Proportion Of Emergency Admissions Research Articles

The Impact of the Second Wave of the COVID-19 Pandemic on Non-COVID Hospital Care in a Tertiary Hospital in Spain.

In 2020, Spain ranked fourth among European countries with the highest excess mortality due to COVID-19 disease. This study evaluates the impact of the COVID-19 pandemic on non-COVID patients in a tertiary hospital during the second pandemic wave in Spain (22 June 2020-6 December 2020). Data from Virgen del Rocío University Hospital in Seville during that timeframe were compared with the data from the same period in the preceding two years (2018-2019). Between-group comparisons were performed using the Chi-squared test, Student's t-test, or Mann-Whitney U tests, as appropriate. A total of 63,137 non-COVID patients were included in this study. During the second pandemic wave, a 19% decrease was observed in the annual number of non-COVID admissions overall (18,260 vs. 22,439, p < 0.001), but a 10% increase in the proportion of emergency admissions (60.6% vs. 54.93%, p < 0.001), a higher severity level of patients (1.79 vs. 1.72, p < 0.001), a longer in-hospital stay (7.02 vs. 6.74 days, p < 0.001), a 26% increase in non-COVID mortality (4.9% vs. 3.9%, p < 0.001), and a 50% increase in global mortality (5.9 vs. 3.9, p < 0.001) were also observed. In terms of both medical and surgical diagnoses, a significant reduction in the number of admissions and an increase in in-hospital mortality were observed. These results demonstrate the significant impact of the pandemic on hospital care, similar to what was previously observed during the initial wave in the same hospital. Our findings emphasize the need to include non-COVID patients when assessing the broad impact of the pandemic on healthcare, beyond its direct effects on COVID-19 patients.

Genitourinary toxicity after pelvic radiation: Prospective review of complex urological presentations

ObjectiveRecent randomised controlled trials underestimated the incidence of genitourinary (GU) complications occurring more than 5 years following pelvic radiotherapy. This study aimed to determine the burden of treatment at a single institution from late GU complications after pelvic radiotherapy. MethodsA prospective study of all presentations for GU complications following pelvic radiotherapy at a tertiary urology department between November 2018 and November 2019 was performed. Subgroup analysis was performed on patients with prostate cancer (PCa) with late toxicity to compare patient demographics, radiotherapy, complications, and management factors. ResultsThere were 117 hospital encounters involving 46 patients with a 56.4% repeat encounter rate. Patients with PCa were the predominant group (n=39, 84.8%). External beam radiotherapy was the most common treatment modality (n=41, 89.1%). The median time from radiotherapy to encounter was 8 (range 0–23) years. Radiation-induced haemorrhagic cystitis was the most common presentation (n=70, 59.8%). Forty-four (42.7%) encounters for GU toxicity were managed operatively and 33 (32.0%) involved a non-operative procedure. Nine patients required packed red cell transfusion, with a total of 154 units transfused. Patients with PCa who presented with late GU toxicity had higher median Radiotherapy Oncology Group grades (p=0.020), proportion of emergency admissions (p=0.047), and frequency of clot urinary retention (p<0.001). ConclusionThere is a high burden of elective and emergency urology workload attributed to late pelvic radiation toxicity. Late GU toxicity occurring ≥5 years after radiotherapy is common and often more severe.

Trends in Emergent Groin Hernia Repair—An Analysis From the Herniamed Registry

Introduction: While the proportion of emergency groin hernia repairs in developed countries is 2.5–7.7%, the percentage in developing countries can be as high as 76.9%. The mortality rate for emergency groin hernia repair in developed countries is 1.7–7.0% and can rise to 6–25% if bowel resection is needed. In this present analysis of data from the Herniamed Registry, patients with emergency admission and operation within 24 h are analyzed.Methods: Between 2010 and 2019 a total of 13,028 patients with emergency admission and groin hernia repairs within 24 h were enrolled in the Herniamed Registry. The outcome results were assigned to the year of repair and summarized as curves. The total patient collective is broken down into the subgroups with pre-operative manual reduction (taxis) of the hernia content, operative reduction of the hernia content without bowel resection and with bowel resection. The explorative Fisher's exact test was used for statistical assessment of significant differences with Bonferroni adjustment for multiple testing.Results: The proportion of emergency admissions with groin hernia repair within 24 h was 2.7%. The percentage of women across the years was consistently 33%. The part of femoral hernias was 16%. The proportion of patients with pre-operative reduction (taxis) remained unchanged at around 21% and the share needing bowel resection was around 10%. The proportion of TAPP repairs rose from 21.9% in 2013 to 38.0% in 2019 (p < 0.001). Between the three groups with pre-operative taxis, without bowel resection and with bowel resection, highly significant differences were identified between the patients with regard to the rates of post-operative complications (4% vs. 6.5% vs. 22.7%; p < 0.0001), complication-related reoperations (1.9% vs. 3.8% vs. 17.7%; p < 0.0001), and mortality rate (0.3% vs. 0.9% vs. 7.5%; p < 0.001). In addition to emergency groin hernia repair subgroups female gender and age ≥66 years are unfavorable influencing factors for perioperative outcomes.Conclusion: For patients with emergency groin hernia repair the need for surgical reduction or bowel resection, female gender and age ≥66 years have a highly significantly unfavorable influence on the perioperative outcomes.

