Non-admitted Patients Research Articles

Patient care is not a ‘tick-box’ exercise

In a recent article, Senior Australian of the Year 2013, Professor Ian Maddocks suggested a new way of caring for older people via ‘community hubs’ that would be located in Residential Aged Care facilities and will provide a range of support and services including palliative care.1 The idea is not unreasonable, reflecting principles of community-based care seen in the UK and USA, and inclusive of a wide-ranging multidisciplinary team including pharmacists. However, disappointingly, Professor Maddocks glosses over how some aspects of the model such as pharmacy services, and allied health could be funded while being clear on how funding for doctors and nurses to work in these hubs could be found. This lack of clarity may reflect the complex nature of pharmacy funding in Australia. In the near future, clinical pharmacy services such as medication reviews for non-admitted and community-based patients may have funding streams. However the pharmacy profession must continue to strive for a funding mechanism that is fully inclusive of all aspects of pharmaceutical care, not just intermittent medication reviews, and allows pharmacists to individualise each and every patients care. Without this, pharmacy aspects of care models may be applied in an ‘over-simplified’ or ‘tick-box’ fashion. Lessons about over-simplification of care models can be acquired from system break-downs in other healthcare jurisdictions. An example of this is the case of the Liverpool Care Pathway (LCP) experience in the UK. Developed from a model of care successfully used in hospices, the LCP for the Dying Patient was a generic guideline to care for the dying, intended to ensure that uniformly good care was given to everyone thought to be dying within hours or within 2 or 3 days, whether they were in hospitals, nursing homes or in their own homes. When used appropriately, the LCP or similar models of care provided excellent support for decision making and care of dying patients. However the LCP started to come under scrutiny when it was identified that patients had been put on the pathway inappropriately without full discussion with the patient or carers. The LCP it appears was being used by some clinicians, possibly due to lack of understanding of the pathway or due to lack of supportive resources put in place to ensure good use of the pathway, as a protocol to be followed, rather than as a set of alerts and a guideline for good practice (as it was intended). The LCP thus became a ‘tick-box’ exercise. In 2013, an Independent review recommended that the LCP be phased out and replaced by ‘individual patient care plans’.2 Lessons such as this need to be heeded and applied to everything we do in caring for dying patients and their families. Palliative care is based on individualised care of the terminally ill patient and their carers. Treatment focus is on symptom-management not on cure; goals are often short-term in nature and patients are encouraged to define those goals when possible. Many non-palliative care staff struggle with this concept of care compared to experience in other specialties. But specialist staff cannot see every patient in need of palliative care and so other teams need take some of the burden, as many already do. In practice, much of the support that palliative care can give has to be via written guidelines – what must be done is to continually reinforce the message that guidelines must be applied with consideration for each and every individual patient context. Pharmacy has come a long way in the past 30 years, but pharmacists still need to continually strive for recognition, both in terms of communicating our role each day to our patients and colleagues, and also as a profession in terms of making a case for adequate resourcing so that we can play that role well. In doing that, we have a responsibility to guarantee that for every patient's care we contribute to, we don't just ‘tick the boxes’ and move on, but that we reflect on our practice to ensure that we provide individualised care. If successful, we can help make new models of care such as ‘community hubs’ an effective way of spreading resources more widely for our ageing population.

Referral to Inpatient Treatment Does not Necessarily Imply a Need for Inpatient Treatment.

We analyzed the dispositional decisions taken in a unit for clinical decision making (UCDM) which was set up to examine all emergency inpatient referrals to a psychiatric hospital. Hospitalization proved unnecessary for at least 17 % of the N = 2,026 inpatient referrals over a one year period. Instead, these patients were admitted to day-hospitals or outpatient treatments, resulting in annual cost savings of approximately <euro>3.3 million. Merely 8 % of those non-admitted patients had to be hospitalized within 28 days of the decision for non-admission being taken. Thus, a specialized UCDM run by clinical experts can help identify cost-effective alternatives to hospitalization.

