General Emergency Department Patients Research Articles

Screening for harmful substance use in emergency departments: a systematic review

BackgroundSubstance use-related emergency department (ED) visits have increased substantially in North America. Screening for substance use in EDs is recommended; best approaches are unclear. This systematic review synthesizes evidence on diagnostic accuracy of ED screening tools to detect harmful substance use.MethodsWe included derivation or validation studies, with or without comparator, that included adult (≥ 18 years) ED patients and evaluated screening tools to identify general or specific substance use disorders or harmful use. Our search strategy combined concepts Emergency Department AND Screening AND Substance Use. Trained reviewers assessed title/abstracts and full-text articles for inclusion, extracted data, and assessed risk of bias (QUADAS-2) independently and in duplicate. Reviewers resolved disagreements by discussion. Primary investigators adjudicated if necessary. Heterogeneity precluded meta-analysis. We descriptively summarized results.ResultsOur search strategy yielded 2696 studies; we included 33. Twenty-one (64%) evaluated a North American population. Fourteen (42%) applied screening among general ED patients. Screening tools were administered by research staff (n = 21), self-administered by patients (n = 10), or non-research healthcare providers (n = 1). Most studies evaluated alcohol use screens (n = 26), most commonly the Alcohol Use Disorders Identification Test (AUDIT; n = 14), Cut down/Annoyed/Guilty/Eye-opener (CAGE; n = 13), and Rapid Alcohol Problems Screen (RAPS/RAPS4/RAPS4-QF; n = 12). Four studies assessing six tools and screening thresholds for alcohol abuse/dependence in North American patients (AUDIT ≥ 8; CAGE ≥ 2; Diagnostic and Statistical Manual of Mental Disorders, 4th Edition [DSM-IV-2] ≥ 1; RAPS ≥ 1; National Institute on Alcohol Abuse and Alcoholism [NIAAA]; Tolerance/Worry/Eye-opener/Amnesia/K-Cut down [TWEAK] ≥ 3) reported both sensitivities and specificities ≥ 83%. Two studies evaluating a single alcohol screening question (SASQ) (When was the last time you had more than X drinks in 1 day?, X = 4 for women; X = 5 for men) reported sensitivities 82–85% and specificities 70–77%. Five evaluated screening tools for general substance abuse/dependence (Relax/Alone/Friends/Family/Trouble [RAFFT] ≥ 3, Drug Abuse Screening Test [DAST] ≥ 4, single drug screening question, Alcohol, Smoking and Substance Involvement Screening Test [ASSIST] ≥ 42/18), reporting sensitivities 64%-90% and specificities 61%-100%. Studies’ risk of bias were mostly high or uncertain.ConclusionsSix screening tools demonstrated both sensitivities and specificities ≥ 83% for detecting alcohol abuse/dependence in EDs. Tools with the highest sensitivities (AUDIT ≥ 8; RAPS ≥ 1) and that prioritize simplicity and efficiency (SASQ) should be prioritized.

Predicting Unscheduled Emergency Department Return Visits Among Older Adults: Population-Based Retrospective Study.

BackgroundUnscheduled emergency department return visits (EDRVs) are key indicators for monitoring the quality of emergency medical care. A high return rate implies that the medical services provided by the emergency department (ED) failed to achieve the expected results of accurate diagnosis and effective treatment. Older adults are more susceptible to diseases and comorbidities than younger adults, and they exhibit unique and complex clinical characteristics that increase the difficulty of clinical diagnosis and treatment. Older adults also use more emergency medical resources than people in other age groups. Many studies have reviewed the causes of EDRVs among general ED patients; however, few have focused on older adults, although this is the age group with the highest rate of EDRVs.ObjectiveThis aim of this study is to establish a model for predicting unscheduled EDRVs within a 72-hour period among patients aged 65 years and older. In addition, we aim to investigate the effects of the influencing factors on their unscheduled EDRVs.MethodsWe used stratified and randomized data from Taiwan’s National Health Insurance Research Database and applied data mining techniques to construct a prediction model consisting of patient, disease, hospital, and physician characteristics. Records of ED visits by patients aged 65 years and older from 1996 to 2010 in the National Health Insurance Research Database were selected, and the final sample size was 49,252 records.ResultsThe decision tree of the prediction model achieved an acceptable overall accuracy of 76.80%. Economic status, chronic illness, and length of stay in the ED were the top three variables influencing unscheduled EDRVs. Those who stayed in the ED overnight or longer on their first visit were less likely to return. This study confirms the results of prior studies, which found that economically underprivileged older adults with chronic illness and comorbidities were more likely to return to the ED.ConclusionsMedical institutions can use our prediction model as a reference to improve medical management and clinical services by understanding the reasons for 72-hour unscheduled EDRVs in older adult patients. A possible solution is to create mechanisms that incorporate our prediction model and develop a support system with customized medical education for older patients and their family members before discharge. Meanwhile, a reasonably longer length of stay in the ED may help evaluate treatments and guide prognosis for older adult patients, and it may further reduce the rate of their unscheduled EDRVs.

