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BACKGROUND AND OBJECTIVES: Patient monitoring systems provide critical information but often produce loud, frequent alarms that worsen patient agitation and stress. This may increase the use of physical and chemical restraints with implications for patient morbidity and autonomy. This study analyzes how augmenting alarm thresholds affects the proportion of alarm-free time and the frequency of medications administered to treat acute agitation. METHODS: Our emergency department's patient monitoring system was modified on June 28, 2022 to increase the tachycardia alarm threshold from 130 to 150 and to remove alarm sounds for several arrhythmias, including bigeminy and premature ventricular beats. A pre-post study was performed lasting 55 days before and 55 days after this intervention. The primary outcome was change in number of daily patient alarms. The secondary outcomes were alarm-free time per day and median number of antipsychotic and benzodiazepine medications administered per day. The safety outcome was the median number of patients transferred daily to the resuscitation area. We used quantile regression to compare outcomes between the pre- and post-intervention period and linear regression to correlate alarm-free time with the number of sedating medications administered. RESULTS: Between the pre- and post-intervention period, the median number of alarms per day decreased from 1332 to 845 (-37%). This was primarily driven by reduced low-priority arrhythmia alarms from 262 to 21 (-92%), while the median daily census was unchanged (33 vs 32). Median hours per day free from alarms increased from 1.0 to 2.4 (difference 1.4, 95% CI 0.8-2.1). The median number of sedating medications administered per day decreased from 14 to 10 (difference - 4, 95% CI -1 to -7) while the number of escalations in level of care to our resuscitation care area did not change significantly. Multivariable linear regression showed a 60-min increase of alarm-free time per day was associated with 0.8 (95% CI 0.1-1.4) fewer administrations of sedating medication while an additional patient on the behavioral health census was associated with 0.5 (95% CI 0.0-1.1) more administrations of sedating medication. CONCLUSION: A reasonable change in alarm parameter settings may increase the time patients and healthcare workers spend in the emergency department without alarm noise, which in this study was associated with fewer doses of sedating medications administered.
Assuntos
Alarmes Clínicos , Serviço Hospitalar de Emergência , Agitação Psicomotora , Humanos , Masculino , Agitação Psicomotora/tratamento farmacológico , Feminino , Pessoa de Meia-Idade , Antipsicóticos/uso terapêutico , Antipsicóticos/administração & dosagem , Adulto , Idoso , Benzodiazepinas/uso terapêutico , Benzodiazepinas/administração & dosagem , Monitorização Fisiológica/métodos , Hipnóticos e Sedativos/uso terapêutico , Hipnóticos e Sedativos/administração & dosagemRESUMO
Introduction: The Virtual Observation Unit (VOU) utilizes telehealth and community paramedicine to provide observation-level care in patients' homes. Patients' experience of this novel program has not been reported. Methods: A phone-based patient experience survey was administered to the patients who were admitted to the VOU at an urban, academic Emergency Department in the Northeast United States. The survey asked about patient's perception of the program's quality of care (0 = worst care possible, 10 = best care possible). t Tests with a Bonferroni adjustment assessed for differences between patient demographic groups. Results: The survey response rate was 40% (124/307). Overall mean scores for perceived quality of care were very high (9.51 ± 1.19). There were no significant differences in patient's perception of quality of care between demographic cohorts of age, gender, race, or ethnicity. Conclusions: Patient experience with a novel VOU program was very positive and did not differ significantly by demographic cohort. Further research is warranted.
