A study of acute asthma in the accident and emergency department

We have conducted a survey of all the asthmatic patients seen at the Leicester Royal Infirmary Accident and Emergency Department during a 1-year period. A significantly greater number of patients were seen in the 8-hour period 1600-2359 hours and a greater number of patients were seen on Sundays and bank holidays. Wheeze was recorded in only 43% of the patients and there was no record of any nocturnal asthmatic symptoms. Peak expiratory flow rate was only recorded in 26% of patients before treatment with nebulized salbutamol (the commonest treatment). Pulse rate, respiratory rate, time of day or month did not determine whether or not a patient was admitted. We conclude that the education of junior doctors in the management of asthma is still deficient.     

A computer-assisted emergency department chart audit

We present a method for a microcomputer-assisted emergency department daily chart audit using a spreadsheet format. Computer technology allows the extraction of a large amount of information from audit data with a minimum of clerical time. The software automatically tabulates, sorts, and updates audit data, and depicts physician performance in a quantitative manner. The software is able to generate a variety of graphics that visually depict physician and departmental performance. The spreadsheet model is flexible, and can be adapted to the needs of various emergency departments or quality assurance activities. The audit has a rapid turnaround time, with charts audited and returned to physicians for feedback within 24 hours of the patient being discharged. Individual physician confidentiality is maintained throughout.     

A qualitative study on the transfer of residents between a nursing home and an emergency department

Nursing home (NH) residents who have exacerbations of chronic health conditions or new illnesses must generally go the emergency department (ED) for health care, later returning to the nursing home when it is felt that they are no longer require acute care. Transfers between settings of care are referred to as transitions, and research has shown that residents are at risk of experiencing negative health outcomes during these periods. This article reports on a qualitative study of resident transfers between one NH and one ED in Canada. Data were collected using interviews, participant observation, and examination of institutional policies and standard practices. Three themes emerged from the data: (1) work of executing transfers; (2) creating and exchanging resident information; and (3) feelings of guilt but not being responsible about how residents' transfers occurred. Although completion of organization-specific forms consumed a considerable amount of practitioners' time, they contributed little to resident transfers or to the sharing of information. There is a need for integrated models of care that transcend settings and promote an understanding of the roles and responsibilities of practitioners working along the entire continuum of care.     

Endocarditis in the emergency department

Clinical presentations and pathogeneses of endocarditis and aspects of its diagnosis and management relevant to emergency department practice are reviewed. Guidelines for admission, laboratory evaluation, and decisions regarding the initiation of therapy in the ED are offered. Also discussed are the role of the emergency physician in the prevention of iatrogenic infection and current recommendations regarding administration of prophylactic antibiotics for ED procedures.     

Hypercalcemia in the emergency department

BACKGROUND: Severe hypercalcemia can be life-threatening. However, its incidence and the underlying causes in the emergency department (ED) have not been determined. In the present study, we investigated these issues and the impacts on renal function and patients' survival. METHODS: We performed a retrospective study to analyze the patients with hypercalcemia in the ED for 1 year. Serum total calcium level greater than 10.3 mg/dL was defined as hypercalcemia. RESULTS: During the study period, 321 of 4293 patients (7.5%) were found to have hypercalcemia (serum calcium 11.7 +/- 1.6 mg/dL). Most of them had mild hypercalcemia (calcium level < 12.0 g/dL, 70.7%). Malignancy (36.4%) and uremia (32.4%) were the most common underlying causes. Normal renal function was observed in only 75 (23.4%) of all patients with hypercalcemia. The total mortality rate was 23.1%, and death was associated with male gender, higher calcium level, lower hemoglobin, and malignancy (all P < 0.05). Logistic analysis found that serum calcium and hemoglobin levels were independent risk factors for mortality. CONCLUSIONS: Severe hypercalcemia is frequently and life-threatening in the ED. Therefore routine determination of serum calcium level is recommended, and immediate therapy should be initiated to treat the patients at high risk.     

Catatonia in the emergency department

The catatonic syndrome has a wide differential diagnosis that includes both psychiatric and organic disorders. We present the cases of two patients with catatonia seen acutely in the emergency department. In these cases, the striking clinical picture proved to be secondary to psychiatric disturbances, and were accompanied by dementia in the second patient. The examining physicians were confused by the presentations, and the correct diagnosis and disposition were delayed. The clinical presentation of the catatonic complex, its differential diagnosis, and the pertinent physical signs are discussed.     

A conceptual model of emergency department crowding

Emergency department (ED) crowding has become a major barrier to receiving timely emergency care in the United States. Despite widespread recognition of the problem, the research and policy agendas needed to understand and address ED crowding are just beginning to unfold. We present a conceptual model of ED crowding to help researchers, administrators, and policymakers understand its causes and develop potential solutions. The conceptual model partitions ED crowding into 3 interdependent components: input, throughput, and output. These components exist within an acute care system that is characterized by the delivery of unscheduled care. The goal of the conceptual model is to provide a practical framework on which an organized research, policy, and operations management agenda can be based to alleviate ED crowding.     

Prisoners in the emergency department

Eight issues in the care of prisoners in the ED have been examined. Close to one-half million persons are incarcerated at any time in the United States, and the numbers can be expected to increase. When seeing prisoners in the ED, the physician must keep in mind two facts: 1) prisoners have a right to medical care; and 2) incarceration demands that certain considerations be made regarding the correctional environment when evaluating, treating and, most importantly, discharging a prisoner back to the cell.     

