Emergency Admissions Of Patients Research Articles

Analysis of NT-proBNP detection guided treatment of elderly patients with dyspnea （ affiliated 146 cases）

Objective To explore the clinical value of N-terminal pro-brain natriuretic peptide （NT-proBNP） in elderly patients with acute dyspnea. Methods Retrospective analysis of 146 cases of patients with emergency admissions of patients （age ≥ 60 years）with dyspnea from January 2012 - December 2013, patients in 2012 with conventional treatment group; patients in 2013 were under the guidance of NT-proBNP treatment group; properties according to the test results of the NT-proBNP clinical reference standard and NT-proBNP to the evaluation of dyspnea and guide rescue, rescue success rate of patients in 2 groups were analyzed and compared. Results 67 cases （ 15 cases were markedly effective,37 cases were effective,ll cases were invalid,4 cases of death） were rescued in 2012, 79 cases （27 cases were markedly effective,44 cases were effective,6 cases were invalid,2 cases of death） were rescued in 2013. Elderly patients with Dyspnea under the guidance of emergency NT-proBNP levels in 2013 （89.87%） , the rescue success rate was higher than that in the 2012 traditional treatment group （77.61%） （x^2 = 4. 11, P 〈 0. 05 ）. Conclusion Rapid determination of NT-proBNP level of elderly patients with dyspnea has high clinical value in emergency rescue. Key words: Dyspnea; N-terminal pro-brain natriuretic peptide; Aged

OC-045 Reduced Risk Of Emergency Admission For Colorectal Cancer Associated With Introduction Of Bowel Cancer Screening Across England: Retrospective National Cohort Study

IntroductionWe examined whether roll out of the bowel cancer screening programme (BCSP) across England was associated with a reduced risk of emergency hospital admission for people presenting with colorectal cancer...

EMERGENCY NEUROMUSCULAR ADMISSIONS ARE AVOIDABLE: A REGIONAL AUDIT OF UNPLANNED HOSPITAL ADMISSIONS OF NEUROMUSCULAR PATIENTS 2009–2011: FINAL RESULTS AND RECOMMENDATIONS

IntroductionNeuromuscular diseases (NMD) require long–term multi–disciplinary care. In 2010–11 there were 5.3 million emergency admissions of which 213,000 related to neurological disorders. 13% of these (∼28,000) were secondary to NMD....

Is secondary preventive care improving? Observational study of 10-year trends in emergency admissions for conditions amenable to ambulatory care

ObjectiveTo identify trends in emergency admissions for patients with clinical conditions classed as ‘ambulatory care sensitive’ (ACS) and assess if reductions might be due to improvements in preventive care.DesignObservational study...

PTU-249 Key worker alerts in emergency admissions of patients with gastrointestinal cancer substantially shorten length of stay and readmission rates

IntroductionA retrospective audit of data from 2007 to 2009 revealed that patients known to have gastrointestinal (GI) cancer admitted as an emergency to our trust had long median length of...

Anticoagulation management in patient undergoing elective and emergency orthopaedic procedures

