Emergency Department Consultations Research Articles

Evaluation of a Digital Scribe: Conversation Summarization for Emergency Department Consultation Calls.

We present a proof-of-concept digital scribe system as an Emergency Department (ED) consultation call-based clinical conversation summarization pipeline to support clinical documentation, and report its performance. We use four pre-trained large language models to establish the digital scribe system: T5-small, T5-base, PEGASUS-PubMed, and BART-Large-CNN via zero-shot and fine-tuning approaches. Our dataset includes 100 referral conversations among ED clinicians and medical records. We report the ROUGE-1, ROUGE-2, and ROUGE-L to compare model performance. In addition, we annotated transcriptions to assess the quality of generated summaries. The fine-tuned BART-Large-CNN model demonstrates greater performance in summarization tasks with the highest ROUGE scores (F1ROUGE-1=0.49, F1ROUGE-2=0.23, F1ROUGE-L=0.35) scores. In contrast, PEGASUS-PubMed lags notably (F1ROUGE-1=0.28, F1ROUGE-2=0.11, F1ROUGE-L=0.22). BART-Large-CNN's performance decreases by more than 50% with the zero-shot approach. Annotations show that BART-Large-CNN performs 71.4% recall in identifying key information and a 67.7% accuracy rate. The BART-Large-CNN model demonstrates a high level of understanding of clinical dialogue structure, indicated by its performance with and without fine-tuning. Despite some instances of high recall, there is variability in the model's performance, particularly in achieving consistent correctness, suggesting room for refinement. The model's recall ability varies across different information categories. The study provides evidence towards the potential of AI-assisted tools in assisting clinical documentation. Future work is suggested on expanding the research scope with additional language models and hybrid approaches, and comparative analysis to measure documentation burden and human factors.

Domestic and International Cosmetic Tourism Complications Presenting to a U.S. Tertiary Hospital.

Cosmetic surgery tourism has become a significant global industry. Oftentimes, patients who develop postoperative complications present for care in their home U.S. state. This study evaluated patients who either traveled abroad or to other states within the United States for cosmetic surgeries and returned with complications treated in the authors' center. We sought to compare rates of complications between patients that underwent cosmetic surgery internationally and domestically. This retrospective cross-sectional study reviewed patients who presented from June 2014 to June 2022 with concerns related to cosmetic surgeries performed in another state or abroad. Binary logistic regressions were performed to assess differences in outcomes between domestic and international cases, including complications, interventions, and admissions. One-hundred twenty-three patients (97.6% female, me an age 34.0 ± 8.7 years, range 16-62 years) comprised 159 emergency department consultations. The most common procedures included abdominoplasty (n=72) and liposuction (n=56). Complications included wound dehiscence (n=39), infection (n=38), and seroma (n=34). Over one-half of patients required intervention. Twenty-nine patients (23.6%) required hospital admission. On multivariate regression analyses, incidence of seroma (p=0.025) and oral (p=0.036) and intravenous antibiotic prescriptions (p=0.045) were significantly greater among the international cohort compared to domestic, whereas all other complication variables were non-significant. There were no other significant differences in operative interventions or hospital admissions between international and domestic cohorts. Compared to domestic tourism cases, international tourism cases were associated with significantly higher rates of seroma formation and antibiotic use. There were no significant differences otherwise in overall complications including infections, operative interventions, or hospital admissions.

Clinical and socioeconomic predictors of shunt malfunction in the pediatric emergency department.

