Direct Admission Group Research Articles

Long‐Term Outcomes in Patients with ST‐Elevation Myocardial Infarction: A Comparative Study of Direct Admissions versus Interhospital Transfers—Insights from a Single‐Center Experience in the United Kingdom

Background. Primary percutaneous coronary intervention (PPCI) is the treatment of choice for patients with ST‐elevation myocardial infarction (STEMI). Delayed reperfusion leads to increased morbidity and mortality. Secular trends in the impact of interhospital transfers (IT) on long‐term mortality in the United Kingdom (UK) have not been previously investigated. We analyzed the impact of IT on 5‐year mortality in STEMI patients admitted to a tertiary care center in the UK (East Midlands North). Methods. Data of STEMI patients admitted to Nottingham University Hospitals NHS Trust from 2011 to 2016 were acquired from the National Institute for Cardiovascular Outcomes Research dataset (NICOR) and then combined with local patient‐level data and mortality data from National Statistics. The baseline characteristics and mortality data of the interhospital transfer (IT) group were compared to those of a gender and age‐matched direct admission (DA) group. Results. Of the total cohort (N = 2386), 29.9% of patients were admitted to the PPCI center via the interhospital transfer (IT) route. Cardiovascular risk profiles in both DA and IT groups were comparable. Five‐year Kaplan–Meier (KM) survival analysis revealed better survival in the direct admission group (83% vs. 77.3%; p ≤ 0.001). In multivariate analysis, increased mortality was associated with severe left ventricular impairment (HR 4.7, 95% CI 2.9–7.6), the presence of cardiogenic shock (HR 3.6 (2.7–4.8)), chronic kidney disease (HR 2.56 (1.4–4.5)), smoking (HR 1.45 (1.1–1.8)), male gender (HR 1.7 (1.4–2.01)), and diabetes (HR 1.4 (1.07–1.8)). The radial access and call‐to‐balloon time less than 120 minutes were also associated with lower mortality (HR 0.52 (0.43–0.63): HR 0.75 (0.61–0.92)). Conclusion. Despite advancements in communication, technology, patient education, transportation systems, and guidelines within the UK’s NHS over the last decade, the delays incurred by IT for STEMI patients remain substantial and are associated with a poor prognosis.

Comparing outcomes following direct admission and early transfer to specialized trauma centers in open tibial fracture treatment: a systematic review and meta-analysis.

Guidelines on the management of open tibia fractures recommend timely treatment in a limb reconstruction center which offer joint orthopedic-trauma and plastic surgery services. However, patient's transfer between centers remains inevitable. This review aims to evaluate the clinical outcomes and hospital factors for patients directly admitted and transferred patients to a limb-reconstruction center. A research protocol adhering to PRISMA standards was established. The search included databases like MEDLINE, EMBASE, and the Cochrane library up until March 2023. Nine articles met the inclusion criteria, focusing on open tibia fractures. Exclusion criteria were experimental studies, animal studies, and case reports. Outcomes of interest were operation and infection rates, nonunion, limb salvage, and the Enneking limb score. The analysis involved data from 520 patients across nine studies published between 1990 and 2023, with the majority (83.8%) having Gustilo Anderson type III open tibia fractures. Directly admitted patients showed lower overall infection rates (RR 0.30; 95% CI 0.10-0.90; P = 0.03) and fewer deep infections (RR 0.39; 95% CI 0.22-0.68; P = 0.001) compared to transferred patients. Transferred patients experienced an average five-day delay in soft tissue closure and extended hospital stays by eight days. Patients transferred without initial surgical management underwent fewer total surgical procedures. The direct admission group displayed more favorable functional outcomes. Low- to moderate-quality evidence indicates worse clinical outcomes for transferred patients compared to directly admitted patients. Early treatment in specialized limb reconstruction units is essential for improved results in the management of open tibia fractures. Therapeutic level IIa.

