Viral Meningitis: Which Patients Can Be Discharged from the Emergency Department?

Background

Even in an era when cases of viral meningitis outnumber bacterial meningitis by at least 25:1, most patients with clinical meningitis are hospitalized.

Objective

We describe the clinical characteristics of an unusual outbreak of viral meningitis that featured markedly elevated cerebrospinal fluid white blood cell counts (CSF WBC). A validated prediction model for viral meningitis was applied to determine which hospital admissions could have been avoided.

Methods

Data were collected retrospectively from patients presenting to our tertiary care center. Charts were reviewed in patients with CSF pleocytosis (CSF WBC > 7 cells/mm³) and a clinical diagnosis of meningitis between March 1, 2003 and July 1, 2003. Cases were identified through hospital infection control and by surveying all CSF specimens submitted to the microbiology laboratory during the outbreak.

Results

There were 78 cases of viral meningitis and 1 case of bacterial meningitis identified. Fifty-eight percent of the viral meningitis cases were confirmed by culture or polymerase chain reaction to be due to Enterovirus. Mean CSF WBC count was 571 cells/mm³, including 20 patients with a CSF WBC count > 750 cells/mm³ (25%) and 11 patients with values > 1000 cells/mm³ (14%). Sixty-four of 78 patients (82%) were hospitalized. Rates of headache, photophobia, nuchal rigidity, vomiting, and administration of intravenous fluids in the Emergency Department were no different between admitted and discharged patients. Only 26/78 (33%) patients with viral meningitis would have been admitted if the prediction model had been used.

Conclusions

Although not all cases of viral meningitis are necessarily suitable for outpatient management, use of a prediction model for viral meningitis may have helped decrease hospitalization by nearly 60%, even though this outbreak was characterized by unusually high levels of CSF pleocytosis.     

Can Patient Variables Measured on Arrival to the Emergency Department Predict Disposition in Medium-acuity Patients?

Background

Emergency department crowding has led to innovative “front end” care models to safely and efficiently care for medium and lower acuity patients. In the United States, most treatment algorithms rely on the emergency severity index (ESI) triage tool to sort patients. However, there are no objective criteria used to differentiate ESI 3 patients.

Can Sudden Cardiac Death Risk in the Young be Identified in the Emergency Department?

Sudden cardiac death in the young is devastating for the family and the community. Although it has diverse etiologies, many are inherited. Discovering the disease in 1 patient offers the chance to save otherwise asymptomatic family members. Although some diseases can be discovered during autopsy, others require electrocardiograms for diagnosis, making it difficult to estimate the prevalence of disease and cause of death. Careful assessment of the history of present illness, family history, and electrocardiogram can guide clinical teams toward sometimes rare and difficult diagnoses. The purpose of this review article is to summarize the bench to bedside diagnosis of inherited dysrhythmia syndromes, which if missed on first presentation to the emergency department, have significant implications for the patient and the entire family.     

Triaging Herpes Zoster Ophthalmicus Patients in the Emergency Department: Do All Patients Require Referral?

Objectives: The objective was to assess the predictive value of clinical signs and symptoms of herpes zoster ophthalmicus (HZO) for development of moderate to severe eye disease. Methods: This was a prospective cohort multicenter study of 54 patients referred to the ophthalmology service after presenting to the emergency department (ED) or primary care clinic with a zosteriform rash of less than 10 days’ duration. Upon referral to ophthalmology, easily assessable clinical signs and symptoms were documented. A complete ocular exam was then performed. Patients were followed for 2 months. Results: Twenty‐three patients (43%) developed moderate to severe disease as defined by corneal or intraocular involvement. Eye redness and rash in the supratrochlear nerve distribution had a statistically significant association with clinically relevant eye disease. All 23 patients who developed moderate to severe eye disease presented with a red eye. Hutchinson’s sign (nasociliary nerve involvement) was not predictive of clinically relevant eye disease. Conclusions: Eye redness was 100% sensitive for predicting moderate to severe eye disease in this sample of patients and should necessitate immediate referral for ophthalmologic assessment. Patients lacking eye redness, even with a positive Hutchinson’s sign, may not require immediate specialist consultation. All patients not being referred require careful instructions to seek further care should they develop any concerning eye symptoms such as redness, pain, photophobia, or visual disturbance. ACADEMIC EMERGENCY MEDICINE 2010; 17:1183–1188 © 2010 by the Society for Academic Emergency Medicine     

Do Elder Emergency Department Patients and Their Informants Agree about the Elder's Functioning?

