Non-urgent Group Research Articles

Upper Gastrointestinal Hemorrhage: Development of the Severity Score.

BackgroundEmergency endoscopy for every patient with upper gastrointestinal hemorrhage is not possible in many medical centers. Simple guidelines to select patients for emergency endoscopy are lacking. The aim of the present report is to develop a simple scoring system to classify upper gastrointestinal hemorrhage (UGIH) severity based on patient clinical profiles at the emergency departments.MethodsRetrospective data of patients with UGIH in a university affiliated hospital were analyzed. Patients were criterion-classified into 3 severity levels: mild, moderate and severe. Clinical and laboratory information were compared among the 3 groups. Significant parameters were selected as indicators of severity. Coefficients of significant multivariable parameters were transformed into item scores, which added up as individual severity scores. The scores were used to classify patients into 3 urgency levels: non-urgent, urgent and emergent groups. Score-classification and criterion-classification were compared.ResultsSignificant parameters in the model were age ≥ 60 years, pulse rate ≥ 100/min, systolic blood pressure < 100 mmHg, hemoglobin < 10 g/dL, blood urea nitrogen ≥ 35 mg/dL, presence of cirrhosis and hepatic failure. The score ranged from 0 to 27, and classifying patients into 3 urgency groups: non-urgent (score < 4, n = 215, 21.2%), urgent (score 4 - 16, n = 677, 66.9%) and emergent (score > 16, n = 121, 11.9%). The score correctly classified 81.4% of the patients into their original (criterion-classified) severity groups. Under-estimation (7.5%) and over-estimation (11.1%) were clinically acceptable.ConclusionsOur UGIH severity scoring system classified patients into 3 urgency groups: non-urgent, urgent and emergent, with clinically acceptable small number of under- and over-estimations. Its discriminative ability and precision should be validated before adopting into clinical practice.

Excess of mortality in patients with chest pain peaks in the first 3 days period after the incident and normalizes after 1 month

Background. Patients presenting with chest pain have a 5% chance of experiencing a coronary event. These patients are at risk of mortality and should be recognized and referred to secondary care.Aim. To determine the relationship between referral type and mortality in patients with chest pain.Methods. The design of the study is an observational study. The setting of the study is a sentinel network of general practices in Belgium, covering 1.6% of the total population. The subjects are 1558 consecutive patients consulting with chest pain in 2003. Descriptive analyses report the standardized mortality ratios. We used the Belgian population of 1999 as the reference population and as the standard population.Results. The standardized mortality ratios of 3 days were 151.0 [95% confidence interval (CI): 82.3–250.3] for the urgent referred group, 45.5 (95% CI: 12.4–116.0) for non-urgent and 13.6 (95% CI: 1.7–49.4) for the non-referred group. The standardized ratios of 1 month were, respectively, 27.6 (95% CI: 18.0–40.4), 6.7 (95% CI: 2.5–14.6) and 4.7 (95% CI: 1.9–9.7). The standardized ratios of 2–12 months were normal for the urgent referral group (1.3; 95% CI: 0.7–2.2) and for the non-urgent referral group (1.0; 95% CI: 0.5–1.9) and even less in the non-referred group (0.4; 95% CI: 0.2–0.9).Conclusions. Mortality in the first 3 days and first month after consulting for chest pain is very high. There is a marked trend in mortality according to the referral type—urgently referred, non-urgently referred and not referred—suggesting risk stratification by the GP. After 1 month, mortality normalizes for all groups, suggesting that the surviving patients are well treated and the condition causing the chest pain no longer influences survival compared to the general population.

‘Two-week rule for all breast referrals’ - another random government target?

Introduction: In December 2009 a government target will demand all new breast referrals are seen within 2 weeks. Currently fast-track patients are seen within two weeks and non-urgent five weeks. We aimed to assess the breast clinic referral pattern according to pathology in fast-track, non-urgent and tertiary groups.

