Critical care provided in an urban emergency department

The emergency department (ED) provides a substantial amount of critical care. The purpose of this study was to quantitate the critical care provided in an urban ED. The study was performed at a large urban hospital with an annual ED volume of 70,000 patients. All patients requiring critical care in the ED or hospital were prospectively observed between September 1 and November 30, 1993. Patients requiring recovery room care or neonatal intensive care were excluded. Data collected included age, disposition, length of stay, triage acuity assignment in the ED, primary diagnosis, and critical care procedures. During the study, 11,989 patients were examined in the ED with 500 (5%) requiring admission, 340 (3%) requiring a critical care intervention, and 96 (1%) being admitted to an intensive care unit (ICU). Ten percent of patients receiving critical care in the ED were admitted to the floor for lack of bed space. Triage assignment of emergent life-threatening or urgent potentially life-threatening condition predicted critical care need and waiting time to examination. The spectrum of critical care procedures performed in the ED and ICU were similar except for advanced life support intervention, which was more common in the ED (17 versus 3), and arterial line placement, which was more common in the ICU (14 versus 1). The spectrum of diagnoses reflected the age of patients with cardiovascular illnesses (33%), metabolic illnesses (18%), and trauma (16%) common in adults (age ≥17) and infectious illnesses (46%) or metabolic illnesses (21%) more common in pediatric patients. Overall, 14% of adult critical care, 23% of pediatric critical care, and 15% of all critical care provided in the areas studied occurred in the ED. A significant proportion of critical care is provided in the ED, and triage acuity assignment reflects this need. A significant proportion of critically ill patients was admitted to the floor for lack of bed space, which highlights the financial constraints in urban hospitals such as the one studied.     

Facial imaging in an urban emergency department.

To describe the facial imaging practice pattern in our an emergency department and to assess the implications of this practice, a retrospective review was conducted of patients with blunt facial trauma requiring facial imaging over a 2-month period. Patients were compared based on their initial imaging study, either facial x-rays (primary FXR) or spiral computed tomography (primary FSCT). Of 211 patients imaged, 148 (70%) received primary FXR and 63 (30%) primary FSCT. A greater proportion of primary FSCT patients had at least one fracture detected (57% v. 26%; odds ratio 3.9, confidence interval 2.0-7.5). Of patients with a fracture on FXR, 29% underwent secondary FSCT. The average facial imaging charges per case detected (patient with a fracture) were $978 for primary FXR and $2,048 for primary FSCT. Physicians made avid use of FSCT. Additional studies are needed to determine the appropriateness of this practice and to improve clinical selection of patients requiring FSCT.     

The role of day hospital in optimization of medical care for patients of a therapeutic department of an outpatient clinic

Day hospital (DH) provides consultations and treatment for all referred patients according to standards of medical care quality. DH has facilities for therapeutic and gastroenterological patients. Treatment in DH is performed according to current standards which cover basic treatment of the diseases (documented medicines, duration of treatment). Efficacy of DH's use of the Standards of Diagnosis and Therapy of Acid-Dependent Diseases associated with Helicobacter pylori (standards of Moscow consensus) is used as illustration. As a result of treatment in DH 93% outpatients resumed their jobs, improvement occurred in 96.7% patients, a complete response was seen in 23%, 1.9% cases failed treatment. Most DH patients (83%) were satisfied with treatment given in DH and think it a convenient replacement of hospital stay.     

Limitations of chest pain follow-up from an urban teaching hospital emergency department

Close outpatient follow-up of chest pain patients released from the emergency department (ED) has been suggested as an important means of detecting atypical presentations of cardiac ischemia. Urban teaching hospital patient populations often have limited private physician follow-up options and rely upon standard teaching hospital clinic systems. We analyzed the follow-up of 318 patients 30 or more years of age with nontraumatic chest pain released from the ED of a large urban teaching hospital. The planned disposition of the released patients was as follows: a medical clinic (136), another clinic or a private physician (76), or ED "as needed" (98); in addition, some patients left against medical advice (AMA) (8). The medical clinics received only 38% (51/136) of planned referrals. No subsequent record could be found for 13% (17/136) of referred patients. Only 17% (23/136) of referred patients were reevaluated within seven days. Two of the patients referred to medical clinics were admitted to the hospital within 24 hours for unstable angina and another was admitted from a medical clinic 16 days after ED evaluation with an acute myocardial infarction. Of patients with ED follow-up "as needed," one patient required admission for unstable angina 27 days after ED evaluation. Of the patients who left AMA, only two were reevaluated within 30 days. These findings suggest that specific measures to enhance follow-up must be instituted at urban teaching hospitals if chest pain patients are to be closely followed after ED release.     