INTRODUCTION Warfarin remains the treatment of choice for the majority of patients with venous thromboembolism, atrial fibrillation and valvular heart disease or valve replacement unless contraindicated. Poor management of patients on warfarin often leads to delay in surgery, life threatening bleeding during or after operation and unnecessary delay in discharge from hospitals in United Kingdom. METHODS We carried out a prospective study on patients who were on warfarin and underwent elective and emergency orthopaedic procedures during period of study- August 2007 to April 2008. All patients included in the study were identified from admission notes during period of study. All data regarding indications for warfarin, pre and post procedures INR, elective or emergency orthopaedic procedures and complications were collected using a standard proforma. RESULTS 18 patients, 12 male and 6 female were included into the study. Patients9 age ranged from 47-87 with mean of 76. The indications for warfarin therapy were atrial fibrillation in 12 patients, deep vein thrombosis in 5 patients and left ventricular aneurysm in 1 patient. 18 procedures, 10 elective and 8 emergency orthopaedic procedures were carried out during period of study. Elective procedures - 7 primary joint arthroplasty, 1 revision hip arthroplasty, 1 removal of metalwork and 1 metatarsophalangeal joint fusion. Emergency procedures - 4 hip hemiarthroplasty, 2 dynamic hip screw fixation, 1 external fixator application and 1 open reduction and internal fixation of ankle. All elective admission patients were pre-assessed in clinic prior to admission and were advised to stop warfarin based on their INR level. Patients with INR 2-3 had their warfarin stopped 4 days prior to surgery while patients with INR 3-4.5 had their warfarin stopped 5 days prior to surgery. This group of patients had their INR check on admission and ranged from 1.1-1.5. This group of patients had no reversal therapy and no cancellations were made to their operation. 8 emergency admission patients had INR of 1.4-4.7 on admission with mean of 2.7. 5 patients had reversal therapy while 3 patients had no reversal therapy. Pharmacological methods used to reduce the INR were fresh frozen plasma in 1 patient and Vitamin K in 4 other patients. 2 patients that received reversal therapy had operation on day 1, 2 on day 3 and 1 on day 5. 1 patient that had no reversal therapy was operated on day 1, 1 on day 3 and 1 on day 5. Patient that received no reversal therapy and operated on day 5 of admission died post-operatively from medical complications. Mean delay for patient that had reversal therapy was 2.2 days compared to 3 days in patient with no reversal therapy. All patients in this study had prophylactic low molecular weight heparin while off warfarin. Patients were recommenced on their normal dose of warfarin the day after their operation. DISCUSSION & CONCLUSIONS We conclude that patients on warfarin with INR 2-3 should have their warfarin stopped 4 days prior to surgery while patients with INR 3-4.5 should stop their warfarin 5 days prior to elective surgery. Trauma patients on warfarin requiring operation should have their INR reversed on admission to shorten delay in waiting time and improve outcomes.

Erect chest radiography in the setting of the acute abdomen: essential tool or an unnecessary waste of resources?

It has been suggested that changes to the training schemes of junior doctors and the increased pressure on emergency departments to manage their patients within a limited time might increase the number of unnecessary investigations performed on emergency admission patients. This, in turn, may lead to an increased number of investigations with normal results. In this study we try to analyse the role of the chest X-ray (CXR) as a diagnostic tool in patients presenting with acute abdominal pain. A retrospective study was performed of the request forms and results of all chest radiography performed on patients admitted on the emergency surgical intake with acute abdominal pain through utilisation of the prospectively maintained electronic radiology database. The indications were compared to the guidelines published by the Royal College of Radiologists (RCR) which have been adopted as the standard of care. A total of 334 chest X-rays were identified of which only 23 (7%) had new findings. Four (1%) patients had free gas under the diaphragm. Of the CXRs, 258 (77%) were reported normal whilst 53 (16%) had old changes which were described in their hospital records and previous radiographs. Of the CXRs with new findings, only 20 were clinically significant and, of these, four (1%) were surgically significant. The majority of CXRs performed on emergency surgical admissions with abdominal pain are unnecessary. By obtaining a clear history, performing a thorough clinical examination and following the RCR guidelines most of the CXRs could be avoided. This would lead to less radiation exposure, reduce delays to diagnosis, and provide significant financial savings.

