Patients Attending Emergency Departments Research Articles

Frequent attendances to National Health Service general practitioner-led urgent care centres in London: an observational study

BackgroundSome patients attend emergency departments more frequently than others and account for a disproportionate number of attendances. However, little is known about repeat attenders at National Health Service urgent care centres. We aimed to describe the volume and characteristics of repeat attenders at such centres. MethodsIn an observational study, we analysed routine attendance data at two urgent care centres in London. We included all adult patients (aged 18 years and older) who attended either centre at least once between Jan 1, 2010, and Dec 31, 2012. We used Poisson regression models to predict the characteristics of frequent attenders. For each patient, the outcome variable was the numbers of repeat visits, and the exposure variable was length of follow-up. The predictors were age, sex, and risk factors recorded at the first visit (socioeconomic status, ethnicity, centre attended, referral to an accident and emergency [A&E] department, referral to a non-A&E service, mental health indication, number of diagnoses, and general practitioner [GP] registration status). We also estimated population attributable fractions for the non-base levels of each risk factor. Findings189 614 attendances were made by 108 677 patients. Although only 3116 (2·9%) attended more than five times, they accounted for a disproportionate number (26 826, 14·1%) of the total attendances. The strongest predictor of frequent attendance was low socioeconomic status (population attributable fraction for men 0·501, 95% CI 0·446–0·550; women 0·353, 0·281–0·418). Frequent attendees were commonly of non-white ethnicity (men 0·057, 0·038–0·076; women 0·030, 0·017–0·044) and unregistered with a GP (men 0·021, 0·015–0·027; women 0·017, 0·013–0·020). Patients referred to non-A&E services at their first visit were less likely to re-attend (men −0·020, −0·024 to −0·015; women −0·011, −0·015 to −0·007). InterpretationAlthough very few patients attended the centres frequently, they contributed disproportionally to the workload of the centres. Patients of low socioeconomic status, non-white ethnicity, and unregistered with a GP were more likely to attend frequently. Interventions to reduce repeat attendances could target these populations via educational programmes or enhanced access to community-based services. The generalisability of these findings is limited because data come from only two urgent care centres in London. FundingThis study was funded by a grant from the Imperial College NHS Trust Healthcare Charity and National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care for Northwest London.

Blood cultures taken from patients attending emergency departments in South Africa are an important antibiotic stewardship tool, which directly influences patient management.

BackgroundFebrile illness with suspected blood stream infection (BSI) is a common reason for admission to hospital in Africa and blood cultures are therefore an important investigation. Data on the prevalence and causes of community acquired BSI in Africa are scarce and there are no studies from South Africa. There are no validated clinical prediction rules for use of blood cultures in Africa.MethodsA prospective observational cohort study of patients attending 2 urban emergency departments in Cape Town, South Africa. The decision to take a blood culture was made by the attending clinician and information available at the time of blood draw was collected. Bottles were weighed to measure volume of blood inoculated.Results500 blood culture sets were obtained from 489 patients. 39 (7.8 %) were positive for pathogens and 13 (2.6 %) for contaminants. Significant independent predictors of positive cultures were diastolic blood pressure <60 mmHg, pulse >120 bpm, diabetes and a suspected biliary source of infection, but not HIV infection. Positive results influenced patient management in 36 of 38 (95 %) cases with the organism being resistant to the chosen empiric antibiotic in 9 of 38 (24 %). Taking <8 ml of blood was predictive of a negative culture. The best clinical prediction rule had a negative predictive value (NPV) of 92 % which is unlikely to be high enough to be clinically useful.DiscussionBlood cultures taken from patients attending emergency departments in a high HIV prevalent city in South Africa are frequently positive and almost always influence patient management. At least 8 ml of blood should be inoculated into each bottle.ConclusionBlood cultures should be taken from all patients attending EDs in South Africa suspected of having BSI particularly if diabetic, with hypotension, tachycardia or if biliary sepsis is suspected.Electronic supplementary materialThe online version of this article (doi:10.1186/s12879-015-1127-1) contains supplementary material, which is available to authorized users.

What has the 4-hour access standard achieved?

Few performance management measures create as much heat and debate as the 4-hour target for emergency departments. This article critically reviews the history, evidence and effectiveness of the 4-hour standard for patients attending emergency departments.

