Emergency care of the hemophiliac patient

Hemophilia is a congenital disorder characterized by prolonged bleeding, many times in association with little or no trauma, in which proper treatment may save lives or prevent permanent sequelae. We report an illustrative case and review the management of common problems with which a hemophiliac might present to the emergency department.     

Emergency medicine redux: the rise and fall of a community medical specialty

The specialty of Emergency Medicine has evolved circuitously . The poor relation of medicine, previously the domain of moonlighting dermatologists and semi-retired physicians, we considered it a diamond in the rough, a wealth of opportunity hidden by the prejudice of established specialties . We tailored the discipline to meet our needs and desires. As we created form from void, we generated an interest in a practical area of medicine previously indulged only theoretically. Now we are enlarging geometrically as a specialty and have discovered that our actual role as practicing physicians in the community hospital setting has turned out differently than we had conceived in training. As we overpower the available market by expanding our numbers, we are learning about some practical realities that are only now becoming apparent.     

Analysis of COVID-19 pandemic impact on the presenting complaints of the emergency department visits

The impact of coronavirus disease 2019 (COVID-19) on economic and medical systems is significant, especially in the emergency department (ED). The patterns of ED visits have also changed significantly and may play a crucial role in rearranging medical resources to the most needed departments during the pandemic.This was a retrospective study conducted in hospitals of the Cathay Health System. All patients presented to the EDs between January 21, 2020 to April 30, 2020 (pandemic stage) and January 21, 2019 to April 30, 2019 (before the pandemic stage). Basic demographics, including visit characteristics, disposition, and chief complaints, of the patients visiting the ED between these 2 periods of time will be compared and analyzed.A total of 71,739 patients were included in the study. A reduction in ED visits was noted in 15.1% (32,950 ED visits) during the pandemic stage. ED visiting patients with the chief complaints of upper respiratory infection and social problems increased by 14.23% and 1.86%, respectively, during the pandemic period. Critical chief complaints such as cardiac arrest, chest pain and altered mental status decreased to less than the ED visits difference (−15.1%) between the pandemic and prepandemic stages, for 0%, −7.67%, and −13.8% respectively.Rearrangement of the ED pediatric staff to the COVID-19 special units and recruiting more social workers to the ED should be performed to respond to the COVID-19 pandemic.     

The efficacy of abdominal and pelvic ultrasound in the emergency department

To assess the diagnostic value of abdominal and pelvic ultrasound to the emergency physician, we followed 43 patients who required ultrasound out of 1,010 patients who presented to the emergency department with abdominal pain and/or vaginal bleeding during the 33-week study period. Ultrasound confirmed the preliminary diagnosis in 12 patients, was supportive in eight patients, and ruled out the preliminary diagnosis in 23 patients. Ultrasound often shortened the evaluation process by narrowing the differential diagnosis or by excluding potentially serious conditions, thus eliminating the need for additional testing and frequently allowing for safe discharge of the patient. We found ultrasound to be helpful, as well as cost-effective, in certain patients with abdominal pain and/or vaginal bleeding in whom an emergency department evaluation without ultrasound could not exclude a condition necessitating admission or urgent surgery.     

Predicting the utilization of helicopter emergency medical services: an approach based on need

Accurately predicting the utilization of helicopter emergency medical services is critical to both resource allocation and fiscal integrity, and health planning agencies may insist that the need for such services be demonstrated before the system can become operational. Most utilization predictions have been based solely on the experience of other services despite wide variation in need and use. This kind of prediction has the serious disadvantage of not considering local demographics and individual system variations. A better method uses needs analysis to predict utilization and to calculate demand. This method is based on a systematic identification of conditions that will benefit significantly from helicopter transport to a referral center, the incidence of those conditions, and the population to be served. The need for service is estimated by multiplying the population by the incidence. The fraction of patients with demonstrated need who will actually use the service is estimated on the basis of the interaction between local characteristics and condition variables.     

Clinical treatment outcomes of hypertensive emergency patients: Results from the hypertension registry program in Northeastern Thailand

Hypertensive emergency care is a challenge in clinical practices due to vital organ complications that may lead to unfavorable outcomes if left untreated. The objectives of this study were to determine the prevalence, clinical characters, treatment, and outcomes of hypertensive emergency patients. A retrospective cohort study was conducted at a university hospital in Northeast Thailand from January 2016 to December 2019. Hypertensive crises patients were consecutively registered to the Hypertension Registry Program. There were 263 674 patients who were admitted to the ER, 60,755 of whom had BP ≥ 140/90 mm Hg and 1,342 of whom were diagnosed with a hypertensive emergency (127 per 100 000 patient‐year). The mean age was 66 years old, and 52.1% of the registered patients were men. The most common target organ damage was caused by stroke (49.8%), followed by acute heart failure (19.3%), and then by acute coronary syndrome (6.5%). Intravenous antihypertensive medication was given in 42.1% of the patients, and 80% were admitted to the hospital. The in‐hospital mortality rate was 1.6%. In conclusion, hypertensive emergencies were not uncommon among the emergency patients. Strokes caused the most common target organ damage. Although there was a high hospital admission rate, the mortality rate was low.     