Development and validation of a scoring system for mortality prediction and application of standardized W statistics to assess the performance of emergency departments

BackgroundIn-hospital mortality and short-term mortality are indicators that are commonly used to evaluate the outcome of emergency department (ED) treatment. Although several scoring systems and machine learning-based approaches have been suggested to grade the severity of the condition of ED patients, methods for comparing severity-adjusted mortality in general ED patients between different systems have yet to be developed. The aim of the present study was to develop a scoring system to predict mortality in ED patients using data collected at the initial evaluation and to validate the usefulness of the scoring system for comparing severity-adjusted mortality between institutions with different severity distributions.MethodsThe study was based on the registry of the National Emergency Department Information System, which is maintained by the National Emergency Medical Center of the Republic of Korea. Data from 2016 were used to construct the prediction model, and data from 2017 were used for validation. Logistic regression was used to build the mortality prediction model. Receiver operating characteristic curves were used to evaluate the performance of the prediction model. We calculated the standardized W statistic and its 95% confidence intervals using the newly developed mortality prediction model.ResultsThe area under the receiver operating characteristic curve of the developed scoring system for the prediction of mortality was 0.883 (95% confidence interval [CI]: 0.882–0.884). The Ws score calculated from the 2016 dataset was 0.000 (95% CI: − 0.021 – 0.021). The Ws score calculated from the 2017 dataset was 0.049 (95% CI: 0.030–0.069).ConclusionsThe scoring system developed in the present study utilizing the parameters gathered in initial ED evaluations has acceptable performance for the prediction of in-hospital mortality. Standardized W statistics based on this scoring system can be used to compare the performance of an ED with the reference data or with the performance of other institutions.

Resource Utilization in Emergency Department Patients with Known or Suspected Poisoning

Previous work has shown poisoning-related emergency department (ED) visits are increasing, and these visits are resource-intensive. Little is known, however, about how resource utilization for patients with known or suspected poisoning differs from that of general ED patients. We reviewed 4years of operational data at a single ED. We identified visits due to known or suspected poisoning (index cases), and paired them with time-matched controls. In the primary analysis, we compared the groups with respect to a broad array of resource utilization characteristics. In a secondary analysis, we performed the same comparison after excluding patients ultimately transferred to a psychiatric facility. There were 405 index cases and 802 controls in the primary analysis, and 374 index cases and 741 controls in the secondary analysis. In the primary/secondary analyses, patients with known or suspected poisoning had longer ED lengths of stay in minutes (370 vs. 232/295 vs. 234), higher rates of laboratory results per patient (40.4 vs. 26.8/39.6 vs. 26.8), greater administration of intravenous medications and fluids per patient (2.0 vs. 1.6/2.1 vs. 1.6), higher rates of transfer to a psychiatric facility (7.7 vs. 0.2%/not applicable), and higher rates of both admission (40.2 vs. 32.8/43.6 vs. 33.1%) and admission to an advanced care bed (21.5 vs. 7.6/23.3 vs. 7.8%). Patients with known or suspected poisoning had lower rates of imaging per patient, for both plain radiographs (0.4 vs. 0.5/0.4 vs. 0.5) and advanced imaging studies (0.3 vs. 0.5/0.4 vs. 0.5). ED patients with known or suspected poisoning are more resource intensive than general ED patients. These results may have implications for both resource allocation (particularly for departments that might see a high volume of such patients) and ED operations management.

Shock Index Correlates with Hospitalization and Mortality in General Emergency Department Patients

The shock index — the ratio of heart rate to systolic blood pressure — has been described primarily in trauma patients to identify those at risk for

National Early Warning Score Lactate (NEWS–L): is it good news for pre-hospital care?