Urinary cell cycle arrest biomarkers and chitinase 3-like protein 1 (CHI3L1) to detect acute kidney injury in the critically ill: a post hoc laboratory analysis on the FINNAKI cohort

BackgroundAcute kidney injury (AKI) is a frequently occurring syndrome in critically ill patients and is associated with worse outcomes. Biomarkers allow early identification and therapy of AKI which may improve outcomes. Urine chitinase 3-like protein 1 (uCHI3L1) was recently identified as a promising urinary biomarker for AKI. In this multicenter study, we evaluated the diagnostic performance for AKI stage 2 or greater of uCHI3L1 in comparison with the urinary cell cycle arrest biomarkers urinary tissue inhibitor of metalloproteinases-2 (TIMP-2)•insulin-like growth factor-binding protein 7 (IGFBP7) measured by NephroCheck Risk®.MethodsPost hoc laboratory study of the prospective observational FINNAKI study. Of this cohort, we included patients with stored admission urine samples and availability of serum creatinine at day 1 of admission. Patients who already had AKI stage 2 or 3 at ICU admission were excluded. AKI was defined and staged according to the KDIGO definition and staging system. The primary endpoint was AKI stage 2 or 3 at day 1. Biomarker performance was assessed by the area under the curve of the receiver operating characteristic curve (AUC). We assessed individual performance and different combinations of urine biomarkers.ResultsOf 660 included patients, 49 (7.4%) had AKI stages 2–3 at day 1. All urine biomarkers were increased at admission in AKI patients. All biomarkers and most combinations had AUCs < 0.700. The combination uCHI3L1•TIMP-2 was best with a fair AUC of 0.706 (0.670, 0.718). uCHI3L1 had a positive likelihood ratio (LR) of 2.25 which was comparable to that of the NephroCheck Risk® cutoff of 2.0, while the negative LR of 0.53 was comparable to that of the NephroCheck Risk® cutoff of 0.3.ConclusionsWe found that uCHI3L1 and NephroCheck Risk® had a comparable diagnostic performance for diagnosis of AKI stage 2 or greater within a 24-h period in this multicenter FINNAKI cohort. In contrast to initial discovery and validation studies, the diagnostic performance was poor. Possible explanations for this observation are differences in patient populations, proportion of emergency admissions, proportion of functional AKI, rate of developing AKI, and observation periods for diagnosis of AKI.

Features of hospitalisations for acute exacerbation of COPD resulting in death

Hospitalisation periods for the acute exacerbation phase of COPD are a strain on health facilities and entail high rates of hospital mortality. The aim of this study was to ascertain the characteristics of treatment periods resulting in death and the risk factors involved on the basis of treatment registers and death certificates. Data on all treatment periods for persons over 44 years of age with a principal diagnosis of COPD that began as emergency admissions applying to the period 1993-2001 was gathered from the hospital treatment register maintained by the Finnish National Research and Development Centre for Welfare and Health, yielding a total of 72 896 cases. Data on the deaths of the patients concerned was then obtained from Statistics Finland and those treatment periods which could be shown to have ended in death (N = 2331) were taken to form the material for analysis. These were compared with a same number of control hospitalisation periods (not ending in death) in terms of specialisation, type and geographical location of the hospital, length of the treatment period and the occurrence of subsidiary diagnoses. Attention was also paid to the season of the year and the days of the week on which admission and death took place. The proportion of emergency admissions that ended in death was 3.2%, The patients concerned having a mean age of 74.5 years for men and 75.0 years for women on admission. The mean duration of the treatment period was 11.5 days (SD 14.8), compared with 8.0 days (SD 7.9) for the controls. A subsidiary diagnosis existed in the case of 53.6% of the periods ending in death and 37.5% of the control periods. Deaths were most frequent on Fridays, 15.6%, and least so on Tuesdays, 13.0%. Where 24.2% of patients admitted on Saturdays or Sundays died during the first 24 hours, the figure for those admitted on weekdays was only 17.7%. Altogether 62.8% of the treatment periods ending in death took place between December and May. The COPD patients admitted at weekends showed the poorest survival, while concurrent diseases and protraction of the treatment period in winter and early spring increased the risk of death. Recognition of risk cases on admission could enable mortality to be reduced and allow savings in terms of costs through the intensification of treatment in these cases.

Trends and determinants of costs associated with the inpatient care of diabetic foot ulcers

The cost of care for diabetic foot ulcers is estimated to be more than $1.5 billion annually. The aim of this study was to analyze inpatient diabetic foot ulcer cost changes over time and to identify factors associated with these costs. The Nationwide Inpatient Sample (2005-2010) was queried using the International Classification of Diseases, Ninth Revision codes for a primary diagnosis of foot ulceration. The primary outcomes were changes in adjusted total hospital charges and costs over time. Multivariable analysis was performed to assess relative increases (RIs) in hospital charges per patient in 2005 vs 2010 adjusting for demographic characteristics, income, comorbidities (Charlson Comorbidity Index ≥3), insurance type, hospital characteristics, diagnostic imaging, revascularization, amputation, and length of stay. Overall, 336,641 patients were admitted with a primary diagnosis of diabetic foot ulceration (mean age, 62.9± 0.1years, 59% male, 61% white race). The annual cumulative cost for inpatient treatment of diabetic foot ulcers increased significantly from 2005 to 2010 ($578,364,261 vs $790,017,704; P< .001). More patients were hospitalized (128.6 vs 152.8 per 100,000 hospitalizations; P< .001), and the mean adjusted cost per patient hospitalization increased significantly over time ($11,483 vs $13,258; P< .001). The proportion of nonelective admissions remained stable (25% vs 23%; P= .32) and there were no differences in mean hospital length of stay (7.0± 0.1days vs 6.8± 0.1days; P= .22). Minor (17.9% vs 20.6%; P< .001), but not major amputations (3.9% vs 4.2%; P= .27) increased over time. Based on multivariable analysis, the main factors contributing to the escalating cost per patient hospitalization included increased patient comorbidities (unadjusted mean difference 2005 vs 2010 $3303 [RI, 1.08] vs adjusted $15,220 [RI, 1.35]), open revascularization (unadjusted $15,145 [RI, 1.25] vs adjusted $30,759 [RI, 1.37]), endovascular revascularization (unadjusted $17,662 [RI, 1.29] vs adjusted $28.937 [RI, 1.38]), and minor amputations (unadjusted $9918 [RI, 1.24] vs adjusted $18,084 [RI, 1.33]) (P< .001, all). Hospital charges and costs related to diabetic foot ulcers have increased significantly over time despite stable hospital length of stay and proportion of emergency admissions. Risk-adjusted analyses suggest that this change might be reflective of increasing charges associated with a progressively sicker patient population and attempts at limb salvage. Despite this, the overall incidence of major amputations remained stable.

Use of mortality rate after aortic surgery as a performance indicator.

Hospital episode statistics (HES) regarding death after aortic surgery were analysed to evaluate their potential value as a performance indicator. HES data for all acute hospitals in England and Wales from 1996 to 2001 were analysed retrospectively. In-hospital mortality was calculated for all patients over 40 years of age who underwent abdominal aortic procedures or died in hospital with a primary diagnosis of aortic aneurysm. Some 38 319 cases were identified, of which 8.9 per cent were complex, 46.8 per cent were elective and 44.4 per cent were emergencies. The elective mortality rate was 6.4 per cent overall; that after emergency operation was 35.0 per cent, rising to 41.6 per cent if urgent procedures were excluded and 63.1 per cent if unoperated cases were included. Over the 5-year interval a median of 68 (interquartile range 30-108) elective procedures were carried out by individual hospitals. Considerable variation was identified in the proportion of elderly patients, tertiary referrals and the proportion of emergency admissions that had surgery. The use of mortality data may be misleading owing to identifiable differences in case mix and selection. Some redefinition of groups may help to provide more valid data, but ultimately only high-quality data with clinical information are likely to allow meaningful comparisons of performance.

A prospective study to assess the implementation of a fast-track system to meet the two-week target for colorectal cancer in Somerset.

OBJECTIVE: This prospective study assesses the introduction of a fast-track referral system for patients with suspected colorectal cancer. PATIENTS AND METHODS: The referral system was initiated in Yeovil District Hospital and Taunton and Somerset Hospital using six screening criteria to select high-risk patients. Data on all high-risk patients from 1 November 1999 to 30 April 2000 was recorded prospectively. Patients with proven colorectal cancer diagnosed between 1 November 1998 and 30 April 1999 have been identified for comparison. RESULTS: There were 158 new cases of colorectal cancer in total (111 elective, 47 emergency). 59 cases of colorectal cancer were diagnosed from 433 fast-track referrals (53% of total elective cases). Median time from referral to diagnosis in the fast-track group was 11 days vs. 32.5 days for nonfast-track elective patients (P < 0.001). Median time from referral to diagnosis for all elective cases was 17 days vs. 38.5 days for patients presenting one year earlier (P < 0.001). 75% of fast-track patients were diagnosed with colorectal cancer within two weeks, compared with 17% of nonfast-track elective patients (P < 0.001). The proportion of emergency admissions was reduced from 40% to 30% (P=0.07) following the introduction of this system. CONCLUSION: Data from the first six months reveal that over half of the elective cases of colorectal cancer were diagnosed within the fast-track system. The median time from referral to diagnosis in these patients was within two weeks and there has been a significant reduction in the time to diagnosis associated with the introduction of this service.

Patient and GP factors associated with emergency medical admissions to one UK district general hospital

Objectives: Despite international debate over growing pressures on hospital beds, particularly from rises in emergency admissions, there are few published data on the characteristics of patients admitted to hospital. Most research has attempted to explore the appropriateness of general practitioner (GP) admissions, yet even the proportion of emergency admissions made via the GP is not known. This study aimed to investigate GP and patient factors associated with acute medical admissions to one hospital in Birmingham, UK.Methods: A study was performed on all acute medical admissions made over one week to a district general hospital in Birmingham and local general practices referring acutely to it. Admissions were identified from routine hospital dataset and the information validated. Factors perceived as linked to admission were explored by semi-structured interview or postal questionnaire with the admitting doctors and with a proportion of patients. The subjects were 158 patients and the 84 GPs involved in a proportion of the admissions. Outcome measures were admission routes, diagnoses, linked medical and social factors.Results: Only 84 (53%) patients were admitted via their GP (or deputy). 47% were self-referrals or admitted via outpatients. Data on 16% patients could not be validated because of GP refusal (3 doctors, 15 patients) or untraceable doctor (10 patients). Most admissions were for respiratory problems (47, 30%), mainly cases of infective illness (13% all admissions, 43% respiratory). Cardiovascular disease involved 16% cases, principally myocardial infarction or angina. Drug overdose was the most frequent single diagnosis, almost 1 in 10 acute admissions. 69% of the GP admissions were over 65 years old (30% over 75) against 36% of the non-GP (p<0.01). Additional influences on GP admissions included: exacerbations of long-standing medical problems (29%); clarification of uncertain diagnoses (61%); and requests for advice (5%). Some admissions also resulted from social pressures including: pressure from carers (15%); visit occurred at night (4%); and even pressure from patients to avoid admission (8%). In 11% of cases, GP admission was stated as solely related to non-acute medical problems. The average length of stay was 10.6 days (range 1 to 120 days). Mean length of stay for patients admitted by a doctor was 13 days compared to 8 days for non-GP admissions (p=0.025). 13% of patients died during or shortly after admission.Conclusions: Most patients sent in by the GPs or selfreferring, in this small sample of urban emergency admissions, were admitted with serious medical problems, on the basis of the coded discharge diagnoses, and required extended hospital stays. GP admissions in this sample appeared a sicker, or less coping, cohort. There was evidence that GPs were attempting to maintain patients at home and felt that around 15% of their admissions might have been managed in some alternative ‘low technology’ environment.