NATIONAL AUDIT OF SEIZURE MANAGEMENT IN HOSPITALS 2 (NASH2)

BackgroundNASH1 (National Audit of Seizure management in UK Hospitals) collected data in 2011 and fed back in 2012. It identified significant shortfalls and variability in the way that care was...

PATIENTS’ IDEAS AND CHOICES ABOUT THE MANAGEMENT OF HEADACHE

<h3>Introduction</h3> Headache is the commonest reason for neurology referrals, and the commonest neurological reason for patients attending Emergency Departments (EDs). An ethical approach to health care requires that patients be provided with informed choice about management. However researchers have not addressed patients9 concerns and choices in managing headache. This study aims to describe the views of patients, their fears, use of emergency departments, their perceived need for a scan and its future outcome for them. <h3>Methods</h3> A qualitative study using semi-structured interviews with 19 adults aged 23–63, referred by General Practitioners (GPs) to neurologists for primary headaches approximately two years previously. Audio-recorded interviews were transcribed and analysed thematically. <h3>Results</h3> Participants described fears about secondary organic causes for headache, like a brain tumour. They described their headaches as stressful, and leading to a vicious cycle of fear. Many believed they needed a brain scan and requested it. Participants reported relief of their fears after a scan, and in some cases relief of headache symptoms. <h3>Discussion</h3> GPs now have open access to scanning, which may relieve physical concerns. Interventions to address health-related anxiety may also help some consulters for headache.

Subtypes of Patients Experiencing Exacerbations of COPD and Associations with Outcomes

Chronic obstructive pulmonary disease (COPD) is a complex and heterogeneous condition characterized by occasional exacerbations. Identifying clinical subtypes among patients experiencing COPD exacerbations (ECOPD) could help better understand the pathophysiologic mechanisms involved in exacerbations, establish different strategies of treatment, and improve the process of care and patient prognosis. The objective of this study was to identify subtypes of ECOPD patients attending emergency departments using clinical variables and to validate the results using several outcomes. We evaluated data collected as part of the IRYSS-COPD prospective cohort study conducted in 16 hospitals in Spain. Variables collected from ECOPD patients attending one of the emergency departments included arterial blood gases, presence of comorbidities, previous COPD treatment, baseline severity of COPD, and previous hospitalizations for ECOPD. Patient subtypes were identified by combining results from multiple correspondence analysis and cluster analysis. Results were validated using key outcomes of ECOPD evolution. Four ECOPD subtypes were identified based on the severity of the current exacerbation and general health status (largely a function of comorbidities): subtype A (n = 934), neither high comorbidity nor severe exacerbation; subtype B (n = 682), moderate comorbidities; subtype C (n = 562), severe comorbidities related to mortality; and subtype D (n = 309), very severe process of exacerbation, significantly related to mortality and admission to an intensive care unit. Subtype D experienced the highest rate of mortality, admission to an intensive care unit and need for noninvasive mechanical ventilation, followed by subtype C. Subtypes A and B were primarily related to other serious complications. Hospitalization rate was more than 50% for all the subtypes, although significantly higher for subtypes C and D than for subtypes A and B. These results could help identify characteristics to categorize ECOPD patients for more appropriate care, and help test interventions and treatments in subgroups with poor evolution and outcomes.

The management of severe hypoglycemia by the emergency system: The HYPOTHESIS study

Background and aimsSevere hypoglycemia is not rare in diabetes and markedly impacts on health resource use. We aimed to describe the characteristics of patients attending emergency departments (EDs) following a severe episode of hypoglycemia, the factors associated with the management of events and the final outcome. Methods and resultsWe carried out a retrospective analysis of cases attending 46 Italian EDs for hypoglycemia from January 2011 to June 2012. A total of 3753 records were retrieved from the databases of the participating centers, part of a network repeatedly involved in collaborative studies; 3516 episodes occurred in subjects with diabetes (median age, 76 years; range, 1–102). Comorbidities were recorded in 2320 (65.9%) diabetes cases; association with trauma or road accidents in 287 (8.2%) and 47 (1.3%), respectively. Patients were treated with insulin (49.8%), oral agents (31.4%), or combination treatment (15.1%). The event required assistance by the out-of-hospital Emergency services in 1821 cases (51.8%). Following the ED visit, admission to hospital departments was deemed necessary in 1161 cases (33.1%). Diabetes treatment (oral agents: OR, 1.63; 95% confidence interval (CI), 1.37–1.94), increasing age (OR, 1.39; 95% CI, 1.31–1.48) and the number of comorbidities (OR, 1.51; 95% CI, 1.38–1.66) were the main drivers of admission. The in-hospital death rate was 10%, associated with the number of comorbidities (OR, 1.28; 95%CI, 1.01–1.63). ConclusionSevere hypoglycemia requiring referral to EDs is associated with a significant work-up of the Emergency services and a remarkable in-hospital death rate in frail individuals with diabetes.

