Emergency Room Referrals Research Articles

Frequency and Correlates of Inappropriate Pediatric Psychiatric Emergency Room Visits

Despite increasing pediatric psychiatric emergency room service (PPERS) visits, data are lacking regarding visit characteristics and appropriateness. This retrospective cohort study consecutively assessed youngsters aged < 18 years between January 1 and December 31, 2002, utilizing data from a 12-page semistructured institutional evaluation form. Appropriateness, severity, acuity, and harm potential of PPERS visits were rated on a Likert scale. Of 1,062 PPERS patient visits (mean +/- SD age: 13.5 +/- 3.1 years, 51.1% male, and 51.2% white), 305 (28.7%) led to hospitalization. Although most patients (68.7%) were in outpatient care, only 21.9% sought and 11.5% completed an outpatient evaluation prior to reaching the emergency room. As many as 34.4% of PPERS visits were somewhat/very inappropriate (optimal care: outpatient evaluation/treatment, even if delayed), 26.6% were somewhat appropriate/neutral (best served by outpatient evaluation/treatment, but timely appointment unavailable), and only 39.0% were fully appropriate. Main reasons for inappropriate PPERS visits were direct emergency room referral from school (P = .0056) or mental health provider (P = .0438) without prior psychiatrist evaluation, or unavailable appointment (P = .0304). Multivariate predictors of inappropriate PPERS visits (r(2) = .296, P < .0001) included current Global Assessment of Functioning score > 48 (P < .0001), absent suicidal ideation/attempt (P < .0001), low harm potential (< 4.4, P < .0001) and severity (< 4.8, P = .0136) (1- to 7-point scale) of presenting complaint, and absent psychosis (P = .0008). Over one third of PPERS visits were inappropriate, characterized by better functioning, low harm potential or severity of presenting complaint, and absent suicidality or psychosis. Development of and improved access to urgent child and adolescent psychiatric outpatient care services in the community and referral agent educational programs may minimize inappropriate PPERS visits.

P02-102 The suicidal adolescent profile: A comparative study between adolescents with and without suicidal behaviours

Context:Suicide and suicidal behaviours are a growing concern among adolescents.Objective:Describe discriminating characteristics of adolescents with suicidal behaviours followed by our psychiatric consultations.Methods:A cross-sectional sample of 100 adolescents (aged 12 to 21), from the adolescent psychiatry and youth suicide consultations, at Hospital Santa Maria Psychiatry Department, were submitted to a semi-structured interview. The sample was divided in two groups: with and without suicidal behaviour (the first being defined has previous suicide attempt, parasuicidal gestures or self-mutilation). Demographic, psychosocial and psychopathological data was taken and compared.Results:98 completed protocol. Suicidal behaviour group included 48 subjects. Age, years of education, family type, sex differences, psychosocial difficulties (school, family, peers, affective), therapeutic objectives (exception on family relations) were not statistically discriminating. Suicidal ideation as consultation motive, emergency room referral, previous attempts of follow-up, not having as objective improvement of family relationships, were highly associated to the suicidal behaviour group (p≤0.001). A non significant tendency was observed towards depressive syndrome in the latter.Conclusion:Identifying adolescents at risk for suicidal behaviours isn't an easy task, most characteristics are not discriminating. The most effective way seems to be asking directly about suicidal ideas. Awareness should increase in emergency room referrals motivated by suicidal ideas, in adolescents who tried multiple follow-ups and that seem to be disappointed by family support.

Prospective Study of the Burden of Acute Gastroenteritis and Rotavirus Gastroenteritis in Children Less Than 5 Years of Age, in Padova, Italy