The aim of this study was to delineate the clinical and socioeconomic variables associated with shunt revision in pediatric patients presenting to the emergency department (ED) with concerns of ventricular shunt malfunction. A retrospective analysis of pediatric ED consultations for shunt malfunction over a 1-year period was conducted, examining clinical symptoms, radiographic findings, and socioeconomic variables. Sensitivities, specificities, and positive and negative predictive values were calculated for each presenting symptom collected. Logistic regression models were used to estimate the odds ratios for shunt revision based on these variables, and multivariate analyses were used to adjust for potential confounders. Of the 271 ED visits from 137 patients, 19.2% resulted in shunt revision. Increased ventricle size on imaging (OR 11.38, p < 0.001), shunt site swelling (OR 9.04, p = 0.01), bradycardia (OR 7.08, p < 0.001), and lethargy (OR 5.77, p < 0.001) were significantly associated with shunt revision. Seizure-like activity was inversely related to revision needs (OR 0.24, p < 0.001). Patients with private or self-pay insurance were more likely to undergo revision compared with those with public insurance (p = 0.028). Multivariate analysis further confirmed the significant associations of increased ventricle size, lethargy, and bradycardia with shunt revision, while also revealing that seizure-like activity inversely affected the likelihood of revision. Patients with severe cognitive and language disabilities were more likely to be admitted to the hospital from the ED but were not more likely to undergo revision. Clinical signs such as increased ventricle size, shunt site swelling, bradycardia, and lethargy may be strong predictors of the need for shunt revision in pediatric patients presenting to the ED with concerns of shunt malfunction. Socioeconomic factors play a less clear role in predicting shunt revision and admission from the ED; however, the nature of their influence is unclear. These findings can help inform clinical decision-making and optimize resource utilization in the ED.

The Increasing Burden of Emergency Department and Inpatient Consultations for "Papilledema".

Increasing incidence of idiopathic intracranial hypertension (IIH), overreported radiologic signs of intracranial hypertension, difficult access to outpatient neuro-ophthalmology services, poor insurance coverage, and medicolegal concerns have lowered the threshold for emergency department (ED) visits for "papilledema." Our objective was to examine referral patterns and outcomes of neuro-ophthalmology ED and inpatient consultations for concern for papilledema. At one university-based quaternary care center, all adults referred for "papilledema" over one year underwent a standardized ED "papilledema protocol." We collected patient demographics, final diagnoses, and referral patterns. Over 1 year, 153 consecutive patients were referred for concern for papilledema. After papilledema protocol, 89 of 153 patients (58%) had bilateral optic disc edema, among whom 89% (79/89) had papilledema (intracranial hypertension). Of the 38 of 153 (25%) consultations for suspected disorder of intracranial pressure without previous fundus examination (Group 1), 74% (28/38) did not have optic disc edema, 21% (8/38) had papilledema, and 5% (2/38) had other causes of bilateral disc edema. Of the 89 of 153 (58%) consultations for presumed papilledema seen on fundus examination (Group 2), 58% (66/89) had confirmed papilledema, 17% (15/89) had pseudopapilledema, and 9% (8/89) had other causes of bilateral optic disc edema. Of the 26 of 153 (17%) patients with known IIH (Group 3), 5 had papilledema and 4 required urgent intervention. The most common diagnosis was IIH (58/79). Compared with IIH, patients with secondary causes of intracranial hypertension were older (P = 0.002), men (P < 0.001), not obese (P < 0.001), and more likely to have neurologic symptoms (P = 0.002). Inpatient and ED consultations for "papilledema" are increasing. Of the 153 ED and inpatient neuro-ophthalmology consultations seen for "papilledema" over 1 year, one-third of patients with optic disc edema of unknown cause before presentation to our ED had new vision- or life-threatening disease, supporting the need for prompt identification and evaluation of optic disc edema in the ED. In the face of limited access to neuro-ophthalmologists, this study supports the need for emergency department access to expert eye-care evaluation or ocular fundus camera for prompt identification of optic disc edema and standardized evaluation for neurologic emergencies.

Enfermedad diverticular

Diverticula are sac-like protrusions that appear in the weak points of the colon wall. They are usually asymptomatic. Diverticular disease develops when symptoms appear. Its etiopathogenesis is likely multifactorial, although it is not fully known. Complicated diverticulosis includes acute diverticulitis, which is the most frequent complication and one of the most common reasons for consultation in emergency departments, and diverticular hemorrhage, one of the most frequent causes of lower gastrointestinal bleeding in our setting. A diagnosis of acute diverticulitis is established through an abdominal computed tomography scan. A diagnosis of hemorrhage is established by performing a full colonoscopy, for which adequate prior preparation of the patient by means of taking an oral laxative solution is recommended. The treatment of acute diverticulitis has classically been based on the use of antibiotics, although current evidence supports a decrease in the use of antibiotic treatment in patients with uncomplicated acute diverticulitis. In this disease, antibiotics must target a polymicrobial etiology consisting mainly of gram-negative and anaerobic bacilli.

