Hospital Emergency Department Attendances Research Articles

Unplanned emergency department attendances due to home and leisure accidents in the elderly Portugal

Abstract Home and Leisure Accidents (HLA) have been identified as a relevant public health issue with individual, societal and economic consequences. So, common cause of injury-related morbidity and mortality, especially among older people. Evidence shows that most of HLA among the older ones are associated with identifiable and modifiable risk factors. However, more detailed information about the context and characteristics of such events is needed. This study aimed to characterize the occurrence of HLA in victims aged 65 and over related to hospital Emergency Department (ED) of the National Health Service in Portugal based on hospital records, through EVITA system. A descriptive analysis of the data was performed. Bivariate comparisons were performed using Pearson’s chi-square test with a significance level of 5%. In this analysis, the statistical program SPSS V.27 was used. During the 2022 year the older people aged 65 and over represented 25% of the total of attendances in the emergency department. In the 2022 year there were 70 452 HLA in people victims aged 65+, constituting 32% of hospital ED attendances by HLA (preliminary data). The results show that 65,9% of the attendances were amongst the age group of 75 years and beyond. More frequently reported in females (64,3%) than in males (35,6%), being these differences statistically significant (p < 0,01). The summer season for both age groups had higher proportion of HLA. In both age groups 65-74 years and 75 years and over most of HLA occurred at home (65,2%; 68,8%), followed by outdoor spaces (12,2%; 6,7%), public area (3,4%; 13,6%) and transport area (9,2%; 5,5%), these differences were statistically significant (p < 0,01). Regarding to the products/agents most involved in the HLA the “floor” was the leading category in age group 65-74 years (27,1%) and in the oldest 75 years and over (43,0%). Considering that globally HLA can be prevented, this information reinforces the importance of this problem and its magnitude. Key messages • The older people represented 25% of the total of attendances in the emergency department in the year in analysis. 13% of ED attendances occurred due to HLA. • The National Injury Surveillance System provides information that allows to know the characteristics and circumstances of HLA that occur in older people.

Orthopaedic patients' emergency department attendance behavior in relation to weather conditions: temperature, rain, day and time, and regional thursday effect.

Great variation was noticed in emergency department (ED) afflux in relation to daily weather conditions, including difficulties in arranging the correct number of orthopaedic on-calls on the floor. This study aimed to quantify the association between the number of patients referred to the orthopaedic team from the ED and weather conditions, particularly daily temperature and rain. Data were obtained from a large state research hospital's ED attendance. Weather information for the local area for the year was obtained from the regional meteorological office. Data were evaluated using descriptive statistics, with one-way analysis of variance for the relationship between the day of the week and patient numbers, the Pearson test for correlations between daily ED patient flow and daily temperature and the Spearman correlation test for correlations between daily patient flow and daily rain status. A positive and meaningful correlation existed between daily patient influx and daily temperature, along with a negative correlation between daily patient flow and daily rain. Throughout the year, significantly more patients were referred to the orthopaedic team on Thursdays than on any other day of the week. Patients tended to visit the ED more on warm days and days without rain. These results may help in organising daily, monthly or seasonal on-call orthopaedic team requirements despite the challenges. Incorporating climate forecasts into planning the on-call service might help alleviate the stress on the team.

The long-run effect of COVID-19 on hospital emergency department attendances:evidence from statistical analysis of hospital data from England

During the COVID-19 pandemic, hospital emergency departments worldwide experienced a pronounced fall in utilisation of emergency care, with a decrease of up to 40% in many countries. Evidence suggests the cause of these changes include both population fear of COVID-19 and the effects of lockdowns and the interaction of these two effects. We analyse a sub-sample of national data on Accident and Emergency (A&E) attendances in England over an extended period from April 2019 to March 2022 for different patient groups, including by age, mental/physical health status, acuity, and common clinical groupings. Our results showed that all patient groups experienced substantial declines in attendances during the first two waves of the pandemic, including high acuity and cardiovascular patients. Mental health patients were the only exception, with a smaller decline in attendances. Our findings suggest that policymakers should recognise the potential harmful effects of lockdowns, public messaging, and changes in health care provision on all patients during health emergencies.

Influence of type of household on prognosis at one year in patients ≥65years attending hospital emergency departments in Spain. The EDEN-6 study.

