ED visit volume and quality of care in acute exacerbations of chronic obstructive pulmonary disease

Objective

The purpose of this study is to determine whether emergency department (ED) visit volume is associated with ED quality of care in patients with acute exacerbations of chronic obstructive pulmonary disease (COPD).

Methods

We performed a prospective multicenter cohort study involving 29 EDs in the United States and Canada. Using a standard protocol, we interviewed consecutive ED patients with COPD exacerbation, reviewed their charts, and completed a 2-week telephone follow-up. The associations between ED visit volume and quality of care (process and outcome measures) were examined at both the ED and patient levels.

Results

After adjustment for patient mix in the multivariable analyses, chest radiography was less frequent among patients with COPD exacerbations in the low-volume (odds ratio [OR], 0.2; 95% confidence interval [CI], 0.1-0.4) and high-volume EDs (OR, 0.1; 95% CI, 0.05-0.5), with medium-volume EDs as the reference. Arterial blood gas testing was less frequent in the low-volume EDs (OR, 0.1; 95% CI, 0.02-0.8). Medication use was similar across volume tertiles. With respect to outcome measures, patients in high-volume EDs were more likely to be discharged (OR, 4.2; 95% CI, 2.2-7.7) and to report ongoing exacerbation at a 2-week follow-up (OR, 1.9; 95% CI, 1.02-3.5).

Conclusions

Traditional positive volume-quality relationships did not apply to emergency care of COPD exacerbation. High-volume EDs used less guideline-recommended diagnostic procedures, had a higher admission threshold, and had a worse short-term patient-centered outcome.     

Predictors of acute decompensation after admission in ED patients with sepsis

Purposes

The aim of the study was to identify predictors of acute decompensation within 48 hours of admission among infected emergency department (ED) patients admitted to a regular nursing floor.

Procedures

This used a case control study of infected ED patients admitted to a regular nursing floor and who received a discharge diagnosis of sepsis. A multivariate logistic regression model was constructed with the dependent variable as transfer to an intensive care unit (ICU) within 48 hours of admission.

Findings

Seventy-eight patients were enrolled—34 in the ICU group and 44 in the floor group. Only low bicarbonate (<20 mmol/L) (odds ratio [OR], 7.40; 95% confidence interval [CI], 2.35-23.30) and absence of fever (OR, 3.66; 95% CI, 1.11-12.60) were predictive of ICU transfer.

Conclusions

Among infected ED patients admitted to a regular floor, absence of fever and low bicarbonate were independently associated with ICU transfer within 48 hours. Particular attention should be paid to similar patients to ensure appropriate identification of severe infection and appropriate risk stratification.     

The Weekend Effect for Patients with Sepsis Presenting to the Emergency Department

Background

Mortality differences in weekend and weekday admissions have been observed for a variety of conditions that require aggressive early intervention. It is unknown if there is a mortality difference that exists for patients presenting to the Emergency Department (ED) with sepsis on the weekend.

Study Objectives

We hypothesized that there is an increase in early inpatient mortality (death on day 1 or day 2 of hospitalization) among patients with sepsis who present to the ED on the weekend vs. weekdays.

Methods

We performed a cross-sectional analysis of 114,611 ED admissions with a principal diagnosis consistent with sepsis from 576 hospitals in the 2008 Nationwide Inpatient Sample. Adjusted analyses controlled for patient and hospital characteristics, and examined the likelihood of either early (day 1 or day 2 of hospitalization) or overall inpatient mortality.

Results

A greater proportion of patients admitted on the weekend died on day 1 and day 2 of hospitalization (5.4% vs. 4.0%, p < 0.001; and 7.5% vs. 6.9%, p = 0.001), the difference for overall inpatient mortality was not significant (17.9% vs. 17.5%, p = 0.08). The risk-adjusted odds ratio (OR) of day 1 and day 2 early inpatient mortality of weekend vs. weekday admissions was 1.10 (95% confidence interval [CI] 1.04–1.17) and 1.08 (95% CI 1.03–1.14), respectively; the association with overall inpatient mortality was not significant (OR 1.03, 95% CI 1.00–1.07).