Cost-effectiveness analysis of direct admission to acute geriatric unit versus admission after an emergency department visit for elderly patients

BackgroundElderly individuals represent an increasing proportion of emergency department (ED) users. In the Greater Paris University Hospitals (APHP) direct-admission study, direct admission (DA) to an acute geriatric unit (AGU) was associated with a shorter hospital length of stay (LOS), lower post-acute care transfers, and lower risk of an ED return visit in the month following the AGU hospitalization compared with admission after an ED visit. Until now, no economic evaluation of DA has been available.MethodsWe aimed to evaluate the cost-effectiveness of DA to an AGU versus admission after an ED visit in elderly patients. This was conducted alongside the APHP direct-admission study which used electronic medical records and administrative claims data from the Greater Paris University Hospitals (APHP) Health Data Warehouse and involved 19 different AGUs. We included all patients ≥ 75 years old who were admitted to an AGU for more than 24 h between January 1, 2013 and December 31, 2018. The effectiveness criterion was the occurrence of ED return visit in the month following AGU hospitalization. We compared the costs of an AGU stay in the DA versus the ED visit group. The perspective was that of the payer. To characterise and summarize uncertainty, we used a non-parametric bootstrap resampling and constructed cost-effectiveness accessibility curves.ResultsAt baseline, mean costs per patient were €5113 and €5131 in the DA and ED visit groups, respectively. ED return visit rates were 3.3% (n = 81) in the DA group and 3.9% (n = 160) in the ED group (p = 0.21). After bootstrap, the incremental cost-effectiveness ratio was €-4249 (95%CI= -66,001; +45,547) per ED return visit averted. Acceptability curves showed that DA could be considered a cost-effective intervention at a threshold of €-2405 per ED return visit avoided.ConclusionThe results of this cost-effectiveness analysis of DA to an AGU versus admission after an ED visit for elderly patients argues in favor of DA, which could help provide support for public decision making.

Interfacility Transfer Patients With Pelvic, Acetabular, and Lower Extremity Fractures Are at Higher Risk for Major Complications and Readmissions.

To compare the adverse event profile and patient comorbidity profile of lower extremity orthopaedic trauma patients admitted via interfacility transfer (IT) to direct admission (DA) patients from home. A total of 39,497 patients from 2012 to 2019 were identified in the American College of Surgeon National Surgical Quality Improvement Program database. DA patients were compared with IT patients for differences in preoperative comorbidities, adverse events, length of stay, and readmissions in the 30-day postoperative period. Student t tests were used to assess continuous variables. Pearson χ 2 test and odds ratios (ORs) were used for categorical variables. The IT group comprised 7167 patients, and the DA group comprised 32,330 patients. IT patients were on average older (65.5 vs. 58.8 years, P < 0.01), more likely to be American Society of Anesthesiologists Status >2 ( P < 0.01), and had a worse comorbidity profile for numerous preoperative risk factors. IT patients had significantly higher rates of mortality [3.3% vs. 1.4%; odds ratio (OR) 2.29; 95% confidence interval (CI), 1.96-2.77], major complications (10.2% vs. 6.1%; OR 1.74; 95% CI, 1.60-1.91), significantly higher readmission rates (5.8% vs. 4.8%, P < 0.01, OR 1.22 95% CI, 1.09-1.36), and more infectious complications (7% vs. 4.7%; OR 1.54; 95% CI, 1.38-1.71) than DA patients. Transfer remained a significant factor predicting major adverse events in regression analysis controlling for patient characteristics and fracture type ( P < 0.01; B 1.197; 95% CI, 1.09-1.32). This study revealed that IT patients undergoing operative management of pelvic, acetabular, and lower extremity fractures are at a significantly increased risk of major complications, readmission, and have a higher morbidity burden than DA patients. As healthcare transitions to value-based care and bundled payments, hospitals that accept a high volume of ITs will face exposure to added risk and financial penalties without adequate policy protections. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Inpatient Outcomes Following a Return Visit to the Emergency Department: A Nationwide Cohort Study.