Death or revascularization among nonadmitted ED patients with low-positive vs negative troponin T results

Study objectiveCompare outcomes among emergency department (ED) patients with low-positive (0.01-0.02 ng/mL) vs negative troponin T. MethodsRetrospective cohort study of nonadmitted ED patients with troponin testing at a tertiary-care hospital. Trained research assistants used a structured tool to review charts from all nonadmitted ED patients with troponin testing, 12/1/2009 to 11/30/2010. Outcomes of death and coronary revascularization were assessed at 30 days and 6 months via medical record review, Social Security Death Index searches, and patient contact. ResultsThere were 57596 ED visits; with 33388 (58%) discharged immediately, 6410 (11%) assigned to the observation unit, and 17798 (31%) admitted or other. Troponin was measured in 2684 (6.7%) of the nonadmitted cases. Troponin was negative in 2523 (94.0%), low positive in 78 (2.9%), and positive (≥0.03 ng/mL) in 83 (3.1%). Of troponin-negative cases, 0.8% (95% CI, 0.4-1.1%) died or were revascularized by 30 days, vs 2.8% (95% CI, 0.0-6.7%) of low-positive cases (risk difference [RD], 2.0%; 95% CI, −1.8 to 5.9%). At 6 months, the rates were 1.7% (95% CI, 1.1-2.2%) and 12.9% (95% CI, 5.0-20.7%) (RD, 11%; 95% CI, 3.3-19.1%). Death alone at 30 days occurred in 0.4% (95% CI, 0.1-0.6%) vs 1.3% (95% CI, 0.0-3.8%) (RD, 0.9%; 95% CI, −1.6 to 3.4%). Death at 6 months occurred in 1.2% (95% CI, 0.8-1.6%) vs 11.7% (95% CI, 4.5-18.9%) (RD, 10%; 95% CI, 3.3-17.7%). ConclusionAmong patients not initially admitted, rates of death and coronary revascularization differed insignificantly at 30 days but significantly at 6 months. Detailed inspection of our results reveals that the bulk of the added risk at 6 months was due to non-cardiac mortality.

Outpatient course and complications associated with home oxygen therapy for mild bronchiolitis.

Home oxygen has been incorporated into the emergency department management of bronchiolitis in high-altitude settings. However, the outpatient course on oxygen therapy and factors associated with subsequent admission have not been fully defined. We conducted a retrospective cohort study in consecutive patients discharged on home oxygen from the pediatric emergency department at Denver Health Medical Center from 2003 to 2009. The integration of inpatient and outpatient care at our study institution allowed comprehensive assessment of follow-up rates, outpatient visits, time on oxygen, and subsequent admission. Admitted and nonadmitted patients were compared by using a χ(2) test and multivariable logistic regression. We identified 234 unique visits with adequate follow-up for inclusion. The median age was 10 months (interquartile range [IQR]: 7-14 months). Eighty-three percent of patients were followed up within 24 hours and 94% within 48 hours. The median length of oxygen use was 6 days (IQR: 4-9 days), and the median number of associated encounters was 3 (range: 0-9; IQR: 2-3). Ninety-three percent of patients were on room air at 14 days. Twenty-two patients (9.4%) required subsequent admission. Fever at the initial visit (>38.0°C) was associated with admission (P < .02) but had a positive predictive value of 15.4%. Age, prematurity, respiratory rate, oxygen saturation, and history of previous bronchiolitis or wheeze were not associated with admission. There is a significant outpatient burden associated with home oxygen use. Although fever was associated with admission, we were unable to identify predictors that could modify current protocols.

Health care consumption and costs due to foot and ankle injuries in the Netherlands, 1986-2010.