Conclusions

Patients admitted through the ED with sepsis on the weekend had a greater likelihood of early mortality, but not overall mortality, when compared to patients admitted on weekdays.     

Risk factors and prognostic predictors of unexpected intensive care unit admission within 3 days after ED discharge

Objective

Our objective was to investigate the risk factors and prognostic predictors of unexpected intensive care unit (ICU) admission within 3 days after emergency department (ED) discharge.

Methods

From January 1, 2001, through December 31, 2005, patients admitted to the ICU unexpectedly within 3 days after being discharged from the ED were enrolled. Medical records of these patients were retrospectively reviewed. We categorized each patient's characteristics into dichotomous groups and used the χ² test to identify risk factors for unexpected ICU admission within 3 days after ED discharge. A multiple logistic regression was applied to examine possible independent predictors of poor prognoses.

Results

During the study period, 365 321 patients visited our ED; 241(0.07%) were unexpectedly admitted to the ICU within 3 days after being discharged from the ED. Mean patient age was 74.2 ± 16.4 years. The rate of ICU admissions caused by medical error was 0.019% ± 0.004% of all visits and 29.0% ± 5.7% of all unexpected ICU admissions. The overall mortality rate was 19.9% (48/241). Risk factors for unexpected ICU admission within 3 days after discharge from the ED were age of 65 years or older (odds ratio [OR], 5.4; 95% confidence interval [CI], 4.0-7.4), ambulance transport (OR, 5.1; 95% CI, 3.9-6.5), no accompanying family (OR, 3.5; 95% CI, 2.7-4.5), nonambulatory status (OR, 4.2; 95% CI, 2.9-5.0), not living at home (OR, 2.5; 95% CI, 1.9-3.3), Medicaid insurance (OR, 3.6; 95% CI, 2.8-4.7), and emergency stay of more than 24 hours (OR, 4.4; 95% CI, 3.4-5.7). The independent predictors of mortality were age of 65 years or older (OR, 2.4; 95% CI, 1.7-3.6), multiple comorbidities (OR, 4.0; 95% CI, 1.8-8.5), medical error leading to ICU admission (OR, 3.9; 95% CI, 1.8-8.3), and Acute Physiology and Chronic Health Evaluation II score of 20 or higher (OR, 2.9; 95% CI, 1.1-7.8).

Conclusions

In our study, the risk factors and prognostic predictors of unexpected ICU admission within 3 days after ED discharge were identified. Based on these risk and prognostic prediction factors, further strategies for decreasing the incidence of serious adverse events of ED-discharged patients can be implemented.     

Gender differences in emergency stroke care and hospital outcome in acute ischemic stroke: a multicenter observational study

Background

We aimed to investigate the effect of gender difference on the accessibility to emergency care, hospital mortality and disability in acute stroke care.

Methods

This study was performed on a single-tiered basic emergency medical service with a comprehensive national health insurance. Demographic variables, risk factors, elapsed time intervals, performing diagnosis and treatment options, hospital mortality, and modified Rankin Scale of acute ischemic stroke during 2008 were collected. We modeled the multivariate regression analysis for gender differences on the accessibility, hospital mortality, and disability. The adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were calculated adjusting for potential risk factors.

Results

The total number of patients was 6635. The time from symptom onset to emergency department (ED) arrival and to computed tomography or magnetic resonance imaging scan and from ED arrival to computed tomography or magnetic resonance imaging scan was significantly longer in women. No significant difference was found in either the time to intravenous thrombolysis or in the number of patients who received intravenous thrombolysis, anti-platelet therapy, anti-coagulation, or operation. The hospital mortality rate was higher in women (3.9%) than in men (2.9%) (P = .03). The increased disability was significantly higher in women (67.8%) than in men (65.1%) (P = .02). The hospital mortality and increased disability showed a non-significant difference between the 2 genders in the adjusted model (OR, 1.10; 95% CI, 0.74-1.64) and (OR, 1.11; 95% CI, 0.96-1.28), respectively.