Emergency department utilisation and treatment for trauma-related presentations of adolescents aged 16–18: a retrospective cross-sectional study

BackgroundA recent study conducted at our tertiary hospital emergency department (ED) reviewed ED consultations and found that adolescents aged 16–18 years present significantly more often for trauma and psychiatric problems than adults over 18 years. Accidental injuries are one of the greatest health risks for children and adolescents. In view of the increased vulnerability of the adolescent population, this study aimed to further analyse trauma-related presentations in adolescents.MethodsWe conducted a single-centre, retrospective, cross-sectional study of all adolescent trauma patients aged 16 to 18 years presenting to the adult ED at the University Hospital (Inselspital) in Bern, Switzerland, from January 2013 to July 2017. We analysed presentation data as well as inpatient treatment and cost-related data. Data of female and male patients were compared by univariable analysis. A comparison group was formed consisting of 200 randomly chosen patients aged 19–25 years old with the same presentation characteristics. Predictive factors for surgical treatment were obtained by multivariable analysis.ResultsThe study population included a total of 1,626 adolescent patients aged 16–18 years. The predominant causes for ED presentation were consistent within case and comparison groups for sex and age and were sports accidents, falls and violence. Male patients were more likely to need surgical treatment (OR 1.8 [95% CI: 1.2–2.5], p = 0.001) and consequently inpatient treatment (OR 1.5 [95% CI: 1.1–2.1], p = 0.01), associated with higher costs (median 792 Swiss francs [IQR: 491-1,598]). Other independent risk factors for surgical treatment were violence-related visits (OR 2.1 [95% CI: 1.3–3.5, p = 0.004]) and trauma to the upper extremities (OR 2.02 [95% CI: 1.5–2.8], p < 0.001). Night shift (OR 0.56 [95% CI: 0.37–0.86], 0.008) and walk-in consultations (OR 0.3 [95% CI: 0.2; 0.4, < 0.001] were preventive factors for surgical treatment.ConclusionsMale adolescents account for the majority of emergency visits and appear to be at higher risk for accidents as well as for surgical treatment and/or inpatient admission due to sports accidents or injuries from violence. We suggest that further preventive measures and recommendations should be implemented and that these should focus on sport activities and injuries from violence.

Virtual Obstetric Hospitalist Support for Obstetric Emergencies and Deliveries: The Mayo Clinic Experience.

Objective: To implement use of obstetric (OB) hospitalist telemedicine services (TeleOB) to support clinicians facing OB emergencies in low-resource hospital settings. Methods: TeleOB was staffed by OB hospitalists working at a tertiary maternity center. The service was available via real-time high-definition audio/video technology for providers at 17 outlying hospitals across a health system spanning two states. The initial 25 service activations are described. Results: TeleOB supported 17 deliveries, two postpartum emergency department (ED) consultations, and four antenatal ED consultations. In 10 of 17 (59%) deliveries, teleneonatology was jointly activated to support neonatal resuscitation. Sixteen (94%) deliveries occurred in multiparas, and five (29%) resulted from spontaneous preterm labor. Eighty percent (20/25) of activations occurred in facilities without maternity services. Conclusions: A TeleOB service staffed by OB hospitalists successfully supports hospitals in an integrated health care system. TeleOB is feasible for support of hospitals with no delivery facilities or with limited maternity care resources.

Atraumatic Limping Child, a Challenge for Pediatricians: An Observational Age-Related Study in a Pediatric Emergency Department.

