Prognosis Assessment in Emergency Department via Nutritional and Muscle Measurements for Home Health Care Patients

Introduction: We examined persons transported to hospital after police use of force to determine whether Emergency Department (ED) assessment and/or mode of transport could be predicted. Methods: A multi-site prospective consecutive cohort study of police use of force with data on ED assessment for individuals ≥18 yrs was conducted over 36 months (Jan 2010-Dec 2012) in 4 cities in Canada. Police, EMS and hospital data were linked by study ID. Stepwise logistic regression examined the relationship between the police call for service and subject characteristics on subsequent ED assessment and mode of transport. Results: In 3310 use of force events, 86.7% of subjects were male, median age 29 yrs. ED transport occurred in 26% (n=726). Odds of ED assessment increased by 1.2 (CI 1.1, 1.3) for each force modality >1. Other predictors of ED use: if the nature of police call was for Mental Health Act (MHA) (Odds 14.3, CI 10.6, 19.2), features of excited delirium (ExD) (Odds 2.7, CI 1.9, 3.7), police-assessed emotional distress (EDP) not an MHA (Odds 2.1, CI 1.5, 3.0) and combined drugs, alcohol and EDP (Odds 1.7, CI 1.9, 3.7). Those with alcohol impairment alone were less likely to go to ED from the scene: OR 0.6 (CI 0.5, 0.7). EMS transported 55% of all patients (n=401), although police transported ~100 people who EMS attended at the scene but did not subsequently transport. For patients brought to the ED, 70% had a retrievable chart (512/726) with a discernible primary diagnosis: 25% for physical injury, 32% for psychiatric and 43% for drug and/or alcohol intoxication. For use of force events that began as MHA calls, patient transport was more often by police car than ambulance OR 1.8 (CI 1.2, 2.5), while those with drug intoxication or ≥3 ExD features were more often brought by ambulance: odds of police transport 0.5 (CI 0.3, 0.9) and 0.4 (CI 0.3, 0.7). Violence or aggression did not predict mode of transport in our study. Conclusion: About one quarter of police use of force events lead to ED assessment; 1 in 4 patients transported had a physical injury of some description. Calls including the Mental Health Act or individuals with drug intoxication or excited delirium features are most predictive of ED use following police use of force. In MHA calls with use of force, persons are nearly twice as likely to go to ED by police car than by ambulance.

Since data on the safety and effectiveness of home telemonitoring and oxygen therapy started directly after Emergency Department (ED) assessment in COVID-19 patients are sparse but could have many advantages, we evaluated these parameters in this study. All COVID-19 patients ≥18 years eligible for receiving home telemonitoring (November 2020-February 2022, Albert Schweitzer hospital, the Netherlands) were included: patients started directly after ED assessment (ED group) or after hospital admission (admission group). Safety (number of ED reassessments and hospital readmissions) and effectiveness (number of phone calls, duration of oxygen usage and home telemonitoring) were described in both groups. 278 patients were included (n = 65 ED group, n = 213 admission group). ED group: 23.8% (n = 15) was reassessed, 15.9% (n = 10) was admitted and 7.7% (n = 5) ICU admitted. Admission group: 15.8% (n = 37) was reassessed, 6.5% (n = 14) was readmitted and 2.4% (n = 5) ICU (re)admitted. Ten patients died, of whom 7 due to COVID-19 (1 in ED group; 6 in the admission group). ED group: median duration of oxygen therapy was 9 (IQR 7-13) days; the total duration of home telemonitoring was 14 (IQR 9-18) days. Admission group: duration of oxygen therapy was 10 (IQR 6-16) days; total duration of home telemonitoring was 14 (IQR 10-20) days. it appears to be safe to start home telemonitoring and oxygen therapy directly after ED assessment.

The aim of this study was to compare vital signs of minimally injured and moderately injured patients during ambulance transport and subsequent emergency department (ED) assessment. We carried out a retrospective chart review. Patients were divided into two groups: minimally injured patients with neck pain (group 1) and moderately injured patients with a closed ankle or wrist fracture (group 2). The Wilcoxon signed-rank test was used to compare vital signs within groups during transport and ED assessment. Groups 1 and 2 included 90 and 118 patients, respectively. In group 1, systolic blood pressure was significantly lower (P=0.001, median difference 8 mmHg) and heart rate was significantly higher (P<0.01, median difference 3 beats/min) during transport than during ED assessment. There was no significant difference in respiratory rate in group 1 or any of the vital signs in group 2. We conclude that transport anxiety has minimal effect on vital signs. In trauma, clinicians should exclude tissue injury before attributing increased systolic blood pressure or heart rate to anxiety.