Conclusion

The adjusted model for risk factors showed no significant difference on hospital mortality and disability between the 2 genders for stroke patients.     

The effect of prolonged ED stay on outcome in patients with necrotizing fasciitis

Objective

Overcrowding in hospitals, especially in EDs, is a serious problem in the United States, Europe, and Taiwan. However, the association between prolonged ED boarding stay and mortality in patients with necrotizing fasciitis remains underinvestigated.

Methods

This was a retrospective study. A total of 195 patients were enrolled and analyzed.The sample was divided into 2 groups: nonmortality and mortality. A stepwise logistic regression model was developed to investigate 3 factors of clinical relevance predicting patient mortality.

Result

The results of the stepwise logistic regression analysis revealed that hypotension (odds ratio [OR], 32.9; 95% confidence interval [CI], 6.9-156.0) and prolonged ED boarding stay (OR, 3.4; 95% CI 1.3-8.6) were both associated with higher mortality. Early operation (OR: 0.16; 95% CI: 0.06 – 0.45) was associated with lower mortality.

Conclusion

Prolonged ED boarding stay was associated with increased mortality in patients with necrotizing fasciitis. Early operation (within 24 hours of ED arrival) was associated with decreased mortality.     

Effect of Delay in Hospital Presentation on Clinical and Imaging Findings in Acute Pulmonary Thromboembolism

Background

There is limited information on the extent and clinical importance of the delay in hospital presentation of acute pulmonary thromboembolism (PTE).

Objective

The aim of this study was to investigate the delay in hospital presentation of PTE and its association with clinical and imaging findings in PTE.

Methods

This prospective study was conducted on patients admitted to our hospital with a diagnosis of acute PTE between September 2007 and September 2011. Relationships between delay in hospital presentation and clinical findings, risk factors, imaging findings, and in-hospital mortality were analyzed.

Results

Of the 195 patients enrolled, 84 (43.1%) patients presented 3 days after the onset of symptoms. Patients with chest pain, history of immobility for more than 3 days, recent surgery, and estrogen use had significantly less delayed presentation. Right ventricular dysfunction was significantly more frequent in patients with delayed presentation (odds ratio [OR] = 2.38; 95% confidence interval [CI] 1.27−4.44; p = 0.006); however, no relationship was found between delay in presentation and pulmonary computed tomographic angiography or color Doppler sonography findings. Patients with delayed presentation were at higher risk of in-hospital mortality (OR = 4.32; 95% CI 1.12−16.49; p = 0.021).

Conclusions

Our study showed that a significant portion of patients with acute PTE had delayed presentation. Also, patients with delayed presentation had worse echocardiographic findings and higher in-hospital mortality.     

Volume of fluids administered during resuscitation for severe sepsis and septic shock and the development of the acute respiratory distress syndrome

Purpose

The purpose of this study was to examine the association between the volume of intravenous (IV) fluids administered in the resuscitative phase of severe sepsis and septic shock and the development of the acute respiratory distress syndrome (ARDS).

Materials and methods

This was a retrospective cohort study of adult patients admitted with severe sepsis and septic shock at a large academic public hospital. The relationship between the volume of IV fluids administered and the development of ARDS was examined using multivariable logistic regression analysis.

Results

Among 296 patients hospitalized for severe sepsis and septic shock, 75 (25.3%) developed ARDS. After controlling for confounding variables, there was no significant association between the volume of IV fluids administered in the first 24 hours of hospitalization and the development of ARDS (odds ratio [OR], 1.05; 95% confidence interval [CI], 0.95-1.18). Serum albumin (OR, 0.52; 95% CI, 0.31-0.87) and Acute Physiology and Chronic Health Evaluation II score (OR, 1.08; 95% CI, 1.04-1.13) on admission were the most informative covariates for the development of ARDS in the regression model.

Conclusions

For patients hospitalized for severe sepsis and septic shock, fluid administration to improve end-organ perfusion should remain the top priority in early resuscitation despite the potential risk of inducing ARDS.     