Atraumatic limping is a frequent cause of consultation in Pediatric Emergency Departments (PED) and often represents a challenge for pediatricians for its variability in etiology ranging from benign causes to potential crippling conditions. The aims of this research are to illustrate the clinical features of acute limping children (LC) and to identify the possible red flags that could help to make a diagnosis of severe pathologies. We carried out a retrospective study about non-traumatic limping children referred to the PED of Bambino Gesù Children's Hospital over a 2-year period. We divided the cohort into three groups based on the patient's age: toddlers, children and adolescents. We considered crippling conditions: oncologic etiologies, bone or neurological infections, epiphysiolysis, Perthes disease, Guillain Barrè syndrome and non-accidental injuries. We analyzed 485 patients. At clinical evaluation, 19.5% of the patients presented at least one sign and/or symptom of red flags. Crippling conditions (6.2% of the total population) showed red flags in 36.7%. Transient synovitis of the hip was the most frequent diagnosis. We found crippling conditions in 30 patients, mostly represented by toddlers. Our data suggest that toddlers and patients presenting red flags should be evaluated with particular suspicion because they have an increased risk of underlying severe conditions.

Protocolo diagnóstico del dolor epigástrico agudo

Acute abdominal pain (AAP) is a common reason for consultation in emergency departments and, in up to one quarter of patients, it is located in the epigastrium. AAD encompasses a wide variety of both intra-abdominal and extra-abdominal clinical syndromes which vary in severity. For this reason, a correct early assessment of vital risk and a proper diagnostic approach based on a case history, physical examination, and additional tests are essential.This protocol includes the most important clinical and physical examination features that will allow for making a correct differential diagnosis of acute epigastric pain.

Traumatismos periféricos atendidos en el Servicio de Urgencias Pediátricas. Estudio descriptivo

IntroductionPeripheral trauma is a very frequent cause of consultation in paediatric emergency departments but few studies have been published describing the characteristics of these patients. Material and methodsWe performed a retrospective descriptive study by reviewing computerised emergency department forms during January and February 2020. ObjectiveTo describe the characteristics of traumatic injuries in our area and to detect possible areas for improvement. ResultsA total of 714 peripheral trauma cases were attended, which represents 9.5% of the total consultations. A total of 52.7% were schoolchildren (6–11 years). The most frequent locations were the ankle (27.5%) and fingers (17.2%). Fracture was detected in 6.7% of cases. Radiographs were requested in 78.6% of the patients, with pathological findings in 9.6% of them. Half of the X-rays were requested due to ankle or finger trauma. Referral to traumatology was made in 16.4% of patients, mainly for elbow and knee trauma, and the most commonly used treatment was general measures (49%) and bandaging (29.4%). ConclusionsPeripheral trauma is very common and, in general, banal. A large number of X-rays are requested with a very low yield, so it seems necessary to establish new protocols to reduce the number of requests. Improving training in elbow and knee trauma could improve paediatricians’ autonomy in dealing with these more complex injuries.

Vitamin D deficiency in Scheuermann's disease is associated with increased adverse outcomes.

Scheuermann's disease is a diagnosis of hyperkyphosis commonly encountered in pediatric patients. Studies in animal models suggest an association with vitamin D deficiency, however, extensive studies have not been performed in humans. This study analyzes the role of vitamin D deficiency on unfavorable results in patients with Scheuermann's disease. The TriNetX database was utilized to perform a retrospective analysis. Patients in the United States aged 0-18years with Scheuermann's disease were identified using International Classification of Diseases, Tenth Revision (ICD-10) codes and categorized into those with and without a diagnosis of vitamin D deficiency. Comparison of patient groups depending on age, sex, ethnic origin, prior diagnosis of fibromyalgia, anxiety disorder, myositis, and major depressive disorder. Statistical analysis was conducted to identify the association between vitamin D levels and unfavorable results including pain, depression, suicide attempt, emergency department (ED) consult, hospitalization, and procedures on the spine or spinal cord. In total, 11,277 patients were identified, 39% of whom had a concurrent diagnosis of scoliosis. A total of 1,024 (9.08%) were deficient in vitamin D. Patients with vitamin D deficiency had greater odds of pain (P<0.0001), depression (P<0.0001), suicide attempt (P=0.0021), ED visits (P=0.0246), and hospital admission (P<0.0015). Conversely, patients with vitamin D deficiency had decreased odds of surgery on the spine or spinal cord (P=0.0009). Vitamin D deficiency is associated with an elevated risk of pain, depression, suicide attempts, ED visits, and hospitalization. Our analysis highlights the need for more research to study the effect of vitamin D on Scheuermann's disease. Level III, Prognostic.