To investigate whether the type of household is associated with prognosis at one year in patients ≥65years of age discharged after medical consultation requiring emergency department care. Data from the Emergency Department and Elder Needs (EDEN) cohort were used. This retrospective cohort included all patients ≥65years of age seen in 52 Spanish emergency departments over one week (April 1-7, 2019) in whom the type of household was recorded and categorized as living at home alone, with relatives, with professional caregivers, or in a nursing home. Patient demographic and other baseline characteristics and management during the index emergency department episode were recorded and used to adjust the following 1-year outcomes: all-cause mortality, hospitalization and emergency department revisit. Associations between type of household and outcomes are expressed as adjusted hazard ratios with 95% confidence intervals using living alone as the reference category. 13,442 patients with a median age of 79years (interquartile range 72-86) were included; 56% were women, 12.2% of patients lived alone, 74.9% with relatives, 3.9% with a professional caregiver, and 9.1% in a nursing home. During the year following discharge, the mortality rate was 14.0%, the hospitalization rate 29.7%, and the emergency department revisit rate 59.3%. In the fully adjusted model, the risk of death was associated only with living in a nursing home (hazard ratio 1.366 (1.101-1.695)). On the other hand, the risk of hospitalization was lower in individuals living in nursing homes (hazard ratio 0.783 [0.676-0.907]) and at home with relatives (hazard ratio 0.897 [0.810-0.992]), while the risk of emergency department revisit was lower in individuals living in nursing homes (hazard ratio 0.826 [0.742-0.920]) or at home with caregivers (hazard ratio 0.856 [0.750-0.976]). The type of household was modestly associated with the one-year prognosis of patients ≥65years of age discharged after attendance at an emergency department. Living in a nursing home is associated with an increased risk of death but a decreased risk of rehospitalization or emergency department revisit, while living at home with relatives or professional caregivers is associated only with a decreased risk of hospitalization and emergency department revisit, respectively.

Emergency services utilization in Jakarta (Indonesia): a cross-sectional study of patients attending hospital emergency departments

BackgroundPre-hospital and emergency services in Indonesia are still developing. Despite recent improvements in the Indonesian healthcare system, issues with the provision of pre-hospital and emergency services persist. The demand for pre-hospital and emergency services has not been the subject of previous research and, therefore, has not been fully understood. Our research explored the utilization of emergency medical services by patients attending hospital emergency departments in Jakarta, Indonesia.MethodsThe study used a cross-sectional survey design involving five general hospitals (four government-funded and one private). Each patient’s demographic profile, medical conditions, time to treatment, and mode of transport to reach the hospital were analysed using descriptive statistics.ResultsA total of 1964 (62%) patients were surveyed. The median age of patients was 44 years with an interquartile range (IQR) of 26 to 58 years. Life-threatening conditions such as trauma and cardiovascular disease were found in 8.6 and 6.6% of patients, respectively. The majority of patients with trauma travelled to the hospital using a motorcycle or car (59.8%). An ambulance was used by only 9.3% of all patients and 38% of patients reported that they were not aware of the availability of ambulances. Ambulance response time was longer as compared to other modes of transportation (median: 24 minutes and IQR: 12 to 54 minutes). The longest time to treatment was experienced by patients with neurological disease, with a median time of 120 minutes (IQR: 78 to 270 minutes). Patients who used ambulances incurred higher costs as compared to those patients who did not use ambulances.ConclusionThe low utilization of emergency ambulances in Jakarta could be contributed to patients’ lack of awareness of medical symptoms and the existence of ambulance services, and patients’ disinclination to use ambulances due to high costs and long response times. The emergency ambulance services can be improved by increasing population awareness on symptoms that warrant the use of ambulances and reducing the cost burden related to ambulance use.

Antibiotic Sensitivity in Complicated and Uncomplicated UTI in Potuakhali Medical College Hospital