The Prevalence of Quality Issues and Adverse Outcomes among 72-Hour Return Admissions in the Emergency Department

Background

Records of patients discharged from the Emergency Department (ED) who return within 72 h and are admitted are often reviewed for potential quality issues.

Objectives

We explored 72-h return admissions and determined the prevalence and predictors for substandard management on the initial visit or any adverse outcome.

Methods

Retrospective review of quality assurance data from 72-h return admissions in three hospitals from 2006–2010 was performed. Any substandard quality on the first visit or change in outcome on the return admission was considered “low quality.” Multivariate logistic regression was used to assess the relationship between cases judged as low quality vs. not low quality.

Results

Of 741,132 ED visits across 5 years, 3682 (0.5%) were 72-h return admissions. Of those, 192 (5%) were low quality. In 158 (4%) and 8 (0.2%) there were moderate and severe deviations from care standards, respectively. Similarly, in 53 (1%) and 14 (0.4%) there were moderate and severe changes in outcome. In adjusted analysis, there were higher rates of low-quality 72-h return admissions in ambulance arrivals (odds ratio [OR] 1.5, 95% confidence interval (CI) 1.1–2.1); and lower rates in Medicaid patients (OR 0.3, 95% CI 0.2–0.7). There were higher rates in low-quality 72-h return admissions in hospital 1 (OR 3.6, 95% CI 2.2–6.1) and hospital 3 (OR 3.2, 95% CI 2.0–4.7) compared to hospital 2.

Conclusions

Poor care on the initial visit or any poor outcome upon returning in 72-h return admissions is relatively rare in the ED. Reporting 72-h return admissions without chart review may not be a good way to measure clinical quality.     

Lower mortality in sepsis patients admitted through the ED vs direct admission

Purpose

Early aggressive resuscitation in patients with severe sepsis decreases mortality but requires extensive time and resources. This study analyzes if patients with sepsis admitted through the emergency department (ED) have lower inpatient mortality than do patients admitted directly to the hospital.

Procedures

We performed a cross-sectional analysis of hospitalizations with a principal diagnosis of sepsis in institutions with an annual minimum of 25 ED and 25 direct admissions for sepsis, using data from the 2008 Nationwide Inpatient Sample. Analyses were controlled for patient and hospital characteristics and examined the likelihood of either early (2-day postadmission) or overall inpatient mortality.

Findings

Of 98?896 hospitalizations with a principal diagnosis of sepsis, from 290 hospitals, 80,301 were admitted through the ED and 18?595 directly to the hospital. Overall sepsis inpatient mortality was 17.1% for ED admissions and 19.7% for direct admissions (P < .001). Overall early sepsis mortality was 6.9%: 6.8% for ED admissions and 7.4% for direct admissions (P = .005). Emergency department patients had a greater proportion of comorbid conditions, were more likely to have Medicaid or be uninsured (12.5% vs 8.4%; P < .001), and were more likely to be admitted to urban, large bed-size, or teaching hospitals (P < .001). The risk-adjusted odds ratio for overall mortality for ED admissions was 0.83 (95% confidence interval, 0.80-0.87) and 0.92 for early mortality (95% confidence interval, 0.86-0.98), as compared with direct admissions to the hospital.

Conclusion

Admission for sepsis through the ED was associated with lower early and overall inpatient mortality in this large national sample.     

The association between hospital type and mortality among critically ill children in US EDs

Study aim

Little is known about the setting of care for critically ill children and whether differences in outcomes are related to the presenting hospital type. This study describes the characteristics of hospitals to which critically ill children present and explores the associations between hospital factors and mortality.

Methods

This is a retrospective cohort study using data from the 2007 Healthcare Cost and Utilization Project National Emergency Department Sample, representative of all US ED visits. Subjects include children aged 0–18 with ICD9 codes for cardiac arrest, respiratory arrest and/or respiratory failure. Predictor variables include: age, sex, presence of chronic illness, self-pay, public insurance, trauma diagnosis, major trauma center, urban hospital, ED volume and teaching hospital. Multivariate logistic regression estimates predictors of mortality. Analyses integrate clusters, strata, and weights from the probability sample.