Journal of Paramedic PracticeVol. 8, No. 10 Spotlight on ResearchNational Early Warning Score Lactate (NEWS–L): is it good news for pre-hospital care?Jack BarrettJack BarrettSearch for more papers by this authorJack BarrettPublished Online:22 Oct 2016https://doi.org/10.12968/jpar.2016.8.10.515AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Dassonville J, et al. (1998) Blood lactate concentrations during exercise: effect of sampling site and exercise mode. Journal of Sports Medicine and Physical Fitness 38(1): 39–46 Google ScholarFeliu J, et al. (1999) Difference between lactate concentration of samples from ear lobe and the finger tip. Journal of Physiology and Biochemistry 55(4): 333–339 Google ScholarForsyth JJ, Farrally MR (2000) A comparison of lactate concentration in plasma collected from the toe, ear, and fingertip after a simulated rowing exercise. British Journal of Sports Medicine 34: 35–38 Crossref, Google ScholarLightowler B, Hoswell A (2016) Can handheld POC capillary lactate measurement be used with arterial and venous laboratory testing methods in the identification of sepsis? Journal of Paramedic Practice 8(8): 396–406 Link, Google ScholarVincent J, et al. (2016) The value of blood lactate kinetics in critically ill patients: a systematic review. Critical Care 20: 257 Crossref, Google Scholar References Jo S, Yoon J, Baek Lee J, Jin Y, Jeong T, Park B (2016) Predictive value of the National Early Warning Score–Lactate for mortality and the need for critical care among general emergency department patients. Journal of Critical Care 36: 60–68. doi https://doi.org/10.1016/j.jcrc.2016.06.016 Crossref, Google Scholar FiguresReferencesRelatedDetails 2 October 2016Volume 8Issue 10ISSN (print): 1759-1376ISSN (online): 2041-9457 Metrics History Published online 22 October 2016 Published in print 2 October 2016 Information© MA Healthcare LimitedPDF download

Predictive value of the National Early Warning Score–Lactate for mortality and the need for critical care among general emergency department patients

Study objectivesWhat is the predictive value of the National Early Warning Score–Lactate (NEWS-L) score for mortality and the need for critical care in general emergency department (ED) patients? MethodsIn this retrospective cohort study, we enrolled all adult patients who visited the ED of an urban academic tertiary-care university hospital in South Korea over 2 consecutive months. The primary outcome was 2-day mortality. The secondary outcomes were the need for critical care (advanced airway use, vasopressor or inotropic agent use, intensive care unit admission) during an ED stay; 2-day composite outcome (2-day mortality and the need for critical care); 7-day mortality; and in-hospital mortality. ResultsDuring the study period, 4624 adult patients visited the ED. Of these, 87 (1.9%) died within 2 days. In total, 481 patients (10.4%) required critical care during their ED stay. The 2-day composite outcome, 7-day mortality, and in-hospital mortality were 10.9% (503/4624), 2.5% (116/4624), and 3.9% (182/4624), respectively. The NEWS-L demonstrated excellent predictive value for 2-day mortality with an area under the receiver operating characteristic curve (AUROC) of 0.96 (95% confidence interval [CI], 0.94-0.98); this value was better than that of the NEWS alone (AUROC 0.94 [95% CI, 0.91-0.96], P=.002). The AUROC of the NEWS-L for the need for critical care was 0.83 (95% CI, 0.81-0.85); for the 2-day composite outcome, it was 0.84 (95% CI, 0.82-0.86); for 7-day mortality, it was 0.94 (95% CI, 0.92-0.96); and for in-hospital mortality, it was 0.87 (95% CI, 0.85-0.90). Logistic regression results confirmed that the ratio of the NEWS to the initial lactate level was 1:1. Similar results were obtained in the subgroup analyses (disease-infection, disease–vascular and heart, disease-others, and nondisease). The high-risk NEWS-L group (NEWS-L≥7, 9.4% of all patients) had an adjusted odds ratio of 28.67 (12.66-64.92) for 2-day mortality in the logistic regression model adjusted for basic characteristics. ConclusionThe NEWS-L can provide excellent discriminant value for predicting 2-day mortality in general ED patients, and it has the best discriminant value regarding the need for critical care and composite outcomes. The NEWS-L may be helpful in the early identification of at-risk general ED patients.

Management of Fever in postpneumococcal vaccine era: comparison of management practices by pediatric emergency medicine and general emergency medicine physicians.