Introduction: Urinary tract infection (UTI) is a common reason for attending hospital emergency departments (ED). A complicated urinary tract infection (UTI) is associated with structural or functional abnormalities of the genitourinary tract or presence of any underlying disease. Objective: To assess the antibiotic sensitivity in complicated and uncomplicated UTI. Materials and Methods: The study was carried out in the Department of Medicine and Department of Microbiology. The urine samples were collected from the OPDs (outpatients departments). These sample collection sites were chosen as they mostly covered the urban area of the city. The duration of the study was one and a half year from July 2018 to January 2020. The urine samples of 200 patients, comprised of 60 males and 140 females, who attended the outpatient departments (OPDs) of three hospitals and had clinical evidence of urinary tract infection, determined by treating physicians, were included in this study. Results: Most common isolated pathogen was Eschericia coli 170(85.0%) followed by staphylococcus aureus 40(20.0%) and Klebsiella (10%). Multiple organisms were found few cases. Regarding drug sensitivity it was observed that maximum sensitivity was to Amikacin 94.0% followed by Nitrofurantoin 92.0%, Levofloxacin 90.0%, Meropenam 88.0%, Amoxicillin+Clavulanate 70.0% and Cefixim 70.0%. Conclusion: Female patients were predominant most common isolated pathogen were Eschericia coli, staphylococcus aureus and Klebsiella. Amikacin, Nitrofurantoin, Levofloxacin, Meropenam and Amoxicillin+Clavulanate were more sensitive antibiotic. Medicine Today 2022 Vol.34(1): 70-74

Characteristics of frequently attending children in hospital emergency departments: a systematic review

ObjectiveTo summarise the literature on frequent attendances to hospital emergency departments (EDs) and describe sociodemographic and clinical characteristics of children who attend EDs frequently.SettingHospital EDs.ParticipantsChildren <21 years, attending hospital EDs...

Proportion of Home and Leisure Accidents in mainland Portugal, in 2019

Abstract Unintentional injuries are recognized by the World Health Organization and the European Union as a preventable public health problem contributing to mortality and morbidity burden and expression in the emergency department (ED). According to EuroSafe injury is the fourth most common cause of death within the EU, being the leading cause of death in the youngest. Whereas injury related fatalities is only a part of the problem and more patients require hospital treatment it is essential measure the size of the injury problem and characteristics of these non-fatal injuries. Information from Injury Data-Base reveals that the majority of injury related ED attendances and hospital admissions result from accidents occur in home and during leisure times. So, the aim of this study it was to know the proportion of Home and Leisure Accidents (HLA) which needed attendance in the emergency rooms of the Hospitals National Health, in Portugal Mailand, in 2019. For the analysis were considered the total number of NHS health entities that have an ED, SONHO information system and National injury surveillance system - EVITA System. Based on hospital emergency records in 2019, was obtained the total number of victims by HLA who needed assistance in this health services. In 2019, there were 526 786 ED attendances due to HLA, so about 11,3% of hospital ED attendances in mainland Portugal were caused by HLA. Globally, it was observed a proportion of HLA with admission in ED higher in males (12,9%) than females (10,1%). Disaggregating the data by age group, it was possible to observe a preponderance of males in victims aged less than or equal to 54 years. On the other hand, females showed a higher proportion in individuals aged 55 and over. Additionally, victims aged 75 and over had the highest proportion of hospital admissions by HLA, both in females (15,5%) and males (13,1%). This study represented a relevant advance contributing to the revelation of the dimension of this problem in Portugal. Key messages The National Injury Surveillance System provides information that allows to know the dimension of this health problem in mainland Portugal. HLA represents 11,3 % of the total hospital ED attendances. HLA are the predominant cause of injury related ED attendances. Males and females have a different proportions of injury. Males aged 54 years and over have higher proportion of HLA than females.

Predictive ability of an expert-defined population segmentation framework for healthcare utilization and mortality - a retrospective cohort study

BackgroundPopulation segmentation of patients into parsimonious and relatively homogenous subgroups or segments based on healthcare requirements can aid healthcare resource planning and the development of targeted intervention programs. In this study, we evaluated the predictive ability of a previously described expert-defined segmentation approach on 3-year hospital utilization and mortality.MethodsWe segmented all adult patients who had a healthcare encounter with Singapore Health Services (SingHealth) in 2012 using the SingHealth Electronic Health Records (SingHealth EHRs). Patients were divided into non-overlapping segments defined as Mostly Healthy, Stable Chronic, Serious Acute, Complex Chronic without Frequent Hospital Admissions, Complex Chronic with Frequent Hospital Admissions, and End of Life, using a previously described expert-defined segmentation approach. Hospital admissions, emergency department attendances (ED), specialist outpatient clinic attendances (SOC) and mortality in different patient subgroups were analyzed from 2013 to 2015.Results819,993 patients were included in this study. Patients in Complex Chronic with Frequent Hospital Admissions segment were most likely to have a hospital admission (IRR 22.7; p < 0.001) and ED visit (IRR 14.5; p < 0.001) in the follow-on 3 years compared to other segments. Patients in the End of Life and Complex Chronic with Frequent Hospital Admissions segments had the lowest three-year survival rates of 58.2 and 62.6% respectively whereas other segments had survival rates of above 90% after 3 years.ConclusionIn this study, we demonstrated the predictive ability of an expert-driven segmentation framework on longitudinal healthcare utilization and mortality.