OBJECTIVE: To compare elder patients' and their informants' ratings of the elder's physical and mental function measured by a standard instrument, the Medical Outcomes Study Short Form 12 (SF-12). METHODS: This was a randomized, cross-sectional study conducted at a university-affiliated community teaching hospital emergency department (census 65,000/year). Patients >69 years old, arriving on weekdays between 10 AM and 7 PM, able to engage in English conversation, and consenting to participate were eligible. Patients too ill to participate were excluded. Informants were people who accompanied and knew the patient. Elder patients were randomized 1:1 to receive an interview or questionnaire version of the SF-12. The questionnaire was read to people unable to read. Two trained medical students administered the instrument. The SF-12 algorithm was used to calculate physical (PCS) and mental (MCS) component scores. Oral and written versions were compared using analysis of variance. The PCS and MCS scores between patient-informant pairs were compared with a matched t-test. Alpha was 0.05. RESULTS: One hundred six patients and 55 informants were enrolled. The patients' average (+/-SD) age was 77 +/- 5 years; 59 (56%; 95% CI = 46% to 65%) were women. There was no significant difference for mode of administration in PCS (p = 0.53) or MCS (p = 0.14) scores. Patients rated themselves higher on physical function than did their proxies. There was a 4.1 (95% CI = 99 to 7.2) point difference between patients' and their proxies' physical component scores (p = 0.01). Scores on the mental component were quite similar. The mean difference between patients and proxies was 0.49 (95% CI = 3.17 to 4.16). The half point higher rating by patients was not statistically significant (p = 0.79). CONCLUSIONS: Elders' self-ratings of physical function were higher than those of proxies who knew them. There was no difference in mental function ratings between patients and their proxies. Switching from informants' to patients' reports in evaluating elders' physical function in longitudinal studies may introduce error.     

Can Anticoagulated Patients be Discharged Home Safely from the Emergency Department after Minor Head Injury?

Background

Anticoagulated patients have increased risk for bleeding, and serious outcomes could occur after head injury. Controversy exists regarding the utility of head computed tomography (CT) in allowing safe discharge dispositions for anticoagulated patients suffering minor head injury.

Clinical Question

What is the risk of delayed intracranial hemorrhage in anticoagulated patients with minor head injury and a normal initial head CT scan?

Evidence Review

Four observational studies were reviewed that investigated the outcomes of anticoagulated patients who presented after minor head injury.

Results

Overall incidence of death or neurosurgical intervention ranged from 0 to 1.1% among the patients investigated. The studies did not clarify which patients were at highest risk.

Conclusion

The literature does not support mandatory admission for all anticoagulated patients after minor head injury, but further studies are needed to identify the higher-risk patients for delayed bleeding to determine appropriate management.     

Domestic Abuse in the Emergency Department: Can a Risk Profile Be Defined?

OBJECTIVES: The main purpose of this study was to determine whether any clinical or demographic characteristics could identify adult female patients presenting to the emergency department (ED) with a history of domestic abuse. A second objective was to describe the frequency, types, and severity of this abuse. METHODS: This study was a crosssectional survey of 611 women conducted in an academically-affiliated, urban ED. Domestic abuse was described as "recent" (within the preceding 12 months) or "lifetime" (recent or past). This included emotional, physical, and sexual abuse. RESULTS: Recent (7.9%, n = 48) and lifetime (38%, n = 232) domestic abuse was reported. For recently abused women, violence had been severe (87.5%, n = 42) and was associated with 1) trauma (OR 5.4, 95% CI = 2.6 to 11.6), 2) obstetrical and gynecological syndromes (OR 5.6, 95% CI = 2.4 to 13.2), and 3) psychiatric symptoms and substance use (OR 7.3, 95% CI = 2.4 to 22.0). The sensitivities and positive predictive values of these risk factors individually (<27.1% and <25.0%, respectively) and in aggregate (56.3% and 20.9%, respectively) were low. These indicators predicted only 27 (56.3%) of recently abused women. Lifetime domestic violence was more likely in homeless women (OR 5.8, 95% CI = 2.2 to 15.0), although less likely in immigrants (OR 0.4, 95% CI = 0.3 to 0.7). CONCLUSIONS: Clinical presentations and demographic characteristics of women presenting to the ED may not be sensitive or predictive indicators of domestic abuse. In the absence of typical clinical or demographic findings, asking all women in the ED about domestic abuse remains a necessary priority.     

