Acute care needs in an Indian emergency department: A retrospective analysis

BACKGROUND: Emergencies such as road traffic accidents (RTAs), acute myocardial infarction (AMI) and cerebrovascular accident (CVA) are the most common causes of death and disability in India. Robust emergency medicine (EM) services and proper education on acute care are necessary. In order to inform curriculum design for training programs, and to improve the quality of EM care in India, a better understanding of patient epidemiology and case burden presenting to the emergency department (ED) is needed.METHODS: This study is a retrospective chart review of cases presenting to the ED at Kerala Institute of Medical Sciences (KIMS), a private hospital in Trivandrum, Kerala, India, from November 1, 2011 to April 21, 2012 and from July 1, 2013 to December 21, 2013. De-identified charts were systematically sampled and reviewed.RESULTS: A total of 1 196 ED patient charts were analyzed. Of these patients, 55.35% (n=662) were male and 44.7% (n=534) were female. The majority (67.14%, n=803) were adults, while only 3.85% (n=46) were infants. The most common chief complaints were fever (21.5%, n=257), renal colic (7.3%, n=87), and dyspnea (6.9%, n=82). The most common ED diagnoses were gastrointestinal (15.5%, n=185), pulmonary (12.3%, n=147), tropical (11.1%, n=133), infectious disease and sepsis (9.9%, n=118), and trauma (8.4%, n=101).CONCLUSION: The patient demographics, diagnoses, and distribution of resources identified by this study can help guide and shape Indian EM training programs and faculty development to more accurately reflect the burden of acute disease in India.     

The role of nurses in the recognition and treatment of patients with sepsis in the emergency department: A prospective before-and-after intervention study

Background

In 2004, the Surviving Sepsis Campaign (SSC), a global initiative to reduce mortality from sepsis, was launched. Although the SSC supplies tools to measure and improve the quality of care for patients with sepsis, effective implementation remains troublesome and no recommendations concerning the role of nurses are given.

Objectives

To determine the effects of a multifaceted implementation program including the introduction of a nurse-driven, care bundle based, sepsis protocol followed by training and performance feedback.

Design and setting

A prospective before-and-after intervention study conducted in the emergency department (ED) of a university hospital in the Netherlands.

Participants

Adult patients (≥16 years old) visiting the ED because of a known or suspected infection to whom two or more of the extended systemic inflammatory response syndrome (SIRS) criteria apply.

Methods

We measured compliance with six bundled SSC recommendations for early recognition and treatment of patients with sepsis: measure serum lactate within 6 h, obtain two blood cultures before starting antibiotics, take a chest radiograph, take urine for urinalysis and culture, start antibiotics within 3 h, and hospitalize or discharge the patient within 3 h.

Results

A total of 825 patients were included in the study. Compliance with the complete bundle significantly improved from 3.5% at baseline to 12.4% after our entire implementation program was put in place. The completion of four of six individual elements improved significantly, namely: measure serum lactate (improved from 23% to 80%), take a chest radiograph (from 67% to 83%), take urine for urinalysis and culture (from 49% to 67%), and start antibiotics within 3 h (from 38% to 56%). The mean number of performed bundle elements improved significantly from 3.0 elements at baseline to 4.2 elements after intervention [1.2; 95% confidence interval = 0.9–1.5].

Conclusions

Early recognition of sepsis in patients presenting to the ED and compliance with SSC recommendations significantly improved after the introduction of a predominantly nurse-driven, care bundle based, sepsis protocol followed by training and performance feedback.     

The care of mental health patients in the emergency department: one rural hospital's approach

Background: The need for mental health services in the Emergency Department (ED) has been steadily increasing, with long waits being reported for patients needing mental health services. In the present setting, patients waited an average of 2–3 h to see a mental health professional. Objective: The objective of this intervention was to greatly decrease the wait times for ED patients with mental health needs. Discussion: Four mental health professionals were trained to complete crisis assessments for patients in the ED, and an Access Center (AC) was added to the ED. The AC is staffed 24 h a day, 7 days a week. The purpose of the AC was to meet the mental health needs of ED patients as quickly as possible. Conclusion: Patients with mental health needs now receive services in a timely manner (< 30 min) despite the fact that the number of patients needing mental health services is steadily increasing. The addition of an Access Center to the ED has resulted in the provision of mental health services within time limits acceptable to both the patients and the medical staff.     