Patient satisfaction in an urban accident and emergency department.

The aim of this study was to assess patients' opinions about their experience of attending an urban Accident and Emergency department. They were given a questionnaire designed to demonstrate any shortcomings in the delivery of care which required corrective actions. Just over half (50.8%) the patients responded, 411 (95%) of whom recorded satisfaction with the outcome of their visit (P = 0.0001). There was significant correlation between patient satisfaction and waiting time to see the doctor (P = 0.003), the doctor's explanation about management (P = 0.02), and total time spent in the department (P = 0.01). A total of 120 patients (27.8%) did not receive any explanation from the nurse about what was going to happen, and 267 (61.6%) received no information about possible delay. These factors did not significantly influence patients' satisfaction with the outcome, but they need to be addressed as they will obviously lead to an improved service.     

Influence of time-to-interventions for emergency department critical care patients on hospital mortality.

INTRODUCTION: Patients seeking ED services require intensive interventions. Minimal literature exists on outcomes of mortality for ED patients admitted directly to ICU beds and outcomes of hospital stay. Wait times of the following interventions-time to first medication, first radiologic examination, first blood work, arrival in the emergency department to order for an ICU bed, and time of admission order to leaving the emergency department-were investigated for associations with hospital mortality. METHODS: This study was a quantitative, retrospective, non-experimental, exploratory, comparative analysis of secondary data. RESULTS: Nearly 54% of patients arrived by ambulance; 46% were walk-ins. Mean minutes to ICU admission order was 206.50; from order to leaving the emergency department, 93.56 minutes; and length of stay in the emergency department, 298 minutes. Mortality rates were higher for weekend admissions than for weekday admissions. An implication of logistic regression was that longer periods from order to leaving the emergency department affected hospital mortality rates. DISCUSSION: Mortality rate was more likely to increase the longer it took to leave the emergency department after an admission order. Further study on timeliness of ED interventions related to hospital outcomes may provide the information to revise practice. Using a system-wide database interfaced with an in-hospital system would facilitate the ability to do outcomes research.     

Non-fatal injuries among pediatric patients seeking care in an urban Ghanaian emergency department

Introduction

It is important to have a venous line in cardiopulmonary arrest (CPA) patients as an emergency treatment measure in prehospital settings, but establishment of a peripheral venous line is difficult in such patients. This study aimed to investigate the current status of intravenous infusion (IVI) in CPA patients by Emergency Life-Saving Technicians (ELSTs) in Japan. We also considered alternative measures in case IVI was difficult or impossible.

Methods

We investigated a nationwide database between 1 January 2005 and 31 December 2008. From a total of 431,968 CPA cases, we calculated the IVI success rate and related parameters. The Bone Injection Gun (BIG) and simulator legs (adult, pediatric, and infant) were used by 100 ELSTs selected for the study to measure the time required and the success rate for intraosseous infusion (IOI).

Results

The number of CPA patients, IVI, adrenaline administration, and the IVI success rate in adult CPA patients increased every year. However, the IVI success rate in pediatric CPA patients did not increase. Although adrenaline administration elevated the ROSC rate, there was no improvement in the 1-month survival rate. The time required for IOI with BIG was not different among the leg models. The success rates of IOI with BIG were 93%, 94%, and 84% (p < 0.05 vs. adult and pediatric) in adult, pediatric, and infant models, respectively.

Conclusions

The rate of success of IVI in adult CPA patients has been increased yearly in Japan. However, as establishing a peripheral venous line in pediatric patients (1-7 years old) by ELSTs is extremely difficult in prehospital settings, there was no increase in the IVI success rate in such patients. As the study findings indicated IOI with BIG was easy and rapid, it may be necessary to consider IOI with BIG as an alternative option in case IVI is difficult or impossible in adult and pediatric patients.     