Convulsión febril

Febrile seizures are the most common seizure disorder in the pediatric population and represent a frequent cause of consultation in emergency departments, confirming its importance. We present an updated and practical review regarding this pathology, along with an operative definition that supports the application of a flowchart that integrates concepts and procedures that can be easily applied at any location nationwide. This review is designed to provide an analytic framework regarding pediatric febrile seizures, as well as present a guideline based on our experience in the emergency department by summarizing the main benzodiazepines in actual use that have been proved to be both safe and effective in treating this disorder, such as lorazepam and midazolam

Protocolo terapéutico del cólico nefrítico

Renal colic is a common consultation in emergency departments. It is severe, limiting pain that requires urgent care and, in many cases, parenteral medication. Additional tests must be done, including a blood test, urinalysis, and imaging tests, to rule out complications that necessitate urgent surgery with decompression of the urinary tract through percutaneous nephrostomy or ureteroscopy with stents. Analgesic treatment is the main pillar and is based on the use of non-steroidal anti-inflammatory drugs first and opioids according to each patient's clinical response. Expulsive treatment with tamsulosin is also used. Most patients can be discharged with a follow-up appointment in the primary care and/or urology department for definitive treatment.

Dolor abdominal agudo médico y quirúrgico. Proceso diagnóstico y terapéutico en urgencias

Acute abdominal pain is one of the most common consultations in emergency departments. It encompasses a wide spectrum of possible diagnoses, from mild gastroenteritis to a life-threatening disease such as aortic aneurysm rupture. The vast majority of patients are discharged, considering it to be nonspecific pain. There are no pathognomonic laboratory tests, although the combination of leukocytosis with an elevated C-reactive protein (CRP) level can point to, depending on the location, a disease that requires imaging tests, such as acute appendicitis. Abdominal ultrasound is the recommended test for the initial approach and computed tomography has the greatest diagnostic resolution. Pain must be treated in all cases, whereas emergency surgery is reserved for severe diseases.

AI Algorithm to Predict Acute Coronary Syndrome in Prehospital Cardiac Care: Retrospective Cohort Study

Background Overcrowding of hospitals and emergency departments (EDs) is a growing problem. However, not all ED consultations are necessary. For example, 80% of patients in the ED with chest pain do not have an acute coronary syndrome (ACS). Artificial intelligence (AI) is useful in analyzing (medical) data, and might aid health care workers in prehospital clinical decision-making before patients are presented to the hospital. Objective The aim of this study was to develop an AI model which would be able to predict ACS before patients visit the ED. The model retrospectively analyzed prehospital data acquired by emergency medical services' nurse paramedics. Methods Patients presenting to the emergency medical services with symptoms suggestive of ACS between September 2018 and September 2020 were included. An AI model using a supervised text classification algorithm was developed to analyze data. Data were analyzed for all 7458 patients (mean 68, SD 15 years, 54% men). Specificity, sensitivity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for control and intervention groups. At first, a machine learning (ML) algorithm (or model) was chosen; afterward, the features needed were selected and then the model was tested and improved using iterative evaluation and in a further step through hyperparameter tuning. Finally, a method was selected to explain the final AI model. Results The AI model had a specificity of 11% and a sensitivity of 99.5% whereas usual care had a specificity of 1% and a sensitivity of 99.5%. The PPV of the AI model was 15% and the NPV was 99%. The PPV of usual care was 13% and the NPV was 94%. Conclusions The AI model was able to predict ACS based on retrospective data from the prehospital setting. It led to an increase in specificity (from 1% to 11%) and NPV (from 94% to 99%) when compared to usual care, with a similar sensitivity. Due to the retrospective nature of this study and the singular focus on ACS it should be seen as a proof-of-concept. Other (possibly life-threatening) diagnoses were not analyzed. Future prospective validation is necessary before implementation.