Results

There were an estimated 29 million pediatric ED visits in 2007 including 42,036 (0.1%) visits for cardiac or respiratory failure. Teaching hospitals (OR 0.57, 95% CI 0.50–0.66), trauma centers (OR 0.76, 95% CI 0.67–0.86), and urban hospitals (OR 0.78, 95% CI 0.63–0.97) were associated with lower mortality odds. Presence of a chronic illness (OR 14.5, 95% CI 10.5–20.1), diagnosis of an injury (OR 1.2, 95% CI 1.1–1.4) and self-pay status (OR 3.6, 95% CI 2.9–4.4) were associated with increased mortality odds.

Conclusions

The majority of children with cardiac and respiratory arrest present to urban teaching hospitals and trauma centers. After accounting for important confounders, mortality is lower at teaching hospitals and/or major trauma centers.     

Clinical predictors for testicular torsion as seen in the pediatric ED

Objective

The aim of the study was to identify clinical findings associated with increased likelihood of testicular torsion (TT) in children.

Design

This study used a retrospective case series of children with acute scrotum presenting to a pediatric emergency department (ED).

Results

Five hundred twenty-three ED visits were analyzed. Mean patient age was 10 years 9 months. Seventeen (3.25%) patients had TT. Pain duration of less than 24 hours (odds ratio [OR], 6.66; 95% confidence interval [CI], 1.54-33.33), nausea and/or vomiting (OR, 8.87; 95% CI, 2.6-30.1), abnormal cremasteric reflex (OR, 27.77; 95% CI, 7.5-100), abdominal pain (OR, 3.19; 95% CI, 1.15-8.89), and high position of the testis (OR, 58.8; 95% CI, 19.2-166.6) were associated with increased likelihood of torsion.

Conclusions

Testicular torsion is uncommon among pediatric patients presenting to the ED with acute scrotum. Pain duration of less than 24 hours, nausea or vomiting, high position of the testicle, and abnormal cremasteric reflex are associated with higher likelihood of torsion.     

Patient anxiety may influence the efficacy of ED pain management

Objective

The aim of this study was to evaluate the incidence of anxiety and rates of anxiety treatment in emergency department (ED) patients presenting with pain-related complaints.

Methods

We prospectively evaluated patients in an urban academic tertiary care hospital ED from 2000 through 2010. We enrolled a convenience sample of adult patients presenting with pain and recorded patient complaint, medication administration, satisfaction, and pain and anxiety scores throughout their stay. We stratified patients into 4 different groups according to anxiety score at presentation (0, none; 1-4, mild; 5-7, moderate; 8-10, severe).

Results

We enrolled 10?664 ED patients presenting with pain-related complaints. Patients reporting anxiety were as follows: 25.7%, none; 26.1%, mild; 23.7%, moderate; and 24.5%, severe. Although 48% of patients described moderate to severe anxiety at ED presentation and 60% were willing to take a medication for anxiety, only 1% received anxiety treatment. Thirty-five percent of patients still reported moderate/severe anxiety at discharge. Severe anxiety at ED presentation was associated with increased demand for pain medication (odds ratio [OR], 1.40; 95% confidence interval [CI], 1.10-1.79) and anxiety medication (OR, 4.34; 95% CI, 3.68-5.11) during the ED stay and decreased satisfaction with the treatment of pain (β coefficient = − 0.328; P < .001). After adjusting for age, sex, and presentation pain scores, patients who reported severe anxiety were more likely to receive an analgesic (OR, 1.33; 95% CI, 1.19-1.50) and an opioid (OR, 1.25; 95% CI, 1.11-1.41) during the ED stay.

Conclusion

Anxiety may be underrecognized and undertreated in patients presenting with pain-related complaints. Patients reporting severe anxiety were less likely to report satisfaction with the treatment of their pain, despite higher rates of analgesic administration.     