Postexposure rabies prophylaxis in an urban emergency department

The purpose of this retrospective study was to identify those patients presenting to an urban emergency department with animal-related wounds, define source animal demographics, and assess adequacy of wound care, rabies immunoprophylaxis, and follow-up. Sixty-three patients comprised the study population; dogs (76%) and cats (16%) were the principal source animals. Postexposure rabies prophylaxis was indicated in ten patients (16%) due to wounds inflicted by stray dogs and cats. Animal behavior and vaccination history were inconsistently addressed, but were documented significantly more often in patients who received prophylaxis. Inclusion of soap in wound care was not significantly more common in the treated group. Human rabies immune globulin was administered incorrectly at least one-third of the time. Appropriate follow-up was arranged in only 31% of cases; this occurred significantly more offen with treated patients. An awareness of both regional epidemiological trends in animal rabies and local health department treatment recommendations will encourage optimal delivery of postexposure treatment in cases of potential rabies exposure.     

Emergency physician knowledge of reimbursement rates associated with emergency medical care

Study Objective

We investigated emergency physician knowledge of the Centers for Medicare & Medicaid Services (CMS) reimbursement for common tests ordered and procedures performed in the emergency department (ED), determined the relative accuracy of their estimation, and reported the impact of perceived costs on physicians' ordering and prescribing behavior.

Methods

We distributed an online survey to 189 emergency physicians in 11 EDs across multiple institutions. The survey asked respondents to estimate reimbursement rates for a limited set of medical tests and procedures, rate their level of current cost knowledge, and determine the effect of health expenditures on their medical decision making. We calculated relative accuracy of cost knowledge as a percent difference of participant estimation of cost from the CMS reimbursement rate.

Results

Ninety-seven physicians participated in the study. Most respondents (65%) perceived their knowledge of costs as inadequate, and 39.3% indicated that beliefs about cost impacted their ordering behavior. Eighty percent of physicians surveyed were unable to estimate 25% of the costs within ± 25%, and no physicians estimated at least 50% of costs within 25% of the CMS reimbursement and only 17.3% of medical services were estimated correctly within ± 25% by 1 or more physicians.

Conclusion

Most emergency physicians indicated they should consider cost in their decision making but have a limited knowledge of cost estimates used by CMS to calculate reimbursement rates. Interventions that are easily accessible and applicable in the ED setting are needed to educate physicians about costs, reimbursement, and charges associated with the care they deliver.     

综合医院急诊危重患者流行病学分析

目的研究急诊科抢救区危重患者的流行病学特点。方法对2011年急诊科抢救区2987例危重患者的年龄、性别、入科及转归时间分布、疾病谱和病死率等进行回顾性分析。结果循环系统、神经系统、呼吸系统疾病是急诊科的前3位危重病;男性多于女性;60～79岁老年组抢救人数最多;病死率由高到低前3位疾病是院前猝死、血液系统疾病和呼吸系统疾病;急诊抢救患者全年出现2个就诊高峰,分别为4月及12月,全天就诊高峰在16：00～20：00。结论危重患者的抢救工作是急诊工作的重中之重,应及时解除危及生命的紧急情况并尽快分流;抢救对象主要为老年心脑血管及呼吸系统疾病;应根据急诊抢救患者的分布特点合理安排人员及物资;建立病死率较高的几种急性单病种的绿色通道,建立院内合作团队,提高抢救成功率;做好相关的健康宣教工作,普及高危人群的急救知识。     

某院门急诊老年患者潜在不适当用药的评价分析

目的 使用Beers标准(2019版)对某院门急诊老年患者潜在不适当用药(PIM)情况进行系统分析,为促进患者用药安全提供依据.方法 回顾性抽取某院2020年第四季度门急诊处方,对65岁及以上的老年患者用药情况进行统计分析,以Beers标准(2019版)为评判依据,评价老年患者PIM情况.结果 共收集该院2020年第四...     

Use of an accident and emergency department by hospital staff.

OBJECTIVE: To assess the number of attendances by hospital staff at an accident and emergency (A&E) department, and reasons for their attendance. METHODS: A&E attendances by hospital staff were studied for a 12 month period. Comparison was made with attendances by non-hospital staff in full or part time employment. Differences between the observed and expected numbers of attendances were analysed using chi 2 analysis. RESULTS: 560 staff attendances were recorded out of 78,103 total attendances. There was an observed excess number of attendances by nursing staff for work related incidents when compared to the control group (P = 0.01). However, there were fewer attendances by nursing staff for non-work related incidents (P = 0.01). Staff other than doctors and nurses attended the A&E department more frequently than the control group for non-work related incidents (P = 0.01), but their attendance for incidents occurring at work were the same as the control group (P = NS). CONCLUSIONS: The increased use of A&E resources by staff other than doctors and nurses may be inappropriate and further research into their reasons for attendance is warranted.