The significance of non-sustained hypotension in emergency department patients with sepsis

Objective  Few studies have documented the incidence and significance of non-sustained hypotension in emergency department (ED) patients with sepsis. We hypothesized that ED non-sustained hypotension increases risk of in-hospital mortality in patients with sepsis. Methods  Secondary analysis of a prospective cohort study. ED patients aged >17 years admitted to the hospital with explicitly defined sepsis were prospectively identified. Inclusion criteria  Evidence of systemic inflammation (>1 criteria) and suspicion for infection. Patients with overt shock were excluded. The primary outcome was in-hospital mortality. Results  Seven hundred patients with sepsis were enrolled, including 150 (21%) with non-sustained hypotension. The primary outcome of in-hospital mortality was present in 10% (15/150) of patients with non-sustained hypotension compared with 3.6% (20/550) of patients with no hypotension. The presence of non-sustained hypotension resulted in three times the risk of mortality than no hypotension (risk ratio = 2.8, 95% CI 1.5–5.2). Patients with a lowest systolic blood pressure <80 mmHg had a threefold increase in mortality rate compared with patients with a lowest systolic blood pressure ≥80 mmHg (5 vs. 16%). In logistic regression analysis, non-sustained hypotension was an independent predictor of in-hospital mortality. Conclusion  Non-sustained hypotension in the ED confers a significantly increased risk of death during hospitalization in patients admitted with sepsis. These data should impart reluctance to dismiss non-sustained hypotension, including a single measurement, as not clinically significant or meaningful. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Immigrants in emergency care: Swedish health care staff's experiences

BACKGROUND: During the past few decades Sweden has developed into a multicultural society. The proportion of patients with different cultural backgrounds increases, which naturally makes new demands on health care staff. AIM: To identify whether staff in somatic and psychiatric emergency care experienced problems in the care of migrants, and if so to compare these. METHOD: The study design was explorative. Focus group interviews of 22 women and 13 men working as nurses and assistant nurses at an emergency ward, an ambulance service and a psychiatric intensive care unit were held. FINDINGS: The results showed that the main problems experienced in all wards were difficulties related to caring for asylum-seeking refugees. Some dissimilarities were revealed: unexpected behaviours in migrants related to cultural differences described by staff working in the emergency ward; migrants' refusal to eat and drink and their inactive behaviour in the psychiatric ward; and a lot of non-emergency runs by the ambulance staff because of language barriers between the emergency services centre and migrants. CONCLUSION: The main problems experienced by the health care staff were situations in which they were confronted with the need to care for asylum-seeking refugees. PRACTICE IMPLICATIONS: These emphasize the importance of support from organizational structures and national policies to develop models for caring for asylum-seeking refugees. Simple routines and facilities to communicate with foreign-language-speaking migrants need to be developed. Health care staff need a deeper understanding of individual needs in the light of migrational and cultural background.     

Procalcitonin as a diagnostic marker for sepsis/septic shock in the emergency department; a study based on Sepsis-3 definition

Introduction

The recent definition of sepsis was modified based on a scoring system focused on organ failure (Sepsis-3). It would be a time-consuming process to detect the sepsis patient using Sepsis-3. Procalcitonin (PCT) is a well-known biomarker for diagnosing sepsis/septic shock and monitoring the efficacy of treatment. We conducted a study to verify the predictability of PCT for diagnosing sepsis based on Sepsis-3 definition.

