Editorial of clinics for ultrasonography in emergency department

Each year approximately 1,000,000 people die by suicide, accounting for nearly 3% of all deaths and more than half (56%) of all violent deaths in the world (Krug, Dahlberg, Mercy, Zwi, & Lozano, 2002). Suicide ideation and suicide attempts are strongly linked to death by suicide and powerfully predict further suicidal behavior (Institute of Medicine, 2002). There are an estimated 100–200 suicide attempts for each completed suicide in young people, and 4 attempts for each completed suicide in the elderly (Institute of Medicine, 2002). Emergency departments (EDs) are the most important site, epidemiologically speaking, for treating those who make suicide attempts. EDs in the United States, for example, record over 500,000 suicide-related visits annually (Larkin, Smith, & Beautrais, 2008). The majority of suicide attempt patients are discharged after medical stabilization and psychosocial evaluation, but carry a significant risk of recidivism (Larkin, Smith, & Beautrais, 2008). Similarly, ED patients who present with suicide ideation (without attempt) have risks of returning to the ED with further ideation or with suicide attempts which are as high as those who present with attempts (Larkin, Beautrais, Gibb, & Laing, 2008). In addition, a significant fraction of those who present to EDs for nonmental health reasons often have occult or silent suicide ideation (estimated at 8–12%) (Claassen & Larkin, 2005). The worldwide economic tsunami and sky-rocketing healthcare costs have ensured that mental health-related visits and presentations for suicidal behavior will continue to rise in the foreseeable future. The closure of psychiatric inpatient facilities, reductions in inpatient beds, moves to treat people in the community, and increased costs of general practitioner visits have coincided with – and likely account for – increased ED attendances by psychiatric and suicidal patients who previously might have been admitted or seen in primary care. The ED is now the default, de facto option for urgent and acute contact for suicidal patients within the health system – and in many countries the ED is the only access to 24/7 healthcare (Fields et al., 2001).

Investigating Rare Events and a Discussion on Waiting Room Chest Pain Evaluations: Answers to the November 2010 Journal Club Questions

The authors sought to describe the epidemiology of and risk factors for recurrent and high-frequency use of the emergency department (ED) by children. This was a retrospective cohort study using a database of children aged 0 to 17 years, inclusive, presenting to 22 EDs of the Pediatric Emergency Care Applied Research Network (PECARN) during 2007, with 12-month follow-up after each index visit. ED diagnoses for each visit were categorized as trauma, acute medical, or chronic medical conditions. Recurrent visits were defined as any repeat visit; high-frequency use was defined as four or more recurrent visits. Generalized estimating equations (GEEs) were used to measure the strength of associations between patient and visit characteristics and recurrent ED use. A total of 695,188 unique children had at least one ED visit each in 2007, with 455,588 recurrent ED visits in the 12 months following the index visits. Sixty-four percent of patients had no recurrent visits, 20% had one, 8% had two, 4% had three, and 4% had four or more recurrent visits. Acute medical diagnoses accounted for most visits regardless of the number of recurrent visits. As the number of recurrent visits per patient rose, chronic diseases were increasingly represented, with asthma being the most common ED diagnosis. Trauma-related diagnoses were more common among patients without recurrent visits than among those with high-frequency recurrent visits (28% vs. 9%; p<0.001). High-frequency recurrent visits were more often within the highest severity score classifications. In multivariable analysis, recurrent visits were associated with younger age, black or Hispanic race or ethnicity, and public health insurance. Risk factors for recurrent ED use by children include age, race and ethnicity, and insurance status. Although asthma plays an important role in recurrent ED use, acute illnesses account for the majority of recurrent ED visits.

The objective was to characterize the medical, social, and psychiatric correlates of frequent emergency department (ED) use among released prisoners with human immunodeficiency virus (HIV). Data on all ED visits by 151 released prisoners with HIV on antiretroviral therapy (ART) were prospectively collected for 12 months. Correlates of frequent ED use, defined as having two or more ED visits postrelease, were described using univariate and multivariate models and generated medical, psychiatric, and social multimorbidity indices. Forty-four (29%) of the 151 participants were defined as frequent ED users, accounting for 81% of the 227 ED visits. Frequent ED users were more likely than infrequent or nonusers to be female; have chronic medical illnesses that included seizures, asthma, and migraines; and have worse physical health-related quality of life (HRQoL). In multivariate Poisson regression models, frequent ED use was associated with lower physical HRQoL (odds ratio [OR] = 0.95, p = 0.02) and having not had prerelease discharge planning (OR = 3.16, p = 0.04). Frequent ED use was positively correlated with increasing psychiatric multimorbidity index values. Among released prisoners with HIV, frequent ED use is driven primarily by extensive comorbid medical and psychiatric illness. Frequent ED users were also less likely to have received prerelease discharge planning, suggesting missed opportunities for seamless linkages to care.