A New Preoperative Predictor of Outcome in Ruptured Abdominal Aortic Aneurysms: The Time Before Shock (TBS)

In patients with ruptured abdominal aortic aneurysm (RAAA) and shock, the time lag between the onset of the symptoms due to RAAA and the presence of a full developed shock syndrome was evaluated to assess its prognostic meaning. This time lag was called time before shock (TBS). Ninety-four patients operated on between 2002 and 2007 have been retrospectively analyzed regarding TBS and the following parameters: presence of shock, severity of bleeding, age, comorbidities, and gender. According to TBS, on a 10-hour cutoff value, three groups of patients were distinguished: patients with TBS of 10 or less (short TBS), patients with TBS greater than 10 (long TBS), and patients without shock. The relationship of these variables with intraoperative and 30-day mortality was analyzed by both univariate and multivariate analyses. In the univariate analysis, patients with short TBS presented with four-fold mortality compared to patients without shock (p=0.000), whereas the increase in mortality of the patients with long TBS was nonsignificant (p=0.448). The mortality in patients with shock (presence of shock) was 3.7 times higher than in patients without shock (p=0.001). The mortality related to massive bleeding was 3.7 times higher than that associated with moderate bleeding (p=0.001). An increased mortality with borderline significance level was observed in patients older than 75 years (p=0.052). The relationship of mortality to the presence of comorbidities and gender was not significant. In the multivariate analysis, the mortality among the patients with short TBS was clearly highest, after either massive or moderate bleeding. In the logistic model with TBS, the Wald test showed as significant both short TBS (p=0.001) and severity of bleeding (p=0.033) but not age (p=0.103) and long TBS (p=0.0401). The model with TBS presented a better performance than that with shock, showing higher sensitivity, higher values of Youden's J, and a greater proportion of the total variation in mortality. Through the model with TBS, two groups of patients (those 75 years or younger with massive bleeding and those older than 75 years with moderate bleeding), both with short TBS, presented with a high risk of death not predicted by the model with shock. TBS seems to complete the information given by the parameter "presence of shock," and its evaluation allows a more effective judgment of the risk of death, at emergency admission of patients with RAAA.

Sampling rate causes bias in APACHE II and SAPS II scores.

To study the effect of sampling rate of laboratory and haemodynamic data on severity scorings and predicted risk of hospital death. Prospective study. Medical-surgical intensive care unit (ICU) with 23 beds in a university hospital. Sixty-nine consecutive emergency admission patients. Blood samples were drawn from indwelling arterial lines for the laboratory tests of all variables contained in the APACHE II and SAPS II scores at 2-hourly intervals from the time of admission up to 24 h or earlier discharge or death of the patient. Haemodynamic data and temperature were collected either manually by the attending nurse once an hour or as 2-min median values automatically using a Clinical Information Management System (CIMS, Clinisoft, Datex-Ohmeda, Helsinki, Finland). Three sets of severity scores were obtained. (1) "Traditional" scores (haemodynamic data from manual records and laboratory values from tests taken at admission and subsequently on clinical basis only). (2) "CIMS" scores (haemodynamic data from 2-min median values and laboratory values prescribed on clinical indication) and (3) "High rate" scores (haemodynamic data from 2-min median values and laboratory values at 2-hourly intervals). Probability of hospital death was calculated using the SAPS II and APACHE II scores, respectively. Increasing the sampling rate of haemodynamic monitoring interval to 2-min from once per hour resulted in 7.8 % and 11.5 % increases (p < 0.001) in the APACHE II and SAPS II scores, respectively. The combined effect of increased sampling rate of haemodynamic and laboratory tests on the APACHE II and SAPS II scores was 14.4 % and 14.5 % compared to traditional scores (p < 0.001), respectively. The probability of hospital death increased from 0.23 and 0.21 ("traditional" SAPS II and APACHE II) to 0.31 and 0.25 ("high rate" SAPS II and APACHE II), respectively, and, because eight patients died, standardised mortality ratio (SMR) decreased from 0.53 to 0.41 (SAPS II) and from 0.60 to 0.50 (APACHE II). Increased sampling rate results in higher scores and lower SMR. Comparisons between hospitals using severity scores are biased due to differences in the sampling rates.

Time-pattern of lactate and lactate to pyruvate ratio in the first 24 hours of intensive care emergency admissions.