BackgroundFoot and ankle injuries account for a large proportion of Emergency Department attendance. The aim of this study was to assess population-based trends in attendances due to foot and ankle injuries in the Netherlands since 1986, and to provide a detailed analysis of health care costs in these patients.MethodsAge- and gender-standardized emergency attendance rates and incidence rates for hospital admission were calculated for each year of the study. Injury cases and hospital length of stay were extracted from the National Injury Surveillance System (non-hospitalized patients) and the National Medical Registration (hospitalized patients). Data were grouped into osseous and ligamentous injuries for foot and ankle separately. An incidence-based cost model was applied to calculate associated direct health care costs.ResultsSince 1986 the overall emergency attendance rate decreased from 858 to 640 per 100,000 person years. In non-admitted patients (90% of cases), ligamentous injuries approximately halved, whereas osseous injuries increased by 28% (foot) and 25% (ankle). The incidence rate for hospital admission increased by 35%, mainly due to an almost doubling of osseous injuries. Attendance rates showed a peak in adolescents and adults until ~45 years of age in males and (less pronounced) in females. The total number of hospital days decreased to 58,708 days in 2010. Hospital length of stay (HLOS) increased with age and was highest for osseous injuries. HLOS was unaffected by gender, apart for longer stay in elderly females with an osseous ankle injury. Health care costs per case were highest for osseous injuries of the ankle (€ 3,461). Costs were higher for females and increased with age to € 6,023 in elderly males and € 10,949 in elderly females. Main cost determinants were in-hospital care (56% of total costs), rehabilitation/nursing care (15%), and physical therapy (12%).ConclusionsSince 1986, the emergency attendance rate of foot and ankle injuries in the Netherlands decreased by 25%. Throughout the years, the attendance rate of (relatively simple) ligamentous injuries strongly reduced, whereas osseous injuries nearly doubled. Attendance rates and health care costs were gender- and age-related. Main cost determinants were in-hospital care, rehabilitation/nursing care, and physical therapy.

New emergency department quality measure: From access block to National Emergency Access Target compliance

The study aims to investigate the effect of time of day and ED occupancy on the ability of EDs to admit or discharge patients within 4 h in accordance with the National Emergency Access Target (NEAT), and to compare this with corresponding levels of access block, the measure for ED performance before NEAT. This is a retrospective analysis of 5 years of ED data from 30 reporting public hospitals in Queensland, Australia. Relationships between these and variations in time of day and occupancy were explored using a Poisson generalised linear model. The main outcome measures are cases of NEAT non-compliance (ED length of stay >4 h for all patients [i.e. admitted and non-admitted] leaving the ED) and access block (ED length of stay >8 h for admitted patients). NEAT performance is found to be dependent on hospital size, and levels vary significantly for admitted and non-admitted patients. A higher proportion of patients breach NEAT during early mornings and low occupancy periods, a trend not observed with the previous access block metric. NEAT non-compliance is also found to rise between 13.00 hours and 17.00 hours, a period when the proportion of access block cases typically drops. EDs face rising levels of NEAT non-compliance at times when corresponding access block levels have traditionally not been a concern. A higher proportion of patients breach the target during periods that would intuitively not be flagged as flow bottlenecks. The findings support the need for service level analysis and new solutions to guide workflow reform and maximise NEAT compliance.

The Longitudinal Course of Post-Stroke Apathy Over Five Years

The prevalence of apathy is high after stroke, but its subsequent course remains unclear. We sought to determine the longitudinal course and predictors of apathy after stroke. Eligible patients admitted after a stroke and healthy control participants who were rated at least once on the Apathy Evaluation Scale were assessed over 5 years. Rates and levels of apathy in patients rose over 5 years. Significant risk factors for apathy were dementia, interval cerebrovascular events, poor physical functioning, and high depression scores. Apathy is common after stroke and becomes more prevalent with time, especially in those who show evidence of cognitive and functional decline.

