Comparison of Adult Diabetic Ketoacidosis Treatment Protocols From Canadian Emergency Departments.

BACKGROUND: Diabetic ketoacidosis (DKA) is a common acute life-threatening complication of poorly controlled diabetes mellitus contributing to considerable mortality and morbidity. Use of standardized treatment protocols improves patient outcomes in the emergency department (ED) for many conditions, but variability in adult DKA treatment protocols has not been assessed across EDs. In this study, we compared DKA treatment protocols from adult EDs across Canada to highlight inconsistencies in recommended DKA management. METHODS: ED staff in Canada were solicited for their treatment protocols used to guide acute ED DKA management. Information regarding initial fluid resuscitation and maintenance fluid, potassium replacement, insulin therapy and bicarbonate administration was abstracted from each protocol, collated in a table and compared. RESULTS: Thirty-six unique protocols were obtained representing 85 institutions (40 urban and 45 rural, with a 65.1% response rate) across Canada, with no protocol use for 4 urban centres. Similarities in protocols included the intravenous insulin infusion rate and instructions for switching to subcutaneous insulin. Variability was noted in the rate, amount and type of fluid bolus given (0.5 to 2 L of normal saline or Ringer's lactate over 15 minutes to 2 hours), the criteria determining the amount, potassium supplementation at normo/hypokalemic ranges, when to add dextrose to maintenance fluid, insulin bolus inclusion and bicarbonate administration. CONCLUSIONS: This is the first comparison of adult DKA treatment protocols in Canada. Although several common approaches were identified, variability was found in initial fluid boluses, initial insulin bolus and role of bicarbonate, necessitating further study to ensure local DKA protocols reflect current evidence-based best practices for optimal patient clinical outcomes.

Impact of lockdown during the COVID-19 outbreak on ophthalmological emergencies in a referral center in France.

PURPOSE: In March 2020, the sudden rise in the number of SARS-CoV-2 infections in France led the government to impose a strict lockdown during which all non-urgent medical consultations were postponed. From March 17 to May 10, 2020, private medical practices were closed, and telemedicine was encouraged. The consequences on ophthalmic care were dramatic, with over 90% of scheduled consultations canceled. The goal of this study was to describe consultations during the 2-month strict lockdown in Paris and to analyze its impact on the visual outcomes of patients consulting in the ophthalmology emergency department (OED). METHODS: Data of patients who presented to the OED of the A. de Rothschild Foundation Hospital (RFH), a tertiary ophthalmology center in Paris, France, during the lockdown period and its immediate aftermath were analyzed. The results were compared to the same time periods in the years 2018 and 2019. Four time periods were defined and numbered chronologically: March 17 to May 10, 2018 (period 1); March 17 to May 10, 2019 (period 2); March 17 to May 10, 2020 (period 3, the lockdown period); May 11 to June 9, 2020 (period 4, the post-lockdown period). RESULTS: The number of consultations was reduced by more than 50% during the lockdown period (n=2909 patients) and by 30% during the post-lockdown period (n=2622) when compared to periods 1 (n=7125) and 2 (n=8058). Even though LP4 saw an increase in the number of patients consulting, there was no increase in the rate of severe diseases (12.8% during LP3 vs. 11.1% during LP4), and the proportion of patients who were admitted was statistically similar (4.3% vs. 3.6%). Neuro-ophthalmic diseases were the most common during LP3 and LP4. Neovascular glaucoma was twice as common during post-LP4 (P=0.08). We noted a significant increase in patients with graft rejection consulting in our OED during the post-LP4 (P<0.001). These results were likely related to a delay in follow-up consultations due to the lockdown measures. CONCLUSION: The reduction in the number of consultations in our OED during the lockdown period affected both minor emergencies and severe ophthalmic diseases, but with no significant delay in diagnosis. More longitudinal and longer study is needed to confirm this and to retrospectively analyze the effects of the COVID-19 outbreak and lockdown.