Data on the burden of rotavirus gastroenteritis in Europe are needed to help understand the potential impact of introducing new rotavirus vaccines. As part of prospective observational study (Rotavirus gastroenteritis Epidemiology and Viral types in Europe Accounting for Losses in Public Health and Society Study, REVEAL) conducted in 2004--2005 in seven European countries, we studied, the characteristics of acute gastroenteritis and rotavirus gastroenteritis in children less than 5 years in primary care, emergency room and hospital settings (Padova, Italy). A total of 757 children with acute gastroenteritis were included and enzyme-linked immunoabsorbent assay (ELISA) results were available for 725 cases. The overall estimated annual incidence for rotavirus gastroenteritis was 4.7%. Overall, rotavirus gastroenteritis was estimated to account for 43.6% of acute gastroenteritis cases. Among children with acute gastroenteritis (AGE) aged 6-23 months, 61.2% were rotavirus positive. Rotavirus gastroenteritis (RVGE) was responsible for 68.8% of hospitalizations, 61% of emergency consultations, and 33% of primary care consultations. The most prevalent serotype was G9 (84.4%) followed by G1 (11.8%). The relative risk for rotavirus gastroenteritis of being referred to hospital after an initial consultation in primary care was 3.37 (95% CI: 1.77-6.43) and 3.38 (95% CI: 2.28-5.01) for emergency room referral. Children with rotavirus gastroenteritis generally had more severe disease than children with rotavirus-negative gastroenteritis. Rotavirus accounts for a significant proportion of acute gastroenteritis cases in children less than 5 years in Italy, many of whom require frequent primary care consultations, or care in emergency room or hospital settings.

The burden of terrorism: High rate of recurrent hospital referrals

Recurrent emergency room referrals and re-hospitalisation of terror victims (external cause of injury E990-E998 and selected cases from E970-E978) [International Classification of Diseases, 9th revision. Clinical modification, 5th ed. (ICD-9-CM). Los Angeles, CA: Practice Management Information Corporation; 1998] have not as yet been examined in the literature. Our objective was to evaluate the extent of hospital services' usage following a terror event and to characterise the casualties who return for hospitalisation and rehabilitation following their discharge. A retrospective longitudinal study including all terror victims who were hospitalised at our level I trauma centre between October 2000 and March 2004. Data on the first hospitalisation of these victims (n=497 cases) were retrieved from the hospital's trauma registry. Data on recurrent emergency room referrals and re-hospitalisation of the 464 cases who survived were taken from the hospital's administrative computerised database. Four hundred and ninety-seven terror victims were hospitalised, of which 464 survived their first hospitalisation. Two hundred and nineteen (47%) were subsequently re-referred to the hospital. The total number of recurrent hospital referral days amounted to 77% of the total first hospitalisation days for all casualties. A strong association was found with regard to severity of injury, length of stay in the intensive care unit (ICU) and total length of stay. Logistic regression analysis found total length of stay of initial hospitalisation as the only significant variable. The recurrent hospitalisation of terror victims places a heavy burden on the health system. Further studies should be conducted to determine the reasons for these recurrent referrals and to explore whether the number of recurrent referrals can be reduced or at least planned for.

Management of adverse clinical events by duty physicians in a nursing home

The nature of adverse clinical events (ACE) during duty hours (16:00-08:00 and holidays), as well as the way they are addressed by duty physicians (DP) in a nursing home (NH) are the subject of this study. Data, including medical details concerning ACEs and the resultant referrals to hospital, were collected prospectively during 183 consecutive days in a 90-bed NH. Ninety-six residents experienced 370 ACEs, representing an average of one for every 44.5 patient days. The highest rate of events was during evening hours (18:00-21:00). The most prevalent ACE was fever (32%). Most cases (53%) were treated by the DPs on site. No intervention was needed in 19% of cases, whereas 28% of ACEs (104 cases) were referred to the Emergency Room (ER) of a general hospital. Sixty-six percent of these were actually admitted. The rate of ER referral of residents was one for every 158 patient days. About 40% of the referred patients had been discharged from hospital the previous week. High fever was the commonest cause for referral: 47%. During the working hours of the study period, the rate of referral by the staff physician was only 1 for every 915 patient days. Only 17% of these had high fever. Evening rounds by staff physicians, strengthening of working relations with hospital physicians, as well as fostering intravenous treatment in NHs, are suggested as means for reducing hospital transfers. A standardized method for the reporting of ACEs and referrals to hospitals should be adopted in order to facilitate comparisons between NHs and to evaluate its use as a quality indicator.

Adding a caveat to the urgent clinical notification of anaemia does not reduce inappropriate emergency room referral rates.

Urgent clinician notification of low haemoglobin values might influence the clinicians' decision to refer patients to the emergency room (ER). We compared the effects of urgent clinician notification for low haemoglobin values with and without an added statement, that an urgent visit to the ER is not required if the patient has a haemoglobin value of 50 g/l or more and is clinically stable. We compared the referral rates and outcomes of 100 consecutive cases reported previously to that of 99 consecutive new cases with the added caveat. Overall 47 (47%) of the historical control patients were referred to the ER compared with 45 (45.5%) in the study group (relative risk, 0.97, 95% CI, 0.72-1.3). Five patients were inappropriately transfused and almost none of the ER visits were an emergency. Adding a caveat to the urgent clinician notification that anaemia in clinically stable patients is not a medical emergency does not decrease the rate of ER referrals. Further studies are needed in order to find ways to decrease the number of inappropriate ER referrals.