Referral patterns, cancer diagnoses, and waiting times after introduction of two week wait rule for breast cancer: prospective cohort study

Objective To investigate the long term impact of the two week wait rule for breast cancer on referral patterns, cancer diagnoses, and waiting times.Design Prospective cohort study.Setting A specialist breast...

Do Longer Delays for Coronary Artery Bypass Surgery Contribute to Preoperative Mortality in Less Urgent Patients?

Priority wait lists are common for managing access to cardiac surgery in publicly funded health systems. We evaluated whether longer delays contribute to the probability of death before surgery among patients prioritized into the less urgent category. We studied records of 9233 patients registered for isolated coronary artery bypass graft (CABG) in British Columbia, Canada. The primary outcome was death before surgery. We estimated the probability that a patient, who could be removed from the list as a result of surgery, death, or other competing events, dies on or before a certain wait-list week. Despite similar death rates in semiurgent and nonurgent groups, 0.63 (95% confidence interval, 0.46-0.80) versus 0.58 (0.36-0.80) per 1000 patient-weeks, nonurgent patients were remaining on the list longer, which contributed to higher cumulative incidence of all-cause death than in semiurgent group (adjusted odds ratio = 1.66; 1.03-2.68). By 52 weeks on the wait list, 0.9% (0.6-1.1) and 1.3% (0.8-1.8) of patients died in semiurgent and nonurgent groups, respectively (P < 0.01). Similar proportions of deaths related to cardiovascular disease estimated over wait-list time in both groups (P = 0.40) were the result of shorter delays in the semiurgent group despite a higher rate of death resulting from cardiovascular disease (0.50 [0.36-0.65] vs. 0.34 [0.17-0.51] per 1000 patient-weeks). Queuing according to urgency of treatment contributed to a higher proportion of CABG candidates dying before surgery from all causes in the nonurgent compared with the semiurgent group despite similar weekly death rates observed in both groups. However, similar probabilities of death resulting from cardiovascular disease observed in both groups over wait-list time were the result of shorter delays in the semiurgent group despite a higher rate of cardiovascular death.

Patients’ perceptions of quality of care at an emergency department and identification of areas for quality improvement

This paper reports a study to identify patient's perceptions of quality of care at an emergency department and areas for quality improvement. Patients are not always satisfied with the care received at emergency departments. More attention needs to be paid to the specific needs and expectations of the non-urgent group of patients, who make up the majority of attenders at many emergency departments. Nurses' and physicians' perceptions about good quality of care do not always agree with patients' perceptions. Instruments measuring patient satisfaction have often been focused on inpatient treatment. A prospective, descriptive survey design was adopted and the study took place in one emergency department at a Swedish university hospital in 2002. The participants were 99 women and 101 men, with an average age of 51 years. The emergency department version of the questionnaire Quality from the Patient's Perspective was used for data collection. Patients estimated quality of care at the emergency department as fairly good, but there were areas in need of improvement. A high percent of inadequate quality was related to the environment in the emergency department. About 20% of patients reported that they did not receive effective pain relief. More than 20% estimated that nurses did not show an interest in their life situation and patients did not receive useful information on self-care and about which physician was responsible for their medical care. The use of a research-based instrument gave valuable information for quality improvement in clinical practice. Many of the identified areas for quality improvement are related to nursing care. Therefore, the importance of nursing care in the emergency department should be highlighted to nurses and physicians and they also need to be more attentive to the need of the individual patient. Identifying areas for quality improvements are important, to know where to take action. These findings may facilitate the work with changing attitudes and working routines, which are needed to deliver effective care and to improve patients' perceptions of quality of care at emergency departments.

