Emergency department diagnosis of pulmonary embolism is associated with significantly reduced mortality: A linked data population study

Objectives: We characterized patients admitted via ED with a principal hospital discharge diagnosis of pulmonary embolism (PE) and compared mortality of those diagnosed in the ED with those diagnosed after admission. Methods: Patients with a hospital discharge diagnosis ICD 10 I26 presenting to the ED in Perth, Western Australia between 1 July 2000 and 30 December 2006 had records from the Emergency Department Information System linked to the Western Australian Hospital Morbidity Data System and the death registry. Results: Of 2250 patients (mean age 60.4), 1227 (54.5%) were female. Of 1931 patients with an ED diagnosis recorded, 1207 (62.5%) were diagnosed with PE in ED. Of these, 383 (17.0%) had presented to an ED within 28 days previously, 142 (37.1%) with either chest pain or breathing problems, with 207 (54.0%) admitted but not receiving a principal hospital discharge diagnosis of PE. There were 127 (5.6%) in‐hospital deaths. Controlling for age and comorbidity with logistic regression, patients diagnosed with PE in ED were less likely to die in hospital, within 7 and 30 days of ED arrival, than those diagnosed after admission (adjusted OR 0.31, 95% CI 0.20–0.47; adjusted OR 0.32, 95% CI 0.19–0.53; adjusted OR 0.30, 95% CI 0.20–0.44; respectively). Conclusion: Making the diagnosis of PE in ED was associated with a substantial survival advantage that persisted after hospital discharge.     

Emergency department workload — A transatlantic comparison

This paper compares the workload of the emergency department of a Level One trauma center in the United States and a large city hospital in the United Kingdom. The referral pattern and diagnostic classification of 5,000 patients presenting to both departments were compared, as were the transportation systems at the two sites. It was shown that similarities existed in many areas. Major trauma formed only a small proportion of the overall workload of both departments. The conclusion is that althofugh the two emergency care systems have fundamental differences in terms of organization and finance, the workloads are remarkably similar. Interesting differences arose in areas such as use of helicopter transport, psychiatric and drug and alcohol related admissions, and in the number of patients brought to hospital under police escort.     

Emergency care workload units: A novel tool to compare emergency department activity

Introduction: Funding bodies have traditionally used attendance figures as a way of determining the allocation of funding for resources in the EDs. Using attendance figures only might not accurately reflect the funding and resources required. The need to create an easily implemented tool to compare workload and resources required was identified. Using the Australasian Triage Scale, a tool was developed to estimate staffing requirements and resource use within each ED. This, although currently not validated, provides a promising start in finding a way to accurately determine ED workload. Methods: Existing data on patient acuity, disposition, numbers of patients and the individual costing of each presentation was used to estimate and define the workload of an ED in emergency care workload units (ECWU). The tool is applied to six de‐identified hospitals within Queensland to demonstrate its potential use for equitable budget and staffing allocation. Results: The tool was applied to a selection of de‐identified EDs within Queensland hospitals. An increased number of ECWU is generated for a patient with a more urgent triage category reflecting a higher resource consumption and workload. Discussion: Although a few studies have been completed in Canada linking workload, resource consumption and cost to triage category, this tool will need to be validated before its use can be fully appreciated. Conclusion: This tool provides a simple method to calculate equitable distribution of staffing and budget allocation based on workload across the different EDs within Australia.     

Emergency department census of patients awaiting admission following reorganisation of an admissions process

Objectives

To determine the impact of reorganisation of an acute admissions process on numbers of people in the emergency department (ED) awaiting admission to a hospital bed in a major teaching hospital.

Methods

We studied all emergency medical patients admitted to St James'' Hospital, Dublin, between 1 January 2002 and 31 December 2004. In 2002, patients were admitted to a variety of wards from the ED when a hospital bed became available. In 2003, two centrally located wards were reconfigured to function as an acute medical admissions unit (AMAU) (bed capacity 59), and all emergency patients were admitted directly to this unit from the ED (average 15 admissions per day). The maximum permitted length of stay on the AMAU was 5 days. We recorded the number of patients in the ED, who were awaiting the availability of a hospital bed, at 0700 and 1700 on the days of recording during the 36 month study period.

Results

The impact of the AMAU reduced overall hospital length of stay from 7 days in 2002 to 5 days in 2003 and 2004 (p<0.0001). The median number of patients waiting in the ED for a hospital bed reduced from 14 in 2002 to 9 in 2003 and 8 in 2004 (p<0.0001). While age and sex of patients did not differ over the years, the factors that independently contributed to the number of patients awaiting admission were the day of the week, the month of the year, and and the extent of the comorbidity index on the previous day''s intake (p<0.0001).