Investigating Rare Events and a Discussion on Waiting Room Chest Pain Evaluations

Internal Medicine JournalVolume 42, Issue 8 p. 958-959 Reply B. Mitra, B. Mitra Emergency & Trauma Centre Department of Epidemiology and Preventive Medicine, Monash UniversitySearch for more papers by this authorP. A. Cameron, P. A. Cameron Emergency & Trauma Centre Department of Epidemiology and Preventive Medicine, Monash UniversitySearch for more papers by this authorP. Archer, P. Archer Emergency Department, Maroondah Hospital, Melbourne, VictoriaSearch for more papers by this authorM. Bailey, M. Bailey Department of Epidemiology and Preventive Medicine, Monash UniversitySearch for more papers by this authorP. Pielage, P. Pielage Emergency Department, Launceston General Hospital, Launceston, Tasmania, AustraliaSearch for more papers by this authorG. Mele, G. Mele Emergency Department, Maroondah Hospital, Melbourne, VictoriaSearch for more papers by this authorD. V. Smit, D. V. Smit Emergency & Trauma CentreSearch for more papers by this authorH. Newnham, H. Newnham Department of Medicine, The Alfred HospitalSearch for more papers by this author B. Mitra, B. Mitra Emergency & Trauma Centre Department of Epidemiology and Preventive Medicine, Monash UniversitySearch for more papers by this authorP. A. Cameron, P. A. Cameron Emergency & Trauma Centre Department of Epidemiology and Preventive Medicine, Monash UniversitySearch for more papers by this authorP. Archer, P. Archer Emergency Department, Maroondah Hospital, Melbourne, VictoriaSearch for more papers by this authorM. Bailey, M. Bailey Department of Epidemiology and Preventive Medicine, Monash UniversitySearch for more papers by this authorP. Pielage, P. Pielage Emergency Department, Launceston General Hospital, Launceston, Tasmania, AustraliaSearch for more papers by this authorG. Mele, G. Mele Emergency Department, Maroondah Hospital, Melbourne, VictoriaSearch for more papers by this authorD. V. Smit, D. V. Smit Emergency & Trauma CentreSearch for more papers by this authorH. Newnham, H. Newnham Department of Medicine, The Alfred HospitalSearch for more papers by this author First published: 21 August 2012 https://doi.org/10.1111/j.1445-5994.2012.02857.xRead the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume42, Issue8August 2012Pages 958-959 RelatedInformation

Although 72-hour emergency department (ED) revisits are increasingly used as a hospital metric, there is no known empirical basis for this 72-hour threshold. The objective of this study was to determine the timing of ED revisits for adult patients within 30 days of ED discharge. This was a retrospective cohort study of all nonfederal ED discharges in Florida and Nebraska from April 1, 2010, to March 31, 2011, using data from the Agency for Healthcare Research and Quality (AHRQ) Healthcare Cost and Utilization Project (HCUP). ED discharges were followed forward to identify ED revisits occurring at any hospital within the same state within 30 days. The cumulative hazard of an ED revisit was plotted. Parametric and nonparametric modeling was performed to characterize the rate of ED revisits. There were 4,782,045 ED discharges, with 7.5% (95% confidence interval [CI] = 7.4% to 7.5%) associated with 3-day revisits, and 22.4% (95% CI = 22.3% to 22.4%) associated with 30-day revisits, inclusive of the 3-day revisits. A double-exponential model fit the data best (p < 0.0001), and a single hinge point at 9 days (multivariate adaptive regression splines [MARS] model) yielded the best linear fit to the data, suggesting 9 days as the most reasonable cutoff for identification of acute ED revisits. Multiple stratified and subgroup analyses produced similar results. Future work should focus on identifying primary reasons for potentially avoidable return ED visits instead of on the revisit occurrence itself, thus more directly measuring potential lapses in delivery of high-quality care. Almost one-quarter of ED discharges are linked to 30-day ED revisits, and the current 72-hour ED metric misses close to 70% of these patients. Our findings support 9 days as a more inclusive cutoff for studies of ED revisits.