Impact of elective hospital admissions on glycaemic control in adolescents with poorly controlled type 1 diabetes

AimDifferent treatment strategies have been used to manage adolescents with poorly controlled type 1 diabetes. We investigated whether a brief elective hospital admission improves haemoglobin A1c (HbA1c) over 12months. MethodsWe studied a retrospective cohort of adolescents with poorly controlled type 1 diabetes attending a tertiary care pediatric diabetes clinic in Montreal, Canada, between January 2005 and December 2010. Hospitalized adolescents (admitted group) were matched with controls (non-admitted group) for age and baseline HbA1c. HbA1c values at baseline, 6 and 12months were obtained from the clinic database. ResultsThirty patients aged 11 to 17 years with a first elective admission for poor metabolic control were paired with 30 non-admitted patients. At baseline, HbA1c was 12.2±1.6% in admitted and 12.0±1.2% in non-admitted patients. There were no clinically important differences in potential confounders between groups. There was no improvement in the primary outcome as assessed by the change in HbA1c at 12months in the admitted group (–1.3±2.3%) compared with the non-admitted group (–2.1±1.7%) (P=0.078). No improvement in intermediary measures of glycaemic control was observed (HbA1c at 6months or change at 6months). After 12months, HbA1c values were higher in the admitted group (10.9±1.9%) versus the non-admitted group (9.9±1.4%) (P=0.016). ConclusionElective hospital admission for adolescents with poorly controlled type 1 diabetes does not seem to be an effective strategy to improve HbA1c over 12months.

Vitamin D and Kidney

After absorption from the gut or entry into the circulation from the skin, vitamin D is hydroxylated to 25(OH)D by 25-hydroxylase enzyme in the liver and then to 1α,25(OH)D3 (or calcitriol) by 1α-hydroxylase enzyme in the kidney and in many cells. The hormonal or active form of vitamin D, that is, 1,25(OH)2D3 acts through a nuclear receptor (VDR) to carry out its many functions. The receptor has been recognized in a wide variety of tissues such as in osteoblasts, distal renal tubular cells, parathyroid gland cells, skin keratinocytes, lymphocytes, enterocytes, prostate, colon, pituitary gland, and ovaries. Many tissues in the body, express 1-hydroxylase and synthesize 1,25(OH)2D3 locally. Vitamin D has at least 2 distinct groups of functions. One is classically endocrine functions regulating PTH secretion and hence its own production. The other is autocrine functions (or paracrine): the cells or tissues concerned make and degrade active vitamin D locally to regulate their own proliferation and differentiation. Vitamin D supplementation can affect many aspects of health because function. Many epidemiologic studies have shown that chronic vitamin D deficiency is associated with an increased risk of diseases such as dementia, hypertension, multiple sclerosis, rheumatoid arthritis, cancer of the colon, prostate, breast, and ovary, and types 1 and 2 diabetes. In the general population and especially in patients with chronic kidney disease (CKD) has been reported. The reasons for hypovitaminosis D in CKD are not known but likely include reduced oral intake of vitamin D because of dietary restrictions and/or anorexia. In this special issue about vitamin D and kidney, Nordenstrom evaluated vitamin D status in patients operated for primary hyperparathyroidism (PHPT) and compared the patients from southern and northern Europe. These authors found that postmenopausal women with PHPT from Spain had lower preoperative levels of 25(OH)D and more severe PHPT Swedish patients, and patients with PHPT and vitamin D deficiency gained more bone density at some sites one year after parathyroidectomy. The effects of vitamin D on gentamicin-induced acute kidney injury in an experimental rat model were investigated by Hur et al. The authors reported that vitamin D does not seem to affect histological findings although some beneficial effects via Renin Angiotensin System and a promising effect on antioxidant system. Cardiometabolic risk factors related to vitamin D and adiponectin in obese children and adolescents were evaluated by Kardas et al. The authors showed that lower vitamin D and adiponectin levels were strongly associated with metabolic risk factors and obesity in children and adolescents. Kidney disease was found to be a major risk factor for vitamin D deficiency population study of both hospitalized and non-admitted patients. Significant independent predictors of vitamin D deficiency in inpatients and outpatients of a nephrology unit were retrospectively studied by Bentli. These authors showed that vitamin D deficiency is an important problem in both inpatients and outpatients of nephrology. Monitoring serum 25(OH)D concentrations regularly and replacement of vitamin D are important. Finally, Yildirim et al. report their findings on the association between inflammatory markers (C-reactive protein, erythrocyte sedimentation rate, and leukocyte count) and the presence of CKD in vitamin D-deficient patients sedimentation rate, and leukocyte count, in vitamin D deficient patients with and without chronic kidney disease.