IntroductionEmergency department (ED) revisits are traditionally used to measure potential lapses in emergency care. However, recent studies on in-hospital outcomes following ED revisits have begun to challenge this notion. We aimed to examine inpatient outcomes and resource use among patients who were hospitalized following a return visit to the ED using a national database.MethodsThis was a retrospective cohort study using the National Health Insurance Research Database in Taiwan. One-third of ED visits from 2012–2013 were randomly selected and their subsequent hospitalizations included. We analyzed the inpatient outcomes (mortality and intensive care unit [ICU] admission) and resource use (length of stay [LOS] and costs). Comparisons were made between patients who were hospitalized after a return visit to the ED and those who were hospitalized during the index ED visit.ResultsOf the 3,019,416 index ED visits, 477,326 patients (16%) were directly admitted to the hospital. Among the 2,504,972 patients who were discharged during the index ED visit, 229,059 (9.1%) returned to the ED within three days. Of them, 37,118 (16%) were hospitalized. In multivariable analyses, the inpatient mortality rates and hospital LOS were similar between the two groups. Compared with the direct-admission group, the return-admission group had a lower ICU admission rate (adjusted odds ratio, 0.78; 95% confidence interval [CI], 0.72–0.84), and lower costs (adjusted difference, −5,198 New Taiwan dollars, 95% CI, −6,224 to −4,172).ConclusionPatients who were hospitalized after a return visit to the ED had a lower ICU admission rate and lower costs, compared to those who were directly admitted. Our findings suggest that ED revisits do not necessarily translate to poor initial care and that subsequent inpatient outcomes should also be considered for better assessment.

Characteristics and Outcomes of Kidney Transplant Recipients Requiring High-Acuity Care After Transplant Surgery: A 10-Year Single-Center Study.

ObjectiveTo study the characteristics and outcomes of a cohort of kidney transplant recipients who required high-acuity care after transplant surgery.Patients and MethodsAll adult (aged ≥18 years) solitary kidney transplant recipients from January 1, 2007, through December 31, 2016, were screened and those who required high-acuity care within the same hospitalization were enrolled. Patient demographic and clinical data were collected from the departmental database and electronic DataMart.ResultsOf 1525 patients, 266 (17.4%) required high-acuity care after the kidney transplant operation: 166 (62.4%) directly from the operating room and 100 (37.6%) after an interval during the same hospitalization. Overall, 2 main indications were hypotension (n=87; 32.7%) and cardiac rhythm disturbances (n=83; 31.2%). Recipients in the direct admission group had higher medium body mass index (31.0 [interquartile range, 26.6-36.0] vs 28.0 [interquartile range, 24.3-32.4] kg/m2; P<.001) and were more likely to have undergone a concomitant procedure with the transplant surgery. Overall, in-hospital mortality was 1.9% (n=5).ConclusionIn contemporary practice, patients with higher body mass index are more likely to require high-acuity care immediately after kidney transplant surgery. The most common reasons are hypotension and cardiac rhythm disorders. The overall intensive care unit mortality rate of these patients is low. However, these patients are at risk for graft loss and death in the long term compared with patients who do not require intensive care unit care after transplant surgery.

128 In-Hospital Outcomes After Emergency Department Revisit in Taiwan: A Nationwide Analysis

Emergency department (ED) revisits are traditionally used to measure potential lapses in emergency care. However, recent studies focusing on in-hospital outcomes following ED revisits have begun to challenge this notion. To our knowledge, there have been no studies that utilize nationwide data to address this issue. We aimed to examine in-hospital clinical outcomes and resource use among patients who are hospitalized following a return visit to the ED using a national database. This was a retrospective cohort study using the National Health Insurance Research Database in Taiwan. One-third of ED visits from 2011 to 2013 were randomly selected and their hospitalizations were included. The in-hospital outcomes (mortality and intensive care unit [ICU] admission) and resource use (length of stay and cost) were analyzed comparing patients who were hospitalized after a return visit to the ED within 3 days vs. patients who were hospitalized during the index ED visit. Multivariable regression models were used to adjust for differences in patient mix. There were 5,575,044 index ED visits during the 3-year study period. Of them, 1,075,892 (19%) were admitted to the hospital following the index ED visit. Among the 4,499,152 patients who were discharged during the index ED visit, 319,772 had a return visit to the ED within 3 days. Of them, 79,999 (25%) were admitted to the hospital. The in-hospital mortality rates were similar between the two groups (3% in the revisit-admission group vs 3% in the direct-admission group, p=0.79). Compared with the direct-admission group, the revisit-admission group had a lower ICU admission rate (2.5% vs. 3.0%, p<0.001), a shorter mean length of stay (8.4 vs. 8.6 days, p<0.001) and lower mean costs (40,954 vs. 48,146 TWD, p<0.001). After adjusting for age, sex, and 29 comorbidities, the patterns of outcome differences persisted, with similar inpatient mortality between the two groups and slightly better outcomes and lower resource use in the revisit-admission group. Patients who were hospitalized after a return visit to the ED within 3 days did not experience worse outcomes or consume more resources than those who were directly admitted during the index ED visit. Our findings suggest that ED revisit is multifactorial and does not necessarily relate to emergency care quality.