A 12-year retrospective analysis of differences between elderly and oldest old patients referred to the emergency department of a large tertiary hospital

ObjectivesGlobally, the average age of the population is increasing. Patients aged >65 years attending hospital emergency departments (EDs) differ from younger patients; in particular, they often present with multiple comorbidities. Our retrospective study evaluates the number of attendances at our ED by elderly patients in the 12 years from January 2005 to December 2017. Our first aim was to evaluate differences presented by elderly patients regarding symptoms, clinical features, color code (i.e. priority assigned to the case, where red is highest and yellow is medium), waiting time and outcome. Patients and methodsWe analyzed data from 201,580 patients aged >65, divided into two groups: 65–84 years and >85 years.Clinical and demographic data were collected from the computerized clinical record (GIPSE®). Results201,580 patients fulfilled the inclusion criteria, of whom 93,262 (46.3%) were male. There were 162,373 patients aged 65–84, and 39,207 aged >85.Patients aged >85 presented more complex cases, and were admitted more frequently with a red color code and were more frequently hospitalized. Larger proportions of this group had dementia, and attended the ED for trauma or gastrointestinal bleeding. The group aged 65–84 were admitted more frequently with a yellow color code and then discharged. They typically attended the ED for chest and abdominal pain. ConclusionThere is an increase in the request for health care especially in an emergency setting. The hospitalization of elderly patients is associated with a deterioration in motor skills and quality of life.Being able to reduce hospitalization in the elderly means avoiding disruption to the home care of people with dementia, and reducing both the risk of falls and hospital infections. In Italy, a program (as already experimented with in the USA) dedicated to the elderly who attend hospital EDs is desirable.

Do employees benefit from collaborations between out of hours general practitioners and emergency departments?

BackgroundIn an attempt to redirect patients who are inappropriately attending hospital emergency departments (ED) and in doing so provide the right care at the right place, out-of-hours GP (General Practitioner) services and EDs increasingly collaborate in Urgent Care Collaborations (UCCs). Work satisfaction is an important factor in analysing the impact of this organisational change. The objective of this study is, firstly, to discover if there is a difference in the employee experiences between those working in UCCs and those in traditional out-of-hours services in which EDs and out-of-hours GP services operate separately (i.e. “usual care”). Secondly, we would like to identify which factors affect employees’ experiences in these settings.MethodsThis study followed a cross-sectional study design, comparing usual care with UCCs. Data regarding employee experiences were collected from physicians, nurses, nurse practitioners, medical assistants and front desk personnel, by means of a questionnaire with scales regarding quality, workload and co-operation between the out-of-hours GP service and ED. Independent samples t-tests were used to determine mean differences between the settings. Multiple linear regression analyses were performed to test which items affected the perceived quality, workload and co-operation.ResultsThe results showed that mutual co-operation alone was perceived as significantly better in UCCs compared to usual care. If divided between employers, no differences were found in the employee experiences working in out-of-hours GP services. ED employees in UCCs experienced a significantly better co-operation with their GP colleagues than their peers in the usual care setting, but also a higher workload. Remarkably, ED employees were less satisfied in general. The multiple regression model showed that perceived quality, workload and co-operation were interrelated. Co-operation was the only aspect that was rated higher in the UCC setting.ConclusionWhile perceived quality is equal and co-operation between out-of-hours GP service and ED is better, the objective and perceived ED workload was higher in UCCs compared to usual care. Though UCCs relieve the pressure on EDs concerning the number of patients, they seem to aggravate the workload. EDs need to be careful not to excessively adjust staff capacity when responding to lower numbers of patients.

Community-associated methicillin-resistant Staphylococcus aureus infections in Aboriginal children attending hospital emergency departments in a regional area of New South Wales, Australia: a seven-year descriptive study.