Predictive variables of an emergency department quality and performance indicator: a 1-year prospective, observational, cohort study evaluating hospital and emergency census variables and emergency department time interval measurements

ObjectiveEmergency department (ED) crowding impacts negatively on quality of care. The aim was to determine the association between ED quality and input, throughput and output-associated variables.MethodsThis 1-year, prospective, observational, cohort...

Evaluating the Effect of Clinical Decision Units on Patient Flow in Seven Canadian Emergency Departments

To evaluate the effect of emergency department (ED) clinical decision units (CDUs) on overall ED patient flow in a pilot project funded in 2008 by the Ontario Ministry of Health and Long-Term Care (MOHLTC). A retrospective analysis of unscheduled ED visits at seven CDU pilot and nine control sites was conducted using administrative data. The authors examined trends in CDU utilization and compared outcomes between pilot-CDU and control sites 1 year prior to implementation, with the first 18 months of CDU operation. Sites that were unsuccessful in their applications for CDU program funding served as controls. Outcomes included ED length of stay (LOS), admission rates, and ED revisit rates. At CDU sites, roughly 4% of ED patients were admitted to CDUs. The presence of a pilot-CDU was independently associated with a small reduction in ED LOS for all low-acuity patients (-0.14 hour, 95% confidence interval [CI]=-0.22 to -0.07) and nonadmitted patients (-0.11 hour, 95% CI=-0.16 to -0.07). A small independent effect on absolute hospital admission rate for all high-acuity patients (-0.8%, 95% CI=-1.5% to -0.03%) and moderate-acuity patients (-0.6%, 95% CI=-1.1% to -0.2%) was also observed. Pilot-CDUs were not associated with changes in ED revisit rates. With only 4% of ED patients admitted to CDUs, the potential for efficiency gains in these EDs was limited. Nonetheless, these findings suggest small improvements in the operation of the ED through CDU implementation. Although marginal, the observed effects of CDU operation were in the desired direction of reduced ED LOS, reduced admission rate, and no increase in ED revisit rate.

Key Performance Indicators in an Acute Surgical Unit: Have We Made an Impact?

Timely access to acute surgery is a worldwide issue and New Zealand is similarly affected. Auckland City Hospital is one of the largest metropolitan public hospitals in New Zealand where more than 60 % of surgical admissions fit into the acute category. In January 2009, an Acute Surgical Unit (ASU) was set up to improve acute surgical flow. Key performance indicators (KPIs) were identified as valuable tools in evaluating ASU service performance. Our goals were to describe the current acute patient pathway, present the early trend of KPIs for the ASU and determine whether an impact has been made on acute surgical patients. A retrospective review of patients admitted with acute general surgical conditions from January 2008 (pre-ASU) to October 2010 was performed. Patient data were identified through hospital electronic records. KPIs assessed included: (1) time to assess referred patients from the emergency department (ED) and from GPs [where patient assessment occurs in the assessment and planning unit (APU)]; (2) preoperative length of stay (LOS[PO]); (3) length of stay of nonadmitted patients (LOS[NA]); (4) case volume "in h" (0730-1730) versus "after h"; and (5) readmission rate. Statistical analysis was performed with one-way ANOVA, regression, and χ(2) tests. Results show a reduction of mean time from referral to assessment from 2.28 to 1.6 h in the ED (p ≤ 0.001). Patients are seen in APU after GP referral sooner as well as the time from referral to assessment reducing from 2 to 1.76 h (p < 0.001). The LOS[PO] has not changed significantly overall (34.58 vs. 34.88 h, p = not significant [NS]). However, there are encouraging signs in high-volume procedures, such as appendicectomy. The mean LOS[PO] for appendicectomy was 7.81 h but is now 6.53 h (p ≤ 0.005). The LOS[NA] has decreased from 15.23 to 9.48 h (p < 0.005). Since the development of the ASU, the number of cases operated on "in hours" is increasing with a corresponding decrease in "after hours" operating. Our KPIs demonstrate an early positive trend of facilitating acute patient flow. There is minimal difference between pre- and post-ASU LOS[PO].The causes are likely multifactorial, including increased case volume displacing minor cases of lesser urgency, lack of operating staff, and shortage of hospital beds in winter months. This study supports the utility of ASU in facilitating patient flow in a NZ metropolitan public hospital.