P1746Prehospital logistics and therapy delays in urban vs. rural regions: implications for quality of acute ST-elevation myocardial infarction care

Abstract Background Treatment and time goals for STEMI care are clearly defined in national and international guidelines. However, initiation of therapy relies in accurate diagnosis after first medical contact (FMC). Prehospital logistics with fast transfer to the next available 24/7 PCI-center can be challenging, especially in rural areas and for transfers across state-borders in Germany. Objective To analyze quality of STEMI care in a high volume PCI center serving a city and a large rural area with focus on EMS (emergency medical service) logistics. Two groups of patients admitted by EMS: (1) direct PCI-center admission vs. (2) secondary admission after transfer from a non-PCI hospital were compared. Methods Various administrative, procedural, therapeutic and clinical parameters were registered for each patient including timelines of acute treatment (tables). Inaccurate treatment delays were calculated as cumulative time in any prolongation in timely diagnosis or therapy after FMC. Results From 340 consecutive STEMI patients in or registry, 299 patients were transferred by EMS. Reperfusion therapy with PPCI was significantly delayed and required double of the time in patients secondary transferred from a non-PCI hospital (Contact-to-Balloon: 195.6±134.8 min vs. 99.6±45.3 min, p&lt;0.001, table 1). An inaccurate delay in timely treatment (delay in correct diagnosis or deferred therapy) was determined in 45% of the patients transferred from non-PCI hospitals vs 26% of directly admitted patients (p=0.02, table 1). Accordingly, correct STEMI diagnosis was established by EMS physician prehospital only in 7.1% in the transfer group vs. 61.9% in the direct admission group (p&lt;0.001, table 1). Our data suggest different reasons for STEMI patients falsely transferred to non-PCI hospitals: a) lower qualification of EMS personnel with ECG misinterpretation and/or false working diagnosis, b) inadequate prehospital logistics with transfer of patients to the next near-by hospital instead of next PCI-center, c) personal or system “thresholds” of EMS physicians in rural areas preventing a direct transfer to PCI-centers. Further analysis of the transfer group (table 2) showed even longer treatment times for patients transferred across state borders compared to transfers within a state (C2B: 264.8±142.2 vs. 143.7±107.0 min, p&lt;0.05, table 2). Importantly, transfers across state borders were not associated with a longer absolute distance (km) to PCI center. However, a rescue helicopter was used for across-state transfers in one third of the cases. Conclusion Quality of acute STEMI care is significantly worse in rural areas predominantly due to suboptimal prehospital logistics and poor prehospital emergency care. Our data underline the importance to establish local STEMI networks irrespective of state borders with clearly defined prehospital transfer strategies, continuous medial education of EMS personnel and assessement of local quality of care.

Impact on mortality of direct admission versus interhospital transfer in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention

INTRODUCTION In a primary percutaneous coronary intervention (PCI) program, interhospital transfer of patients with ST-elevation myocardial infarction (STEMI) can increase ischemic time, compared to patients who are admitted directly to a catheterization laboratory. OBJECTIVES To assess the impact of interhospital transfer in patients with STEMI undergoing primary PCI, in terms of time to reperfusion and one-year mortality. METHODS This was an observational, retrospective, longitudinal study of patients with STEMI admitted to Hospital de Braga between June 2011 and May 2016, who were treated successfully within 12 hours of symptom onset. A total of 1222 patients were included and divided into two groups according to admission to Hospital de Braga: direct or interhospital transfer. RESULTS In this study, 37.0% (n=452) of the population were admitted directly to Hospital de Braga and 63.0% (n=770) were transferred from other hospitals. Although timings (in min) until reperfusion were longer in interhospital transfer patients (symptom onset-first medical contact (median 76.5, IQR 40.3-150 vs. 91.0, IQR 50-180, p=0.002), first medical contact-reperfusion (median 87.5, IQR 69.0-114 vs. 145, IQR 115-199, p<0.001) and symptom onset-reperfusion (median 177, IQR 125-265 vs. 265, IQR 188-400, p<0.001)), one-year mortality did not differ significantly between the groups (53 [11.7%] vs. 71 [9.2%], p=0.193). In multivariate analysis, age, symptom onset-reperfusion time and especially Killip class IV at admission (HR 11.2, 95% CI 6.35-19.8, p<0.001) were the main independent predictors of one-year mortality. CONCLUSION Interhospital transfer of patients with STEMI increased the time before PCI. No differences were detected between groups in one-year mortality. This may be related to the fact that the direct admission group had twice as many patients in Killip class IV as the interhospital transfer group.

Impacto na mortalidade da admissão direta versus transferência inter‐hospitalar nos doentes com enfarte agudo do miocárdio com elevação do segmento ST submetidos a intervenção coronária percutânea primária

IntroductionIn a primary percutaneous coronary intervention (PCI) program, interhospital transfer of patients with ST‐elevation myocardial infarction (STEMI) can increase ischemic time, compared to patients who are admitted directly to a catheterization laboratory. ObjectivesTo assess the impact of interhospital transfer in patients with STEMI undergoing primary PCI, in terms of time to reperfusion and one‐year mortality. MethodsThis was an observational, retrospective, longitudinal study of patients with STEMI admitted to Hospital de Braga between June 2011 and May 2016, who were treated successfully within 12 hours of symptom onset. A total of 1222 patients were included and divided into two groups according to admission to Hospital de Braga: direct or interhospital transfer. ResultsIn this study, 37.0% (n=452) of the population were admitted directly to Hospital de Braga and 63.0% (n=770) were transferred from other hospitals. Although timings (in min) until reperfusion were longer in interhospital transfer patients (symptom onset‐first medical contact (median 76.5, IQR 40.3‐150 vs. 91.0, IQR 50‐180, p=0.002), first medical contact‐reperfusion (median 87.5, IQR 69.0‐114 vs. 145, IQR 115‐199, p<0.001) and symptom onset‐reperfusion (median 177, IQR 125‐265 vs. 265, IQR 188‐400, p<0.001)), one‐year mortality did not differ significantly between the groups (53 [11.7%] vs. 71 [9.2%], p=0.193). In multivariate analysis, age, symptom onset‐reperfusion time and especially Killip class IV at admission (HR 11.2, 95% CI 6.35‐19.8, p<0.001) were the main independent predictors of one‐year mortality. ConclusionInterhospital transfer of patients with STEMI increased the time before PCI. No differences were detected between groups in one‐year mortality. This may be related to the fact that the direct admission group had twice as many patients in Killip class IV as the interhospital transfer group.

Effects of emergency department boarding on mortality in patients with ST-segment elevation myocardial infarction

ObjectivePatients with ST-segment elevation myocardial infarction (STEMI) are sometimes boarded in the emergency department (ED) after percutaneous coronary intervention (PCI). We evaluated the effects of direct and indirect admission to the CCU on mortality and the effect on length of stay (LOS) in patients with STEMI. MethodThis was a retrospective observational study of patients with STEMI between Jan 2014 and Nov 2017. The patients were divided into the direct admission (DA) group, who were admitted into the CCU immediately after PCI, and the indirect admission (IA) group, who were admitted after boarding in the ED. The primary endpoint was in-hospital mortality. Secondary endpoints were 3-month mortality, LOS in CCU and hospital, and LOS under intensive care. ResultsDuring the study period, 780 patients were enrolled and analyzed. The in-hospital mortality rate and 3-month mortality rate were 5.9% (46 patients) and 8.5% (66 patients). The DA group and IA group had similar in-hospital and 3-month mortality rates (P = .50, P = .28). The median CCU LOS and hospital LOS was similar for both groups (P = .28, P = .46). However, LOS under in intensive care for the IA group was significantly longer than that of the DA group (DA, 31.9 h; IA, 38.7 h; P < .001). ConclusionThis study suggests that direct admission after PCI and indirect admission was not associated with mortality in patients with STEMI. In addition, the stay in ED also appears to be associated with the duration of stay under critical care.