Comprehensive geriatric assessment in emergency Department by OPAL (Older People Assessment and Liaison) can prevent admissions.

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).

To evaluate statewide emergency department assessment and management of pain in pediatric patients as a quality improvement initiative. 2002 Survey of Illinois Hospital emergency department's pediatric pain assessment and management strategies, in conjunction with a retrospective chart review of children, ages 0 to 15 years, treated for an extremity fracture. Survey results were available for 123 (59.4%) hospitals; 933 charts (107 hospitals) were reviewed for pain management. Survey results were compared with practices identified by chart review. Use of a pain assessment scale estimated by the survey was 92%, compared with 59% use by chart review. Use of pain assessment scales for infants was limited. Fifty percent of patients in moderate to severe pain would be offered an analgesic. Six- to 15-year-old children would be offered opioids more often than children aged 0 to 1 and 2 to 5 years. Offering higher potency narcotic analgesics was associated with patient's age, geographic location of the facility, and emergency department volume. Providing an analgesic (odds ratio 4.53, 95% confidence interval 2.89-7.10), offering supportive care (odds ratio 2.37, 95% confidence interval 1.44-3.89), and pediatric-focused annual nurse competencies (odds ratio 1.90, 95% confidence interval 1.18-3.06) correlated with reduction of the patient's pain. Disparity exists between perceived and documented emergency department pain management practices for children. Quality improvement initiatives should focus on improving pain assessment in infants, treating moderate to severe pain in children of all age groups, and education of health care providers in pain management strategies. Resources should target health care processes effective in decreasing pediatric pain.

Concordance of field and emergency department assessment in the prehospital management of patients with dyspnea

To determine the accuracy of emergency department (ED) paediatric anaphylaxis diagnosis, and to identify factors associated with misdiagnosis. Retrospective chart review of children aged 0-18 years with allergic presentations to three Victorian EDs in 2014. Cases were included if an ED diagnosis of anaphylaxis was recorded, or the presentation met international consensus criteria for anaphylaxis. Of the 60 143 paediatric ED presentations during the study period, 1551 allergy-related presentations were identified and reviewed. One hundred and eighty-seven met consensus criteria for anaphylaxis, and another 24 were diagnosed with anaphylaxis without meeting criteria. Of the 211 presentations, 105 cases were given an ED diagnosis of anaphylaxis and 106 cases were given an alternative diagnosis in ED. ED assessment had a sensitivity of 43.2% (95% confidence interval (CI) 36.1-50.7%) and specificity of 97.9% (95% CI 96.9-98.7%) for anaphylaxis. Multiple logistic regression demonstrated that an ED anaphylaxis diagnosis was associated with previous anaphylaxis (odds ratio (OR) 3.20; 95% CI 1.52-6.75), arrival by ambulance (OR 2.80; 95% CI 1.36-5.74), a high-acuity triage category (OR 4.51; 95% CI 2.20-9.25) and presentation to a tertiary hospital (OR 2.86; 95% CI 1.44-5.67). ED diagnosis of anaphylaxis was less likely in those with resolution of symptoms and signs in at least one organ system prior to arrival (OR 0.27; 95% CI 0.12-0.62). In children with allergic presentations, ED assessment has a low sensitivity but high specificity for anaphylaxis. Attention to resolved pre-hospital symptoms and awareness of diagnostic criteria are important considerations for accurate ED diagnosis of anaphylaxis.

Advances in stroke care will have the greatest effect on stroke outcome if care is delivered within a regional stroke system designed to improve both efficiency and effectiveness. The ultimate goal of stroke care is to minimize ongoing injury, emergently recanalize acute vascular occlusions, and begin secondary measures to maximize functional recovery. These efforts will provide stroke patients with the greatest opportunity for a return to previous quality of life and decrease the overall societal burden of stroke.