ObjectiveCommunity-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) can cause bacterial skin infections that are common problems for Aboriginal children in New South Wales (NSW). MRSA is not notifiable in NSW and surveillance data describing incidence and prevalence are not routinely collected. The study aims to describe the epidemiology of CA-MRSA in Aboriginal children in the Hunter New England Local Health District (HNELHD).MethodsWe linked data from Pathology North Laboratory Management System (AUSLAB) and the HNELHD patient administration system from 33 hospital emergency departments. Data from 2008–2014 for CA-MRSA isolates were extracted. Demographic characteristics included age, gender, Aboriginality, rurality and seasonality.ResultsOf the 1222 individuals in this study, 408 (33.4%) were Aboriginal people. Aboriginal people were younger with 45.8% aged less than 10 years compared to 25.9% of non-Aboriginal people. Most isolates came from Aboriginal people who attended the regional Tamworth Hospital (193/511 isolates from 149 people). A larger proportion of Aboriginal people, compared to non-Aboriginal people, resided in outer regional (64.9% vs 37.2%) or remote/very remote areas (2.5% vs 0.5%). Most infections occurred in summer and early autumn. For Aboriginal patients, there was a downward trend through autumn, continuing through winter and spring.DiscussionAboriginal people at HNELHD emergency departments appear to represent a greater proportion of people with skin infections with CA-MRSA than non-Aboriginal people. CA-MRSA is not notifiable in NSW; however, pathology and hospital data are available and can provide valuable indicative data to health districts for planning and policy development.

Agreement between triage category and patient's perception of priority in emergency departments.

BackgroundPatients attending hospital emergency departments (ED) commonly cite the urgency and severity of their condition as the main reason for choosing the ED. However, the patients’ perception of urgency and severity may be different to the nurses’ perception of their urgency and severity, which is underpinned by their professional experience, knowledge, training and skills. This discordance may be a cause of patient dissatisfaction. The purpose of this study is to understand the extent of agreement/disagreement between the patient’s perceived priority and actual triage category and associated factors.MethodsA cross-sectional survey of 417 patients attending eight public hospital EDs in Queensland, Australia between March and May 2011 was conducted. The survey included patient’s perceived priority and other health-related, socio-demographic and perceptual factors. Patients’ triage category data were retrieved from their ED records and linked back to their survey data. Descriptive and multinomial logistic regression analyses were used.ResultsOver 48 % of the respondents expected to be given higher priority than the actual triage category they were assigned; 31 % had their perceived priority matched with the triage category; and 20 % of the respondents expected a lower priority than the triage category they received (Kappa 0.07, p < 0.01). Patients who expected a higher priority tended to be more frequent users (≥3 times in the past six months), and to score higher on perceived seriousness, perceived urgency, and pain score compared to the patients whose perceived priority matched the triage category or anticipated a lower priority. In the multivariate analysis, only perceived urgency remained significantly associated with expected higher priority (OR = 1.27, 95 % CI: 1.14–1.43).DiscussionOur findings clearly confirmed the discrepancy between patient perception of urgency and staff assessment of urgency. This can have important implications particularly for the patients who underrate the urgency of their condition. Improved and open communication and the incorporation of the ‘patient voice’ into the triage process require understanding the patient’s perspectives and their involvement in the decision making process.ConclusionsNoted differences between patient and practitioner perception of clinical urgency were identifed in this study.

Clinical severity and molecular characteristics of circulating and emerging rotaviruses in young children attending hospital emergency departments in France

Group A rotavirus (RVA) is the leading cause of acute gastroenteritis in young children worldwide. A prospective surveillance network has been set up to investigate the virological and clinical features of RVA infections and to detect the emergence of potentially epidemic strains in France. From 2009 to 2014, RVA-positive stool samples were collected from 4800 children <5 years old attending the paediatric emergency units of 16 large hospitals. Rotaviruses were then genotyped by RT-PCR with regard to their outer capsid proteins VP4 and VP7. Genotyping of 4708 RVA showed that G1P[8] strains (62.2%) were predominant. The incidence of G9P[8] (11.5%), G3P[8] (10.4%) and G2P[4] (6.6%) strains varied considerably, whereas G4P[8] (2.7%) strains were circulating mostly locally. Of note, G12P[8] (1.6%) strains emerged during the seasons 2011–12 and 2012–13 with 4.1% and 3.0% prevalence, respectively. Overall, 40 possible zoonotic reassortants, such as G6 (33.3%) and G8 (15.4%) strains, were detected, and were mostly associated with P[6] (67.5%). Analysis of clinical records of 624 hospitalized children and severity scores from 282 of them showed no difference in clinical manifestations or severity in relation to the genotype. The relative stability of RVA genotypes currently co-circulating and the large predominance of P[8] type strains may ensure vaccine effectiveness in France. The surveillance will continue to monitor the emergence of new reassortants that might not respond to current vaccines, all the more so as all genotypes can cause severe infections in infants.