Effect of neutrophil CD64 for diagnosing sepsis in emergency department

BACKGROUND:The aim of this study is to investigate the diagnostic and prognostic value of neutrophil CD64(nCD64)as a novel biomarker in sepsis patients.METHODS:One hundred fifty-one adult patients diagnosed with sepsis and 20 age-matched healthy controls were enrolled in the study.Patients with sepsis were further subdivided into a sepsis group and a septic shock group.nCD64 expression,serum procalcitonin(PCT)level,C-reactive protein(CRP)level,and white blood cell(WBC)count were obtained for each patient,and Sequential Organ Failure Assessment(SOFA)scores were calculated.RESULTS:nCD64 expression was higher in the sepsis group with confirmed infection than in the control group.The receiver operating characteristic(ROC)curve of nCD64 was higher than those of SOFA score,PCT,CRP and WBC for diagnosing infection.The area under the curve(AUC)of nCD64 combined with SOFA score was the highest for all parameters.The AUC of nCD64 for predicting 28-day mortality in sepsis was signifi cantly higher than those of PCT,CRP,and WBC,but slightly lower than that of SOFA score.The AUC of nCD64 or PCT combined with SOFA score was signifi cantly higher than that of any single parameter for predicting 28-day mortality.CONCLUSION:nCD64 expression and SOFA score are valuable parameters for early diagnosis of infection and prognostic evaluation of sepsis patients.     

Validating a point of care lactate meter in adult patients with sepsis presenting to the emergency department of a tertiary care hospital of a low- to middle-income country

BACKGROUND: Timely identification of high blood lactate levels in septic patients may allow faster detection of those patients requiring immediate resuscitation. Point-of-care (POC) testing is being increasingly utilized in the emergency department (ED). We examined the accuracy and time-saving effect of a handheld POC lactate device for the measurement of fingertip and whole blood lactate as compared with reference laboratory blood testing in septic ED patients.     

A comparison of perspectives on costs in emergency care among emergency department patients and residents

BACKGROUND: Costs of care are increasingly important in healthcare policy and, more recently, in clinical care in the emergency department (ED). We compare ED resident and patient perspectives surrounding costs in emergency care.     

End-of-life care for older people in subacute care: A retrospective clinical audit

Background

With an ageing population and chronic illness the leading cause of death, challenges exist in meeting the healthcare needs of older people. For older people, care may be provided in subacute care services where, although the focus is on rehabilitation and optimisation of functioning, many older people will die.

Implementation of guidelines in primary health care. A challenge for the municipal health centres in Finland

Objective - To assess the implementation of guidelines in Finnish primary health care units. Design - A semi-quantitative analysis of a cross-sectional interview survey. Setting - All municipal health centres in a selected region in Finland. Subjects - Head physicians and head nurses of the 31 participating units. Main outcome measures - Number of guidelines adopted; methods used in the implementation; and the unit's estimated purposefulness in the implementation of guidelines. Results - All health centres had adopted at least one guideline in the defined task areas, but only one-third of the units had implemented several guidelines. The implementation methods utilised were usually directive and passive rather than co-operative and problem-solving. Half of the units used training and methods involving active partici pation of the personnel, and in one-third a multiprofessional approach was applied. Clients' representatives were hardly ever involved in the adaptation of guidelines. A quarter of the health centres were assessed as purposeful in their policy to implement guidelines, the large units being more goal-oriented than the smaller ones. Conclusions - A minority of health centres are goal-oriented in the adoption of guidelines and use versatile methods to support the implementation; this presents an important managerial challenge for national health care development in Finland.     