[Lessons Learned - Observational Study After One Year of 'Domestic Violence Consultation' at the University Emergency Department Bern]. / Lessons Learned ­ Beobachtungsstudie nach einem Jahr Sprechstunde «Häusliche Gewalt¼ am Universitären Notfallzentrum Bern.

Lessons Learned - Observational Study After One Year of 'Domestic Violence Consultation' at the University Emergency Department Bern Abstract. The number of violent crimes in domestic violence has been steadily increasing in Switzerland since 2011. In November 2018, the University Emergency Department Bern established standardized care for victims of domestic violence with an integrated follow-up. In this retrospective study, the results one year after the establishment of the special consultation hour as well as the challenges are presented. Of the 53 individuals primarily treated at the emergency department for domestic violence, 69.8 % (n = 37) were offered a follow-up appointment. Specific subgroups were less likely to be offered follow-up appointments. It became apparent that despite instructions for action and training, not all affected groups were perceived in the same way.

[Prevalence of the kidney disease at the emergency department of hospital Fousseyni Daou of Kayes]. / Prevalence de la maladie renale au service des urgences de l'hopital Fousseyni Daou de Kayes.

INTRODUCTION: Kidney disease (KD) is defined as a set of functional, morphological and histological kidney abnormalities. It is a truly global public health problem. Its prevalence is estimated to be 50 times that of end-stage renal disease (ESRD). In Kayes, there is no data on the prevalence of kidney disease, hence the interest of this study. OBJECTIVES: to determine the prevalence of renal disease, its main causes and the main factors of aggravation of this pathology in the emergency department at hospital Fousseyni DAOU of Kayes. METHODOLOGY: Retrospective cross-sectional study carried out from January 1, 2014 to February 1, 2015. We included all hospitalized patients in whom a renal damage marker (elevation of plasma creatinine, urinary sediment abnormality, ultrasound, histology and significant proteinuria) has been found. RESULTS: the prevalence of kidney disease was 9.9% (109/1099). Eighty-nine met the inclusion criteria. The study population was composed of 47 women (52.8%) and 42 men (47.2%), with a sex ratio of 0.89 in favor of women. The average age was 40.09 years with a predominance of patients in the age group [40-59]. The main reasons for consultation were hypercreatininaemia (48.3%), edematous syndrome (16.9%), low back pain (10.1%). High blood pressure (55.1%) and lower extremity edema (46.1%) were the medical history frequently found in our study. The kidney disease found was in order of growth: chronic renal failure (51%); acute renal failure (28%); proteinuria (16%), hematuria (3%), morphological abnormality of the kidneys (2%). Tubulointerstitial nephropathy represented 64% of acute renal failure with P = 0.000306. Vascular nephropathy constituted 46.7% of chronic renal failure with P = 0.000251. No cases of glomerular nephropathy were found in patients over 60 years of age.The most common causes were represented by nephrotoxic drugs injuries; infectious; high blood pressure and diabetes. The most observed aggravating factors are herbal medicine, urinary tract infections, renal hypoperfusion and unbalanced hypertension. CONCLUSION: kidney disease is not uncommon in the emergency room at Hospital Fousseyni Daou of Kayes. The most common causes are nephrotoxic drugs, hypertension and diabetes.