Background. The primary objective of this study was to compare management practices of general emergency physicians (GEMPs) and pediatric emergency medicine physicians (PEMPs) for well-appearing young febrile children. Methods. We retrospectively reviewed the charts of well-appearing febrile children aged 3–36 months who presented to a large urban children's hospital (PED), staffed by PEMPs, or a large urban general emergency department (GED), staffed by GEMPs. Demographics, immunization status, laboratory tests ordered, antibiotic usage, and final diagnoses were collected. Results. 224 cases from the PED and 237 cases from the GED were reviewed. Children seen by PEMPs had significantly less CXRs (23 (10.3%) versus 51 (21.5%), P = 0.001) and more rapid viral testing done (102 (45%) versus 40 (17%), P < 0.0001). A diagnosis of a viral infection was more common in the PED, while a diagnosis of bacterial infection (including otitis media) was more common in the GED. More GED patients were prescribed antibiotics (41% versus 27%, P = 0.002), while more PED patients were treated with oseltamivir (6.7% versus 0.4%, P < 0.001). Conclusions. Our findings identify important differences in the care of the young, well-appearing febrile child by PEMPs and GEMPs and highlight the need for standardization of care.

Emergency department (ED) utilization by HIV‐infected ED patients in the United States in 2009 and 2010 – a national estimation

The aim of the study was to describe the emergency department (ED) resource utilization patterns of ED visits by patients reported to be HIV-infected in the USA in 2009 and 2010 and to compare them with those of the general ED patient population. We identified demographics, HIV infection status, and ED utilization patterns in 2009 and 2010 from a weighted sample of US ED visits using the National Hospital Ambulatory Medical Care Survey, a nationally representative survey. Data on visits by patients aged ≥ 13 years were analysed using procedures for multiple-stage survey data. In 2009 and 2010, 1 192 535 visits were documented for HIV-infected patients. The estimated annual ED visit rates were 633 per 1000 known HIV-infected persons and 438 per 1000 non-HIV-infected persons [rate difference 195; 95% confidence interval (CI) 194, 197]. While no difference was recorded in the level of acuity between HIV-infected ED patients and general ED patients, the total number of diagnostic/screening services ordered and medications administered in the ED was significantly higher for visits by HIV-infected patients. HIV-infected patients making ED visits also had a longer duration of stays [mean 5.4 h (95% CI 4.6, 6.2 h) vs. 3.6 h (95% CI 3.5, 3.8 h) for HIV-uninfected patients] and were more likely to be admitted [28% (95% CI 22, 34%) vs. 15% (95% CI 14, 16%), respectively] than their non-HIV-infected counterparts. ED visits by HIV-infected individuals occur at rates higher than those of visits by the general population, and consume significantly more ED resources than visits by the general population. These national findings represent baseline prior to full implementation of the 2010 Patient Protection and Affordable Care Act.

The influence of physician seniority on disparities of admit/discharge decision making for ED patients

ObjectivesDifferences in disposition between emergency physicians (EPs) have been studied in select patient populations but not in general emergency department (ED) patients. After determining whether a difference existed in admit/discharge decision making of EPs for general ED patients, we focus our study in examining the influence of EP seniority on the decision to discharge ED patients. MethodsIn a 1-year retrospective study, we included a convenience sample of all 18 953 adult nontraumatic ED patients. We reviewed the admit/discharge dispositions at each shift made by 16 EPs. EPs were categorized by seniority to determine whether seniority influenced disposition. Three groups had 5, 4, and 7 EPs each, with >10 years, 5 to 9 years, and <5 years of working experience, respectively. ResultsPatient demographics, triage level, and number of patients per shift did not differ statistically between EPs and each group. The number of discharged patients per shift differed statistically between EPs (P < .001) and each group. The most senior EPs had the lowest discharge rates compared with EPs in intermediate and junior groups. They had lower discharge rates for patients at triage levels 1, 2, and 3 as well as for all patients. However, no difference in unscheduled ED revisit rates was found. ConclusionsEPs vary in their admit/discharge decision making for general ED patients. More importantly, the most senior EPs were found to have the lowest discharge rates compared with their junior colleagues.