Interfacility Transfer Is a Risk Factor for Venous Thromboembolism in Lower Extremity Fracture Patients.

To compare the incidence of venous thromboembolism (VTE) among patients with pelvic and/or lower extremity fractures directly admitted to our institution versus those transferred from an outside hospital for definitive management. Retrospective cohort. Tertiary care orthopaedic hospital. Six hundred ninety patients who received definitive care for a lower extremity fracture at our institution between 2010 and 2017. Interfacility transfer for definitive management of pelvic or lower extremity fracture. VTE incidence and time to surgery. The interfacility transfer (TR) group comprised 126 patients, and the direct admission (DA) group comprised 564 patients. TR patients had a significantly higher incidence of VTE compared with the DA group: 9.5% versus 0.7%, respectively (P < 0.001). Time to surgery was also longer in the TR group compared with the DA group: 3.05 ± 3.00 days versus 2.16 ± 2.42 days, respectively (P = 0.005). Demographics for TR and DA did not significantly differ with regard to age, sex, length of stay, or American Society of Anesthesiologist score. In the TR group, no complete and explicit documentation regarding thromboprophylaxis administration while at the outside facility was found. Patients undergoing interfacility transfer for definitive management of pelvic and lower extremity fractures are at a significantly increased risk of the development of VTE. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Safety and Time Course of Drip-and-Ship in Treatment of Acute Ischemic Stroke

The drip-and-ship approach allows intravenous tissue plasminogen activator therapy and adjuvant endovascular treatment in acute ischemic stroke, even in rural areas. Here, we examined the safety and time course of the drip-and-ship approach. Fifty consecutive cases treated with the drip-and-ship approach (drip-and-ship group) in June 2009 to March 2016 were retrospectively examined. Changes in mean blood pressure, systemic complications, and neurological complications were compared according to method of transportation. Time courses were compared between drip-and-ship and direct admission groups during the same period. In the drip-and-ship group, 33 and 17 patients were transferred to hospital by ambulance and helicopter, respectively. One patient suffered hemorrhagic infarction during transportation by ambulance. Mean blood pressure change was lower in patients transferred by helicopter than ambulance (<5 mmHg versus 12.2 mmHg, respectively). The mean onset-to-door times in the drip-and-ship and direct admission groups were 71 and 64 minutes, respectively, and mean door-to-needle times were 70 and 47 minutes, respectively (P =.002). Although mean transportation time from the primary stroke hospital to our hospital was 32 minutes, the entry-to-exit time from the primary stroke hospital was 113 minutes. Thereafter, there was an average delay of 100 minutes until reperfusion compared with the direct admission group. Drip-and-ship was relatively safe in this small series. Transportation by helicopter was less stressful for acute ischemic stroke patients. It is important to reduce door-to-needle time and needle-to-departure time in the primary stroke hospital to minimize the time until treatment in cases of acute ischemic stroke.

Direct admission to stroke centers reduces treatment delay and improves clinical outcome after intravenous thrombolysis

We aimed to examine whether direct access to hospitals offering intravenous thrombolysis is associated with functional outcomes in patients with acute ischemic stroke treated with intravenous thrombolysis. We enrolled patients who received intravenous thrombolysis within 4.5hours of symptom onset using a prospective multicenter registry database. Patients referred directly from the field to organized stroke centers were compared with those who were transferred from non-thrombolysis-capable hospitals in terms of clinical outcomes at 90days after intravenous recombinant tissue plasminogen activator treatment. We also investigated onset-to-door time and onset-to-needle time according to admission mode. A total of 820 patients (mean age of 67.3years and median National Institutes of Health Stroke Scale score of 9) were enrolled. Seventeen percent of patients with AIS who received intravenous thrombolytic therapy at 12 hospitals (n=142) were transferred from other hospitals. The direct admission group had a shorter median onset-to-admission time (63 versus 121minutes, P<0.001) and onset-to-needle time (110 versus 161minutes, P<0.001) as compared with the indirect admission group. Direct admission was associated with a good outcome with an odds ratio of 1.57 (95% confidence interval: 1.02–2.39, P=0.036) after adjustment for baseline variables. Direct admission to a hospital with intravenous thrombolysis facilities available at all times was associated with shorter onset-to-needle time and better outcome in patients with AIS undergoing thrombolytic therapy. Our findings support the implementation of regional stroke care programs transporting patients directly to stroke centers to promote faster treatment and to achieve better outcomes.