INTRODUCTION: La maladie rénale (MR) définie comme l'ensemble des anomalies rénales fonctionnelle, morphologique et histologique. Elle est un véritable problème mondial de santé publique. Sa prévalence serait 50 fois celle de l'insuffisance rénale terminale (IRT). A Kayes, il n'existe pas de donnée sur la prévalence de la maladie rénale, d'où l'intérêt de cette étude. OBJECTIFS: déterminer la prévalence de la maladie rénale, ses principales causes et les principaux facteurs d'aggravation de cette pathologie dans le service des urgences de l'hôpital Fousseyni DAOU de Kayes. MÉTHODOLOGIE: Etude transversale rétrospective réalisée du 1er janvier 2014 au 1er février 2015. Etaient inclus, tous les patients hospitalisés chez qui au moins un marqueur d'atteinte rénale (élévation de la créatinine plasmatique, anomalie du sédiment urinaire, anomalie échographique ou histologique et une protéinurie significative) a été retrouvé. Les paramètres analysés étaient socio-épidémiologiques, cliniques et para-cliniques. Nous avons exclu tous les patients dont les dossiers médicaux étaient inexploitables. RÉSULTATS: la prévalence de la maladie rénale était de 9,9% (109/1099). Quatre-vingtneuf répondaient aux critères d'inclusion. La population d'étude était composée de 47 femmes (52,8%) et de 42 hommes (47,2%), avec un sex-ratio de 0,89 en faveur des femmes. La moyenne d'âge était de 40,09 ans avec une prédominance des patients de la tranche d'âge [40-59]. Les principaux motifs de consultation étaient hypercréatininémie (48,3%), syndrome œdémateux (16,9%), douleur lombaire (10,1%). L'hypertension artérielle (55,1%) et œdème des membres inférieurs (46,1%) étaient les antécédents pathologiques fréquemment retrouvées dans notre étude. La maladie rénale retrouvée était par ordre de croissance : insuffisance rénale chronique (51%) ; insuffisance rénale aigue (28%) ; protéinurie (16%), hématurie (3%), anomalie morphologique des reins (2%). La néphropathie tubulo-interstitielle représentait 64% des insuffisances rénales aiguës avec P= 0,000306. La néphropathie vasculaire constituait 46,7% des insuffisances rénales chroniques avec P= 0,000251. Aucun cas de néphropathie glomérulaire n'a été retrouvé chez les patients de plus de 60 ans.Les causes les plus fréquentes étaient représentées par les causes toxiques (médicaments néphrotoxiques) ; infectieuses ; l'hypertension artérielle et le diabète. Les facteurs d'aggravations les plus observés sont la phytothérapie, l'infection urinaire, l'hypoperfusion rénale et l'HTA non équilibrée. CONCLUSION: la maladie rénale n'est pas rare aux urgences de l'hôpital Fousseyni Daou de Kayes. Les causes les plus fréquemment rencontrées sont les médicaments néphrotoxiques, l'HTA et le diabète.

Do Adult Patients With Type 1 or 2 Diabetes Who Present to the Emergency Department With Hyperglycemia Have Improved Outcomes if They Have Access to Specialized Diabetes Care?

OBJECTIVES: Few studies have examined the effect of specialized care on patients with diabetes who present to the emergency department (ED) visits for acute hyperglycemia. The objective of this study was to characterize ED patients presenting with hyperglycemia and compare the 30-day outcomes of those followed by specialized diabetes clinics with those not followed. We hypothesized that patients followed by specialized clinics would have improved clinical outcomes compared with those who had no specialized follow up. METHODS: We conducted this single-centre retrospective cohort study of adults (≥18 years) with an ED visit for hyperglycemia over 1 year (January to December 2014). Data from ED visits were linked to specialized diabetes clinic records, which contained diabetes-specific clinical data not available in ED visit records. Descriptive statistics were summarized and comparisons between groups were performed, when appropriate. RESULTS: There were 456 patients (55.0% men; mean age, 47.7 years; 46.3% with type 1 diabetes) with 250 followed by the specialized diabetes clinics. The 206 patients who were not followed by the diabetes clinics (45%) were more likely to have a recurrent hyperglycemia ED visit (32.5% vs 9.6%, p<0.001) and to require hospitalization for hyperglycemia (14.1% vs 5.2%, p=0.001) within 30 days of initial presentation. CONCLUSIONS: Patients followed by specialized diabetes clinics had fewer recurrent ED visits and hospital admissions for hyperglycemia at 30 days compared with those not followed, suggesting that greater continuity of care between endocrinology and emergency medicine may help reduce these adverse outcomes for patients with diabetes.

[Impact of models of care integrating direct access to physiotherapy in primary care and emergency care contexts in patients with musculoskeletal disorders: A narrative review]. / Impact des modèles de soins intégrant l'accès direct à la kinésithérapie dans un contexte de soins primaires ou d'urgence pour les patients présentant une affection musculosquelettique : revue de la littérature.