ST segment elevations: Always a marker of acute myocardial infarction?

Chest pain is one of the chief presenting complaints among patients attending Emergency department. The diagnosis of acute myocardial infarction may be a challenge. Various tools such as anamnesis, blood sample (with evaluation of markers of myocardial necrosis), ultrasound techniques and coronary computed tomography could be useful. However, the interpretation of electrocardiograms of these patients may be a real concern. The earliest manifestations of myocardial ischemia typically interest T waves and ST segment. Despite the high sensitivity, ST segment deviation has however poor specificity since it may be observed in many other cardiac and non-cardiac conditions. Therefore, when ST-T abnormalities are detected the physicians should take into account many other parameters (such as risk factors, symptoms and anamnesis) and all the other differential diagnoses. The aim of our review is to overview of the main conditions that may mimic a ST segment Elevation Myocardial Infarction (STEMI).

Are patients admitted to emergency departments with regular supraventricular tachycardia (SVT) treated appropriately?

Regular supraventricular tachycardia (SVT) is frequently encountered in clinical practice. Guidelines are available from the National Service Framework (NSF) for the treatment of patients attending emergency departments (ED) with SVT. These recommend a thyroid-function test (TFT) and arrhythmia electrocardiography (ECG), and referral to a heart-rhythm specialist on discharge. Hospital admission is rarely required. In our multicentre study, we examined the implementation of these guidelines among patients attending the ED with SVT. Only 34% of patients had specialist referrals, with an average wait of 50.3 days (the majority of delays resulted from referral requests from general practitioners). A history of previous SVT, the mode of tachycardia termination, patient age and/or comorbidities were similar for the 27 (23.5%) patients who were admitted overnight. Of these, 15 (13%) of the total 115 patients who attended ED with regular SVT were referred for Holter monitoring despite having ECGs demonstrating arrhythmia. Low referral rates, unnecessary investigations and admissions indicate a need for improvement for better patient care and to minimise healthcare costs. We have formulated a standard operating procedure, which will be available via the College of Emergency Medicine website.

The role of the emergency department in the acute management of chronic or recurrent pain

Exacerbation of chronic pain is a common presenting problem for patients attending emergency departments (EDs), with many making multiple visits. This paper aims to identify the role of the ED in the acute management of patients with persistent or chronic nonmalignant pain through a review of current literature. Four databases were searched using the MeSH and subject search terms "chronic nonmalignant pain", "persistent pain" and "emergency" and synonyms associated with these terms. Literature related to the underlying causes of suboptimal chronic pain management along with the sequelae associated with treatment or management was extracted. Three main themes emerged: patient expectations and satisfaction, barriers to care, and strategies/principles to improve ED management for this patient group. The presence of these themes appears to be partially due to time limitations for chronic issues in an acute department, accompanied by a lack of clear guidelines. It is evident that the ED is not the ideal setting for managing patients with chronic pain however it is the last resort for many who do present, and who will continue to present should their pain persist. It is time to ensure that the ED provides a consistently supportive, cohesive and integrated approach to managing patients with chronic pain syndromes.

Reducing short-stay hospital admissions by ruling out non-ST elevation myocardial infarction and estimating coronary artery disease likelihood on an emergency department observation ward.

