Emergency department visits among patients with left ventricular assist devices

Continuous-flow left ventricular assist devices (LVADs) are increasingly implanted to support patients with end-stage heart failure. These patients are at high risk for complications, many of which necessitate emergency care. While rehospitalization rates have been described, there is little data regarding emergency department (ED) visits. We hypothesize that ED visits are frequent and often require admission after LVAD implantation. We performed a retrospective review of patients in our health-care system followed by the advanced heart failure service for LVAD management after implantation between January 2011 and July 2015. We accounted for all ED visits in our system through February 2016, 7 months after the last implantation included. Clinically relevant demographic variables and ED visit details were recorded and analyzed to describe this population. We identified 81 patients with complete data, among whom there were 283 visits (3.49 visits/patient), occurring at a rate of approximately 7.3 ED visits per patient per year alive with LVAD. The most common reason for an ED visit is a complication related to bleeding (18% of visits), followed by chest pain (14%) and dizziness or syncope (13%). Thirty-six percent of patients were discharged from the ED without hospital admission. A growing populace with implanted LVADs represents an important population within emergency medicine. They are at risk for significant complications and frequently present to the ED. While many of these visits may be managed without hospital admission, this specialized patient group represents a potential area for improvement in provider education.     

Emergency department visits in African Americans with mild cognitive impairment and diabetes

AimsDementia, diabetes, and African American race are three factors that are independently associated with emergency department (ED) use. This study tested the hypothesis that ED use is associated with worse cognitive function in African Americans with Mild Cognitive Impairment (MCI) and poorly controlled diabetes.MethodsThis study examined differences in ED use among African Americans with MCI and diabetes in a secondary data analysis of baseline data from a one-year randomized controlled trial (N = 101).ResultsOver one year, 49/92 participants (53.3%) had at least one ED visit. At baseline, participants who had an incident ED visit had significantly fewer years of education; lower scores on neuropsychological tests assessing working memory, psychomotor speed, and complex scanning; higher diabetes-related interpersonal distress scores; lower adherence to a diabetes medication; and higher hemoglobin A1c levels compared to participants with no ED visits (p ≤ 0.05 for all comparisons).ConclusionsThis study identified multiple risk factors for ED visits in older African Americans with MCI and diabetes. Targeted interventions may be necessary to reduce the need for ED care in high risk populations.     

Emergency department return visits in chronic obstructive pulmonary disease: the importance of psychosocial factors

STUDY OBJECTIVES: Relapses are common after treatment of decompensated chronic obstructive pulmonary disease (COPD) in the emergency department. The purpose of this study was to identify psychosocial and pulmonary function variables that distinguish patients who relapse from those who do not. DESIGN: Retrospective case analysis. A relapse was defined as an unscheduled return to the ED within two weeks of treatment. SETTING: 475-bed Veterans Administration Medical Center. TYPE OF PARTICIPANTS: 33 male veterans with COPD who used the ED. MEASUREMENTS: Demographic profile, a Likert-scaled questionnaire about illness beliefs, and physiologic data obtained by chart review. MAIN RESULTS: Patients who relapsed at least once (R patients) were more likely to be widowed, separated, or divorced than patients who did not relapse at any time (N patients) (52.4% vs 8.3%; P = .011). R patients were more likely to have lost a first-order relative within three years (57.1% vs 8.3% P = .006). Stepwise logistic regression showed that the loss of a first-order relative, a negative attitude about prognosis, and a higher forced vital capacity distinguished R from N patients. Stepwise linear regression showed that six specific illness beliefs, distance of the home from the hospital, and baseline bronchodilator response correlated with the number of relapses (multiple r2 = 0.82; P less than .001). CONCLUSION: Social and psychological parameters are closely correlated with relapse in patients with decompensated COPD.     

Emergency department complaints: a one-year analysis

We conducted an analysis of all complaints received in a busy suburban emergency department during 1985. All complaints were handled in a standardized fashion, and were categorized as billing, physician, nursing, or miscellaneous. Data were expressed as a "complaint frequency" (complaints per 1,000 patient visits). Complaints were analyzed for the following characteristics: reason, gender of the patient, gender of the complaining party, relationship of the complaining party to the patient, health care provider, patient age, and patient disposition. The chi-square method was used to identify characteristics associated with a high risk for complaints. There were a total of 244 complaints, arising from 64,910 patient visits, yielding an overall complaint frequency of 3.8. The largest number of complaints (135), involved billing (frequency, 2.0). The most common (60) was insurance carrier rejection of the bill as a nonemergency. The next most common billing complaint (25) was a charge mistakenly billed too high by the ED. There were 70 complaints regarding emergency physicians, for a complaint frequency of 1.1. Of these, 17 were due to a perceived lack of communication with the patient, the patient's family, or the patient's private physician. Eighteen complaints were regarding a perceived misdiagnosis. One physician had a significantly higher complaint frequency than the group as a whole (P less than .005). There were 17 complaints regarding the nursing staff, for a complaint frequency of 0.2. Twenty-two complaints were classified as miscellaneous. Expressing data as complaint frequencies allows comparison of trends in a department, staff members, and different EDs with varied patient populations.(ABSTRACT TRUNCATED AT 250 WORDS)     