Conclusions

This study found that reorganisation of a system for acute medical admissions can significantly impact on the number of patients awaiting admission to a hospital bed, and allow an ED to operate efficiently and at a level of risk acceptable to patients.     

Emergency department staff and susceptibility to pertussis: A seroprevalence study

Objective: To determine the proportion of ED staff who are susceptible to pertussis. There was evidence that some winter leave in southern Tasmania might be a reason of pertussis infection among unimmunized staff. This results in loss of individual earning and loss of availability of staff during the peak demand periods in the ED. There is evidence in the literature that underdiagnosis and undertreatment of pertussis occurs worldwide. Methods: All ED staff were approached to participate in this seroprevalence study. A self‐completed questionnaire was used to record pervious immunization history for pertussis. Blood samples were collected and analysed to detect and quantify immunoglobulin G and immunoglobulin A titres for pertussis. All confidence intervals (CI) are at 95%. Settings: The Royal Hobart Hospital and the co‐located Hobart Private Hospital. Results: Ninety‐seven of 106 eligible staff took part in the present study, a participation rate of 92% (CI 84–96). Ninety‐one of 97 subjects (94%, CI 87–98) believed that they had been immunized for pertussis in childhood; six subjects had either not been immunized or were unsure (6%, CI 2–13). Twenty‐three subjects (24%, CI 16–33) had been immunized as adults. There was serologic evidence of recent infection for 21 participants (22%, CI 14–31). Thirty‐one participants (32%, CI 23–42) were susceptible to pertussis on the basis of low immunoglobulin G titres. Conclusion: ED staff should routinely be offered booster immunization for pertussis.     

Emergency department visits involving opioids in Connecticut, 2011–2015

Background: Opioid abuse has demonstrated an unwavering elevation in the past decade. This study examined emergency department (ED) utilization for this growing public health problem in the state of Connecticut.

Methods: We evaluated the ED discharges involving opioids in individuals treated in Connecticut EDs from 2011 to 2015. International Classification of Disease, 9th Revision, Clinical Modification and external cause of injury codes were used to identify cases.

Results: There were 38,003 ED visits involving opioids during the study period. Visits were most prevalent in males (63.4%) and in those aged 18–44 years (71.8%). The rate of visits (per 10,000 ED visits) in whites (72.7) was more than three times that of blacks (24.7) and nearly double that of individuals of Hispanic ethnicity (37.7). The rate of visits for females under the age of 18 was slightly greater than that for males in the same age groups (2.7 vs. 2.4/10,000 ED visits, respectively).

Conclusion: Manual labor work and racial stereotyping are possible causal factors for higher rates of opioid-related ED visits among white males between the ages of 18 and 44, while higher levels of emotional distress may be contributing to similar rates among females under the age of 18 and over the age of 65.     

Emergency department design and patient perceptions of privacy and confidentiality

The study objective was to determine if Emergency Department (ED) patients experience fewer breaches of privacy and confidentiality in a larger, renovated ED compared to a similar patient population before renovation. We surveyed a convenience sample of patients regarding their privacy and confidentiality at the conclusion of their ED stay. In the post-renovation ED, 14% of patients overheard conversations about themselves or other patients, compared to 36% of patients in the ED before renovation. This was likely a result of both an increase in the department size (564 square feet per treatment space post-renovation vs. 375 square feet per treatment space pre-renovation) and the elimination of rooms separated only by curtains. Issues of privacy and confidentiality should be taken into consideration in the design of new departments and those to be renovated.     

The utility of clinical features in patients presenting with nontraumatic headache: an investigation of adult patients attending an emergency department

OBJECTIVE: When patients present to an emergency department because of nontraumatic headache, they often present a diagnostic challenge. This study aimed to examine the utility of clinical features in detecting serious underlying causes of nontraumatic headache in adult patients presenting to an emergency department. METHODS: A prospective observational study of alert adult patients presenting to 1 UK emergency department over a period of 14 months was conducted. Patients were excluded if their headache was related to trauma or they had been previously recruited into the study. A standardized data collection form was used to record details of the history and examination findings. Investigation and management were conducted according to the existing departmental protocols. Patients were followed up for 3 months following their initial presentation. Each factor in the history and examination was examined for its ability to predict a serious underlying cause of headache. RESULTS: Five hundred and eighty-nine patients were included in the study with complete follow-up details obtained on 558 (94.7%) patients. Seventy-five (13.4%) patients were found to have a serious pathological cause of their headache. Four features were found to be significant independent predictors of serious pathology, these were age >50 years (likelihood ratio (LR) = 2.34), sudden onset, (LR = 1.74), any abnormality on neurological examination (LR = 3.56), and presentation due to associated features (LR = 2.27). Taken in combination, the presence of any 1 of the first 3 features has a sensitivity of 98.6% and specificity of 34.4% (Positive LR = 1.50, Negative LR = 0.04). CONCLUSION: Three features, age greater than 50, sudden onset, and an abnormal neurological examination, are identified as significant independent predictors of serious pathology, which, in combination, can exclude the presence of such pathology in adult patients presenting with nontraumatic headache.     