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Serviço Hospitalar de Emergência , Satisfação do Paciente , Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Adulto , Idoso , Qualidade da Assistência à Saúde , Telemedicina , Serviços de Assistência Domiciliar/organização & administração , New England , Adulto Jovem , Percepção , Idoso de 80 Anos ou mais , Unidades de Observação ClínicaRESUMO
OBJECTIVES: Opioid use disorder (OUD) is a national epidemic, and Black and Hispanic patients are less likely to receive treatment when compared to white patients. In this study, race was used as a proxy to assess potential effects of racism on the referral process for OUD treatment. Our primary aim was to examine whether Black or Hispanic patients experienced increased barriers to inpatient OUD detoxification (detox) placement at a community-integrated, substance use disorder support program based in an emergency department (ED). Our secondary aim was to determine if Black and Hispanic patients were more likely to have >3 referrals. METHODS: This retrospective cohort study was conducted at a large urban safety-net hospital and included patients seen in the ED from July 2018 to September 2019 with ICD-10 codes for an opioid-related visit and who sought placement to inpatient detox. A generalized linear mixed model controlling for multiple visits, age, sex, insurance, time, day of week, and time of year was used to assess the association between race/ethnicity and hypothesized barriers to placement. The proportion of patients with >3 visits for referral to inpatient detox was compared between Black and Hispanic patients and white patients using a chi-squared test. RESULTS: We identified 1733 encounters from 782 unique patients seeking connection to inpatient detox for OUD. Of the 1733 encounters, 45% were among Black and Hispanic patients. Hispanic and Black men had significantly lower odds of having a barrier to inpatient OUD detox than white men (OR = 0.734, 95% CI 0.542-0.995). No significant difference was found for Hispanic and Black women (OR = 1.212, 95% CI 0.705-2.082). More Black and Hispanic patients experienced >3 referrals to inpatient detox compared to white patients (19.2% vs 12.9%, p = 0.016). CONCLUSIONS: This study suggests in the context of near-universal health insurance coverage, an ED-based OUD support program staffed by diverse community members can mitigate inequities in access to inpatient detox. However, the increased number of ED visits for OUD detox placement by Black and Hispanic patients suggests racial inequities in OUD treatment exist after linkage to care. Additional research should explore the causes, specifically structural and interpersonal racism, and determine solutions to address racial inequities in detox placement as well as maintenance in treatment programs.
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Serviços Médicos de Emergência , Transtornos Relacionados ao Uso de Opioides , Etnicidade , Feminino , Humanos , Pacientes Internados , Masculino , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Estudos Retrospectivos , Estados UnidosAssuntos
Serviço Hospitalar de Emergência , Produtos de Degradação da Fibrina e do Fibrinogênio/análise , Fibrinolíticos/uso terapêutico , Tromboembolia Venosa/diagnóstico , Tromboembolia Venosa/terapia , Adulto , Fatores Etários , Técnicas de Apoio para a Decisão , Prática Clínica Baseada em Evidências , Humanos , Fatores de RiscoRESUMO
BACKGROUND: Boston Medical Center (BMC), a safety-net hospital, treated a substantial portion of the Boston cohort that was sick with COVID-19. Unfortunately, these patients experienced high rates of morbidity and mortality given the significant health disparities that many of BMC's patients face. Boston Medical Center launched a palliative care extender program to help address the needs of critically ill ED patients under crisis conditions. In this program evaluation our goal was to assess outcomes between those who received palliative care in the emergency department (ED) vs those who received palliative care as an inpatient or were admitted to an intensive care unit (ICU). METHODS: We used a matched retrospective cohort study design to assess the difference in outcomes between the two groups. RESULTS: A total of 82 patients received palliative care services in the ED, and 317 patients received palliative care services as an inpatient. After controlling for demographics, patients who received palliative care services in the ED were less likely to have a change in level of care (P<0.001) or be admitted to an ICU (P<0.001). Cases had an average length of stay of 5.2 days compared to controls who stayed 9.9 days (P<0.001). CONCLUSION: Within a busy ED environment, initiating palliative care discussions by ED staff can be challenging. This study demonstrates that consulting palliative care specialists early in the course of the patient's ED stay can benefit patients and families and improve resource utilization.