Emergency Department Occupancy Ratio is Associated With Increased Early Mortality

Background

To measure emergency department (ED) crowding, the emergency department occupancy ratio (EDOR) was introduced.

Objective

Our aim was to determine whether the EDOR is associated with mortality in adult patients who visited the study hospital ED.

Methods

We reviewed data on all patients who visited the ED of an urban tertiary academic hospital in Korea for 2 consecutive years. The EDOR is defined by the total number of patients in the ED divided by the number of licensed ED beds. We tested the association between the EDOR (quartile) and each outcome using a multivariable logistic regression analysis adjusted for potential confounders: age, sex, emergency medical services transport, transferred case, weekend visit, shift, triage acuity, visit cause of injury, operation, vital signs, intensive care unit or ward admission, and ED length of stay (quartile). The main outcome measures were survival status at discharge and at 1–7 days.

Results

A total of 54,410 adult patients were enrolled. The EDOR ranged from 0.41 to 2.31 and the median was 1.24. On multivariable analyses, in comparison with the lowest (first) quartile, the highest (fourth) quartile of the EDOR was associated with 1-day mortality (adjusted odds ratio [OR] = 1.42; 95% confidence interval [CI] 1.08–1.88), 2-day mortality (adjusted OR = 1.31; 95% CI 1.04–1.67), and 3-day mortality (adjusted OR = 1.27; 95% CI 1.02–1.58). The EDOR was not significantly associated with 4- to 7-day mortalities and overall mortality at discharge.

Conclusions

The EDOR is associated with increased 1- to 3-day mortality even after controlling for potential confounders.     

Severe Sepsis in Do-not-resuscitate Patients: Intervention and Mortality Rates

Background

Severe sepsis is a high-mortality disease, and early resuscitation decreases mortality. Do-not-resuscitate (DNR) status may influence physician decisions beyond cardiopulmonary resuscitation, but this has not been investigated in sepsis.

Objective

Among Emergency Department (ED) severe sepsis patients, define the incidence of DNR status, prevalence of central venous catheter placement, and vasopressor administration (invasive measures), and mortality.

Methods

Retrospective observational cohort of consecutive severe sepsis patients to single ED in 2009–2010. Charts abstracted for DNR status on presentation, demographics, vitals, Sequential Organ Failure Assessment (SOFA) score, inpatient and 60-day mortality, and discharge disposition. Primary outcomes were mortality, discharge to skilled nursing facility (SNF), and invasive measure compliance. Chi-squared test was used for univariate association of DNR status and outcome variables; multivariate logistic regression analyses for outcome variables controlling for age, gender, SOFA score, and DNR status.

Results

In 376 severe sepsis patients, 50 (13.3%) had DNR status. DNR patients were older (79.2 vs 60.3 years, p < 0.001) and trended toward higher SOFA scores (7 vs. 6, p = 0.07). DNR inpatient and 60-day mortalities were higher (50.5% vs. 19.6%, 95% confidence interval [CI] 15.9–44.9%; 64.0% vs. 24.9%, 95% CI 25.1–53.3%, respectively), and remained higher in multivariate logistic regression analysis (odds ratio [OR] 3.01, 95% CI 1.48–6.17; OR 3.80, 95% CI 1.88–7.69, respectively). The groups had similar rates of discharge to SNF, and in persistently hypotensive patients (n = 326) had similar rates of invasive measures in univariate and multivariate analyses (OR 1.19, 95% CI 0.45–3.15).

Conclusion

In this sample, 13.3% of severe sepsis patients had DNR status, and 50% of DNR patients survived to hospital discharge. DNR patients received invasive measures at a rate similar to patients without DNR status.     

Return visit characteristics among patients who leave without being seen from a pediatric ED

Objectives

The primary aim of this study was to evaluate for differences in acuity level and rate of admission on return visit between patients who leave without being seen (LWBS) and those who are initially evaluated by a physician. Our secondary aim was as well as to identify predictors of which LWBS patients will return to the ED with high acuity or require admission.

Methods

A cross-sectional study using an administrative database at an academic tertiary-care pediatric hospital in the United States from January 1, 2006, to December 31, 2008 was done.