Patients' satisfaction and wait times at Guelph General Hospital Emergency Department before and after implementation of a process improvement project

A process improvement program (PIP) was implemented in the emergency department (ED) at Guelph General Hospital in July 2009. The purpose of this study was to examine patients' satisfaction and wait times by level of Canadian Triage and Acuity Scale (CTAS) score before and 6 months after implementation of this program. Two samples were recruited: one was recruited before implementation of the PIP, January to June 2009 (T1), and one was recruited 6 months after implementation, January to June 2010 (T2). Patients were contacted by telephone to administer a survey including patient satisfaction with quality of care. Time to physician initial assessment, numbers left without being seen, and length of stay (LOS) were obtained from hospital records to compare wait times before and 6 months after implementation of the PIP. Patients (n = 301) reported shorter wait times after implementation (e.g., 12% reported seeing a physician right away at T1 compared to 29% at T2). Time to physician initial assessment improved for patients with CTAS scores of III, IV, and V (average decrease from 2.1 to 1.7 hours), fewer patients (n = 425) left without being seen after implementation, and the mean and 90th percentile of LOS decreased for all patients except the mean LOS for discharged patients with a CTAS score of I. Total time spent in the ED for admitted patients decreased from 11.11 hours in the 2009 period to 9.95 in the 2010 period, and for nonadmitted patients, the total time decreased from 3.94 to 3.29 hours. The overall satisfaction score improved from a mean of 3.17 to 3.4 (of 4; p < 0.001). Implementation of the ED PIP corresponded with decreased wait times, increased patient satisfaction, and improved patient flow for patients with CTAS scores of III, IV, and V.

Evaluation of a Flexible Acute Admission Unit: Effects on Transfers to Other Hospitals and Patient Throughput Times

To prevent overcrowding of the emergency department, a flexible acute admission unit (FAAU) was created, consisting of 15 inpatient regular beds located in different departments. We expected the FAAU to result in fewer transfers to other hospitals and in a lower length of stay (LOS) of patients needing hospital admission. A before-and-after interventional study was performed in a level 1 trauma center in the Netherlands. Number of transfers and LOS of admitted ED patients in a 4-month period in 2008 (control period) and a 4-month period in 2009 (intervention period) were analyzed. Of 1,619 regular admission patients, 768 were admitted in the control period and 851 in the intervention period. The number of transfers decreased from 80 (10.42%) to 54 (6.35%) (P = .0037). The mean ED LOS of both the non-admitted patients and the admitted patients needing special care significantly increased (105 minutes vs 117 minutes [P = .022] and 176 minutes vs 191 minutes [P < .001], respectively). However, the mean LOS of FAAU-admissible patients was unaltered (226 minutes vs 225 minutes, P = .865). The FAAU reduced the number of transfers of admitted patients to other hospitals. The increase in LOS for special care patients and non-admitted patients was not observed for regular, FAAU-admissible patients. Flexible bed management might be useful in preventing overcrowding.

Societal Consequences of Falls in the Older Population: Injuries, Healthcare Costs, and Long-Term Reduced Quality of Life

Fall incidents are a major cause of morbidity and mortality in older adults. The aim of this cohort study was to determine the incidence, costs, and quality of life for fall-related injuries in the older Dutch population presenting at the emergency department. Data on fall-related injuries in persons aged 65 years or older were retrieved from the Dutch Injury Surveillance System, which records injuries treated at the emergency department, and a patient follow-up survey conducted between 2003 and 2007. Injury incidence, discharge rates, healthcare costs, and quality of life measures were calculated. Fall-related injuries were to the upper or lower limb in 70% of cases and consisted mainly of fractures (60%), superficial injuries (21%), and open wounds (8%). Falls led to a total healthcare cost of €474.4 million, which represents 21% of total healthcare expenses due to injuries. Both admitted and nonadmitted patients reported a reduced quality of life up to 9 months after the injury. Fall-related injuries in older adults are age and gender related, leading to high healthcare consumption, costs, and long-term reduced quality of life. Further implementation of falls prevention strategies is needed to control the burden of fall-related injuries in the aging population.