Blood lactate measurement within the emergency department: A two-year retrospective analysis

We evaluate in this retrospective cohort, the clinical situations leading emergency physicians to take a blood lactate sample, the prevalence of hyperlactatemia and its impact on short-term adverse outcome. ED patients requiring a blood lactate measurement (BLM) during a two-year period were included. Early patients' outcomes were extracted and discharge diagnoses were classified into 12 diagnostic categories. A total of 118,737 patients were analyzed. A BLM was carried out in 13,089 of them. Surprisingly, the proportion of patients having a BLM was higher in those admitted for seizure (31.4%) than in those admitted for infection (27.9%). Ten percent of patients who had a blood lactate test had a lactate level >4?mmol/l (1,315). Among them, 23.2% were admitted for infections, 20% for seizures, and 11% for cardiovascular diseases. After excluding the patients older than 75?years from the analysis in order to prevent a selection bias, the patient's severity was independently associated to an age over 65?years (OR: 1.26), an arterial blood sampling (OR: 2.77) and the blood lactate level (OR: 1.31). The blood lactate level was very informative to detect the sicker patients in the infection group whereas its interest was poor in the group of patients admitted for seizures. In conclusion, blood lactate testing has become routine in emergency departments and a large proportion of patients have abnormal blood lactate levels. The most frequent causes of high blood lactate in the ED are infection and seizures but the prognostic value of blood lactate seems to be different from one diagnostic category to the other.     

The influence of crowding on clinical practice in the emergency department

Background

This study aimed to clarify the association between the crowding and clinical practice in the emergency department (ED).

Using transprofessional care in the emergency department to reduce patient admissions: A retrospective audit of medical histories

The demand for emergency department (ED) services has increased significantly, due to our increasingly ageing population and limited access to primary care. This article reports outcomes from a transprofessional model of care in an ED in Victoria, Australia. Nurses, physiotherapists, social workers, and occupational therapists undertook additional education to increase the range of services they could provide and thereby expedite patient flow through the ED. One hundred patients who received this service were matched against 50 patients who did not. The most common reasons for patient admission were limb injury/limb pain (n = 47, 23.5%) and falls (n = 46, 23.0%). Transprofessional interventions included applying supportive bandages, slings, zimmer splints and controlled ankle motion (CAM) boots, and referral to new services such as case management and mental health teams. The rate of hospital admissions was significantly lower in the transprofessional group (n = 27, 18.0%) than in the reference group (n = 19, 38%, p = 0.005). This group also had a slightly lower re-presentation rate (n = 4, 2.7%) than patients in the reference group (n = 2, 4.0%). There are many benefits that support this model of care that in turn reduces ED overcrowding and work stress. A transprofessional model may offer a creative solution to meeting the varied needs of patients presenting for emergency care.     

休克指数对急诊严重脓毒症和脓毒性休克预后评估的意义

目的 通过测定严重脓毒症和脓毒性休克患者休克指数(SI)水平,探讨其对严重脓毒症和脓毒性休克预后的影响.方法 本文采用回顾性研究的方法,选取2011年9月至2013年8月间入住首都医科大学附属北京友谊医院急诊监护室的严重脓毒症和脓毒症休克患者100例,根据28 d转归再分为生存组(n=48)和院内死亡组(n=52).分别测量并计算所有患者入院时的休克指数(SI1)和入院后就接受液体复苏后2h的休克指数(SI2).结果 (1)死亡组入院时和液体复苏后2h休克指数(1.5±0.05)、(1.2±0.04)高于生存组(1.3±0.08)、(0.9±0.05),二者的差异具有统计学意义(P＜0.01);(2)根据ROC曲线分析并计算AUC值,死亡组SI1、SI2曲线下面积(AUC)分别是0.707 5、0.889 4,SI2≥1为截断点评价严重脓毒症及脓毒性休克患者的预后评价的敏感性为80.3％,特异性为78.4％.结论 入院后复苏2h的休克指数(SI2)较入院时休克指数(SI1),能较好的预测严重脓毒症和脓毒性休克患者的预后.     

The risk stratification and prognostic evaluation of soluble programmed death-1 on patients with sepsis in emergency department

Objective

To evaluate the efficacy of soluble programmed death-1 (sPD-1) for risk stratification and prediction of 28-day mortality in patients with sepsis, we compared serum sPD-1 with procalcitonin (PCT), C-reactive protein (CRP), and the Mortality in Emergency Department Sepsis (MEDS) score.