Results

There were 3525 patients who LWBS during the study period (1.2% of total ED visits). Of these, 87% were triaged as nonurgent, and 13% as urgent at their initial visit. Two hundred eighty-nine (8%) of LWBS patients returned to the ED within 48 hours. Compared with the population who returned to the ED after previous evaluation, patients who LWBS from their initial visit and returned had significantly lower odds of urgent acuity at time of return visit (odds ratio [OR], 0.22; 95% confidence interval [CI], 0.15-0.32) and of being admitted (OR, 0.58; 95% CI, 0.40-0.84). Urgent acuity at initial visit (OR, 2.86; 95% CI, 1.35-6.04) and number of ED visits in last 6 months (OR, 1.24; 95% CI, 1.02-1.52) were significant predictors of admission at return visit among the LWBS population.

Conclusions

Generally, patients who LWBS from a pediatric ED were unlikely to return for ED care, and those who did were unlikely to either be triaged as urgent or require hospital admission. This study showed that urgent acuity during the initial visit and number of previous ED visits were significant predictors of admission on return. Identification of these predictors may allow a targeted intervention to ensure follow-up of patients who meet these criteria after they LWBS from the pediatric ED.     

Pre-Endoscopic Rockall and Blatchford Scores to Identify Which Emergency Department Patients with Suspected Gastrointestinal Bleed Do Not Need Endoscopic Hemostasis

Background

The pre-endoscopic Rockall Score (RS) and the Glasgow-Blatchford Scores (GBS) can help risk stratify patients with upper gastrointestinal bleed who are seen in the Emergency Department (ED). The RS and GBS have yet to be validated in a United States patient population for their ability to discriminate which ED patients with upper gastrointestinal bleed do not need endoscopic hemostasis.

Objective

We sought to determine whether patients who received a score of zero on either score (the lowest risk) in the ED still required upper endoscopic hemostasis during hospitalization.

Methods

Retrospective electronic medical record chart review was performed during a 3-year period (2007–2009) to identify patients with suspected upper gastrointestinal bleed by ED final diagnosis of gastrointestinal hemorrhage and related terms at a single urban academic ED. The RS and GBS were calculated from ED chart abstraction and the hospital records of admitted patients were queried for subsequent endoscopic hemostasis.

Results

Six hundred and ninety patients with gastrointestinal bleed were identified and 86% were admitted to the hospital. One hundred and twenty-two patients had an RS equal to zero; 67 (55%; 95% confidence interval [CI] 46–63%) of these patients were admitted to the hospital and 11 (16%; 95% CI 9–27%) received endoscopic hemostasis. Sixty-three patients had a GBS equal to zero; 15 (24%; 95% CI 15–36%) were admitted to the hospital and 2 (13%; 95% CI 4–38%) received endoscopic hemostasis.

Conclusions

Some patients who were identified as lowest risk by the GBS or RS still received endoscopic hemostasis during hospital admission. These clinical decision rules may be insufficiently sensitive to predict which patients do not require endoscopic hemostasis.     

Outcomes and prognostic factors of patients with lung cancer and pneumonia-induced respiratory failure in a medical intensive care unit: A single-center study

Purpose

To evaluate the outcomes and prognostic factors of 28-day mortality following medical intensive care unit (MICU) admission of patients with lung cancer and pneumonia-induced respiratory failure.

Materials and methods

Patients admitted to the MICU of a tertiary referral hospital between 2000 and 2009 were retrospectively studied.

Results

In total, 143 patients were included. Their mean age was 65 ± 8 years and 94% were male. The 28-day mortality rate was 57%. Multivariate analysis was performed to identify variables associated with 28-day mortality. At 72 hours after admission, a history of radiotherapy (OR = 2.80, 95% CI: 1.15-6.78), Pao₂/Fio₂ (P/F) ratio at admission of < 100 mmHg (OR = 5.62, 95% CI: 2.10-15.07), P/F ratio after 72 hours of < 100 mmHg (OR = 4.61, 95% CI: 1.24-17.15), and arterial pH after 72 hours of < 7.30 (OR = 5.78, 95% CI: 1.15-28.89) were associated with increased mortality.