Quality assurance in the emergency department

Quality assurance (QA) is an increasingly important element in the administrative management of the ED. The need to critically self-evaluate physician performance, allocate scarce resources, and conduct careful risk management requires a methodology well met by a comprehensive QA plan. Aggressive collection of potential problems requires multiple methodologies to review complaints, accomplish generic screening, perform audits, address administrative concerns, and satisfy reviews mandated by the Joint Commission on Accreditation of Hospitals. The means by which such wide-ranging issues can be brought into a single comprehensive plan require an efficient and flexible model of ED administration that includes problem identification, resolution and monitoring, risk management, and sensible administration. The QA elements of monitoring, assessment, improvement, documentation, generic screening, and standards of care are examined.     

Organization structure and the performance of hospital emergency services

A comparative study of 30 hospital emergency departments (EDs) and nearly 1,500 individuals associated with them was conducted. Data were obtained from institutional records, physicians, patients, and other sources. The object was to investigate the relationship between the organization and performance of these health service systems. The study assessed the quality of medical care, the quality of nursing care, and the economic efficiency of hospital EDs. The results show substantial interinstitutional differences in these criteria. They also show a significant relationship between medical and nursing care, but not between the quality of care and economic efficiency. Differences in ED performance are related to medical staffing patterns, medical teaching affiliation, personnel training, scope of emergency services, number of patient visits processed, and hospital size and complexity. Not all of these variables, however, correlate positively with all three criteria of performance, nor are they equally important to each.     

Echocardiography in the Emergency Department: From the Perspective of the Emergency Physician and the Cardiologist

Echocardiography performed in the emergency department must adapt to this new setting for noninvasive diagnostic testing. Emergency physicians require echocardiography to provide rapid diagnosis in life-threatening emergencies. New initiatives are being proposed by emergency physicians in the delivery of this test. Cardiologists now use echocardiography in the emergency-department to make the diagnosis of heart disease earlier and with greater accuracy.     

The 1980 patient urgency study: Further analysis of the data

The patient urgency study was a comprehensive nationwide evaluation of patient and physician perceptions of the urgency of need for medical care. Half of the patients in the study were between the ages of 13 and 21. The necessity for immediate care, specifically emergency department care, and admission varied proportionately with increasing age. There was little variation in patient volume by day of the week, although the 8:00 AM to 4:00 PM shift was demonstrably the busiest; the midnight to 8:00 AM shift, however, had proportionately more sick patients. Sixty percent of the patients came to the ED because they believed that they had an emergency problem; 62% of patients had a personal physician. The average number of patients admitted in the ED population was 12.5%, with a range of 4.1% to 22.9%. ED residents underestimated the urgency of need for medical care 6.7% of the time, in comparison with only 3.7% for career emergency physicians. Physicians noted that 7.4% of patients who left without being seen initially required immediate care.     

Medical expertise as a critical influencing factor on the length of stay in the ED: A retrospective cohort study

Overcrowding in the emergency departments (ED) is a significant issue associated with increased morbidity and mortality rates as well as decreased patient satisfaction. Length of stay (LOS) is both a cause and a result of overcrowding. In Israel, as there are few emergency medicine (EM) physicians, the ED team is supplemented with doctors from specialties including internal medicine, general surgery, orthopedics etc. Here we compare ED length of stay (ED-LOS), treatment time and decision time between EM physicians, internists and general surgeons.A retrospective cohort study was conducted examining the Emergency Department length of stay (ED-LOS) for all adult patients attending Sheba Medical Center ED, Israel, between January 1st, and December 31st, 2014. Using electronic medical records, data was gathered on patient age, sex, primary ED physician, diagnosis, eventual disposition, treatment time and disposition decision time. The primary outcome variable was ED-LOS relative to case physician specialty and level (ED, internal medicine or surgery; specialist or resident). Secondary analysis was conducted on time to treatment/ decision as well as ED-LOS relative to patient classification variables (internal medicine vs surgical diagnosis). Specialists were compared to specialists and residents to residents for all outcomes.Residents and specialists in either EM, internal medicine or general surgery attended 57,486 (51.50%) of 111,630 visits to Sheba Hospital''s general ED. Mean ED-LOS was 4.12 ± 3.18 hours. Mean treatment time and decision time were 1.79 ± 1.82 hours, 2.84 ± 2.17 hours respectively. Amongst specialists, ED-LOS was shorter for EM physicians than for internal medicine physicians (mean difference 0.28 hours, 95% CI 0.14–0.43) and general surgeons (mean difference 0.63 hours, 95% CI 0.43–0.83). There was no statistical significance between residents when comparing outcomes.Increasing the number of EM specialists in the ED may support efforts to decrease ED-LOS, overcrowding and medical errors whilst increasing patient satisfaction and outcomes.     

Do Internists and Emergency Physicians Agree on the Appropriateness of Emergency Department Visits?

The purpose of this study was to determine the levels of agreement between three methods of assessing appropriateness of emergency department (ED) visits. In particular, we tested the agreement between internists and emergency physicians reviewing the ED nurses' triage notes, containing information that might be available by telephone to an internist. For 892 adult patient ED visits reviewed, we found only moderate agreement ( κ = 0.47) between these groups. In cases of disagreement, emergency physicians were 10.3 times more likely than internists to classify those with minor discharge diagnoses as appropriate for ED care. As managed care grows, the determination of ED appropriateness may depend on open discussions between physician groups, as well as on access to timely care in office settings.