BACKGROUND: Musculoskeletal disorders are increasing in prevalence, principally due to sedentary behaviors. Strong evidence supports an early need for first-line treatment including physiotherapy. New and innovative models in primary and emergency care have been drawn up and put the physiotherapist's skills to work in early and first-line management of patients with musculoskeletal disorders. The objectives of this review were to identify and describe studies assessing models of care integrating direct access to physiotherapy in primary care and in emergency care for patients with musculoskeletal disorders and to provide perspectives on the application of these two models in France. METHODS: A literature review was carried out including studies extracted from four scientific databases: PubMed, CINAHL, Embase, and PEDro. The selected articles had to address the clinical effectiveness or efficiency of these models for the provision of care in primary or in emergency care. A narrative literature review method was used. The synthesis deals with the qualitative analysis of the included studies. RESULTS: Thirty-nine studies were included in this review: 19 on assessment of the direct access to physiotherapy model in primary care and 20 on the direct access to physiotherapy model in emergency departments as concerns patients with musculoskeletal disorders. The studies showed that the different models incorporating direct access to physiotherapy in primary or in emergency care provided better outcomes in terms of quality and access to care while maintaning a similar degree of safety. However, the methodology of the studies included was estimated as being of heterogeneous quality. CONCLUSION: The studies dealing with the new models for provision of care integrating direct access to physiotherapy in primary care or emergency care impart two lessons: (1) they are not designed to replace the physician; (2) collaboration between different health professionals aimed at improving patients' access to efficient care is to be encouraged. It would be worthwhile to focus upon dissemination factors that would enhance the efficiency of these innovative models in other countries, as in France.

[Assessing violence against nurses at reception in hospital emergency departments in Tunis]. / Évaluer la violence à l'encontre des infirmiers à l'accueil des urgences des hôpitaux de Tunis.

Violence against health professionals is a global public health problem. A study carried out of hospital emergency departments in Tunis sought to analyse assaults on nurses. It reveals high levels of violence, particularly at weekends and during night shifts. Under-reporting of such incidents is observed, revealing a sort of 'culture of silence' which, over time, can lead to suffering in the workplace and a deterioration in the quality of care.

Risk Factors for Adverse Outcomes in Adult and Pediatric Patients With Hyperglycemia Presenting to the Emergency Department: A Systematic Review.

Hyperglycemia is a significant cause of morbidity and mortality, often resulting in adverse outcomes. This review aimed to identify predictors of adverse outcomes, such as repeated hospital visits, hospitalization or death, in patients presenting to the emergency department (ED) with hyperglycemia. Electronic searches of Medline and EMBASE were conducted for studies in English of patients presenting to the ED with hyperglycemia. Both adult and pediatric populations were included, with and without diabetes. Two reviewers independently screened all titles and abstracts for relevance. If consensus was not reached, full-length manuscripts were reviewed. For discrepancies, a third reviewer was consulted. Study quality was assessed using the Newcastle-Ottawa Quality Assessment Scale. Study- and patient-specific data were extracted and presented descriptively. Eight observational studies were reviewed; they included a total of 96,970 patients. Predictors of adverse outcomes included age, lowest income quintile, urban dwellers, presence of comorbidities, coexisting hyperlactatemia, having a family physician, elevated serum creatinine level, diabetes managed with insulin, sentinel visit for hyperglycemia in the past month, and high blood glucose level measured in the ED. Conflicting evidence was found for whether known history of diabetes was associated with risk. Factors associated with favourable outcomes included systolic blood pressure of 90 to 150 mmHg and tachycardia. This systematic review found 12 factors associated with adverse outcomes, and 2 factors associated with more favourable outcomes in patients presenting to the ED with hyperglycemia. These factors should be considered for easier identification of patients at higher risk for adverse outcomes to guide management and follow up.