The median emergency department (ED) boarding time for admitted patients has been a nationally reportable core measure that now also affects ED accreditation and reimbursement. However, no direct national probability samples of ED boarding data have been available to guide this policy until now. The authors studied new National Hospital Ambulatory Medical Care Survey (NHAMCS) survey items to establish baseline values, to generate hypotheses for future research, and to help improve survey quality in the future. This was a cross-sectional, multistage, stratified annual analysis of EDs and ED visits from the National Hospital Ambulatory Medical Care Survey public use files from 2007 to 2010, a total of 139,502 visit records. These data represent the only national measure of ED boarding. The main outcome of interest was boarding duration for individual patient visits. Data analyses accounted for complex sampling design. The national median boarding time was 79 minutes, with an interquartile range of 36 to 145 minutes. The prevalence of boarding for more than 2 hours among admitted patients was 32% (95% confidence interval [CI] = 30% to 35%). Average ED volume, occupancy, acuity, and hospital admission rates increased abruptly from the second to the third quartile of median boarding duration. The half of hospitals with the longest median boarding times accounted for 73% of ED visits and 79% of ED hospitalizations nationally. Thirty-nine percent of EDs (95% CI = 32% to 46%) reported never holding patients for more than 2 hours, but visit-level analysis at these EDs found that 21% of admissions did in fact stay in the ED over 2 hours. Only 19% of EDs (95% CI = 16% to 22%) used a strategy of moving admitted patients to alternative sites in the hospital during crowded times. In this national survey, ED boarding of admitted patients disproportionately affects hospitals with higher ED volumes, which also see sicker patients who wait longer to be seen, but not hospitals with higher proportions of Medicaid or uninsured visits. This finding implies that, unlike other quality measures, there is a negative volume-outcome relationship for timely hospitalization from the ED.

Improving Quality of Asthma Care After Emergency Department Discharge: Evidence Before Action

To reduce mortality, the Taiwan government has vigorously promoted free cancer screening and preventive health screening services. Cancers are usually advanced by the time they are discovered in the emergency department. Through this study, we aimed to understand the characteristics of cancer patients diagnosed through the emergency department and thus identify high-risk populations by comparing cancer staging and survival rates in patients diagnosed in the emergency department and those diagnosed in the non-emergency department. The retrospective study enrolled a total of 389,043 patients over the age of 20 who were newly diagnosed with one of the five major cancers (including lung cancer, colorectal cancer, breast cancer, prostate cancer, and oral cancer) between 2008 and 2017 and analyzed their diagnostic pathway, cancer stage at diagnosis, and survival time. Of the study participants, 59,423 patients (about 15.3%) were diagnosed with cancer through the emergency department. We found that a sizable proportion of older people and patients with low education and low incomes were diagnosed through emergency department visits, and those with a health condition comorbidity severity of 3 had the highest proportion diagnosed by the emergency department, advanced stages at diagnosis, and risk of death. These can be classified as high-risk groups. In addition, 76.4% of patients diagnosed in the emergency department had advanced cancer, and the risk of death was 1.46 times higher than that of patients diagnosed in the non-emergency department. Although cancer screening is available, it does not reduce the proportion of patients with advanced cancer who are diagnosed through or at the time of diagnosis in the emergency department. The present study found that the government's cancer screening did not affect the proportion or number of cancers diagnosed through emergency department visits. Therefore, the government should focus on more cancer screening, health education in high-risk groups, and strengthening the link between emergency and oncology departments to reduce the risk of death for patients diagnosed through emergency department visits.

Freestanding Emergency Departments: What Is Their Role in Emergency Care?

Identifying older emergency department (ED) patients with clinical features associated with adverse postdischarge outcomes may lead to improved clinical reasoning and better targeting for preventative interventions. Previous studies have used single-country samples to identify limited sets of determinants for a limited number of proxy outcomes. The objective of this study was to identify and compare geriatric syndromes that influence the probability of postdischarge outcomes among older ED patients from a multinational context. A multinational prospective cohort study of ED patients aged 75 years or older was conducted. A total of 13 ED sites from Australia, Belgium, Canada, Germany, Iceland, India, and Sweden participated. Patients who were expected to die within 24 hours or did not speak the native language were excluded. Of the 2,475 patients approached for inclusion, 2,282 (92.2%) were enrolled. Patients were assessed at ED admission with the interRAI ED Contact Assessment, a geriatric ED assessment. Outcomes were examined for patients admitted to a hospital ward (62.9%, n=1,436) or discharged to a community setting (34.0%, n=775) after an ED visit. Overall, 3% of patients were lost to follow-up. Hospital length of stay (LOS) and discharge to higher level of care was recorded for patients admitted to a hospital ward. Any ED or hospital use within 28 days of discharge was recorded for patients discharged to a community setting. Unadjusted and adjusted odds ratios (ORs) were used to describe determinants using standard and multilevel logistic regression. A multi-country model including living alone (OR=1.78, p≤0.01), informal caregiver distress (OR=1.69, p=0.02), deficits in ambulation (OR=1.94, p≤0.01), poor self-report (OR = 1.84, p≤0.01), and traumatic injury (OR=2.18, p≤0.01) best described older patients at risk of longer hospital lengths of stay. A model including recent ED visits (OR=2.10, p≤0.01), baseline functional impairment (OR=1.68, p≤0.01), and anhedonia (OR=1.73, p≤0.01) best described older patients at risk of proximate repeat hospital use. A sufficiently accurate and generalizable model to describe the risk of discharge to higher levels of care among admitted patients was not achieved. Despite markedly different health care systems, the probability of long hospital lengths of stay and repeat hospital use among older ED patients is detectable at the multinational level with moderate accuracy. This study demonstrates the potential utility of incorporating common geriatric clinical features in routine clinical examination and disposition planning for older patients in EDs.