National Emergency Department Overcrowding Study tool is not useful in an Australian emergency department

Objective: To determine the accuracy and usefulness of the National Emergency Department Overcrowding Study (NEDOCS) tool in an urban hospital ED in Australia by direct comparison with subjective assessment by senior ED staff. Method: A sample of simultaneous subjective and objective data pairs were collected six times a day for a period of 3 weeks. All senior medical staff in the ED answered a brief questionnaire along with the senior charge nurse for the ED. Simultaneously, the senior charge nurse also documented the total number of patients in the ED, the number of patients awaiting admission, the number of patients on ventilators, the longest time waited by an ED patient for ward bed, and the waiting time for the last patient from the Waiting Room placed on a trolley. The objective indicators were entered into a Web‐based NEDOCS tool and transformed scores were compared with the averaged and transformed subjective scores for each sample time. Bland–Altmann and Kappa statistics were used to test the agreement between the objective and subjective measuring methods. Results: The mean difference between the subjective and objective methods was small (3.5 [95% confidence interval ?0.875–7.878] ); however, the 95% limits of agreement was wide (?46.52–53.43). The Kappa statistic used to assess the extent of reproducibility between categorical variables was 0.31 (95% confidence interval 0.17–0.45). Conclusion: The present study suggests that NEDOCS method of processing the objective overcrowding data does not accurately reflect the subjective assessment of the senior staff working at that time in the ED. This might be because the assumptions of the original NEDOCS study are flawed.     

Emergency department from the mental health client's perspective

ABSTRACT:  General hospital emergency departments (EDs) are obvious places for individuals in psychiatric distress or a mental health crisis to seek assistance. However, the typical mental health presentation does not fit with the treatment norm of most EDs creating a tension around the care of individuals with mental illnesses. Eight focus groups were held with mental health patients and their families to determine their satisfaction with care received in regional EDs with particular emphasis on their evaluation of the role of the psychiatric emergency nurse. Themes identified were: waiting in the ED, attitudes of treatment staff, diagnostic overshadowing, 'no where else to go', family needs, and a wish list for ideal services. These issues are described in this paper along with clinical and systemic implications.     

Ultrasonography in patients without trauma in the emergency department: impact on discharge diagnosis.

OBJECTIVE: The aim of this study was to examine to what extent findings on ultrasonography performed in the emergency department (ED) after hours confirm or alter the referral diagnosis in patients without trauma as reflected in the discharge diagnosis. METHODS: In this prospective study, data from 136 ultrasonographic examinations performed in patients without trauma after hours in the ED during January and February 2002 were evaluated against the suspected preimaging diagnosis of the referring ED physician and the actual discharge diagnosis from the ED or after hospitalization. The rate of preimaging and postimaging concordance was statistically analyzed and compared by calculation of confidence intervals and by the McNemar test. RESULTS: Normal ultrasonographic findings were documented in 54 patients (40%), and pathologic findings were documented in 82 (60%). Thirty-four (25%) of the 136 examinations were concordant with the initial referring physician's diagnosis. Of the 102 studies that were not concordant with the initial referral suspected diagnoses, that is, being either a study with normal findings or offering an alternative diagnosis, 81 (79.4%) were concordant with the discharge diagnosis. CONCLUSIONS: After-hours ultrasonographic findings in patients without trauma seen in the ED seem to have a high impact on the discharge diagnosis and are concordant with it in more than 80% of cases.     

A possible role of ID-Migraine™ in the emergency department: study of an emergency department out-patient population

Headache symptoms account for 1–3% of admissions to an emergency department (ED). Most patients affected by a primary headache (PH) have migraine, although they are often misdiagnosed as 'headache not otherwise specified'. We investigated the possibility of using ID-Migraine (ID-M) to improve migraine recognition in the ED setting. We planned a pilot study involving ED out-patients with a diagnosis of PH. Diagnoses of a blinded headache expert were subsequently matched with the ID-M results. We tested ID-M on 230 patients (199 PH, 31 secondary headaches). Considering only PH, ID-M exhibited a sensitivity of 0.94 and specificity of 0.83 with a positive predictive value (PPV) of 0.99. The ID-M is a simple migraine screener with high sensitivity, high specificity and high PPV, even in an ED-derived population. Methodical use of this tool in an ED setting may, once a secondary headache has been excluded, lead to rapid diagnosis of migraine.     