Childhood Poisoning: A Population Study in Trieste, Italy, 1975–1994

We describe the epidemiology of 1918 cases of childhood poisoning referred to the emergency room in Trieste, Italy, from 1975 to 1994. The incidence rate of emergency room referral and subsequent hospitalization was calculated on the basis of the distribution of children resident in Trieste by calendar year. The occurrence of childhood poisoning was described according to time trends, age and gender of the child, route of exposure, symptoms at presentation to the emergency room, role of the child or others, intention, and substance involved in the poisoning. The association between presence of symptoms and characteristics of referral, host factors and substances involved was evaluated by estimating the odds ratio in multivariate models. Possible determinants of the clinical decision to treat certain cases were evaluated using logistic regression. Despite an increasing incidence of referral (from 155 per 100,000 persons per year in 1975–79 to 352 per 100,000 in 1990–94), hospital admission rates showed a two-fold decrease. Younger children (age 0–4 years) were more likely to be asymptomatic and required treatment and hospitalization less often than older children (age ≥10 years). Trends show a decrease in pharmaceutical poisonings due probably to the introduction of child-resistant containers and an increase in domestic poisons. We also observed a steady increase in carbon monoxide inhalation and alcohol poisonings, mostly among teenagers.

Do Physicans Have a Bias toward Action?

In an attempt to replicate the findings of a classic study of medical decision making, the authors studied decision making in modern pediatrics practice. They prepared case scenarios and surveyed pediatricians for three common clinical decisions: tympanostomy tube placement, radiography orders, and emergency room referrals. Initial reviewers rated the cases according to the likelihoods that they would take the clinical actions mentioned. Subsequently, other physicians presented with a subset of scenarios in which the initial reviewers were least likely to act tended to be more active in the tympanostomy (p = 0.004) and radiography (p = 0.076) decisions. In these cases the physicians appeared to have a bias toward action. For a subset of scenarios in which the initial reviewers were most likely to act, subsequent reviewers were neither more nor less likely to act than the initial reviewers.

949 EVALUATION OF EARLY POSTPARTUM DISCHARGE PROGRAM IN A LARGE METROPOLITAN HOSPITAL

An increase in deliveries from 9,000 to over 12,000 per annum necessitated the adoption of an early discharge program at the LAC-USC Med. Ctr. in November 1974. ‘Normal’ mothers/infants were identified by strict protocol and discharged at <48 hrs. instead of ≥72 hrs. This report represents the result of an evaluation study of the program covering the period June 21 to August 31, 1976. Basic demographic prenatal and delivery information was obtained from the hospital discharge and home visit referral forms. Information on patient's safety and satisfaction was obtained from two questionnaires, one completed by patient and visiting nurse between 3rd and 5th postpartum day, and the other by the patient 10 to 14 days postpartum. There were 1,276 early discharge patients representing 47% of deliveries: 810 cases had home visits by a visiting nurse. In the mothers 15% had problems, 2% required emergency room referrals, and 0.25% hospital readmission. In the infants, 16% had problems, 6% required emergency room referrals and 0.9% had hospital readmission. A comparison of 147 patients discharged between 25-36 hrs. with those discharged between 49-60 hrs. postpartum did not reveal any significant difference in problems found at home visit. Eighty-five percent of the patients expressed satisfaction with the program.

Compliance with psychiatric emergency room referrals

Compliance with psychiatric emergency room referrals

Compliance with psychiatric emergency room referrals.

An attempt was made to identify some of the major variables, such as age, sex, ethnicity, and diagnosis, that might be determinants of compliance with psychiatrists' recommendations to enter outpatient treatment after emergency room visits. In general, it was found that older Puerto Rican and white women, usually those diagnosed as having some kind of depression, had the highest rate of compliance. Black patients, as well as all patients diagnosed as schizophrenic, had the lowest probability of outpatient follow-up. A telephone survey of those patients who did not go for outpatient treatment within six months after referral was conducted to elicit their reasons for not going. Several hypotheses were developed concerning reasons for lack of compliance with recommendations for outpatient follow-up, and a number of suggestions were made about possible methods for increasing the compliance rate.