Acute lung injury (ALI) affects an estimated 190,000 persons per year in U.S. intensive care units (ICUs), but little is known about its prevalence in the emergency department (ED). The objective was to describe the prevalence of ALI among mechanically ventilated adult nontrauma patients in the ED. The hypothesis was that the prevalence of ALI in adult ED patients would be low. This was a retrospective cohort study of admitted nontrauma patients presenting to an academic ED. Two trained investigators abstracted data from patient records using a standardized form. The use of mechanical ventilation in the ED was identified in two phases. First, all ED patients were screened for the current procedural terminology (CPT) code for endotracheal intubation (CPT 31500) from January 1, 2003, to December 31, 2006. Second, each patient record was reviewed to verify the use of mechanical ventilation. ALI was defined in accordance with a modified version of the American-European Consensus Conference criteria as: 1) hypoxemia defined as PaO(2) /FiO(2) ratio ≤300 mm Hg on all arterial blood gases (ABGs) in the ED and the first 24 hours of admission, 2) the presence of bilateral infiltrates on chest radiograph, and 3) the absence of left atrial hypertension. Data are presented in absolute numbers and percentages. Interobserver agreement was evaluated using the kappa statistic. Of the 552 patients who received mechanical ventilation in the ED and were subsequently admitted, a total of 134 (24.3%, 95% confidence interval [CI] = 20.8% to 28.0%) met hypoxemia criteria. Of these, 34 had evidence of left atrial hypertension, 52 did not have chest radiograph findings consistent with ALI, and two did not have a chest radiograph performed; the remaining 46 met ALI criteria. An additional two patients who died in the ED had clinical evidence of ALI. Thus, 48 of 552, or 8.7% (95% CI = 6.6% to 11.3%), met criteria for ALI. The kappa value for determination of ALI was 0.84 (95% CI = 0.54 to 1.0). The prevalence of ALI was nearly 9% in adult nontrauma patients receiving mechanical ventilation in the ED. Further study is required to determine which types of patients present to the ED with ALI, the extent to which lung protective ventilation is used, and the need for ED ventilator management algorithms.

RAND Study Highlights Evolving Value of Emergency Medicine: Emergency Physicians Play Key Role as Gatekeepers to Hospital

Barcode-assisted medication administration (BCMA) is technology with demonstrated benefit in reducing medication administration errors in hospitalized patients; however, it is not routinely used in emergency departments (EDs). EDs may benefit from BCMA, because ED medication administration is complex and error-prone. A naïve observational study was conducted at an academic medical center implementing BCMA in the ED. The rate of medication administration errors was measured before and after implementing an integrated electronic medical record (EMR) with BCMA capacity. Errors were classified as wrong drug, wrong dose, wrong route of administration, or a medication administration with no physician order. The error type, severity of error, and medications associated with errors were also quantified. A total of 1,978 medication administrations were observed (996 pre-BCMA and 982 post-BCMA). The baseline medication administration error rate was 6.3%, with wrong dose errors representing 66.7% of observed errors. BCMA was associated with a reduction in the medication administration error rate to 1.2%, a relative rate reduction of 80.7% (p < 0.0001). Wrong dose errors decreased by 90.4% (p < 0.0001), and medication administrations with no physician order decreased by 72.4% (p = 0.057). Most errors discovered were of minor severity. Antihistamine medications were associated with the highest error rate. Implementing BCMA in the ED was associated with significant reductions in the medication administration error rate and specifically wrong dose errors. The results of this study suggest a benefit of BCMA on reducing medication administration errors in the ED.