Factors for Self-Managing Care Following Older Adults' Discharge from the Emergency Department: A Qualitative Study.

Cette étude avait pour but d'identifier les facteurs qui influent sur la capacité des personnes âgées à prendre en charge leur santé après une consultation au service des urgences (SU). Les questionnaires de l'enquête (n = 380) ont été remplis en SU par des personnes âgées et leurs aidants et visaient à évaluer leur perception de la compréhension de l'information qui leur était fournie. Des entrevues (n = 51) ont été réalisées avec un sous-échantillon de participants au cours des quatre semaines suivant leur consultation au SU et ont examiné les facteurs ayant une incidence sur l'autogestion des problèmes de santé. La perception de la compréhension de l'information reçue en SU (« oui, certainement ¼) était meilleure lors de la consultation au SU (91 %) que lors du suivi (71 %), lorsque 20 % des participants ne comprenaient pas ou n'étaient pas certains qu'ils avaient compris ce qui leur avait été communiqué en SU. Les patients ont rapporté que l'autogestion de leurs problèmes de santé était influencée par: la communication avec le personnel du SU, la compréhension des attentes suivant le congé de l'hôpital, l'état de santé, la disponibilité des aidants et divers facteurs externes. De plus, les soignants ont aussi mentionné l'appui aux soignants et la résistance des patients aux recommandations. L'utilisation de stratégies adaptées aux aînés en SU (p. ex. recommandations écrites, confirmation de la compréhension des recommandations), particulièrement celles liées à l'identification des personnes à risque et de celles nécessitant davantage de soutiens transitoires ou un meilleur accès ou intégration aux ressources disponibles dans la communauté amélioreraient l'autogestion des problèmes de santé suivant les consultations en SU.This study identified factors affecting seniors' ability to self-manage their health following an Emergency Department (ED) visit. Surveys (n = 380) completed by older adults and their caregivers in the ED assessed their understanding of information provided. Interviews (n = 51) completed with a participant subsample up to four weeks post-ED visit examined self-management factors. Perceived understanding of the information ("Yes, definitely") received in the ED was greater at the time of the visit (91%) than at follow-up (71%). Patients reported self-management was influenced by communication with ED staff, understanding of post-discharge expectations and the health condition(s), caregiver availability, and various external factors. Caregivers also identified support for caregivers and patient resistance to recommendations. Senior-friendly strategies (e.g., recommendations in writing, confirmed understanding of recommendations), particularly those related to identifying those at risk and needing greater transitional supports, and greater access to and integration with community supports could enhance post-ED self-management.

[Is the orientation of patients suffering from depressive disorder to the psychiatric emergencies by a general practitioner associated with the decision to hospitalize?] / L'orientation des patients souffrant d'un trouble dépressif aux urgences psychiatriques par le médecin traitant est-elle associée à la décision d'hospitalisation : étude observationnelle.

INTRODUCTION: Depressive disorders affect nearly 350 million people worldwide and are the world's leading cause of incapacity. Patients who are depressed preferentially approach their general practitioner (GP), who is their first point of contact, in 50-60% of cases. The aim of our study is to assess whether the orientation of patients suffering from anxiety-depressive disorder towards a GP in a general emergency is a factor associated with hospitalization when compared to patients who present themselves spontaneously for the same disorders. Our secondary objective was to identify the different profiles of patients who were hospitalized for these disorders as an emergency. MATERIALS AND METHODS: We conducted a cross-sectional study for the year 2015, targeting patients who presented as general emergencies at the centre hospitalier de Troyes and who had received a psychiatric diagnosis in the context of an anxiety or depressive disorder. RESULTS: Five hundred and twenty four patients were included. A univariate analysis showed that referral by the attending physician was associated with hospitalization in 57.9% vs. 42.1% cases (P=0.007), at an odds ratio at 1.98 [1.22-3.21] by multivariate analysis. Analysis by ascending hierarchical classification made it possible to identify 3 profiles for hospitalized patients: 1) patients with a known psychiatric history, a history of past or current follow-ups directed by a psychiatrist, with at least one psychotropic treatment, the presence of psychotic symptoms and a low suicidal risk compared to the rest of the study population; 2) patients without a psychiatric history, or a history of past or ongoing psychiatric follow-up and the absence of ongoing psychotropic treatment. These patients were referred by a GP (67% vs 23%, P<0.001) and their suicidal risk was higher (59% vs 26%, P<0.001); 3) patients about whom the psychiatrist had little information at the time of the emergency consultation. CONCLUSIONS: The relevance of GPs in orientation towards emergencies pleads in favor of a partnership and an early exchange between treating physicians and the psychiatrists.