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COVID-19 , Cuidados Paliativos , Humanos , Estudos Retrospectivos , COVID-19/terapia , Serviço Hospitalar de Emergência , Unidades de Terapia Intensiva , Hospitais , Pacientes Internados , Mortalidade Hospitalar , Tempo de InternaçãoRESUMO
Importance: Emergency department (ED) triage substantially affects how long patients wait for care but triage scoring relies on few objective criteria. Prior studies suggest that Black and Hispanic patients receive unequal triage scores, paralleled by disparities in the depth of physician evaluations. Objectives: To examine whether racial disparities in triage scores and physician evaluations are present across a multicenter network of academic and community hospitals and evaluate whether patients who do not speak English face similar disparities. Design, Setting, and Participants: This was a cross-sectional, multicenter study examining adults presenting between February 28, 2019, and January 1, 2023, across the Mass General Brigham Integrated Health Care System, encompassing 7 EDs: 2 urban academic hospitals and 5 community hospitals. Analysis included all patients presenting with 1 of 5 common chief symptoms. Exposures: Emergency department nurse-led triage and physician evaluation. Main Outcomes and Measures: Average Triage Emergency Severity Index [ESI] score and average visit work relative value units [wRVUs] were compared across symptoms and between individual minority racial and ethnic groups and White patients. Results: There were 249â¯829 visits (149â¯861 female [60%], American Indian or Alaska Native 0.2%, Asian 3.3%, Black 11.8%, Hispanic 18.8%, Native Hawaiian or Other Pacific Islander <0.1%, White 60.8%, and patients identifying as Other race or ethnicity 5.1%). Median age was 48 (IQR, 29-66) years. White patients had more acute ESI scores than Hispanic or Other patients across all symptoms (eg, chest pain: Hispanic, 2.68 [95% CI, 2.67-2.69]; White, 2.55 [95% CI, 2.55-2.56]; Other, 2.66 [95% CI, 2.64-2.68]; P < .001) and Black patients across most symptoms (nausea/vomiting: Black, 2.97 [95% CI, 2.96-2.99]; White: 2.90 [95% CI, 2.89-2.91]; P < .001). These differences were reversed for wRVUs (chest pain: Black, 4.32 [95% CI, 4.25-4.39]; Hispanic, 4.13 [95% CI, 4.08-4.18]; White 3.55 [95% CI, 3.52-3.58]; Other 3.96 [95% CI, 3.84-4.08]; P < .001). Similar patterns were seen for patients whose primary language was not English. Conclusions and Relevance: In this cross-sectional study, patients who identified as Black, Hispanic, and Other race and ethnicity were assigned less acute ESI scores than their White peers despite having received more involved physician workups, suggesting some degree of mistriage. Clinical decision support systems might reduce these disparities but would require careful calibration to avoid replicating bias.
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Etnicidade , Triagem , Adulto , Humanos , Feminino , Pessoa de Meia-Idade , Estudos Transversais , Serviço Hospitalar de Emergência , Dor no PeitoRESUMO
Many patients with acute behavioral or mental health emergencies use the emergency department for their care. Psychiatric patients have a higher incidence of chronic medical conditions and are at greater risk for injury than the general population. Patients with acute behavioral emergencies may stress already overcrowded emergency departments. This article addresses high-risk areas of the treatment and management of emergency department patients presenting with behavioral emergencies. This article identifies methods successful in determining whether the patient's behavioral emergency is the result of an organic disease process, as well as recognizing other potential acute medical emergencies in this high-risk population.
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Serviço Hospitalar de Emergência , Transtornos Mentais/diagnóstico , Adulto , Emergências , Humanos , Gestão de RiscosRESUMO
This cohort study examines the risk factors for developing delirium and/or agitation in patients in the emergency department waiting for an inpatient bed.
Assuntos
Delírio , Serviço Hospitalar de Emergência , Agitação Psicomotora , Humanos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Masculino , Feminino , Idoso , Pessoa de Meia-Idade , Pacientes Internados/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Idoso de 80 Anos ou mais , Hospitalização/estatística & dados numéricos , Fatores de TempoRESUMO
BACKGROUND: Although the use of magnetic resonance imaging (MRI) for the diagnosis of acute stroke is increasing, this method has not proved more effective than computed tomography (CT) in the emergency setting. We aimed to prospectively compare CT and MRI for emergency diagnosis of acute stroke. METHODS: We did a single-centre, prospective, blind comparison of non-contrast CT and MRI (with diffusion-weighted and susceptibility weighted images) in a consecutive series of patients referred for emergency assessment of suspected acute stroke. Scans were independently interpreted by four experts, who were unaware of clinical information, MRI-CT pairings, and follow-up imaging. RESULTS: 356 patients, 217 of whom had a final clinical diagnosis of acute stroke, were assessed. MRI detected acute stroke (ischaemic or haemorrhagic), acute ischaemic stroke, and chronic haemorrhage more frequently than did CT (p<0.0001, for all comparisons). MRI was similar to CT for the detection of acute intracranial haemorrhage. MRI detected acute ischaemic stroke in 164 of 356 patients (46%; 95% CI 41-51%), compared with CT in 35 of 356 patients (10%; 7-14%). In the subset of patients scanned within 3 h of symptom onset, MRI detected acute ischaemic stroke in 41 of 90 patients (46%; 35-56%); CT in 6 of 90 (7%; 3-14%). Relative to the final clinical diagnosis, MRI had a sensitivity of 83% (181 of 217; 78-88%) and CT of 26% (56 of 217; 20-32%) for the diagnosis of any acute stroke. INTERPRETATION: MRI is better than CT for detection of acute ischaemia, and can detect acute and chronic haemorrhage; therefore it should be the preferred test for accurate diagnosis of patients with suspected acute stroke. Because our patient sample encompassed the range of disease that is likely to be encountered in emergency cases of suspected stroke, our results are directly applicable to clinical practice.