Blood lactate elevation in critically ill patients commonly is taken as a sign of impaired tissue perfusion. Simultaneous elevation of lactate to pyruvate ratio (L/P ratio) may be helpful in discriminating between different mechanisms of hyperlactatemia and thus in determining the relevance of the finding. We studied prospectively the prevalence and the time pattern of hyperlactatemia and simultaneous L/P ratio elevation in 98 consecutive emergency admission patients in a 23-bed surgical-medical University Hospital intensive care unit. Blood lactate, L/P ratio, and blood gases were measured at 2-h intervals during the initial 24 h of intensive care unit admission. Hyperlactatemia (blood lactate over 2 mmol/L) was found in 48 (49%) patients, and the median peak value of the non-survivors was higher than that of the survivors [5.3 (interquartile range 1.9-7.5) vs. 1.9 (1.3-2.9) mmol/L, respectively, p = 0.003]. Hyperlactatemia at admission (n = 31) was associated with a higher hospital mortality than hyperlactatemia developing later (n = 17) (29.0% vs. 5.9%, P = 0.003). Sustained admission hyperlactatemia (>6 h) was associated with higher mortality than short-lasting hyperlactatemia (36.8% vs. 0%, P = 0.008). Simultaneously elevated L/P ratio (L/P ratio > 18; n = 16) was associated with higher mortality than hyperlactatemia with normal L/P ratio (n = 32; 37.5% vs. 12.5%, respectively, P = 0.03) and was found mainly in patients who had severe circulatory failure. The hyperlactatemia of patients with sepsis was not associated with L/P ratio elevation. We conclude that hyperlactatemia is common in emergency admission patients. Hyperlactatemia with L/P ratio elevation and lactic acidosis is likely to be associated with inadequate tissue perfusion. Hyperlactatemia persisting more than 6 h and simultaneous elevation of L/P ratio are associated with increased mortality.

Emergency admission for surgery predicts disease progression during adjuvant 5-Fluouracil (5-FU)-based chemotherapy

To determine the prognostic significance of a number of variables in patients that receive adjuvant chemotherapy for colorectal cancer. We reviewed the Cancer Centre records of 194 patients who received adjuvant chemotherapy following potentially curative resection of Dukes' B or C colorectal cancer. Eight variables were examined to determine which factor(s) predicted disease progression during the 6-month chemotherapy period. Admission for emergency resection (due to bowel obstruction or perforation) rather than elective resection, and a poorly differentiated tumour rather than moderately/well differentiated were independent significant factors in predicting disease progression (P < 0.001 and P=0.011, respectively). However, sex, age, Dukes' stage, number of involved lymph nodes, delays in starting chemotherapy and compliance with chemotherapy regime had no significant effect on 6-month tumour progression. These preliminary findings confirm data which suggest that emergency admission patients may suffer from intrinsically more aggressive disease than the average population with colorectal cancer.

Day treatment: suitability and referral procedure.

In a prospective screening of emergency admissions of patients suffering from neurosis, personality disorder or adjustment reaction, 100 were assessed as suitable for early transfer to day hospital treatment, 101 as unsuitable, and 39 as not requiring further intervention. Of the unsuitable patients, 39 were grossly disturbed; the remainder did not differ in severity from those thought suitable, but there was a specific reason against day treatment in all but 13 of the 62--most commonly alcohol abuse, physical problems, social problems or aggression. Patients' attitudes were also important. Recruitment of patients had to be active, with regular visits to the wards by day hospital staff.

Is Survey Cancer of the Lung Curable?

