[Importance of outpatient medical consultation prior to going to the hospital emergency department in patients over 65 years of age: Impact on hospitalization results]. / Importancia de la consulta ambulatoria previa a la visita a las urgencias hospitalarias en pacientes mayores: impacto sobre resultados de hospitalización.

OBJECTIVE: Investigate factors associated with a previous outpatient medical consultation (POMC), to the health center or another physician, before attending a hospital emergency department (ED), in patients aged >65 and its impact on the hospitalization rate and variables related to ED stay. SITE: Fifty-two Spanish EDs. PARTICIPANTS: Patients over 65 years consulting an ED. MAIN MEASUREMENTS AND DESIGN: A cohort (n=24645) of patients aged >65 attended for one week in 52 ED. We recorded five sociodemographic variables, six functional, three episode-related severity and analyzed their crude and adjusted association with the existence of a POMC at ED consultation. The primary outcome variable was the need for admission and the secondary variables were complementary examinations and ED stay length. We analyzed whether the POMC influenced these outcomes. RESULTS: 28.5% of the patients had performed a POMC prior to their visit to the ED. Living in a residence, NEWS-2 score ≥5, aged ≥80, dependency functions, severe comorbidity, living alone, cognitive impairment, male gender and depression were independently associated with a POMC. Also was associated with a greater need for hospitalization and shorter length of stay in the ED. No minor consumption of diagnostic resources in patients with POMC. CONCLUSION: Patients presenting to the ED following POMC are admitted more frequently, suggesting that they are appropriately referred and that minor emergencies are probably effectively resolved in the POMC. Their stay in the ED prior to hospitalization is shorter, so the POMC would facilitate clinical resolution in the ED.

Clinical relevance of pharmacist intervention in an emergency department.

OBJECTIVES: To evaluate the clinical relevance of pharmacist intervention on patient care in emergencies, to determine the severity of detected errors. Second, to analyse the most frequent types of interventions and type of drugs involved and to evaluate the clinical pharmacist's activity. METHODS: A 6-month observational prospective study of pharmacist intervention in the Emergency Department (ED) at a 400-bed hospital in Spain was performed to record interventions carried out by the clinical pharmacists. We determined whether the intervention occurred in the process of medication reconciliation or another activity, and whether the drug involved belonged to the High-Alert Medications Institute for Safe Medication Practices (ISMP) list. To evaluate the severity of the errors detected and clinical relevance of the pharmacist intervention, a modified assessment scale of Overhage and Lukes was used. Relationship between clinical relevance of pharmacist intervention and the severity of medication errors was assessed using ORs and Spearman's correlation coefficient. RESULTS: During the observation period, pharmacists reviewed the pharmacotherapy history and medication orders of 2984 patients. A total of 991 interventions were recorded in 557 patients; 67.2% of the errors were detected during medication reconciliation. Medication errors were considered severe in 57.2% of cases and 64.9% of pharmacist intervention were considered relevant. About 10.9% of the drugs involved are in the High-Alert Medications ISMP list. The severity of the medication error and the clinical significance of the pharmacist intervention were correlated (Spearman's ρ=0.728/p<0.001). CONCLUSIONS: In this single centre study, the clinical pharmacists identified and intervened on a high number of severe medication errors. This suggests that emergency services will benefit from pharmacist-provided drug therapy services.

[Analysis of the concordance of antibiotic treatment for patients with severe sepsis in emergencies]. / Análisis de la concordancia del tratamiento antibiótico de pacientes con sepsis grave en Urgencias.

OBJECTIVES: Antibiotic treatment is vital in patients with severe sepsis/septic shock. The objectives were to assess the degree of concordance between antibiotic prescribed in emergencies and post requirements; to relate it to health outcomes (mortality) and to analyze the reasons for disagreement. MATERIAL AND METHODS: Retrospective descriptive study of antibiotic treatment prescribed in emergencies and the subsequent treatment in patients with criteria of severe sepsis/septic shock in 2013. We collected patient demographic characteristics, infectious focus, antibiotic prescribed from emergencies and subsequent changes. It was considered concordant if there were no changes, if there were changes, but the initial antibiotic was right and suspensions for end of treatment. Mortality and evolution were analyzed. RESULTS: Six hundred patients were included. A 60% experienced changes respect to the antibiotic treatment initiated in emergencies (87.6% justified), with a degree of overall antibiotic concordance of 47.5% The mortality rate at end-point was 9.83%, with no statistically significant relationship with the degree of concordance (OR=0.864 (0.503-1.484)/χ2=0.28; p=0.597). Reasons for change of antibiotic: clinical outcome (17.96%), change of spectrum (35.03%), de-escalation (41.32%), sequential therapy (8.68%). An 11% required ICU admission. Clinical outcomes: resolution of the disease (79.2%), readmission after 30 days (7.7%) and transfer to health centers (4.5%). The median hospital stay was 7 days. CONCLUSIONS: The degree of concordance antibiotic was quite high, and the mortality rate was lower than that described in the literature, without relating to the discordance. The presence of concordance was associated with fewer readmissions and ICU admissions. The main reasons for disagreement were inadequate spectrum selection and change after microbiological crops.