Gastrointestinal function and quality of life after pylorus-preserving pancreatoduodenectomy

The pylorus-preserving pancreatoduodenectomy (PPPD) has taken the place of the conventional Whipple pancreato-duodenectomy as the standard procedure for various periampullary disease. With recent advances in surgical techniques and improvements in perioperative management, the number of long-term survivors after PPPD is increasing. As a result, surgeons should pay more attention to the patients' postoperative gastrointestinal function, nutrition, and quality of life (QOL). Gastric stasis, which is a frequent complication during the early postoperative period after PPPD, prolongs the hospital stay and impairs the QOL in the intermediate term. Several possible pathogeneses for this gastric stasis have been postulated; however, the precise mechanism remains unclear. The gastric emptying function gradually recovers to the preoperative level by 6 months after PPPD. Pancreatic functions are likely to be maintained for at least 1 year after PPPD; however, in some cases, they tend to gradually deteriorate over time after the operation, depending on the type of pancreatic reconstruction or the preoperative condition of the pancreas. It is important to note that preoperative and postoperative pancreatic exocrine function strongly influence the postoperative outcome regarding such factors as pancreatic fistula, body weight maintenance, nutrition, and the QOL. The QOL, as assessed by questionnaire, normally returns to the preoperative level within 6 months after PPPD, and this correlates with the changes in gastrointestinal function and nutritional status. It still remains an unresolved question, however, whether the Billroth-I PPPD really leads to better long-term nutritional status, but worse early gastric emptying function, than the Billroth-II type of reconstruction.     

Emergency department crowding: a point in time

STUDY OBJECTIVE: This is a pilot study designed to assess the feasibility of a point prevalence study to assess the degree of crowding in hospital emergency departments (EDs). In addition, we sought to measure the degree of physical crowding and personnel shortage in our sample. METHODS: A mail survey was sent to a random sample of 250 EDs chosen from a database compiled by the American College of Emergency Physicians of 5,064 EDs in the United States. In addition to demographic information, respondents were asked to count the patients and staff in their EDs at 7 PM local time on Monday, March 12, 2001 (index time). RESULTS: The response rate was 36%. At the index time, there was an average of 1.1 patients per treatment space, and 52% of EDs reported more than 1 patient per treatment space. There was also evidence of personnel shortage, with a mean of 4.2 patients per registered nurse and 49% of EDs having each registered nurse caring for more than 4 patients. There was a mean of 9.7 patients per physician. Sixty-eight percent of EDs had each physician caring for more than 6 patients. There was crowding present in all geographic areas and all hospital types (teaching-nonteaching status of the hospital). Consistent with the crowded conditions, 11% of institutions were on ambulance diversion and not accepting new acute patients. Delays in transfer of admitted patients out of the ED contributed to the physical crowding. Twenty-two percent of patients in the ED were already admitted and were awaiting transfer to an inpatient bed; 73% of EDs were boarding 2 or more inpatients. The amount of crowding quantified by this point prevalence study was confirmed by the amount of crowding reported for the previous week: 48% of EDs were boarding inpatients during the previous week for a mean of 8.9 hours, 4.2 days per week; 31% had been on diversion; 59% had been routinely using their halls for patients; 38% had been doubling their rooms; and 47% had been using nonclinical space for patient care. CONCLUSION: Our low response rate limits this pilot study. Nonetheless, this study, as well as others, demonstrates that EDs throughout the United States are severely crowded. Such crowding raises concerns about the ability of EDs to respond to mass casualty or volume surges.     

Comparison of quality of life after pylorus-preserving pancreatoduodenectomy and Whipple resection

BACKGROUND/AIMS: There have been many supportive data that the postoperative changes in nutritional status are more favorable after pylorus-preserving pancreatoduodenectomy than after Whipple resection; however, few reports are available on the postoperative changes in subjective quality of life after pancreatoduodenectomy. The aim of this study was to compare the postoperative change in quality of life after pylorus-preserving pancreatoduodenectomy and Whipple resection. METHODOLOGY: A total of 36 patients (31 with pylorus-preserving pancreatoduodenectomy and five with Whipple resection) were studied regarding quality of life before and at short term (within two months) and at long term (six months to one year) after surgery, using a questionnaire. The questionnaire consisted of 13 physical and 10 psychosocial items. The medical records were also reviewed to evaluate their objective nutritional status. Postoperative changes in quality of life and nutritional status were compared between the pylorus-preserving pancreatoduodenectomy and Whipple groups. RESULTS: Overall and physical quality of life scores dropped at short term and then recovered at long term in the pylorus-preserving pancreatoduodenectomy group, but showed a persistently low value even at long term in the Whipple group. The change in physical quality of life showed almost parallel changes with the nutritional status in both groups. However, the scores of psychosocial quality of life, which reflected the patient's mental status, remained low even at long term in both pylorus-preserving pancreatoduodenectomy and Whipple groups. CONCLUSIONS: Quality of life is more favorable after pylorus-preserving pancreatoduodenectomy than after Whipple resection, but long-standing mental health care is necessary in patients with pyloruspreserving pancreatoduodenectomy and Whipple resection.     