Can Intraocular Pressure Measurements be Used to Screen for Elevated Intracranial Pressure in Emergency Department Patients?

Background

Handheld measurement of intraocular pressure (IOP) has been previously shown to accurately predict elevated intracranial pressure (ICP) in neurosurgical patients. Handheld tonometry may have clinical utility in the prediction of elevated ICP among a cohort of emergency department (ED) patients receiving lumbar puncture (LP).

Objective

To ascertain the sensitivity and specificity of IOP for the prediction of elevated ICP in ED patients undergoing LP.

Methods

In this prospective observational pilot study, all ED patients over the age of 18 years and undergoing LP in the ED for any reason were eligible to participate. Study participants had IOP measured with the Tono-Pen XL (Reichert, Inc., Depew, NY) while in the supine position before LP. OP was measured in the lateral recumbent position. Elevated IOP was defined as ≥ 20 mm Hg; elevated ICP was defined as ≥ 20 mm H₂O.

Results

There were 82 patients screened and 46 patients enrolled at the time of interim analysis. Of the 46 patients, 32 had a successful LP in the lateral recumbent position. There were 18/32 patients with a successful LP in the lateral recumbent position who had elevated opening pressure; 9/32 patients with a successful LP had an elevated IOP. Furthermore, 4/9 patients with elevated IOP also had an elevated opening pressure. There was only one patient who had elevated IOP, elevated ICP, and diagnostic cerebrospinal fluid (sensitivity 24%, 95% confidence interval [CI] 9–48%; specificity 63%, 95% CI 32–88%; positive predictive value 28%, 95% CI 14–47%; negative predictive value 72%, 95% CI 53–96%).

Conclusions

Handheld tonometry has poor sensitivity and specificity for the prediction of increased ICP, and should not be used as a screening tool in the ED.     

Why Don't Emergency Department Patients Have Advance Directives?

OBJECTIVES: In 1997 the authors determined that only 27% of their adult ED patients had advance directives (ADs). The purpose of this follow-up study was to determine the reasons why their adult ED patients do not have ADs. METHODS: This prospective study enrolled patients from a convenience sample of representative shifts in the ED selected over a three-month period. Survey questions included demographic information, whether the patients had a life-threatening medical problem, whether they had an AD, with whom they had discussed their ADs, and the reasons why they did not have an AD. We excluded those who refused participation or who were incapacitated (i.e., any patient with a condition that precluded him or her from answering the questionnaire himself or herself, such as an altered level of consciousness, dementia, mental retardation, or inability to understand English). RESULTS: Four hundred seventy-six subjects were enrolled during the study period from an ED census of 816 adult patients. Three hundred forty patients were not included in the study for the following reasons: inability to complete the survey, refusal to participate, or not being approached by the interviewers. Of those enrolled, 77% of the patients did not have an AD (females, 73%; males, 80%). The most frequent reasons given for not having an AD were: 40% never thought about it, 24% preferred family to make the decision, and 23% were procrastinating. Factors jointly predictive of having an AD were older age, having a specialist, having a life-threatening medical problem, and not being Catholic. Patients who had ADs were discussing their ADs with their primary care physicians (PCPs) only 5% of the time. CONCLUSION: Many patients, even when they have life-threatening medical problems, do not have an AD, and several reasons for this have been identified. Few of these ED patients who had ADs had discussed them with their physicians. Further studies should assess whether more physician intervention would increase the percentage of patients who have ADs.     

What is the Role of Sugammadex in the Emergency Department?