Comparing policies for children of parents attending hospital emergency departments after intimate partner violence, substance abuse or suicide attempt

To improve identification of child maltreatment, a new policy (‘Hague protocol’) was implemented in hospitals in The Netherlands, stating that adults attending the hospital emergency department after intimate partner violence, substance abuse or a suicide attempt should be asked whether they care for children. If so, these children are referred to the Reporting Center for Child Abuse and Neglect (RCCAN), for assessment and referrals to support services. An adapted, hospital-based version of this protocol (‘Amsterdam protocol’) was implemented in another region. Children are identified in the same manner, but, instead of a RCCAN referral, they are referred to the pediatric outpatient department for an assessment, including a physical examination, and referrals to services. We compared results of both protocols to assess how differences between the protocols affect the outcomes on implementation, detection of child maltreatment and referrals to services. Furthermore, we assessed social validity and results of a screening physical examination. We included 212 families from the Amsterdam protocol (cohort study with reports by pediatric staff and parents) and 565 families from the Hague protocol (study of RCCAN records and telephone interviews with parents). We found that the RCCAN identified more maltreatment than pediatric staff (98% versus at least 51%), but referrals to services were similar (82% versus 80% of the total sample) and parents were positive about both interventions. Physical examination revealed signs of maltreatment in 5%. We conclude that, despite the differences, both procedures can serve as suitable methods to identify and refer children at risk for maltreatment.

Knowledge of the diagnostic algorithm for pulmonary embolism in primary care

BackgroundDiagnostic algorithms for pulmonary embolism (PE) have been validated in patients attending hospital emergency departments. However, general practitioners (GPs) are often the professionals of first resort for the majority of non-critical cases of PE. AimTo evaluate the knowledge of the diagnostic algorithm for PE among GPs in France. Design and settingQuestionnaire-based survey of GPs with a private practice. MethodAll GPs in the study area were sent a questionnaire including several questions on the diagnosis of PE and two clinical cases scenario with suspected PE. Factors associated with knowledge of the diagnostic algorithm were analysed by univariate and multivariate analyses. ResultsFive-hundred and eight questionnaires were distributed and 155 (30.5%) were available for analysis. Only 55% of the GPs did know about clinical scores for the assessment of clinical probability of PE and 42% of the GPs were aware that clinical probability is needed to interpret the result of D-dimer testing. Forty GPs (26%) gave valid responses to both clinical cases, 54 GPs (35%) had one valid case out of the two and 61 (39%) gave invalid responses to both clinical cases. Participation in specific training on PE was significantly associated with valid responses to the two clinical cases in multivariate analysis (p<0.017). ConclusionThe majority of GPs were unaware of the diagnostic algorithm for PE. Clinical probability was rarely assessed and knowledge about D-dimers was poor. Specific training on PE and greater awareness of clinical probability scores may promote knowledge of PE algorithm diagnosis.

Predictive score for mortality in patients with COPD exacerbations attending hospital emergency departments.

