3% of total variance. The factor structure was stable across male/female, teen/young adult, and AmED experience/no experience subgroups. The resultant unit-weighted subscales showed strong internal consistency and satisfactory convergent validity. Baseline scores on the IM, SO, and JT subscales predicted changes in AmED use over a subsequent 3-month period. The AmED_EXPI appears to be a reliable and valid tool for measuring expectancies about the effects of caffeine during alcohol intoxication. Copyright © 2017 by the Research Society on Alcoholism.

The Effect of Acute Consumption of Energy Drinks on Blood Pressure, Heart Rate and Blood Glucose in the Group of Young Adults.

PubMed

Nowak, Dariusz; Gośliński, Michał; Nowatkowska, Kamila

2018-03-19

Energy drinks (EDs) are very popular among young people, who consume them for various reasons. A standard ED typically contains 80 mg of caffeine, as well as glucose, taurine, vitamins and other ingredients. Excessive consumption of EDs and accumulation of the above ingredients, as well as their mutual interactions, can be hazardous to the health of young adults. The purpose of this study was to assess the effect of acute consumption of energy drinks on blood pressure, heart rate and blood glucose. The study involved 68 volunteers, healthy young adults (mean age 25 years), who were divided into two groups: the first consumed three EDs at one-hour intervals, and the second drank the same amount of water. All participants had their blood pressure (BP)-systolic and diastolic (SBP and DBP)-as well as heart rate (HR) and blood glucose (BG) measured. In addition, participants could report any health problems before and after consuming each portion of ED. In the above experiment, having consumed three portions of ED (240 mg of caffeine), the participants presented a significant increase in DBP ( p = 0.003), by over 8%, which coincided with a lack of any significant impact on SBP ( p = 0.809). No significant changes were noted in HR ( p = 0.750). Consumption of EDs caused a significant increase ( p < 0.001) in BG, by ca. 21%, on average. Some participants reported various discomforts, which escalated after 2 and 3 EDs. Acute consumption of EDs contributed to increased diastolic blood pressure, blood glucose and level of discomfort in healthy young people. Our results reinforce the need for further studies on a larger population to provide sufficient evidence.

Survey of California emergency departments about practices for management of suicidal patients and resources available for their care.

PubMed

Baraff, Larry J; Janowicz, Nicole; Asarnow, Joan R

2006-10-01

To determine the resources available and current practices for the treatment of patients with suicidal ideation or attempts in California emergency departments (EDs). We conducted a mail and e-mail survey of the directors of all 346 EDs in the state of California. Data collected included identification of hospital and respondent, type of hospital, presence of separate psychiatric ED, total number of ED patients and number of ED patients with suicidal ideation or attempts who were treated per week, mental health personnel on call to evaluate suicidal patients, criteria for patient disposition, available disposition options, delays in patient care, changes desired in the ED treatment of suicidal patients, and adequacy of community resources for suicidal patients. Two hundred twenty-three of 346 (64.5%) ED directors responded to the survey. Overall, the mean estimate of the proportion of ED visits by suicidal patients was 1.7%. Though evaluation of patients with suicidal ideation by a mental health professional was the usual practice, 51 respondents (23%) reported that they occasionally send patients with suicidal ideation home without such an evaluation, and 8.5% reported this was done more than 10% of the time. No single type of mental health professional, including psychiatrist, social worker, county or private psychiatric evaluation team, psychiatric nurse, or psychologist, was available for evaluation of suicidal patients in more than 50% of respondent EDs. In the majority of EDs, psychiatric evaluations were performed by either mobile county or private psychiatric evaluation teams or social workers on call to the ED. Psychiatrists were reported to evaluate the majority of suicidal patients in only 10% of EDs. Only 27% of respondents had the ability to admit patients to a psychiatric service at their hospital. When patients needed to be transferred, the estimated mean wait for these transfers was 7 hours. Seventy-one percent of respondents reported needing improved access to mental health personnel for evaluation of suicidal patients; 61% reported needing improved access to mental health personnel for patient disposition. In California EDs, there are limited mental health services for suicidal patients. Regional solutions to emergency and nonemergency mental health problems are needed, including improved access to mental health personnel for ED evaluation, disposition, and follow-up of suicidal patients and community mental health resources for patient referrals.

Emergency Department Use in a Cohort of Older Homeless Adults: Results from the HOPE HOME Study

PubMed Central

Raven, Maria C.; Tieu, Lina; Lee, Christopher T.; Ponath, Claudia; Guzman, David; Kushel, Margot

2018-01-01

Objective The median age of single homeless adults is over 50, yet little is known about their emergency department (ED) use. We describe use of and factors associated with ED use in a sample of homeless adults 50 and older. Methods We recruited 350 participants who were homeless and 50 or older in Oakland, CA. We interviewed participants about residential history in the prior six months, health status, health-related behaviors, and health services use, and assessed cognition and mobility. Our primary outcome was the number of ED visits in the prior six months based on medical record review. We used negative binomial regression to examine factors associated with ED use. Results In the six months prior to enrollment, 46.3% of participants spent the majority of their time unsheltered, 25.1% cycled through multiple institutions including shelters, hospitals and jails, 16.3% primarily stayed with family or friends, and 12.3% had become homeless recently after spending much of the prior six months housed. Half (49.7%) of participants made at least one ED visit in the past six months; 6.6% of participants accounted for 49.9% of all visits. Most (71.8%) identified a regular non-ED source of healthcare; 7.3% of visits resulted in hospitalization. In multivariate models, study participants who used multiple institutions (incidence rate ratio [IRR] = 2.27; 95% confidence interval [CI] = 1.08–4.77) and who were unsheltered (IRR = 2.29; 95% CI = 1.17–4.48) had higher ED use rates than participants who had been housed for most of the prior six months. In addition, having health insurance/coverage (IRR= 2.6; CI = 1.5–4.4), a history of psychiatric hospitalization (IRR = 1.80; 95% CI = 1.09–2.99), and severe pain (IRR = 1.72; 95% CI = 1.07–2.76) were associated with higher ED visit rates. Conclusions A sample of adults aged 50 and older who were homeless at study entry had higher rates of ED use in the prior six months than the general US age-matched population. Within the sample, ED use rates varied based on individuals’ residential histories, suggesting that individuals’ ED use is related to exposure to homelessness. PMID:27520382