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Hemorragias Intracranianas/diagnóstico , Imageamento por Ressonância Magnética , Isquemia Miocárdica/diagnóstico , Acidente Vascular Cerebral/diagnóstico , Tomografia Computadorizada por Raios X , Adulto , Idoso , Idoso de 80 Anos ou mais , Serviço Hospitalar de Emergência , Humanos , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de TempoRESUMO
OBJECTIVE: Ischemic stroke is a leading cause of morbidity and mortality worldwide. While the incidence of ischemic stroke is highest in older populations, incidence of ischemic stroke in adults has been rising particularly rapidly among young (e.g., premenopausal) women. The evaluation and timely diagnosis of ischemic stroke in young women presents a challenging situation in the emergency department, due to a range of sex-specific risk factors and to broad differentials. The goals of this concepts paper are to summarize existing knowledge regarding the evaluation and management of young women with ischemic stroke in the acute setting. METHODS: A panel of six board-certified emergency physicians, one with fellowship training in stroke and one with training in sex- and sex-based medicine, along with one vascular neurologist were coauthors involved in the paper. Each author used various search strategies (e.g., PubMed, PsycINFO, and Google Scholar) for primary research and reviewed articles related to their section. The references were reviewed and evaluated for relevancy and included based on review by the lead authors. RESULTS: Estimates on the incidence of ischemic stroke in premenopausal women range from 3.65 to 8.9 per 100,000 in the United States. Several risk factors for ischemic stroke exist for young women including oral contraceptive (OCP) use and migraine with aura. Pregnancy and the postpartum period (up to 12 weeks) is also an important transient state during which risks for both ischemic stroke and cerebral hemorrhage are elevated, accounting for 18% of strokes in women under 35. Current evidence regarding the management of acute ischemic stroke in young women is also summarized including use of thrombolytic agents (e.g., tissue plasminogen activator) in both pregnant and nonpregnant individuals. CONCLUSION: Unique challenges exist in the evaluation and diagnosis of ischemic stroke in young women. There are still many opportunities for future research aimed at improving detection and treatment of this population.
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Isquemia Encefálica/diagnóstico , Isquemia Encefálica/terapia , Serviço Hospitalar de Emergência , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/terapia , Adolescente , Adulto , Isquemia Encefálica/sangue , Anticoncepcionais Orais , Feminino , Humanos , Enxaqueca com Aura , Gravidez , Complicações na Gravidez , Estudos Retrospectivos , Fatores de Risco , Fatores Sexuais , Fumar , Acidente Vascular Cerebral/sangue , Ativador de Plasminogênio Tecidual/sangue , Adulto JovemRESUMO
Acute ischemic stroke is a challenging and time-sensitive diagnosis. Diagnosis begins with rapid detection of acute stroke symptoms by the patient, their family or caregivers, or bystanders. If acute stroke is suspected, EMS providers should be called for rapid assessment. EMS providers will utilize prehospital stroke tools to diagnose and determine potential stroke severity. Once at the hospital, the stroke team works rapidly to solidify the patient history, perform a focused neurologic examination and obtain necessary laboratory tests and brain imaging to accurately diagnose acute ischemic stroke and properly treat the patient.
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Isquemia Encefálica/diagnóstico , Acidente Vascular Cerebral/diagnóstico , Doença Aguda , Encéfalo/diagnóstico por imagem , Isquemia Encefálica/diagnóstico por imagem , Angiografia por Tomografia Computadorizada , Serviços Médicos de Emergência , Serviço Hospitalar de Emergência , Humanos , Imageamento por Ressonância Magnética , Neuroimagem , Acidente Vascular Cerebral/diagnóstico por imagem , Tomografia Computadorizada por Raios XRESUMO
Neurologic diseases are a major cause of death and disability in elderly patients. Due to the physiologic changes and increased comorbidities that occur as people age, neurologic diseases are more common in geriatric patients and a major cause of death and disability in this population. This article discusses the elderly patient presenting to the emergency department with acute ischemic stroke, transient ischemic attack, intracerebral hemorrhage, subarachnoid hemorrhage, chronic subdural hematoma, traumatic brain injury, seizures, and central nervous system infections. This article reviews the subtle presentations, difficult workups, and complicated treatment decisions as they pertain to our older patients."