A case of glaucomatocyclitic crisis in the emergency department

Glaucomatocyclitic crisis is caused by an idiopathic inflammatory process of the trabecular meshwork, causing a decrease in aqueous outflow. This decrease causes the cyclitis-associated ocular hypertension. There is rarely any pain or other findings typically associated with glaucoma. Thus, the diagnosis is easily missed. Patients may present with nonspecific symptoms such as blurry vision or periorbital discomfort. Examination typically reveals a noninjected, slightly mydriatic eye. Slit-lamp examination may reveal fewer-than-expected inflammatory cells in the anterior chamber, with only occasional small nonpigmented keratic precipitates on the corneal epithelium. The intraocular pressure is typically increased (30 to 70 mm Hg), despite an open angle. Therapy is aimed at controlling the increased intraocular pressure with the use of topical imidazolines, beta-blockers, and carbonic anhydrase inhibitors. Complications related to prolonged and recurrent attacks of increased intraocular pressure may result in damage to the optic nerve head and visual field compromise.     

A 5-year time study analysis of emergency department patient care efficiency.

STUDY OBJECTIVES: We conducted a 5-year time study analysis of emergency department patient care efficiency. Our specific aims were (1) to calculate the main ED patient care time intervals to identify areas of inefficiency, (2) to measure the effect of ED and inpatient bed availability on patient flow, (3) to quantitatively assess the effects of administrative interventions aimed at improving efficiency, and (4) to evaluate the relationship between waiting times to see a physician and the number of patients who leave without being seen (LWBS) by a physician. METHODS: Seven 1-week ED patient flow time studies were conducted from September 1993 to July 1998 using identical study design and methodology. Patients presenting with complaints of chest pain, abdominal pain, vaginal bleeding, and extremity injury were included to represent the level of severity of patient conditions seen in our Los Angeles County hospital ED. The calculated time intervals representing the main phases of evaluation and treatment were (1) triage presentation to completion of registration, (2) completion of registration to ED treatment area entry, (3) ED treatment area entry to initial medical assessment, (4) triage presentation to initial medical assessment, (5) initial medical assessment to disposition order, and (6) disposition order to patient discharge from the ED. Total ED lengths of stay (LOS) were also calculated as overall measures of efficiency. Time intervals were compared depending on the availability of ED and hospital inpatient beds. The effects of administrative interventions on the specific time intervals were assessed. The relationship between the median waiting time to see a physician and the number of LWBS patients was evaluated. Administrative interventions were implemented by a special interdepartmental continuous quality improvement committee. Interventions were aimed at specific sources of delay and inefficiency identified by the time studies. RESULTS: Eight hundred twenty-six patients were included in the 7 time studies. The unavailability of ED and inpatient beds was associated with significant delays. There was a significant reduction of the median total ED LOS from 6.8 hours to 4.6 hours over the first 5 periods, presumably resulting from the administrative interventions. Median total ED LOS, however, increased from 4.6 hours to 6.0 hours during the last 2 periods, possibly as a result of an increase in our ED patient census and reductions in both nursing and physician staffing imposed by the recent Los Angeles County fiscal crisis. The number of LWBS patients was closely correlated to waiting time to see a physician ( r =0.79, beta=5.20, P =.033). CONCLUSION: Time studies are an effective method of identifying areas of patient care delay. In our ED, targeted administrative interventions apparently reduced the total ED LOS and improved overall efficiency. Despite initial decreases in ED LOS, efficiency appeared to be adversely affected by reductions in nursing and physician staffing and increases in our patient census. The strength of the relationship between waiting times to see a physician and the number of LWBS patients suggests that decreasing waiting times may reduce the number of LWBS patients.     

A case-control study of food poisoning seen at an accident and emergency department

We investigated the hypothesis that sporadic food poisoning is a result of the consumption of food cooked or prepared outside the home. We did a case-control study, set in an urban emergency department, to find out the odds ratios for the risk of food poisoning associated with various patterns of consumption. We found that recent eating out (exposure on the day of or day before presentation) was associated with an odds ratio of 2.41 (95% CI 1.29-4.50) for presenting with food poisoning.     

Acute heart failure in the emergency department: a follow-up study

Acute heart failure (AHF) is a major public health issue due to high incidence and poor prognosis. Only a few studies are available on the long-term prognosis and on outcome predictors in the unselected population attending the emergency department (ED) for AHF. We carried out a 1-year follow-up analysis of 1234 consecutive patients from selected Italian EDs from January 2011 to June 2012 for an episode of AHF. Their prognosis and outcome-associated factors were tested by Cox proportional hazard model. Patients’ mean age was 84, with 66.0 % over 80 years and 56.2 % females. Comorbidities were present in over 50 % of cases, principally a history of acute coronary syndrome, chronic obstructive pulmonary disease, diabetes, chronic kidney disease, valvular heart disease. Death occurred within 6 h in 24 cases (1.9 %). At 30-day follow-up, death was registered in 123 cases (10.0 %): 110 cases (89.4 %) died of cardiovascular events and 13 (10.6 %) of non-cardiovascular causes (cancer, gastrointestinal hemorrhages, sepsis, trauma). At 1-year follow-up, all-cause death was recorded in 50.1 % (over 3 out of 4 cases for cardiovascular origin). Six variables (older age, diabetes, systolic arterial pressure <110 mm/Hg, high NT pro-BNP, high troponin levels and impaired cognitive status) were selected as outcome predictors, but with limited discriminant capacity (AUC = 0.649; SE 0.015). Recurrence of AHF was registered in 31.0 %. The study identifies a cluster of variables associated with 1-year mortality in AHF, but their predictive capacity is low. Old age and the presence of comorbidities, in particular diabetes are likely to play a major role in dictating the prognosis.