D-二聚体对急诊脓毒症患者预后价值的前瞻性研究

目的 探讨D-二聚体浓度能否预测急诊脓毒症患者28 d病死率,以及D-二聚体浓度对于脓毒症患者预后的意义.方法 采用前瞻性研究方法,选取2009年10月至2010年7月首都医科大学附属北京朝阳医院急诊科766例脓毒症患者,检测患者入院时的血中D-二聚体浓度(固相免疫层析法),并记录各项实验室检测指标和临床生理指标.以28 d为终点比较存活组与死亡组患者的D-二聚体水平、急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分和简化急性生理学评分系统Ⅱ(SAPSⅡ)评分;分析D-二聚体水平与28 d病死率的关系.结果 766例脓毒症患者28 d内共有233例死亡,死亡组血中D-二聚体浓度(μg/L)明显高于存活组[1220.0(789.0,1835.0)比323.0(158.0,642.0),P＜0.01].D-二聚体水平与APACHEⅡ评分和SAPSⅡ评分均呈显著正相关(r1=0.643,r2=0.632,均P＜0.01).D-二聚体水平预测28 d病死率的受试者工作特征曲线(ROC曲线)下面积为0.880,95％可信区间(95％CI)为0.855～0.904,P＜0.001,预测28 d病死率的最佳界值为663.5 μg/L.血中D-二聚体＞663.5μg/L、APACHEⅡ评分＞19.5分和SAPSⅡ评分＞39.5分是预测患者28 d病死率的独立危险因素[优势比(OR值)分别为17.5、15.7、19.6,均P＜0.001].D-二聚体＜ 250.0、250.0～663.5、＞663.5 μg/L 3组间28 d病死率(1.4％、12.3％、64.2％)、APACHEⅡ评分[分:11(9,13)、13(11,16)、19(15,22)]、SAPSⅡ评分[分:24(18,29)、31(24,36)、40(33,49)]比较差异均有统计学意义(均P＜0.01).结论 D-二聚体水平是预测急诊脓毒症患者28 d病死率的独立指标.其预测能力与APACHEⅡ评分和SAPSⅡ评分十分相近;检测D-二聚体水平有助于脓毒症患者的危险分层.     

The prognostic value of sepsis scores and dichotomized triage score in patients presenting to the emergency department with fever: A prospective,observational study

BackgroundThe performance of the Quick Sequential Organ Failure Assessment (qSOFA) score needs to be explored further in the emergency triage room. This study aims to explore the performance of triage (tqSOFA) versus the dichotomized triage score (DTS) in patients admitted to the emergency room triage with fever.MethodsThis research was designed as a prospective, observational study within a six-month period, including patients who presented to the emergency room triage with infrared fever ≥ 37.5 °C.Results771 patients were analyzed.The highest sensitivity for predicting overall hospitalization and intensive care admission was seen for DTS (95.4 %, 100 %; p < 0.0001, p < 0.0001, respectively) (AUC:0.697, 95 % CI 0.663 to 0.730; AUC:0.684, 95 % CI 0.650 to 0.717, respectively). The highest sensitivity for predicting 1st week and 1st month mortality was found for DTS (100 %, 96.3 %; p < 0.0001, p < 0.0001, respectively). However, the highest specificity for predicting 1st week and 1st month mortality was observed in tqSOFA (94.1 %, 95.16; p = 0.0845, p < 0.0001, respectively) (AUC:0.658, 95 % CI 0.623 to 0.691; AUC:0.698, 95 % CI 0.664 to 0.730, respectively).ConclusionWe found DTS to be as effective as tqSOFA and SIRS in determining all hospitalization times and mortality.     

Death and do-not-resuscitate order in the emergency department: A single-center three-year retrospective study in the Chinese mainland

BACKGROUND: Consenting to do-not-resuscitate (DNR) orders is an important and complex medical decision-making process in the treatment of patients at the end-of-life in emergency departments (EDs). The DNR decision in EDs has not been extensively studied, especially in the Chinese mainland.