Hospital costs of complications after a pancreatoduodenectomy

BackgroundA pancreatoduodenectomy (PD) is a highly advanced procedure associated with considerable post-operative complications and substantial costs. In this study the hospital costs associated with complications after PD were assessed.MethodsA retrospective cohort study was conducted on 100 consecutive patients who underwent a pylorus-preserving (PP)PD between January 2012 and July 2013. Per patient, all complications occurring during admission or in the 30-day period after discharge were documented. All hospital costs related to the (PP)PD were defined as the costs of all medical interventions and resources during the hospitalisation period as recorded by the electronic supply tracking system.ResultsThe median hospital costs ranged from €17 482 for a patient without complications to €55 623 for a patient with a post-operative haemorrhage. A post-operative haemorrhage was associated with a 39.6% increase in total hospital costs after adjusting for patient characteristics. Other factors significantly associated with an increase in total hospital costs were: the presence of a malignancy other than a pancreatic adenocarcinoma (29.4% cost increase), the severity grade of a complication (34.3–70.6% increase) and the presence of a post-operative infection (32.4% increase).ConclusionsThis study provides an in-depth analysis of hospital costs and identifies factors that are associated with substantial cost consequences of specific complications occurring after a PD.     

Emergency department throughput: an intervention

Shortening emergency department (ED) boarding time and managing hospital bed capacity by expediting the inpatient discharge process have been challenging for hospitals nationwide. The objective of this study is was to explore the effect of an innovative prospective intervention on hospital workflow, specifically on early inpatient discharges and the ED boarding time. The intervention consisted of a structured nursing “admission discharge transfer” (ADT) protocol receiving new admissions from the ED and helping out floor nursing with early discharges. ADT intervention was implemented in a 38-bed hospitalist run inpatient unit at an academic hospital. The study population consisted of 4486 patients (including inpatient and observation admissions) who were hospitalized to the medicine unit from March 2013–March 2014. Of these hospitalizations, 2259 patients received the ADT intervention. Patients’ demographics, discharge and ED boarding data were collected for from March 4, 2013 to March 31, 2014 for both intervention and control groups (28 weeks each). Chi-square and unpaired t tests were utilized to compare population characteristics. Poisson regression analysis was conducted to estimate the association between intervention and hospital length of stay adjusted for differences in patient demographics. Mean age of the study population was 58.6 years, 23% were African Americans and 55% were women. A significant reduction in ED boarding time (p < 0.001) and improvement in early (before 2 PM) hospital discharges (p = 0.01) were noticed among patients in the intervention groups. There was a slight but significant reduction in hospital length of stay for observation patients in the intervention group; however, no such difference was noted for inpatient admissions. Our study showed that dedicating nursing resources towards ED-boarded patients and early inpatient discharges can significantly improve hospital workflow and reduce hospital length of stay.     

Hospitalization and emergency department visits among seniors receiving homecare: a pilot study

Background

The objective of this study was to examine the Minimum Data Set (MDS) and Geriatric Depression Scale (GDS) as measures of depression among nursing home residents.

Methods

The data for this study were baseline, pre-intervention assessment data from a research study involving nine nursing homes and 704 residents in Massachusetts. Trained research nurses assessed residents using the MDS and the GDS 15-item version. Demographic, psychiatric, and cognitive data were obtained using the MDS. Level of depression was operationalized as: (1) a sum of the MDS Depression items; (2) the MDS Depression Rating Scale; (3) the 15-item GDS; and (4) the five-item GDS. We compared missing data, floor effects, means, internal consistency reliability, scale score correlation, and ability to identify residents with conspicuous depression (chart diagnosis or use of antidepressant) across cognitive impairment strata.

Results

The GDS and MDS Depression scales were uncorrelated. Nevertheless, both MDS and GDS measures demonstrated adequate internal consistency reliability. The MDS suggested greater depression among those with cognitive impairment, whereas the GDS suggested a more severe depression among those with better cognitive functioning. The GDS was limited by missing data; the DRS by a larger floor effect. The DRS was more strongly correlated with conspicuous depression, but only among those with cognitive impairment.

Conclusions

The MDS Depression items and GDS identify different elements of depression. This may be due to differences in the manifest symptom content and/or the self-report nature of the GDS versus the observer-rated MDS. Our findings suggest that the GDS and the MDS are not interchangeable measures of depression.