[Domestic Violence at the University Emergency Department Bern: A Retrospective Analysis from 2006 to 2016]. / Häusliche Gewalt am Universitären Notfallzentrum Bern: eine retrospektive Analyse von 2006 bis 2016.

Domestic Violence at the University Emergency Department Bern: A Retrospective Analysis from 2006 to 2016 Abstract. Domestic Violence (DV) is considered as one of the largest medical risks worldwide. In Switzerland, DV is defined as offence requiring public prosecution since 2004. The present retrospective cohort study aims to investigate cases of DV in one of the largest Swiss emergency departments. The aggressors are predominantly male and either (ex-)partner or (ex-)husband of the victim. The head and the extremities are most often injured. Strangulation was documented in 16 % of the cases. Prevalence in our ED is very low with 0.07 % in 2016 (overall 0.09 % 2006-2016) and much lower compared with international data. We assume that we face many unreported cases and that victims are reluctant to seek medical help. Healthcare professionals should receive regular education in domestic violence, standards of care must be defined, and a sensitive and open-minded communication style is essential.

A retrospective study of complaint letters sent to a Swiss Emergency Department between 2009 and 2014.

OBJECTIVE: Patient complaints are a valuable resource for monitoring and improving patient safety and quality of care. The purpose of this study was to analyze the complaint letters received at a Swiss academic emergency department (ED) over six years. METHODS: A retrospective study of all complaint letters sent to a Swiss academic ED between 2009 and 2014 was conducted. The following data were extracted: epidemiology items, reasons for complaints, hospital responses, follow-up, and severity of the events mentioned in the complaints. All complaint letters related to adult patients evaluated in the ED between 2009 and 2014 were included and a qualitative evaluation was performed based on a systematic taxonomy. Context, patient characteristics, mode of resolution and clinical severity of the related adverse event were evaluated. RESULTS: A total number of 156 complaints were recorded, corresponding to an annual complaint rate of 5.5 to 8.8 per 10,000 visits. The complaints concerned mostly three domains (clinical care, management and patient or caregiver relationship) with a slight predominance for organisation and logistics (39%) compared with 31.4% for standard of care and 29.6% for communication/relational complaints. The majority of complaints were sent within one month of the ED visit. Most complaints were resolved with written apologies or explanations. The consequences of 73.5% of the events in question were considered minor or negligible, 19% moderate, and 6.5% major. Only 1% (two cases) was related to situations with catastrophic consequences. CONCLUSION: Complaint incidence in our ED was low and remained stable over the six-year observation period. Most of the complaints pertained to incidents that entailed negligible or minor consequences. As most complaints were due to inadequate communication, interventions targeting improvement of the doctor/patient communication are required.

Hyperglycemia in Young Adults With Types 1 and 2 Diabetes Seen in the Emergency Department: A Health Records Review.