Torsion du cordon spermatique chez l’enfant : impact du mode de consultation sur le délai de prise en charge et le taux d’orchidectomie

Acute scrotal pain is a true surgical emergency as patients presenting with acute scrotal pain may suffer from spermatic cord torsion and gonadal loss. We assessed whether the type of consultation (first consultation in our center or secondary transfer from a peripheral hospital or primary care practice), distance from home to hospital, and duration of pain had an impact on the orchiectomy rate. We retrospectively reviewed the medical records of all patients under 15years of age suffering from acute scrotal pain who had surgical exploration between January 2007 and January 2010 in our center. Patient demographics, transfer status, time to consultation in our center, time to surgery, operative findings and clinical outcome were reviewed. Of the 76 patients with acute scrotal pain in whom surgical exploration was performed, 59 had acute spermatic cord torsion, 16 had torsion of the testicular appendage, and 1 had orchitis. In patients with acute spermatic cord torsion, the median age was 13 years (range: 0.18-14.97). In patients with acute spermatic cord torsion, 32 came straight to our center (direct admission group, 54.2%), and 27 (45.8%) came after a prior consultation out of side the center (transfer group). The median journey was 19km (range: 2.5-113) in the direct admission group and 44km (range: 2.5-393) in the transfer group (P=0.0072). The median time between pain onset and consultation at our center was 4.3h (range: 0.5-48) in the direct admission group, and 11h (range: 2-48) in the transfer group (P=0.6139). The median time between admission at our center and surgery was 2.5h, with no difference between the 2 groups (P=0.8789). The orchiectomy rate was 25% in the direct admission group and 14.8% in the transfer group (P=0.5177). In children who underwent orchiectomy, the duration of pain was consistently over 6h. The duration of pain was greater in patients with orchiectomy (12h [range: 1-72]) than in patients without orchiectomy (12h [range: 6-48]; P=0.0001). In this study, the orchiectomy rate depended on the duration of pain but not on transfer status. Acute scrotal pain must lead to surgical exploration as soon as possible, requiring close collaboration between peripheral hospitals, primary care physicians, and referral centers.

The clinical consequences of a pre-hospital diagnosis of stroke by the emergency medical service system. A pilot study

BackgroundThere is still a considerable delay between the onset of symptoms and arrival at a stroke unit for most patients with acute stroke.The aim of the study was to describe the feasibility of a pre-hospital diagnosis of stroke by an emergency medical service (EMS) nurse in terms of diagnostic accuracy and delay from dialing 112 until arrival at a stroke unit.MethodsBetween September 2008 and November 2009, a subset of patients with presumed acute stroke in the pre-hospital setting were admitted by EMS staff directly to a stroke unit, bypassing the emergency department. A control group, matched for a number of background variables, was created.ResultsIn all, there were 53 patients in the direct admission group, and 49 patients in the control group. The median delay from calling for an ambulance until arrival at a stroke unit was 54 minutes in the direct admission group and 289 minutes in the control group (p < 0.0001).In a comparison between the direct admission group and the control group, a final diagnosis of stroke, transient ischemic attack (TIA) or the sequelae of prior stroke was found in 85% versus 90% (NS). Among stroke patients who lived at home prior to the event, the percentage of patients that were living at home after 3 months was 71% and 62% respectively (NS).ConclusionsIn a pilot study, the concept of a pre-hospital diagnosis of stroke by an EMS nurse was associated with relatively high diagnostic accuracy in terms of stroke-related diagnoses and a short delay to arrival at a stroke unit. These data need to be confirmed in larger studies, with a concomitant evaluation of the clinical consequences and, if possible, the level of patient satisfaction as well.