Chest pain is an important presentation in adult patients attending emergency departments (ED). The process of ruling out an acute coronary syndrome (ACS) conventionally requires a short in-patient stay. This places a significant burden on healthcare systems. Recent developments have encouraged us to explore the role of an ED observation ward in the management of these patients.We designed and implemented two proformas (‘flowformas’). The first provides integrated guidance and documentation for the management of chest pain in the ED. In patients determined to be at low risk of short-term adverse outcomes the ACS rule-out process is now completed on the ED observation ward rather than on the cardio-respiratory admission ward. The second proforma is used before discharge to determine the likelihood of underlying coronary artery disease (CAD), thereby allowing risk-based follow-up arrangements to be made. We collected data on all patients admitted to EDU on the NSTEMI rule-out pathway over a 12-month period.Between Feb 2012 and Feb 2013, 816 patients fulfilling the criteria were admitted on the pathway. 67 patients (8%) required admission due to ACS. 15 patients were admitted on two, and one on three occasions.In conclusion, it is possible to deliver ACS rule-out on an emergency observation ward. This reduces healthcare costs and shortens hospital stay.

Community Stepdown Care: A Safe Alternative for Selected Elderly Patients Attending Emergency Department?

Background. The Community Stepdown Care Initiative attempts to provide right siting of care for elderly emergency department attendees whose main need is rehabilitation. Objectives. The aim of this study was to compare reattendance and rehospitalisation rates, length of stay, medical complication rates, and discharge destination between the community hospital cohort and the acute hospital cohort. Methods. A retrospective cohort study was conducted from June 2007 to November 2008. Results. Two hundred and thirty patients were enrolled in the study. 68 patients were successfully transferred to stepdown care; 162 patients were admitted to acute hospital. The odds ratio of reattendance was similar in both cohorts at 2 weeks, 6 months, and 12 months. The odds ratio of rehospitalisation was similar in both cohorts at 2 weeks, 3 months, 6 months, and 12 months. There was no statistical difference in the medical complication rates between the cohorts. Patients were more likely to be discharged home from the community hospital compared to acute hospital (adjusted OR 4.11, P=0.03). 14% of patients from the acute hospital cohort was discharged to community hospital. Conclusions. For selective elderly emergency department attendees whose predominant need is rehabilitation, stepdown care is a safe alternative compared to usual acute hospital care.

NATIONAL AUDIT OF SEIZURE MANAGEMENT IN HOSPITALS: INITIAL FINDINGS

BackgroundLittle is known about the organisation and delivery of epilepsy care in the UK. The National Audit of Seizure management in Hospitals (NASH) is the first comprehensive UK-wide epilepsy audit.MethodsNASH...

Evaluating acute medical admissions through emergency departments in Hong Kong: can one adjust for case-mix variation?

BackgroundHealthcare systems are under pressure to efficiently and safely reduce acute care admissions to hospital. There is a need to develop a standardised system for assessing emergency department performance which...

Staff responses to an emergency department admission alert system

Megan Stowe discusses the benefits of software that alerts clinical nurse specialists when cancer patients attend emergency departments

Economic and Social Burden Due to Injuries and Violence in Nepal: A Cross-Sectional Study

Introduction: Injury and violence cause five million deaths annually in the world which is around 9% of the global mortality. Eight out of fifteen leading causes of deaths in the age group 15-25 are injury related. Objective: To assess the incidence, severity and socio-economic burden of injuries and violence in two cities of Nepal. Methods: Relevant data was collected from 17th August 2008 to 16th September 2008 from injured patients attending emergency departments at six health centres in two cities. Results: In total, 505 injury cases were reported. 42.5% of the injuries occurred in roads and 34.1% at home. 65% of road traffic injuries involved motorcycles. The majority (57%) of the injured subjects were economically active. A single injury case cost 126.2 US$ including all the expenses and the loss due to inability to work. Conclusion: The high incidence of injuries, especially road traffic injuries, adds a huge economic burden to nation.