Patients with diabetes who are in emerging adulthood, defined as the life stage between 18 and 29 years of age, have unique challenges in managing their illness and are at risk for acute complications and loss to follow up. This study's objective was to describe emergency department (ED) utilization because of hyperglycemia in emerging adults with diabetes and to characterize 30-day outcomes, including return visits and admission for hyperglycemia. This was a health-records review of emerging adults presenting over a 1-year period to 4 tertiary care EDs; the patients had known histories of diabetes and final diagnoses of hyperglycemia, diabetic ketoacidosis or hyperosmolar hyperglycemia. Research personnel collected data concerning patients' characteristics, treatments and dispositions and determined whether the patients returned to the ED because of hyperglycemia within 30 days. Descriptive statistics were used to summarize the data where appropriate. There were 160 ED encounters for hyperglycemia, representing 91 unique emerging-adult patients. Mean (SD) age was 23 (3.6) years, and 52.7% were female; 80 (87.9%) had known type 1 diabetes, and 11 (12.1%) had type 2 diabetes. Of 160 visits, 84 (52.5%) resulted in hospital admission; 54 (33.8%) returned to the ED because of hyperglycemia within 30 days of their initial encounters and 20 (12.5%) were admitted on the subsequent visit. We characterized ED use and 30-day outcomes of emerging adults with diabetes and hyperglycemia. Future research should focus on earlier identification of those at higher risk for recurrent ED visits or admission and on the efficacy of interventions to prevent these adverse outcomes.

Reliability of Best Possible Medication Histories Completed by Non-admitted Patients in the Emergency Department.

BACKGROUND: Accreditation standards have outlined the need for staff in emergency departments to initiate the medication reconciliation process for patients who are at risk of adverse drug events. The authors hypothesized that a guided form could be used by non-admitted patients in the emergency department to assist with completion of a best possible medication history (BPMH). OBJECTIVE: To determine the percentage of patients in the non-acute care area of the emergency department who could complete a guided BPMH form with no clinically significant discrepancies (defined as no major discrepancies and no more than 1 moderate discrepancy). METHODS: This prospective exploratory study was conducted over 4 weeks in February and March 2016. Data were collected using the self-administered BPMH form, patient interviews, and a data collection form. After completion of the guided BPMH form, patients were randomly selected for interview by a pharmacy team member to ensure their self-completed BPMH forms were complete and accurate. Eligible patients were those with non-acute needs who had undergone triage to the waiting room. Patients who were already admitted and those with immediate triage to the acute care or trauma area of the emergency department were excluded. RESULTS: Of the 160 patients who were interviewed, 146 (91.3%) completed the form with no more than 1 moderate discrepancy (but some number of minor discrepancies). There were no discrepancies in 31 (19.4%) of the BPMH forms, and 101 (63.1%) of the forms had only minor discrepancies. CONCLUSIONS: Most of the patients interviewed by the pharmacy team were able to complete the BPMH form with no clinically significant discrepancies. The self-administered BPMH form would be a useful tool to initiate medication reconciliation in the emergency department for this patient population, but used on its own, it would not be a reliable source of BPMH information, given the relatively low number of patients who completed the form with no discrepancies.

CONTEXTE: Les normes d'agrément ont souligné la nécessité pour le personnel des services des urgences d'amorcer le processus de bilan comparatif des médicaments chez les patients à risque d'événements indésirables liés aux médicaments. Les auteurs ont avancé que des patients au service des urgences ne requérant pas une hospitalisation pourraient remplir un formulaire dirigé et ainsi aider à établir leur meilleur schéma thérapeutique possible (MSTP). OBJECTIF: Déterminer le pourcentage de patients dans l'aire de soins non urgents du service des urgences qui sont en mesure de remplir un formulaire dirigé de MSTP sans divergence cliniquement significative (c'est-à-dire aucune divergence majeure et pas plus d'une divergence modérée). MÉTHODES: La présente étude préliminaire prospective a été menée sur une période de quatre semaines en février et en mars 2016. Les données ont été recueillies à l'aide d'un formulaire autoadministré de MSTP, d'entrevue avec les patients et d'un formulaire de collecte de données. Une fois les formulaires dirigés de MSTP remplis, des patients ont été sélectionnés aléatoirement et interrogés par un des membres de l'équipe de pharmacie afin de s'assurer de l'exhaustivité et de l'exactitude des renseignements fournis de soi-même. Les patients admissibles à l'étude étaient ceux ne nécessitant pas de soins urgents et ayant passé au triage dans la salle d'attente. Les patients déjà hospitalisés et ceux dirigés immédiatement après le triage dans l'aire de soins urgents ou de trauma du service des urgences ont été exclus. RÉSULTATS: Parmi les 160 patients interrogés, 146 (91,3 %) avaient rempli le formulaire avec au plus une divergence modérée (mais un certain nombre de divergences mineures). Dans 31 (19,4 %) des formulaires de MSTP, il n'y avait aucune divergence et, dans 101 (63,1 %) des formulaires, il n'y avait que des divergences mineures. CONCLUSIONS: La plupart des patients interrogés par l'équipe de pharmacie étaient en mesure de remplir le formulaire de MSTP sans qu'apparaisse de divergence cliniquement significative. Le formulaire autoadministré de MSTP serait un outil pratique pour établir un bilan comparatif des médicaments dans le service des urgences pour cette population de patients, mais employé seul, il ne représenterait pas une source fiable d'information sur le MSTP, compte tenu du nombre relativement restreint de patients ayant rempli le formulaire sans qu'apparaisse de divergence.