BackgroundOlder people account for 25% of all Emergency Department (ED) admissions. This is expected to rise with an ageing demographic. Older people often present to the ED with complex medical needs in the setting of multiple comorbidities. Comprehensive Geriatric Assessment (CGA) has been shown to improve outcomes in an inpatient setting but clear evidence of benefit in the ED setting has not been established. It is not feasible to offer this resource-intensive assessment to all older adults in a timely fashion. Screening tools for frailty have been used to identify those at most risk for adverse outcomes following ED visit. The overall aim of this study is to examine the impact of CGA on the quality, safety and cost-effectiveness of care in an undifferentiated population of frail older people with medical complaints who present to the ED and Acute Medical Assessment Unit.MethodsThis will be a parallel 1:1 allocation randomised control trial. All patients who are ≥ 75 years will be screened for frailty using the Identification of Seniors At Risk (ISAR) tool. Those with a score of ≥ 2 on the ISAR will be randomised. The treatment arm will undergo geriatric medicine team-led CGA in the ED or Acute Medical Assessment Unit whereas the non-treatment arm will undergo usual patient care. A dedicated multidisciplinary team of a specialist geriatric medicine doctor, senior physiotherapist, specialist nurse, pharmacist, senior occupational therapist and senior medical social worker will carry out the assessment, as well as interventions that arise from that assessment. Primary outcomes will be the length of stay in the ED or Acute Medical Assessment Unit. Secondary outcomes will include ED re-attendance, re-hospitalisation, functional decline, quality of life and mortality at 30 days and 180 days. These will be determined by telephone consultation and electronic records by a research nurse blinded to group allocation.Ethics and disseminationEthical approval was obtained from the Health Service Executive (HSE) Mid-Western Regional Hospital Research Ethics Committee (088/2020). Our lay dissemination strategy will be developed in collaboration with our Patient and Public Involvement stakeholder panel of older people at the Ageing Research Centre and we will present our findings in peer-reviewed journals and national and international conferences.Trial registrationClinicalTrials.gov NCT04629690. Registered on November 16, 2020

Comprehensive geriatric assessment in emergency Department by OPAL (Older People Assessment and Liaison) can prevent admissions

In 2014, the South Australian coroner recommended that residents of residential aged care facilities (RACF) who had sustained a head injury should be transported to emergency departments (ED) for assessment and a head CT scan, with the view to preventing mortality. The evidence base for the recommendation is unclear. To determine the rate of emergent intervention (neurosurgery, transfusion of blood products or reversal of anti-coagulation) in residents transferred to ED with minor head trauma who had their usual cognitive function on ED assessment. This was a retrospective cohort study by medical records review at two university-affiliated community ED. Participants were patients from RACF attending ED who had suffered minor head trauma and had their usual cognitive function. Exclusions were altered conscious state, new neurological findings or associated orthopaedic injury requiring hospital admission. The primary outcome was rate of emergent intervention in residents transferred to ED with minor head trauma who had their usual cognitive function on ED assessment. A total of 366 patients was studied; median age 86 years, 45% taking anti-coagulant/anti-platelet medication. Eighty per cent underwent head CT. Six per cent had intracranial haemorrhage (ICH; 95% CI 4-8.9%). No patient underwent neurosurgery. One had emergent intervention, reversal of anti-coagulation (0.3%, 95% CI 0.05-1.5%). The rate of emergent intervention for ICH in patients from RACF who sustained a minor head trauma but had their normal cognitive function was <1%. None underwent neurosurgical intervention. The low rate of intervention seriously challenges the appropriateness of routine transfer and CT for this patient group.

Background: Emergency department (ED) overcrowding is a significant healthcare challenge that continues to strain medical facilities internationally. The need to assess myocardial injury in the ED is thought to be common, accounting for greater than 13 million visits annually. Therefore, we sought to assess the frequency and impact of myocardial injury assessment on the intermediates to ED overcrowding – ED disposition distribution and time to disposition – at an urban ED. Methods: In this single-center, retrospective cohort study from February 1, 2023, to January 31, 2024, the disposition distribution and median time to disposition were recorded for ED patient encounters. The study population was divided into encounters resulting in ED assessment for myocardial injury with conventional troponin measurement (ED-Tn group) and all other encounters without ED assessment for myocardial injury (control group). Pearson test was used for analyzing disposition distribution and Wilcoxon test for comparing time to disposition between the two defined groups. Results: 66,984 patient encounters resulted in a disposition of discharge or admission during the study period. 15,918 (23.8%) were categorized into ED-Tn group, while 51,066 (76.2%) were categorized into control group. The ED-Tn group had a significantly lower discharge frequency of 51% compared to the control group with 59.1% (p&lt;0.001). The median time to disposition was significantly higher for the ED Tn group at 212 minutes (IQR = 124, 325) compared to the control group at 184 minutes (IQR = 95, 313; p&lt;0.001). When considering only those patients who were discharged from the ED, the difference in median time to disposition was even more pronounced for the ED-Tn group at 226 minutes (IQR = 139, 340) compared to the control group at 178 minutes (IQR = 86, 311; p&lt;0.001). Conclusions: In an urban ED, myocardial injury assessments comprised a quarter of all ED evaluations, linked to increased admission and extended time to disposition for these patients. Implementing high-sensitivity troponin could improve efficiency of ED assessment for myocardial injury and alleviate overcrowding, given the resource-intensive and time-intensive nature of these assessments.