Chances of late surgery in relation to length of wait lists

BackgroundThe proportion of patients who undergo surgery within a clinically safe time is an important performance indicator in health systems that use wait lists to manage access to care. However, little is known about chances of on-time surgery according to variations in existing demand. We sought to determine what proportion of patients have had late coronary bypass surgery after registration on wait lists of different size in a network of hospitals with uniform standards for timing of surgery.MethodsUsing records from a population-based registry, we studied wait-list times prospectively collected in a cohort of patients registered on wait lists for coronary artery bypass grafting procedures. We compared the number of weeks from registration to surgery against target access times established for three urgency groups. The chances of undergoing surgery within target time have been evaluated in relation to wait-list size at registration and the number of surgeries performed without registration on a wait list.ResultsIn 1991–2001, two in three patients were at risk of late surgery when registered on wait lists for isolated coronary bypass procedures in British Columbia, Canada. Although urgent patients had never seen a wait list with clearance time exceeding one week, the odds of on-time surgery were reduced by 25%, odds ratio [OR] = 0.75 (95% confidence interval [CI] 0.65–0.87) for every additional operation performed without registration on a list. When the wait list at registration required a clearance time of over one month, semi-urgent patients had 51% lower odds of on-time surgery as compared to lists with clearance time less than one week, OR = 0.49 (95%CI 0.41–0.60), after adjustment for age, sex, comorbidity, calendar period, hospital and week on the list. In the non-urgent group, the odds were 69% lower, OR = 0.31 (95%CI 0.20–0.47). Every time an operation in the same hospital was performed without registration on a wait list, the odds of on-time surgery for listed patients were reduced by 7%, OR = 0.93 (95%CI 0.91–0.95) in the semi-urgent group, and by 10%, OR = 0.90 (95%CI 0.87–0.94), in the non-urgent group.ConclusionChances of late surgery increase with the wait-list size for semi-urgent and non-urgent patients needing coronary bypass surgery. The weekly number of patients who move immediately from angiography to the operation without registration on a wait list reduced chances of surgery within target time in all urgency groups of listed patients. When advising patients who will be placed on the wait list about the expected time to treatment, hospital managers should take into account the current list size as well as the weekly number of patients who require CABG immediately after undergoing coronary angiography.

Nonurgent Emergency Department Patient Characteristics and Barriers to Primary Care

Nonurgent (NU) emergency department (ED) use is at the forefront of medico-political agendas, and diversion of NU patients has been entertained as a management strategy. Before policy changes are implemented, this population should be better understood with respect to their characteristics and reasons for not presenting to primary care providers (PCPs) instead of EDs. This study compares NU with urgent and semiurgent (USU) patients and describes the NU patients' reasons for not seeking care with a PCP before presenting to the ED. This was a secondary analysis from a cross-sectional study with sequential sampling in the EDs of five Quebec tertiary care hospitals (October 19, 1999, to May 26, 2000). Data on medical history, social support, awareness and utilization of health care, ED visits, referrals, activities of daily living, and sociodemographics were obtained. The NU group included patients with triage code 5 and the USU group included patients with triage codes 2, 3, and 4 using the Canadian Triage and Acuity Scale. Patient characteristics were structured into the Andersen behavioral model for health care utilization. Of 2,348 patients approached, 1,783 patients (77%) were eligible and agreed to participate. NU patients (n = 454) were younger than USU patients (n = 1,329) (mean age, 43 [SD +/- 18.1] vs. 49 [SD +/- 20.1] years). Patients in the NU group had better health (number of prior conditions, 3.1 vs. 3.9), were less likely to arrive by ambulance (5% vs. 22%), and were less often admitted from the ED (4% vs. 24%). While 70% of NU compared with 75% of USU patients were followed up by a PCP, only 22% of NU and 27% of USU patients sought PCP care before presenting to the ED. The reasons given by NU patients for not seeking PCP care were accessibility (32%), perception of need (22%), referral/follow-up to the ED (20%), familiarity with the ED (11%), trust of the ED (7%), and no reason (7%). NU ED patients are different from USU patients and have multiple reasons for not seeking primary care before going to the ED. This may help explain why various diversion strategies have been unsuccessful and indicate that a multifaceted approach may be better suited to this group of patients. The design of new interventions, however, will benefit from further research that clarifies the impact of NU patients on the health care system.