Summary 1. The prevalence per 100,000 of proved bronchogenic carcinoma among 142,156 surveyed Philadelphians on whom appropriate basic data were available was: three for females, 37 for group as a whole, 69 for males, and 284 for males over 45. 2. The survivorship of 100 consecutive cases of proved bronchogenic carcinoma detected by photofluorograms taken from January 1, 1947 to May 31, 1953 at two official Philadelphia survey units is presented. Of the 57 patients with a minimal three-year follow-up period, only five (9 per cent) were resected and alive at the end of the three years after their first abnormal photofluorograms. 3. Exploration was carried out in 52 instances but resection was only possible in 30. Immediate hospital mortality was 17 per cent. 4. Detailed survival studies on the 57 patients surveyed prior to August 31, 1950 suggest a more grave prognosis for those younger than 55, those whose photofluorograms obviously suggested neoplasm or tuberculosis, those with respiratory symptoms severe enough to have caused them to seek medical advice, those with bronchoscopic abnormality of any type, those with undifferentiated carcinomas, and those with concomitant active tuberculosis. 5. Paradoxically, the fate of patients hospitalized within three months of their abnormal photofluorograms was worse than that of those with delays of more than three months. Two factors may obscure the true relationship between prompt hospitalization and ultimate fate. The first is the emergency admission of patients whose photofluorograms at once suggested neoplasm and who were mostly already beyond salvage. The second is the better prognosis of those whose film lesions were inconspicuous. 6. Examination of individual components of delay in hospitalization revealed three causes for significant delay—the radiologist, the patient, and the clinician. 7. Any photofluorographic abnormality in men over 45 should be considered as possibly due to lung cancer. The highest salvage may well lie in the group whose films least suggest malignancy. 8. Of 29 patients on whom earlier “negative” films were available, 13 were still considered negative on review while 16 had lesions which had been missed. The fate of the “erroneous negatives” was better than that of the “true negatives.” 9. With present techniques, less than 10 per cent of survey-detected lung cancer appears curable. Suggestions are made for improving the situation currently, but it is recommended that the search continue for new more effective case-finding techniques.

USDA and AEC expand research with radioactive chemicals on soil and plant problems

1. The prevalence per 100,000 of proved bronchogenic carcinoma among 142,156 surveyed Philadelphians on whom appropriate basic data were available was: three for females, 37 for group as a whole, 69 for males, and 284 for males over 45.2. The survivorship of 100 consecutive cases of proved bronchogenic carcinoma detected by photofluorograms taken from January 1, 1947 to May 31, 1953 at two official Philadelphia survey units is presented. Of the 57 patients with a minimal three-year follow-up period, only five (9 per cent) were resected and alive at the end of the three years after their first abnormal photofluorograms.3. Exploration was carried out in 52 instances but resection was only possible in 30. Immediate hospital mortality was 17 per cent.4. Detailed survival studies on the 57 patients surveyed prior to August 31, 1950 suggest a more grave prognosis for those younger than 55, those whose photofluorograms obviously suggested neoplasm or tuberculosis, those with respiratory symptoms severe enough to have caused them to seek medical advice, those with bronchoscopic abnormality of any type, those with undifferentiated carcinomas, and those with concomitant active tuberculosis.5. Paradoxically, the fate of patients hospitalized within three months of their abnormal photofluorograms was worse than that of those with delays of more than three months. Two factors may obscure the true relationship between prompt hospitalization and ultimate fate. The first is the emergency admission of patients whose photofluorograms at once suggested neoplasm and who were mostly already beyond salvage. The second is the better prognosis of those whose film lesions were inconspicuous.6. Examination of individual components of delay in hospitalization revealed three causes for significant delay—the radiologist, the patient, and the clinician.7. Any photofluorographic abnormality in men over 45 should be considered as possibly due to lung cancer. The highest salvage may well lie in the group whose films least suggest malignancy.8. Of 29 patients on whom earlier “negative” films were available, 13 were still considered negative on review while 16 had lesions which had been missed. The fate of the “erroneous negatives” was better than that of the “true negatives.”9. With present techniques, less than 10 per cent of survey-detected lung cancer appears curable. Suggestions are made for improving the situation currently, but it is recommended that the search continue for new more effective case-finding techniques.