Patients With Acute Stroke Admitted on the Second Visit

The aim of this study was to identify the characteristics of patients with stroke who were discharged home despite their need for acute hospital treatment. This study included 611 consecutive patients with ischemic stroke who were admitted to our hospital within 7 days of stroke onset. The patients were divided into two groups: those directly admitted and those readmitted after having previously been seen at our hospital or other facilities. The patients' characteristics and symptoms at the time of their initial visit were analyzed. In all, 61 patients (10.0%) were initially discharged. The presence of hypertension, a summer admission, ambulance transport, and evaluation by neurologists were more frequent in the direct admission group than in the nondirect admission group. There was a lower incidence of consciousness disturbance and motor deficits in the nondirect admission group than in the direct admission group. The incidence of visual disturbance, gait disturbance, vertigo or dizziness, nausea, and sensory disturbance was higher in the nondirect admission group than in the direct admission group. On logistic regression model analysis, evaluation by nonneurologists (odds 33.0), hypertension (3.14), absence of consciousness disturbance (5.26), absence of paralysis (2.27), and presence of sensory disturbance (3.45) were independently associated with being initially discharged. Physicians tend to consider that a patient has no need to be admitted into hospital if the patient is alert, has a sensory disturbance, or has no paralysis.

Direct transport versus interhospital transfer of patients with severe head injury in Norway

This study compares injury severity and outcome of patients with severe head injury admitted directly to a neurosurgical department with those initially transferred to a local hospital. A retrospective analysis of all patients with severe head injury admitted to the Department of Neurosurgery at St Olav University Hospital, Norway, was carried out from 1998 throughout 2002. The study included 146 patients with a median age of 34 (1-88) years. Patients transported directly (57%) had lower field Glasgow Coma Scale (fGCS) [5.5 (3-15) vs. 7 (3-15), P=0.002], higher Injury Severity Score [31.8 (9-75) vs. 27.0 (9-75), P=0.023], higher mortality rates (31 vs. 15%, P=0.042) and reached the neurosurgical department earlier [1.8 (0.3-15.8) vs. 5.5h (0.8-23.0), P<0.001] than those undergoing transfer to a local hospital. Significantly more patients in the direct admission group with a fGCS <or=8 (83%) were intubated at the scene of accident than in the transfer group (38%) (P<0.001). Multiple regression analysis adjusting for age, GCS and pupillary abnormalities did not predict increased mortality for the transfer group [odds ratio 0.43 (0.16, 1.14), P=0.09]. Patients with a severe head injury admitted directly to the neurosurgical department are more severely injured, more frequently get advanced medical treatment in the field, and are undergoing surgery earlier than transferred patients.

Pre- and inter-hospital transport of severely head-injured patients in rural Northern Norway.

The purpose of this study was to survey the time consumed during the pre- and inter-hospital transport of severely head injured patients in Northern Norway. All patients (n = 85) operated for an intracranial mass lesions within 48 h after injury during the 10-year period 1986-1995 were included in this retrospective analysis. Ambulance records, transfer notes, and hospital records were reviewed. The transport of patients was classified as either direct from the trauma scene to the University Hospital (direct admission group) or as an inter-hospital transfer (transfer group). Forty-seven (55%) patients were in the direct admission group, and 38 (45%) were transferred through another hospital. The majority of patients (81%) were transported by air ambulance. Median time from injury to arrival in the emergency room was 5 (1-44) h. Time necessary for transport was significantly (p < 0.001) shorter in the direct admission group (median 3 h) compared to the transfer group (median 8 h). The inter-hospital transfer time was < or = 3 h in 17%. Clearly, the advanced air ambulance service in Northern Norway makes rapid inter-hospital transfer possible despite extremely long geographical distances. Our findings indicate that this possibility is not always utilized.

An Early Labor Assessment Program

McNiven, Patricia S.; Williams, Jack I.; Hodnett, Ellen; Kaufman, Karyn; Hannah, Mary E. Author Information