Chest pain research in Australasian emergency medicine: Putting our mark on the world stage

Chest pain research in Australasian emergency medicine: Putting our mark on the world stage

Cost-Driven Injury Prevention: Creating an Innovative Plan to Save Lives With Limited Resources

Pedestrian injury costs >$20 billion annually. Countermeasures such as blinking crosswalks can be expensive but expectedly vital to injury prevention efforts. We aimed to create a new framework of cost-driven surveillance. The purpose of our study was to carry out a detailed analysis of the hospital cost and its relationship to location of pedestrian injury. Targeting identified "high cost areas" with effective countermeasures could save lives and be most cost-effective. Our hypothesis is that pedestrian injury creates a tremendous public funding burden and that hotspot sites can be mapped based on corresponding hospital costs. We conducted a retrospective analysis of billing records of 694 auto versus pedestrian victims treated at Level I trauma center in our city in the sample year 2004. Total cost was computed using cost to charge ratios for hospital and ambulance fees and actual cost of professional fees. City district "price tags" were assigned per detailed patient cost data to corresponding spatial analysis of intersections. χ(2) analyses were conducted on demographic variables. Multiple regression analysis determined predictors of total cost. The total cost of injury was $9.8 million, whereas the total charge was $20.8 million. Ninety percent of victims resided in our City. Thirty-one percent were admitted and cost of their care accounted for 76% of the total. Admitted patients were older than nonadmitted patients (47 years vs. 38 years; t = 5.45; p = 0.00). Spatial analysis determined that of 11 city districts, three districts accounted for almost 50% of the total cost. Seventy-six percent of the total cost was publicly funded. The strongest predictors of cost were length of stay (â = 0.77; t(220) = 30.42; p = 0.000) and ventilator days (â = 0.51; t(220) = 6.69; p = 0.000). These findings provide a roadmap to target costly hot spots for city planning of preventive countermeasures. In a climate of limited resources, this kind of roadmap outlines the three regions that could most benefit from countermeasures from both an injury prevention and cost-containment standpoint. Cost-driven surveillance is useful in city strategic planning for cost-effective and life-saving pedestrian injury prevention.

Prospective Validation of Two Systems of Classification for the Diagnosis of Acute Appendicitis

The objectives of this study were (1) to validate the Alvarado score and pediatric appendicitis score (PAS) in a prospectively identified pediatric cohort and (2) to assess abdominal ultrasonography (AUS) as a tool to increase the diagnostic reliability of both scores. Prospective study conducted from January 10, 2008, to January 1, 2009. All patients attended at the emergency department with suspected acute appendicitis (AA) who had a blood sample collected were included. Items from both scores were recorded. The performance of an AUS, the decision to admit the patient, and the therapeutics were decided by the physician, disregarding the scores values. Nonadmitted patients were contacted by telephone. Ninety-nine patients were included. Mean age was 11 years, and 62.6% were males. Appendectomy was performed in 44.4% patients. The area under the receiver operating characteristic curve for the Alvarado score was 0.96 and that for PAS was 0.97. Not a single patient with an Alvarado score less than 5 or PAS less than 4 had AA. All patients with an Alvarado score greater than 8 or PAS greater than 7 had AA. For both scores, the optimum cutoff point was 6 (sensibility of 90.4% and specificity of 91.2% for the Alvarado score and sensibility of 88.1% and specificity of 98.2% for PAS). Abdominal ultrasonography was performed on 31 patients (sensibility of 84.6% and specificity of 94.4%). We studied the value of scores and AUS together. Assuming an Alvarado score from 1 to 4 and PAS from 1 to 3 as no AA, an Alvarado score from 9 to 10 and PAS from 8 to 9 as AA, and proceeding according to the AUS for intermediate values, a sensibility of 93.3% and 97.2% and a specificity of 100% and 97.6%, respectively, were obtained. Both scores are a useful tool in the evaluation of children with possible AA. For extreme values of scores, the results really ensure their use in the emergency department. The AUS can help on decision making for intermediate values.