BackgroundSugammadex is a medication newly available to many emergency physicians. It effectively, and within minutes, reverses neuromuscular blockade in patients who have received rocuronium or vecuronium. The role of sugammadex for the reversal of neuromuscular blockade after rapid sequence intubation in the emergency department (ED) is evolving, and limited emergency medicine-specific literature exists.ObjectiveThis narrative review evaluates the role of sugammadex for the reversal of neuromuscular blockade in the ED.DiscussionThe basic pharmacology, duration of action, adverse effects, and important medication and disease interactions specific to sugammadex are well described. Case reports suggest sugammadex can reverse neuromuscular blockade to facilitate an urgent, neurologic examination by an emergency physician or consultant. Multiple case reports of failure to improve airway patency with the use of sugammadex, even when neuromuscular blockade is completely reversed, and concern for added difficulty of definitive airway management in a patient with spontaneous movement suggest that sugammadex should largely be omitted from failed or difficult airway management strategies. Instead, it is important to focus on the ability to oxygenate and ventilate, including progression to surgical airway or jet ventilation if needed.ConclusionSugammadex is an effective, rapid reversal agent for rocuronium and has the potential use to facilitate an urgent neurologic examination shortly after administration of rocuronium. Its routine inclusion in a failed or difficult emergency airway is not supported by available literature.     

Procedural Sedation and Analgesia in the Emergency Department: What Are the Risks?

The practitioner of emergency medicine is routinely faced with patients in need of emergent procedures and pain control and sedation. Our challenge is to make our patients' experiences as painless and as safe as possible, while maximizing our ability to perform the procedure at hand; this is not always an easy task given the propensity of each human body to react differently to interventions and stimuli. We can best meet this challenge by understanding how our patients and pharmaceutical agents intermingle in the risk-benefit equation we formulate before starting our "experiment." Coupling this information with fundamentally sound patient care and monitoring will minimize bad experiences with PSA for both the patient and practitioner.     

Does the Emergency Medical Treatment and Labor Act Affect Emergency Department Use?

Background

Emergency departments (EDs) face increasing patient volumes and economic pressures. These problems have been attributed to the Emergency Medical Treatment and Labor Act (EMTALA).

Study objective

To determine whether modifying EMTALA might reduce ED use.

Methods

We surveyed ED patients to assess their knowledge of hospitals’ obligations to treat all patients regardless of insurance and to determine whether knowledge is associated with ED use.

Results

Among 4136 study subjects, 72% reported awareness of the law. Sixty-one percent of subjects were moderate ED users (≥ 1 additional ED visit in 12 months). Moderate users more often knew the law (74% vs. 70%, p = 0.005). Multivariate regression showed that factors associated with moderate use were: awareness of EMTALA (odds ratio [OR] 1.44; 95% confidence interval [CI] 1.24–1.67), adult patient (OR 1.94; 95% CI 1.69–2.22), and government insurance (OR 2.67; 95% CI 2.30–3.08) or uninsured (OR 1.72; 95% CI 1.42–2.08). Only 8% of subjects were high-frequency users (≥5 visits). High-frequency users were more often aware of EMTALA (78% vs. 72%, p = 0.02). Covariates associated with high frequency were EMTALA awareness (OR 1.69; 95% CI 1.28–2.24), adult patient (OR 2.59; 95% CI 2.00–3.36), and government insurance (OR 3.73; 95% CI 2.76–5.06) or uninsured (OR 3.77; 95% CI 2.65–5.35).

Conclusion

Many patients know that the law requires hospitals to provide care. This knowledge is associated with more frequent ED use. EMTALA changes might reduce ED use, but broader policy implications should be considered.     

What are the experiences of Emergency Department nurses in caring for clients with a mental illness in the Emergency Department?

Background

Australian Emergency Departments are experiencing increased numbers of clients with a mental illness and Emergency Departments are becoming increasingly utilised as the first point of contact and portal into the mental health care system. Therefore nurses working within the Emergency Departments find themselves having to care for clients with a mental illness as part of their daily work. The aim of this study was to gain an understanding of the experiences of Emergency Department nurses caring for clients with a mental illness in the Emergency Department.

Methods

An interpretive phenomenological study was undertaken using semi structured interviews to enable the lived experiences of Emergency Department nurses to be discovered and articulated. Six Registered Nurses working within an Emergency Department were interviewed, and these participants were asked to tell the story of their experiences in their own words.