Risk factors of extended-spectrum beta-lactamaseproducing Enterobacteriaceae bacteremia in Thai emergency department: a retrospective case-control study

Abstract Background: Infections caused by resistant extended-spectrum beta-lactamase (ESBL)-producing enteric bacteria and their risk factors are globally recognized. However, such risk factors have not been explored in emergency department (ED) where the first choice of empirical antimicrobials is crucial. Objective: Determine risk factors of ESBL bacteremia in ED, especially in our geographic area. Methods: A retrospective case-double-control study was conducted at King Chulalongkorn Memorial Hospital. All adult ED patients with ESBL-producing E. coli and K. pneumoniae in blood cultures between October 2007 and October 2008 were recruited for this study. The potential risk factors were analyzed and compared with non- ESBL-producing bacteremic patients (control group 1) and matched general ED patients (control group 2). Nonbeta- lactam susceptibility testing among the cohort was also evaluated. Results: Thirty ESBL (cases), 103 group 1 controls, and 100 group 2 controls were assessed. Based on the univariate analysis, age, chronic kidney diseases, malignancy, poor functional status, previous hospitalization within 90 days, and previous antimicrobial exposure especially to cephalosporins, quinolones, and carbapenems within 30 days were the risk factors for ESBL bacteremia compared with both types of control patients. Age &gt; 60 and previous cephalosporin use were consistently identified as the risk factors by multivariate models using both control groups. The susceptibility to non-beta-lactam agents in the ESBL group was significantly lower than the non-ESBL. No carbapenem resistance was found. Conclusion: Elderly ED patients, especially those who had previous cephalosporin exposure within 30 days, were at higher risk of ESBL-producing bacteremic infections. ESBLs tended to have less susceptibility to the non-β-lactam agents.

TXT Rx: using health information technology to safely discharge suicidal patients from the ED

BackgroundIncreasingly, postsuicide attempt patients are discharged after emergency department (ED) and mental health evaluation, only to recidivate in the weeks to months after discharge.Study objectivesTo evaluate the feasibility, acceptability and...

A Descriptive Study of Heavy Emergency Department Users at an Academic Emergency Department Reveals Heavy ED Users Have Better Access to Care Than Average Users

Emergency department (ED) overcrowding has been a significant problem for the last 10 years. Several studies have shown that a relatively small number of ED patients are responsible for a disproportionate amount of ED visits. This study aims to describe the frequent users of our emergency department. This was an institutional review board-approved descriptive study performed by a retrospective review of electronic records. This pilot describes and compares patients who had 12 or more ED visits during the study year with those who visited less. The 234 patients who met criteria for high-frequency use (HFU) of the emergency department were responsible for a total of 4633 visits. Sex, race, and age distribution of HFU patients were similar to those of general ED patients. Eighty-four percent of HF users have insurance and 93% have primary care providers. A relatively small percentage of HFU visits, 4%, were mental health-related visits and 3% were alcohol- and drug-related visits. The HFU visits are socially connected: 93% have their own homes; 94% have relatives or friends; 73% have a religious affiliation. Pain or pain-related conditions are the most common diagnoses. These patients are also frequent users of ambulatory care services. The similarities between our HFU and the general ED population are more numerous than their differences. The HFU patients of our emergency department are different in terms of age, employment status, and type of insurance. IMPLICATIONS FOR NURSES: A detailed description of local HFU may help to inform planning and better meet ED patients' needs. As one of many results of this study, the ED chairman met with the Hematology-Oncology team and reviewed the protocol for ED management of sickle cell crisis. The meeting resulted in a revised protocol, including an immediate change in their pain medication from meperidine to either morphine or hydromorphone.

Spectrum and Frequency of Pediatric Illness Presenting to a General Community Hospital Emergency Department

Knowledge of the range of pediatric illness presenting to a general emergency department (ED) is needed to optimize the quality of care delivered there. It was hypothesized that the pediatric population treated at a general ED exhibited a broad range of medical complaints, while differing significantly from children seen in a pediatric ED. General ED records from 1 week each season were reviewed, and patient age, chief complaint, diagnosis, time of arrival, season, and disposition were recorded. Data on 874 patients were analyzed and compared with pediatric ED data. General ED patient age affected chief complaint, diagnosis, and admission rate (9.5% less than or equal to 1 year admitted vs 2.6% greater than 1 year, P less than .001). General ED patients were older (7.9 vs 6.0 years, P less than .001) and admitted less frequently (3.8% vs 11%, P less than .001). Admission rates varied by arrival time only at the general ED, where minor trauma was more common (41% vs 22%, P less than .001). It is concluded that a wide range of pediatric illness is treated in a general ED, supporting the decision to have pediatric emergency physicians on staff, and that significant differences exist in the spectrum and frequency of pediatric illness seen in a general ED and pediatric ED.