BackgroundLimited information is available about predictors of short-term outcomes in patients with exacerbation of chronic obstructive pulmonary disease (eCOPD) attending an emergency department (ED). Such information could help stratify these patients and guide medical decision-making. The aim of this study was to develop a clinical prediction rule for short-term mortality during hospital admission or within a week after the index ED visit.MethodsThis was a prospective cohort study of patients with eCOPD attending the EDs of 16 participating hospitals. Recruitment started in June 2008 and ended in September 2010. Information on possible predictor variables was recorded during the time the patient was evaluated in the ED, at the time a decision was made to admit the patient to the hospital or discharge home, and during follow-up. Main short-term outcomes were death during hospital admission or within 1 week of discharge to home from the ED, as well as at death within 1 month of the index ED visit. Multivariate logistic regression models were developed in a derivation sample and validated in a validation sample. The score was compared with other published prediction rules for patients with stable COPD.ResultsIn total, 2,487 patients were included in the study. Predictors of death during hospital admission, or within 1 week of discharge to home from the ED were patient age, baseline dyspnea, previous need for long-term home oxygen therapy or non-invasive mechanical ventilation, altered mental status, and use of inspiratory accessory muscles or paradoxical breathing upon ED arrival (area under the curve (AUC) = 0.85). Addition of arterial blood gas parameters (oxygen and carbon dioxide partial pressures (PO2 and PCO2)) and pH) did not improve the model. The same variables were predictors of death at 1 month (AUC = 0.85). Compared with other commonly used tools for predicting the severity of COPD in stable patients, our rule was significantly better.ConclusionsFive clinical predictors easily available in the ED, and also in the primary care setting, can be used to create a simple and easily obtained score that allows clinicians to stratify patients with eCOPD upon ED arrival and guide the medical decision-making process.

Characteristics of people with epilepsy who attend emergency departments: Prospective study of metropolitan hospital attendees

One fifth of people with established epilepsy attend hospital emergency departments (EDs) and one half are admitted each year. These ED visits are not necessarily required, and unplanned hospitalizations are costly. Reducing avoidable ED visits and admissions is a target in most health services. The development of interventions is, however, challenging. Policymakers lack information about users' characteristics, factors associated with ED use, as well as quality of care. This study provides this information. We prospectively recruited patients attending three London EDs for seizures. They completed questionnaires on service use and psychosocial state. Eighty-five patients were recruited. The mean age was 41; 53% were male. The average number of ED attendances in the prior year (mean 3.2; median 2) exceeded that of other ED users and those with most chronic conditions. ED use was not homogenous, with some patients attending frequently. Compared to the wider epilepsy population, ED attendees experienced more seizures, anxiety, had lower knowledge of epilepsy and its management and greater perceived epilepsy-related stigma. In the previous 12 months, most patients' epilepsy outpatient care was consistent with standard criteria for quality. In descending order, lower knowledge, higher perceived stigma, poorer self-medication management, and seizure frequency were associated with more emergency visits. People with epilepsy presenting to EDs reattend frequently. Interventions aiming at reduced ED use by this population should address lower knowledge, stigma, suboptimal self-management, and frequent seizures reported by patients.

A holistic client‐centred program for vulnerable frequent hospital attenders: cost efficiencies and changed practices

A small percentage of Australians frequently attend hospital emergency departments (ED) with potentially avoidable health crises. These individuals are termed 'vulnerable' due to their complex health and social needs. When these needs are unmanaged, unnecessary ED and hospital-admission costs are incurred. A holistic community-based program was developed to engage a cohort of vulnerable individuals in strategies to improve their health and health behaviours, and health service use. A purposive sample of frequent ED attendees was identified in one Australian metropolitan health region. Core program elements included working with clients within their environment, problem solving, empowerment, education, goal setting and mentoring. Evaluation data included services provided for, and time spent with, clients; hospital admission and emergency department attendances and related costs; client engagement data; mental health measures; client stories and participant interviews. Data was analysed from 37 clients. On average, staff spent 34 hours with each client, costing approximately $1,700 each. Significant improvements resulted in client health and health behaviours. Crisis emergency department and inpatient admissions decreased, and planned outpatient clinic use increased. Low-cost community-based intervention for frequent ED attendees has the potential for significant tertiary hospital savings.

Health care professionals’ knowledge and attitudes regarding substance use and substance users

In Ireland one in four (28%) of those attending hospital emergency departments have substance abuse-related injury/illness and one in eight (13%) present in a state of clinical intoxication. Health care professionals working in emergency departments are frequently exposed to patients with substance use problems and are in ideal positions to provide early diagnosis and treatment. The success rate in detecting these patients is however disturbingly low (25-50%) and as a result many substance use problems are misdiagnosed or remain undetected. International studies that focus on primary care and addiction within the mental health sector suggest that health care professionals' knowledge and attitudes regarding substance use and substance users may negatively influence the care that these patients receive. There is a dearth of empirical research, internationally, and particularly in Ireland that addresses health care professionals' knowledge and attitudes in relation to substance use and substance users with no empirical evidence to ascertain in particular, emergency department doctors' and nurses' knowledge and attitudes.