Results

Results are based on data collected from six participant interviews. Three major themes emerged related to caring for clients with a mental illness in the Emergency Department: (i) Time as a causative factor, (ii) environment and the influence of surroundings and (iii) understanding the client's personal journey.

Conclusions

Data obtained from participants in this study confirm what has been reported in the literature, that is, that there has been an increase in presentations of clients with a mental illness to the Emergency Department, and the results of this study highlight that time constraints specific to the Emergency Department impact both the client with the mental illness and the Emergency Department nurse caring for these clients. In addition, narratives from Emergency Department nurses purport that the environment within the Emergency Department is not conducive to the provision of optimal care to this client group who have unique care needs and require a specialised management focus. Furthermore, the participants expressed that they had difficulty conceptualising the role of the Emergency Department in the client's personal journey. The concept of recovery in mental health comes into conflict with the culture within the Emergency Department that views recovery as a restoration or return to health rather than the unique journey of the client living with a mental illness.     

Whats that noise? Bedside monitoring in the Emergency Department

ObjectiveTo determine the frequency, duration and type of audible monitor alarms in an ED, utilising the standard manufacturer’s classification.MethodsThe audible monitor alarms and the timing of any intervention related to the patient monitoring was observed and recorded.Results110 Patients admitted to the Majors area or Resuscitation Room were observed for a total of 93 hours. One monitor was observed at a time. Alarm noise was generated 29% of the observation time. Overall, 429 alarms lasting 21 hours 27 minutes were judged to be positive and 143 alarms lasting 5 hours 47 minutes, negative. 74% of Resuscitation Room and 47% of Majors alarms were silenced or paused. Alarm limit parameters were only adjusted after 5% of alarms in Resuscitation Room and 6% of alarms in Majors.ConclusionsWhilst high level monitoring is desired from a patient safety perspective, it contributes to a significant ambient noise level, which is recognised by all who pass through an ED, and can be detrimental to patients, relatives and staff. We have demonstrated that there is a high probability of near-continuous alarm noise from patient monitoring in a 10-bedded Majors area. We make suggestions for methods of noise reduction and intend to implement some of these within our own ED.     

Can Risk Stratification Tools Be Utilized to Safely Discharge Low-Risk Febrile Neutropenic Patients from the Emergency Department?

BackgroundChemotherapy-induced febrile neutropenia (FN) is one of the more common oncological emergencies. Despite evidence in the oncology literature suggesting that low-risk cases of FN can be managed safely at home, most patients with FN who present to the emergency department (ED) are admitted. FN risk stratification methods, such as Multinational Association for Supportive Care in Cancer (MASCC) and Clinical Index of Stable Febrile Neutropenia (CISNE) scores, may be useful when considering patient disposition. We sought to address whether the existing body of literature is adequate to support the use of these methods when treating patients with FN in the ED.MethodsA PubMed search from January 1, 2016 to March 19, 2021 was performed using the following search strategy: “febrile neutropenia” OR (fever AND neutropenia)) AND (emerg* OR outpatient) AND (admit OR admission OR hospitalization). General review articles and case reports were omitted. Each of the articles selected underwent a structured review.ResultsThe search yielded 371 articles, which were independently screened for relevance by two authors, and 23 articles were selected for inclusion. MASCC score was used in 10 of the identified studies and each of these studies concluded that the score was useful in the ED. Most of the identified studies found that CISNE score had a higher sensitivity than MASCC score (96.7% vs. 32.9%, respectively), but a lower specificity (22.2% vs. 89.5%).ConclusionsFN risk stratifications tools, such as MASCC and CISNE scores, are supported by the existing literature and may be included as part of the decision-making process when considering patient disposition.     

Does the U Stand for Useless? The Urine Drug Screen and Emergency Department Psychiatric Patients

Background

Behavioral emergencies account for a significant portion of emergency department (ED) visits in the United States. Substance abuse is common in this population and may precipitate or exacerbate preexisting psychiatric illness. Contrary to ED policy guidelines, many behavior health centers (BH) require a urine drug screen (UDS) in stable patients prior to transfer.