Clinical and epidemiological characteristics of patients with influenza A (H1N1) 2009 attended to at the emergency room of a children's hospital

In June 2009, the first influenza pandemic of the twenty-first century, due to the swine origin influenza A (H1N1) 2009 virus, was declared. This study aimed to describe the epidemiological and clinical features, complications, lethality and risk factors for hospital admission of microbiologically confirmed cases of influenza A (H1N1) 2009 infection seen at the emergency department of a children's hospital. All cases of children with influenza A (H1N1) 2009 viral infection, confirmed microbiologically by real-time reverse transcription polymerase chain reactions and treated in the emergency room between July and December 2009, were prospectively included. Patients were compared according to admission requirement to study variables associated with the risk of hospitalisation. Oseltamivir was the antiviral used for the treatment and its safety was analysed. Four hundred and twelve patients with influenza A (H1N1) 2009 infection were included. The most frequent symptoms were: fever (96%), cough (95%) and coryza (90%). Eighty-five patients (20.6%) were admitted: three to the paediatric intensive care unit and two died. Hospitalised children were younger than those not admitted (median age 5 vs 8years; p = 0.001). Age under 1year (OR 6.01; CI 95% 2.77-13.05), pneumonia (OR 7.99; CI 95% 3.50-18.22) and haemoglobinopathy or underlying blood disorders (OR 5.99; CI 95% 1.32-27.30) were statistically significant risk factors for admission. No differences were observed regarding onset of antiviral treatment among admitted and non-admitted patients. Treatment with oseltamivir was well tolerated. In conclusion, the incidence of severe cases and lethality of influenza A (H1N1) 2009 infection were low in our setting, even in a population with risk factors for developing complications.

Cutaneous conditions leading to dermatology consultations in the emergency department.

IntroductionWe established the most common cutaneous diseases that received dermatology consultation in the adult emergency department (ED) and identified differentiating clinical characteristics of dermatoses that required hospital admission.MethodsA retrospective chart review of 204 patients presenting to the ED who received dermatology consultations at Los Angeles County/University of Southern California Medical Center, an urban tertiary care teaching hospital.ResultsOf all patients, 18% were admitted to an inpatient unit primarily for their cutaneous disease, whereas 82% were not. Of nonadmitted patients, the most commonly diagnosed conditions were eczematous dermatitis not otherwise specified (8.9%), scabies (7.2%), contact dermatitis (6.6%), cutaneous drug eruption (6.0%), psoriasis vulgaris (4.2%), and basal cell carcinoma (3.6%). Of patients admitted for their dermatoses, the most highly prevalent conditions were erythema multiforme major/Stevens-Johnson syndrome (22%), pemphigus vulgaris (14%), and severe cutaneous drug eruption (11%). When compared with those of nonadmitted patients, admitted skin conditions were more likely to be generalized (92% vs 72%; P = 0.0104), acute in onset (<1 month duration) (81% vs 51%; P = 0.0005), painful (41% vs 15%; P = 0.0009), blistering (41% vs 7.8%; P < 0.0001), and ulcerated or eroded (46% vs 7.8%; P < 0.0001). They were more likely to involve the mucosa (54% vs 7.2%; P < 0.0001) and less likely to be pruritic (35% vs 58%; P = 0.0169).ConclusionWe have described a cohort of patients receiving dermatologic consultation in the ED of a large urban teaching hospital. These data identify high-risk features of more severe skin disease and may be used to refine curricula in both emergency and nonemergency cutaneous disorders for emergency physicians.