AimsThe Personality Disorder Service in the Northern Health & Social Care Trust was originally set up to deliver evidence-based treatment for people with the diagnosis of personality disorder. This group of people historically have been stigmatised, excluded and let down by services, despite their complex needs and frequent history of childhood trauma. The team developed a Mentalization Based Therapy (MBT) programme originally commencing in 2013.To identify recent completers of the MBT 2 18 month programme and to assess whether there was any reduction or change in pattern to the number of days spent as inpatient both during and after having completed the programme, whether there was a reduction in the frequency of same day assessments with community mental health teams or unscheduled care and finally whether there was any reduction in terms of volume of crisis assessments and presentations to Emergency Department.MethodsUsing validated Quality Improvement Methods, a Plan Do Study Act Cycle was commenced which involved identifying patients who had begun and finished the MBT programme and minimum of 12 months had passed since completion in order to follow-up.We then broke down this data into 3 domains. By using EPEX, Paris and Electronic Care Record computer systems, it was possible to analyse days spent as inpatient, same day assessments and crisis assessments as well as Emergency Department attendance.For these periods of time, they were split into pre-commencement of programme (18 months), during programme (18 months) and post-completion of programme (12 months) to see if there was any tangible decrease in these numbers.19 service users were identified that had initially been referred to Personality Disorder Service between 2016 and 2018 and who subsequently began MBT2 programme between 2017 and 2019. Given the length of completion of the programme, this allowed us to gather a full set of data with regard to these patients up to completion of programme in 2021. Subsequent period of 12 months was then analysed post-completion of treatment taking us up to 2022.ResultsThe average time spent in inpatient admission days prior to starting therapy for 18 months (n = 19) was 21.74 days, this decreased to 6.53 during therapy and 3.68 post-therapy (12 month follow-up) = 5.52 adjusted for 18 months. This represents a reduction of 74.61%.The average number of same day assessments and unscheduled care (n = 8) seeking prior to admission was 1.38. This decreased to 0.75 during therapy and 0.88 post-therapy adjusted to 1.32 for 18 months, which represents a small decline of 4.35%.Finally, the average number of Crisis contacts and Emergency Department assessments were 2.63 in the 18 months before commencing therapy, 1.26 during therapy and 0.58 in the 12 months post-therapy, 0.87 adjusted for 18 months. This represents a reduction of 66.92%ConclusionIt is clear from analysis of the data that there has been a substantial decrease in time spent as admitted inpatient as well as number of contacts with Crisis Assessors and Emergency Departments in association with completion of the MBT 18 month programme.This demonstrates that, by using an evidence-based and well-established programme, which carries a high time commitment for both service users and practitioners, it is possible to considerably reduce use of other, more acute services and keep patients with a diagnosis of EUPD out of hospital longer and on a sustained basis and also to reduce presentations to Emergency Departments which was often on the basis of self-harm and/or overdoses.The dual result is that it can be validated objectively that service users are suffering less distress after having completed the programme, which will lead to better quality of life, whilst also reducing the burden on costly inpatient services with the end result being an important investment in mental health services in Northern Ireland and the prototype for the developing regional service.

Background: Proper pain assessment is directly related to proper pain management.The American pain society (APS) in 1996 instituted “the pain as the 5th vital sign”, in an effort to reduce the burden of underassessment and inadequate pain management. The objective of this study is to find out the practice of pain assessment and to make improvement.&#x0D; Methods: This was an observational study of pain assessment by the medical officer in emergency department (ED).Convenience sampling was done at three different shift in ED. All the data of pain assessment was taken and tabulated and analysed to know the practice of pain assessment. Standard as set at 80%. In first stage data collection was done for one month as per convenience. Following the observed finding, in the second stage intervention was done. After this in third stage re-data collection was done to see the improvement.&#x0D; Results: A total of 503 patients were enrolled in this study. Out of this 53% (n=265) were in first stage and 47% (n=238) in third stage of the study. In first stage of the study there was 7% (n=19) documentation of numerical rating scale (NRS) and PQRST (P-precipitating and palliating factor, Q-quality of pain, R-radiation, S-site of pain, T-timing of pain) was not documented. After intervention in third stage documentation of NRS was done in 70% (n=167) and documentation of PQRST were variable.&#x0D; Conclusions: The study revealed that existing practice of pain assessment in the emergency department is poor but after the intervention there was remarkable improvement in the pain assessment.