The diagnostic and therapeutic challenge of atrial flutter in children: a case report

BackgroundPalpitations represent a common cause for consultation in the pediatric Emergency Department (ED). Unlike adults, palpitations in children are less frequently dependent from the heart, recognizing other causes.Case presentationA 11-year-old male came to our pediatric ED for epigastric pain, vomiting and palpitations. During the previous 6 month the patient was affected by SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus). Electrocardiogram (ECG) revealed supraventricular tachycardia. Therefore, adenosine was administered unsuccessfully. The administration of adenosine, however, allowed us to make diagnosis of atypical atrial flutter. Multiple attempts at both electrical cardioversion, transesophageal atrial overdrive, and drug monotherapy were unsuccessful in our patient. Consequently, a triple therapy with amiodarone, flecainide, and beta-blocker was gradually designed to control the arrhythmic pattern with the restoration of a left upper atrial rhythm. There was not any evidence of sinus rhythm in the patient clinical history.ConclusionsThe present study underlines the rarity of this type of dysrhythmia in childhood and the difficulties in diagnosis and management, above all in a patient who has never showed sinus rhythm. Raising awareness of all available treatment options is essential for a better management of dysrhythmia in children

Arritmias cardíacas. Diagnóstico electrocardiográfico y manejo terapéutico en urgencias

Cardiac arrhythmias are a very common reason for consultation in emergency departments. The most common symptoms that occur are palpitations, chest pain, dyspnea, symptoms of low cardiac output, and syncope, although they can be diagnosed as an incidental asymptomatic finding. The detailed, systematic analysis of a 12-lead electrocardiogram is one of the fundamental tools for its diagnosis. They are classified as tachyarrhythmias and bradyarrhythmias, each of which has specific management according to the symptoms they produce and if they are accompanied by hemodynamic instability or not. Atrial fibrillation is the arrhythmia that causes the most consultations in the emergency department. When faced with wide QRS tachycardia, ventricular tachycardia should be suspected. Immediate care and treatment are needed to reverse it due to its potential mortality, even if it is associated with hemodynamic stability.

Asistencia ventilatoria de la insuficiencia respiratoria aguda en urgencias. Ventilación mecánica no invasiva y alto flujo nasal

Acute or acute-on-chronic respiratory failure is a common reason for consultation in emergency departments (ED). When conventional treatment is not enough for patients to improve, non-invasive mechanical ventilation (NIMV) and high-flow nasal cannula play a fundamental role. Although they were initially exclusively used in critical care units, they have begun to be used in other units in recent years, including hospital EDs. The literature has shown that early use in EDs decreases mortality, improves survival, and decreases the risk of orotracheal intubation and patients’ overall length of stay. Therefore, knowledge of the technique, adequate patient selection, and training for the staff who care for these patients in the hospital emergency department are important.

Manejo diagnóstico del síncope en urgencias

Syncope is a very common cause for consultation in emergency departments (EDs). Therefore, identifying patients who present criteria for considering it to be high risk is fundamental for proper management. Most of the causes are benign, with neurally mediated syncope and orthostatic hypotension representing the largest proportion of cases seen in EDs. Syncope due to cardiac causes, generally secondary to arrhythmias and aortic stenosis, is more common in the older adult population. In an assessment, it must be confirmed if there was a transient loss of consciousness, if its origin is syncopal or not, and consider if there is an etiological diagnosis. A physical examination and ECG must be performed on all patients. Based on the results and the case history, other additional tests can be proposed, such as a blood test, echocardiogram, carotid sinus massage, or prolonged monitoring.

Protocolo diagnóstico del dolor torácico agudo en urgencias

Chest pain is a very common cause for consultation in hospital emergency departments (HEDs). It is estimated that it represents about 5% to 20% of the total volume of visits per year. As it has a highly varied etiology, it represents a diagnostic challenge. For this reason, verifying alarm signs that are able to identify situations that are life threatening to the patient per se is an initial priority in order to determine whether there is a need for emergency action or not. In HEDs, it is important to have a diagnostic protocol for this type of situation, as it encompasses time-sensitive diseases that not only the patient's quality of life, but also their survival depend on.