Emergency department focused bedside echocardiography in massive pulmonary embolism

Background

Massive pulmonary embolism (PE) is a common consideration in unstable patients presenting to the emergency department (ED) with chest pain, dyspnea, or cardiac arrest. It is a potentially lethal condition necessitating prompt recognition and aggressive management. Conventional diagnostic modalities in the ED, including chest computed tomography angiography and ventilation-perfusion scanning, require the unstable patient to leave the department, and raise concerns over renal injury. Several case reports document findings of massive PE on echocardiography performed in the ED; however, none was performed, interpreted, and acted upon in the form of thrombolytic therapy by an emergency physician without the additional benefit of a cardiologist’s interpretation or a confirmatory imaging study.

Objective

We present a case that illustrates the utility of ED focused bedside echocardiography in suspected massive PE and briefly review direct and indirect ultrasound findings of acute PE.

Case Report

A case of massive PE in a 61-year-old woman is reported. In this patient with marked dyspnea, progressive hemodynamic instability, and contraindications to definitive imaging, ED focused bedside echocardiography provided valuable information that strongly suggested the diagnosis and led to alteplase administration. To our knowledge, this case represents the first report of thrombolytic therapy administration for acute massive PE based solely on clinical presentation and an emergency physician-performed bedside echocardiogram.

Conclusion

In the hands of an experienced emergency physician ultrasonographer, ED focused bedside echocardiography provides a safe, rapid, and non-invasive diagnostic adjunct for evaluation of the patient suspected of having massive PE.     

Nontraumatic Headaches in the Emergency Department: Evaluation of a Clinical Pathway

Objective.— To determine the impact and efficacy of a clinical pathway in the management of patients with nontraumatic and afebrile headache (NTAH) in the emergency department (ED). Background.— Nontraumatic and afebrile headache is one of the most common neurological symptoms in the ED. However, data about the application of an evidence‐based operative protocol are lacking. Methods.— A before–after intervention study comparing adult patients presenting to the ED with atraumatic headache was conducted during a 6‐month period from April to September 2005 and with the same type of patients in the same period in 2006 after a clinical pathway had been implemented. According to their clinical presentations, patients of the 2006 group were divided into 3 subgroups and managed following the established protocol. Study results were based on analysis of 6 months of clinical outcome, the number of CT head scans in the ED, number of neurological consultations in the ED, number of admissions, and length of stay in the ED. Results.— A total of 686 patients were enrolled in the study, of which 374 were those presenting to our ED with NTAH in 2006 and managed with the aid of the study protocol; the other 312 patients were those who presented in 2005, before the intervention. The study protocol was strictly applied to 247 patients (66%) of the 2006 group. There were fewer neurological consultations after the intervention (41.2% vs 52.5%, difference: ?11.3%, 95% confidence intervals [CI]: ?18.7% to ?3.9%; P = .003); likewise, admissions were significantly reduced after the intervention (9.0% vs 14.7%, difference: ?5.7%, 95% CI: ?10.6% to ?0.8%; P = .02). No significant differences were found between the 2 groups for number of CT head scans (42.2% vs 38.4%, difference: 3.7%, 95% CI: ?3.5% to 11%; P = .3). Mean length of stay in the ED was lower after the intervention, though not significantly (170.6 ± 102 minutes vs 180.5 ± 105 minutes, difference: ?9.8 minutes, 95% CI: ?20.3 to 5.7; P = .09). A 6‐month follow‐up was completed involving 302 (96.7%) patients in the first group and 370 (98.9%) in the second group. There was only one misdiagnosis after the intervention while 2 incorrect diagnoses were made before the intervention (0.27% vs 0.6%, difference: ?0.33%, 95% CI: ?2.1% to 0.9%; P = .5). Conclusions.— Our diagnostic protocol for NTAH appears to be safe and sensitive in diagnosing malignant headaches. In addition, it may improve use of resources by reducing the need for neurological consultations and admissions without increasing the number of CT scans or prolonging length of stay in the ED. Furthermore, when using the protocol ED physicians seem more confident in their evaluations of headache resulting in fewer requests for specialist input.