[Faintness in emergency departments is frequent, benign but expensive: An epidemiologic study of hospitalization's risk factors to reduce overcrowdings of emergency departments]. / Les malaises adressés aux urgences sont fréquents, bénins et coûteux : étude épidémiologique des facteurs de risque d'hospitalisation en vue de désencombrer les urgences.

INTRODUCTION: We assessed (i) the frequency of consultations for faintness in the Emergency department (ED) of a University hospital centre (UHC), (ii) clinical epidemiology and (iii) cost of faintness, taking a particular interest into the determining risk factors for hospitalization. METHODS: This epidemiological study has been conducted retrospectively, from data obtained for every patient having consulted for faintness in ED of Reims UHC (01/01/12-03/31/12). Every medical record was classified as syncope/lipothymia/brief consciousness loss on one hand and as syncope according to the definition of the French Health High Authority (FHHA). RESULTS: Three hundred and forty-one patients out of 5953 (5.7%) were referred for faintness during the study period. Medical records were analysed for 296 patients. Sixty-two point eight percent were women, with a median age of 43years. Physical examination was normal for 57% of patients. For 48% of cases, there was no complete consciousness loss thus corresponding to lipothymia, which is not taken into account by the FHHA definition. Median length of stay in the ED was 4hours and 67 patients (22.6%) were hospitalized. Minimal estimated cost was 280,000 euros. Risk factors independently associated with hospitalization were age≥60 and complete consciousness loss unlike predisposing circumstances to vagal hypertonia. CONCLUSION: Age≥60 and complete consciousness loss seemed to be associated with hospitalization.

Acute management and outcomes of patients with diabetes mellitus presenting to Canadian emergency departments with hypoglycemia.

OBJECTIVES: This retrospective chart audit examined the demographics, investigations, management and outcomes of adult patients with diabetes mellitus presenting to Canadian emergency departments (EDs). METHODS: All sites conducted a search of their electronic medical records using International Classification of Diseases, Tenth Revision, codes to identify ED visits for hypoglycemia between 2008 and 2010. Patient characteristics, demographics, ED management, ED resources and outcome are reported. RESULTS: A total of 1039 patients over the age of 17 years were included in the study; 347 (33.4%) were classified as type 1 diabetes and 692 (66.6%) were classified as type 2 diabetes. Type 2 diabetes patients were significantly older (73 vs. 49 years; p<0.0001) and had more chronic conditions recorded on their chart (all p<0.001). Most subjects arrived by ambulance, and triage scores revealed severe presentations in 39% of cases. Treatments for hypoglycemia were common (75.7%) during prehospital transport; 38.5% received intravenous glucose and 40.1% received glucagon. Hypoglycemia treatments in the ED included oral (76.8%), intravenous (29.6%) and continuous infusion (27.7%) of glucose. Diagnostic testing (81.9%) commonly included electrocardiograms (51.9%), chest radiography (37.5%) and head computed tomography scans (14.5%). