Are Geriatric Patients Placed in an Emergency Department Observation Unit on a Chest Pain Pathway More Likely Than Non-Geriatric Patients to Re-Present to the Hospital within 30 Days?

BACKGROUND: Emergency department observation units (EDOUs) are used frequently for low-risk chest pain evaluations. OBJECTIVE: The purpose of this study was to determine whether geriatric compared to non-geriatric patients evaluated in an EDOU for chest pain have differences in unscheduled 30-day re-presentation, length of stay (LOS), and use of stress testing. METHODS: We conducted an exploratory, retrospective, cohort study at a single academic, urban ED of all adult patients placed in an EDOU chest pain protocol from June 1, 2014 to May 31, 2015. Our primary outcome was any unscheduled return visits within 30 days of discharge from the EDOU. Secondary outcomes included EDOU LOS and stress testing. We used Wilcoxon non-parametric and χ2 tests to compare geriatric to non-geriatric patients. RESULTS: There were 959 unique EDOU placements of geriatric (n = 219) and non-geriatric (n = 740) patients. Geriatric compared to non-geriatric patients had: no significant difference in unscheduled 30-day return visits after discharge from the EDOU (15.5% vs. 18.5%; p = 0.31); significantly longer median EDOU LOS (22.1 vs. 20.6 h; p < 0.01) with a greater percentage staying longer than 24 h (42% vs. 29.1%; p < 0.01). Geriatric patients had significantly fewer stress tests (39.7% vs. 51.4%; p < 0.01), more of which were nuclear stress tests (78.2% vs. 39.5%; p < 0.01). CONCLUSIONS: In this exploratory retrospective study, geriatric EDOU chest pain patients did not have an increased rate of re-presentation to the hospital within 30 days compared to non-geriatric patients. Geriatric patients had a longer EDOU LOS than non-geriatric patients. Geriatric patients in the EDOU had fewer stress tests, but more of those were nuclear stress tests.

Confidentiality and Capacity.

This article focuses on confidentiality and capacity issues affecting patients receiving care in the emergency department. The patient-physician relationship begins with presumed confidentiality. The article also clarifies instances where a physician may be required to break confidentiality for the safety of patients or others. This article then discusses risk management issues relevant to determining a patient's capacity to accept or decline medical care in the emergency department setting. Situations pertaining to refusal of care and discharges against medical advice are examined in detail, and best practices for mitigating risk in informed consent and barriers to consent are reviewed.

The physical examination of the eye.

This article is a review of the anatomy of the eye and its surrounding tissues. A working knowledge of the functional anatomy of the eye will aid the emergency physician in performing a thorough yet efficient physical examination of the eye. A goal-directed physical examination of the eye will allow the emergency physician to attempt to identify (or exclude) visionthreatening disease processes and facilitate communication with the ophthalmologist.

The role of post-reduction radiographs after shoulder dislocation.

We sought to determine whether post-reduction radiographs add clinically important information to what is seen on pre-reduction X-rays in Emergency Department (ED) patients with anterior shoulder dislocations. In this prospective, observational study, clinicians recorded preliminary pre-reduction and post-reduction X-ray readings on patients with shoulder dislocations. The films were subsequently reviewed by a blinded attending radiologist. Seventy-three patients presented to the ED with shoulder dislocations over an 18-month period; 55 of these patients had pre- and post-reduction X-rays and were included in the study. Eight of these patients had fractures seen on preliminary reading of post-reduction X-rays; one (1.8%, 95% confidence interval [CI] 0-9.7%) of these fractures was not seen on preliminary reading of pre-reduction films. On preliminary reading, all patients' shoulders were relocated on post-reduction X-rays (100%; 95% CI 93.5-100%). Forty of these patients had their X-rays read by a blinded attending radiologist. Sixteen fractures were seen on post-reduction X-rays, of which 6 (15.0%; 95% CI 5.7-29.8%) were not seen on pre-reduction X-rays. All patients (100%; 95% CI 91.2-100%) whose post-reduction films were read by blinded attending radiologists had shoulder relocation confirmed. In conclusion, although the majority (62.5%) of fractures associated with shoulder dislocations are seen on pre-reduction radiographs, more than one-third (37.5%) of fractures may be visible only on post-reduction X-rays. None of the fractures missed on pre-reduction X-rays changed patient management in the ED. There were no persistent shoulder dislocations found on post-reduction films.

Trends in geriatric emergency medicine.

To better understand future emergency department use, it is valuable to analyze the current emergency department use rates of the geriatric population. This article reviews emergency department use by demographics, causes of death, principal reason for emergency department visits, number of emergency department visits per person per year, prescription drugs used, and recent trends in emergency department visits.

Current Trends in Geriatric Emergency Medicine.

The number of geriatric visits to United States emergency departments continues to rise. This article reviews demographics, statistics, and future projections in geriatric emergency medicine. Included are discussions of US health care spending, geriatric emergency departments, prehospital care, frailty of geriatric patients, delirium, geriatric trauma, geriatric screening and prediction tools, medication safety, long-term care, and palliative care.

The use of intravenous recombinant tissue plasminogen activator in acute ischemic stroke.

We sought to determine the frequency of use of intravenous (i.v.) recombinant tissue plasminogen activator (rt-PA) in patients presenting to our institution with acute ischemic stroke (AIS). This observational study involved keeping a log of all patients presenting to our institution with symptoms consistent with AIS who were potential candidates for emergency thrombolysis over a 3-year period. The log included brain computed tomography (CT) scan results, whether or not rt-PA was administered, and contraindications to thrombolysis. It also included each patient's time flow through the system, from symptom onset to decision time regarding (and administration of) thrombolytics. Over the 36-month period of the study, there were 142 patients who presented to the Emergency Department (ED) who initially were thought to be potential candidates for thrombolysis for AIS. Ninety-five (68.5%) of these 142 patients had a confirmed diagnosis of AIS. On further clarification of symptom onset, 77 (81%) of these 95 patients with AIS actually presented within 3 h, and 17 (22%) of these 77 patients met criteria for thrombolysis and had no contraindications. All 17 (100%) patients with AIS presenting within 3 h of onset and without contraindications received i.v. rt-PA in the ED. In conclusion, i.v. rt-PA can be administered for AIS within the 3-h window if a hospital is committed to providing this treatment. Thrombolysis remains a treatment for a minority of AIS patients.

Basic neuroanatomy and stroke syndromes.

Stroke should not solely be considered a disease of the elderly, and racial disparities are most evident among young adults. Acute stroke can present at any age and it is important to be familiar with the evaluation and treatment of stroke to provide timely care. The National Institute of Health Stroke Scale helps physicians objectively evaluate stroke patients. This article presents an overview of basic information on neuroanatomy, pathophysiology, and stroke syndromes.

Professional liability insurance.

This article introduces the emergency physician to professional liability insurance: the type of insurance, whether it is the only type available in the region, and, if claims-made insurance, whether the tail coverage rate is reasonable; the limits of liability and whether these are appropriate for emergency medicine in the region; the policy exclusions and restrictions; the insurance company's financial strength; whether an attorney is provided for a claim, whether fees are covered by the policy, whether they are subtracted from the policy limit, whether the physician can choose a defense attorney, and whether the physician's consent is required for the insurance company to settle a case.

The impact of footwear and packweight on injury and illness among long-distance hikers.

OBJECTIVE: To determine the prevalence and predictors of injury and illness among long-distance hikers. METHODS: This was a cross-sectional study of long-distance hikers (> 500 miles [805 km]) along the Appalachian Trail and Pacific Crest Trails between August and October of 2006. An 8-page survey instrument was made available to hikers at a designated station near the northern terminus of the respective trails. The survey questions were yes/no or multiple choice. Independent variables included packweight, footwear, and type and frequency of water purification. chi(2) tests to compare categorical data and the Cochran-Armitage test for trend were used (P < .05 significant). We used logistic regression to compare the variables concurrently, and significance was determined using likelihood ratio tests. Profile likelihood confidence intervals for the odds ratios are reported. RESULTS: Of the 128 hikers completing surveys that met inclusion criteria, the mean age was 33 years (range = 18-65 years), 94% walked >1500 miles (2400 km), and 70% were male. Using univariate analysis, trends were noted in the proportion of hikers reporting paresthesias and increasing packweight (35% with 10-20 pound [4.5-9 kg] packs, 50% with 21-30 pound [9.5-13.5 kg] packs, and 69% with >31 pound [14 kg] packs [P < .002]), as well as in the proportion of hikers reporting paresthesias and increasing footwear rigidity (29% sandals, 36% running shoes, 42% hiking shoes, and 68% hiking boots [P < .001]). In multivariate analysis compared to sandals, the odds ratio of suffering from paresthesias with running shoes was 1.57 (95% CI 0.3, 12.2), hiking shoes 1.73 (95% CI 0.3, 13.9), and hiking boots 3.9 (95% CI 0.7, 32.1) (P = .16). Compared to 10 to 20 pound (4.5-9 kg) packs, the odds ratios of suffering from paresthesias with 21 to 30 pound (9.5-13.5 kg) packs was 1.5 (95% CI 0.6, 3.9), and for > 31 pounds (14 kg) was 2.2 (CI 0.7, 7.1) (P = .03). Adjusting for footwear and pack weight, only pack weight was significantly associated with paresthesias. Packweight and footwear were not significantly associated with other musculoskeletal injuries, such as joint sprains or chronic pain, and muscle injuries. CONCLUSIONS: There is an association between packweight and the prevalence of paresthesias among long-distance hikers. The association between type of footwear and the prevalence of paresthesias is significant when analyzed independently, but loses its significance when the variables are examined together. This suggests that there is confounding between footwear and packweight.