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Doenças do Sistema Nervoso/diagnóstico , Fatores Etários , Idoso , Lesões Encefálicas Traumáticas/diagnóstico , Lesões Encefálicas Traumáticas/terapia , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/terapia , Infecções do Sistema Nervoso Central/diagnóstico , Infecções do Sistema Nervoso Central/terapia , Hemorragia Cerebral/diagnóstico , Hemorragia Cerebral/terapia , Emergências , Serviço Hospitalar de Emergência , Hematoma Subdural Crônico/diagnóstico , Hematoma Subdural Crônico/terapia , Humanos , Ataque Isquêmico Transitório/diagnóstico , Ataque Isquêmico Transitório/terapia , Doenças do Sistema Nervoso/fisiopatologia , Doenças do Sistema Nervoso/terapia , Convulsões/diagnóstico , Convulsões/terapia , Hemorragia Subaracnóidea/diagnóstico , Hemorragia Subaracnóidea/terapiaRESUMO
This article reviews the various imaging modalities available for the evaluation of patients presenting with a potential stroke syndrome, specifically acute ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage. It reviews the various computed tomography (CT) modalities, including noncontrast brain CT (NCCT), CT angiography, and CT perfusion. It discusses multimodal magnetic resonance imaging in the evaluation of patients with acute stroke, including diffusion-weighted imaging, T2-weighted sequences/fluid-attenuated inversion recovery, magnetic resonance angiography, perfusion-weighted imaging, and gradient-recalled echo. At the end of this article, a brief review on how to read an NCCT geared toward the emergency physician is included.
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Neuroimagem , Acidente Vascular Cerebral/diagnóstico por imagem , Encéfalo/diagnóstico por imagem , Encéfalo/patologia , Angiografia Cerebral , Hemorragia Cerebral/diagnóstico , Hemorragia Cerebral/diagnóstico por imagem , Hemorragia Cerebral/patologia , Imagem de Difusão por Ressonância Magnética , Humanos , Angiografia por Ressonância Magnética , Imageamento por Ressonância Magnética , Neuroimagem/métodos , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/patologia , Hemorragia Subaracnóidea/diagnóstico , Hemorragia Subaracnóidea/diagnóstico por imagem , Hemorragia Subaracnóidea/patologia , Tomografia Computadorizada por Raios XRESUMO
Of the many different complaints of patients presenting to the emergency department, some of the most difficult to diagnose and manage involve pathology of the head and neck. Often diagnoses of conditions affecting this part of the body are elusive, and occasionally, even once the diagnosis has been made, the management of these disorders remains challenging. This article addresses some of the high-risk chief complaints of the head and neck regarding diagnosis and management. These complaints include headache, seizure, acute focal neurologic deficits, throat and neck pain, ocular emergencies, and the difficult airway.
Assuntos
Oftalmopatias/diagnóstico , Intubação Intratraqueal/métodos , Doenças do Sistema Nervoso/diagnóstico , Infecções Respiratórias/diagnóstico , Transtornos Cerebrovasculares/diagnóstico , Transtornos Cerebrovasculares/etiologia , Emergências , Epiglotite/diagnóstico , Epiglotite/etiologia , Oftalmopatias/etiologia , Cefaleia/diagnóstico , Cefaleia/etiologia , Humanos , Cervicalgia/diagnóstico , Cervicalgia/etiologia , Doenças do Sistema Nervoso/etiologia , Faringite/diagnóstico , Faringite/etiologia , Infecções Respiratórias/etiologia , Gestão de Riscos , Convulsões/diagnóstico , Convulsões/etiologia , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/etiologiaRESUMO
This study retrospectively analyzed 123 patients undergoing helicopter emergency medical services transport for ischemic stroke (ischemic cerebrovascular accident) to the Massachusetts General Hospital during 2000-2004. To assess for system improvements over time, data were analyzed between the 2 consecutive 30-month periods comprising the 5-year study. Patients transported during the latter 30 months were transported from lesser distances (P = .002), were more likely to be younger than 65 years (P = .005), and were more likely to have documented symptom onset time (P = .03) and National Institutes of Health Stroke Scale (odds ratio, 3.6; 95% confidence interval, 1.7-7.6; P = .001). Time end points analysis found no significant improvements in any intervals compared across the 2 study eras. Age older than 65 years was the only covariate associated with a more rapid arrival at the Massachusetts General Hospital (odds ratio, 2.4; 95% CI, 1.1-5.4; P = .03). This study of our stroke transport system identified both areas of good performance and also areas for focusing further improvement efforts.