The decision to delivery interval in emergency and non-urgent cesarean sections

Objective: The aim of this study was to assess the decision to delivery interval (DDI) in our obstetric unit in comparison to current recommendations. Study design: A retrospective analysis of all non-elective cesarean sections during a 10 months period in a delivery ward of a university tertiary health care facility was performed. The DDI was compared between emergency and non-urgent cesarean sections. Results: The DDI was 25.8±10.8 and 46.2±19.9 min in the emergency and non-urgent cesareans, respectively ( P<0.01). In the emergency group, 71% delivered within 30 min compared to 35% in the non-urgent group ( P<0.05) and in the emergent-crash group 100% delivered within 30 min compared to 59% in the emergent-non-crash group ( P<0.05). No correlation was found between the DDI and umbilical artery pH or Apgar score at 1 or 5 min in infants of each cesarean group. Conclusion: The proposed 30 min DDI standard was achieved in 100, 71, 47 and 35% of emergent-crash, emergent, emergent-non-crash and non-urgent cesareans sections, respectively.

A Three-Year Review of Complaints in Emergency Department

A three-year retrospective analysis of complaints in an emergency department (ED) in Hong Kong was performed as part of a risk management and quality assurance program for improving patient care and reducing future complaints. The incidence, validity, causes, pattern, legal risk and settlement time of all complaints were studied. From June 1995 to May 1998, there were 71 complaints out of a total of 728040 ED attendance. They were classified into urgent and non-urgent patient groups, yielding a frequency of 0.1 complaint per 1,000 patient visits. Among the 71 complaints, 42 (59%) complaints were judged valid, corresponding to a total of 47 (47%) dissatisfactions. About two third of the complaints had only one dissatisfaction. The frequent dissatisfaction categories were insufficient communication, misdiagnosis and inadequate patient management. Four complaints were potential legal cases but none had subsequent action or claim. More than 51 (70%) complaints were settled within 3 weeks. Regular assessment of complaint is helpful to improve the ED service as well as patient satisfaction.

MEDICAL CONSEQUENCES OF TERRORISM: The Conventional Weapon Threat

As long as gunpowder and explosives are used to solve disagreements between nations, ethnic groups, and individuals, victims of blast injury continue to arrive occasionally at trauma centers around the world. Bombs planted in crowded urban locations or suicide bombings continue to stress civilian EMS and urban medical systems. Although the clinical presentation depends on whether the blast occurs in open or confined quarters, open air, or water, the pattern of injury inflicted on the body is relatively consistent. The proximity to the detonating device is probably much more important than the size of the bomb. If not injured by secondary, tertiary, or other miscellaneous mechanisms of most conventional bombs with 1 to 20 kg of TNT, people at distances exceeding 6 m will probably not experience substantial blast-induced injury. Three systems are prone to injury. The first is the auditory system, with damage to the eardrum in milder cases and inner-ear injury in more severe cases. The alimentary tract with contusions, hematoma, and occasional perforation of a hollow viscus is the second system involved. Solid organs are rarely damaged in survivors of blast injury. Close proximity to the blast can impose traumatic amputation of limbs (i.e., arms and legs) and ear lobes. Most of these victims succumb to their injuries in the immediate post-injury phase, but the hallmark of blast injury is the involvement of the respiratory system. With expeditious evacuation performed by efficiently coordinated and highly skilled EMS personnel, more patients with blast injuries arrive with signs of life to the medical facility. At the medical facility, the staff need to triage many victims into urgent and nonurgent groups. Only lifesaving procedures should be performed during the initial phase. Later, medical care is directed at patients moved to ICUs. Prompt evacuation after necessary lifesaving procedures in the field; proper triage and distribution; prudent hospital triage and surgical care; and, last but not least, expert critical care provide the best possible outcome in such circumstances.