Conclusions

The prognosis of patients with lung cancer and severe pneumonia after 72 hours of MICU management mainly depends on the severity of the underlying lung injury, which is reflected by a history of radiotherapy and a low P/F ratio, rather than on cancer stage or disease status.     

Validation of self-reported chronic obstructive pulmonary disease among patients in the ED

Background

To determine whether the self-reported diagnosis of adults who present to the emergency department (ED) with an acute exacerbation of either asthma or chronic obstructive pulmonary disease (COPD) is validated by medical record review.

Methods

This is cross-sectional study of 78 consecutive adults, 55 years and older, presenting to 3 EDs with symptoms suggestive of an exacerbation of asthma or COPD. We used current spirometric guidelines for a “spirometrically validated” diagnosis of COPD (eg, postbronchodilator forced expiratory volume in 1 second/forced ventilatory capacity <70%). Patients without office spirometry result were classified with COPD using clinical validation based on at least one of the following: primary care physician diagnosis of COPD, chronic bronchitis, or emphysema in the medical record or chest radiography, chest computed tomography, or arterial blood gas (ABG) diagnostic of COPD.

Results

Among 60 patients who self-reported diagnosis of COPD, 98% (95% confidence interval, 89-100) had clinically validated or spirometrically validated COPD. In addition, 83% (95% confidence interval, 59-96) of patients who reported either asthma only or no respiratory disease had clinically validated or spirometrically validated COPD. In no case was the chest radiograph or the ABG useful as a stand-alone test in establishing the diagnosis of COPD.

Conclusions

Patients 55 years and older presenting to the ED with acute asthma or COPD, even those with clinical symptoms but no diagnosis of COPD, are likely to have COPD. Clinicians should maintain a high index of suspicion for COPD when older asthma patients deny COPD.     

Factors Associated With Home Discharge Among Veterans With Stroke

Objective

To determine which patient-, treatment-, and facility-level characteristics were associated with home discharge among patients hospitalized for stroke within the Department of Veterans Affairs.

Design

Retrospective observational study.

Setting

Veterans Affairs facilities nationwide.

Participants

Veterans hospitalized for stroke during fiscal year 2007 to fiscal year 2008 (N=12,565).

Intervention

Not applicable.

Main Outcome Measure

Discharge location after hospitalization.

Results

There were 10,130 (80.6%) veterans discharged home after hospitalization for acute stroke. Married veterans were more likely than nonmarried veterans to be discharged home (odds ratio [OR]=1.23; 95% confidence interval [CI]=1.11–1.35). Compared with veterans admitted to the hospital from home, patients admitted from extended care were less likely to be discharged home (OR=.04; 95% CI=.03–.07). Compared with those with occlusion of cerebral arteries, patients with intracerebral hemorrhage (OR=.61; 95% CI=.50–.74) or other central nervous system hemorrhage (OR=.78; 95% CI=.63–.96) were less likely to be discharged home, whereas patients with occlusion of precerebral arteries (OR=1.36; 95% CI=1.07–1.73) were more likely to return home. Evidence of congestive heart failure (OR=.85; 95% CI=.76–.95), fluid and electrolyte disorders (OR=.86; 95% CI=.77–.96), internal organ procedures and diagnostics (OR=.87; 95% CI=.78–.97), and serious nutritional compromise (OR=.49; 95% CI=.40–.62) during hospitalization remained independently associated with lower odds of home discharge. Longer hospitalizations and receipt of rehabilitation services while hospitalized acutely were negatively associated, whereas treatment on more bed sections and rehabilitation accreditation of the facility were positively associated with home discharge. Region exerted a statistically significant effect on home discharge.

Conclusions

We found sociological, clinical, and facility-level factors associated with home discharge after hospitalization for acute stroke. Findings document the importance of considering a broad range of characteristics rather than focusing only on a few specific traits during discharge planning.