Preferences and Perceptions of Patients Attending Emergency Departments with Low Acuity Problems in Hong Kong

ObjectiveTo explore why patients in Hong Kong seek medical advice from the emergency department (ED) and to identify the methods by which patients would prefer to be updated on the likely waiting time for medical consultation in the ED.MethodsThe study recruited 249 semi‐urgent and non‐urgent patients in the ED of Prince of Wales Hospital from 26th September 2005 to 30th September 2005 inclusive. A convenience sample of subjects aged ≥15 years old in triage categories 4 or 5 were verbally consented and interviewed by research nurses using a standardized questionnaire.ResultsFrom 1715 potential patients, 249 were recruited ad hoc (mean age 44 years [SD18]; 123 females). About 63% indicated that an acceptable ED waiting time was less than or equal to two hours, and 88% felt that having individual number cards and using a number allocation screen in the ED waiting area would be useful. Perceived reasons for attending the ED rather than other health care providers such as primary health care or the general outpatient clinic (GOPC) included: a desire for more detailed investigations (56%); a perception that more professional medical advice was given in the ED (35%); patients were under the continuing care of the hospital (19%); and patients were referred to the ED by other health care professionals (11%). Notably, 26% of participants had considered attending the GOPC prior to attending the ED. Patients educated to tertiary level expected a shorter waiting time than those educated to lesser degrees (p=0.026, Kruskal‐Wallis test). Suggestions were made on how to provide a more pleasant ED environment for the wait for consultations, which included the provision of a television screen with sound in the waiting area (43%), more comfortable chairs (37%) and health care promotion programs (32%).ConclusionPatients chose ED services because they believed they would receive more detailed investigations and more professional medical advice than available alternatives. Clear notification of the likely waiting times and enhancement of comfort before consultation are considered desirable by patients. Enhanced public education about the role of the ED and making alternatives to ED care more accessible may be useful in reducing inappropriate ED attendances in Hong Kong.

Need of Improvement in Emergency Medical Service in Urban Cities

An effective Emergency Medical Service system does not exist in Nepal. For an effective EMS system to be developed the scale of the problem and the existing facilities need to be studied. Prospective observational study was carried out on 1964 patients attending Emergency Department at Patan Hospital during one month period of September 2006. The patients were specifically enquired on mode of transport used, place of origin and whether they called for an ambulance or not. Patients triage category at the time of triaging was also noted. Information on ambulance service were collected by direct interview with the service providers and the total number of patients attending Emergency Departments daily were collected from the major hospitals of the urban Lalitpur and Kathmandu. MS Excel and SPSS software were used for data entry, editing and analysis. Total 9.9% patients arrived in ambulance whereas 53.6% came in a Taxi, 11.4% came in private vehicle, 13.5 % came by bus, 5.4% came by bike and the rest 6.2% came by other modes of transportation. Only 13.5% of triage category I patients took the ambulance. There were 31 service providers with 49 ambulances and 720 patients per day attend Emergency Departments in the surveyed area. Very less number of patients use the ambulance service for emergency services. The available ambulances are not properly equipped and do not have trained staff and as such are only a means of transportation to the hospitals of urban Lalitpur and Kathmandu.

Characteristics of frequent attenders in an emergency department: analysis of 1-year attendance data

Background:There is a significant literature examining the reasons why patients attend emergency departments frequently. This body of work suggests that sociodemographic characteristics are important in understanding why patients re-attend, but...

Appropriate tetanus prophylaxis practices in patients attending Emergency Departments in Italy

Objective This study evaluated the physician compliance with tetanus prophylaxis and immunization practices for patients with wounds attending Emergency Departments (EDs) of four randomly selected non-academic acute care public hospitals in Italy. Methods All presenting patients (≥16 years) within randomly selected week periods were studied. Physician and nurse, who were not involved in care, interviewed each patient regarding: socio-demographics, wound characteristics, and tetanus immunization history; they also collected, through direct observation, data of the physician practices for tetanus prophylaxis and immunization. Results A total of 29.8% patients had a wound tetanus-prone and this was more frequently observed in those lower educated, who arrive at the ED with medical referral during daytime and in the weekday, whose injury occurred outdoor, who had not completed the primary vaccination series or has received a booster dose ≤10 years before, and for a wound in abdomen, pelvis, and lower extremity. Overall, 54% of the physicians recorded for each patient information about the characteristics of the wound and the tetanus immunization history and this was more frequently for those patients traumatized outdoor, injured less than 1 h before, when the wound was non-tetanus-prone, and less frequently when the wound site was head and neck. Only 1.5% of the physicians correctly adhere to guidelines on tetanus prophylaxis and immunization in wound management and this more frequently adopted for younger patients’ and when the physician recorded information about tetanus immunization history. Conclusion Health policies and programs should be aimed at improving the quality of health care.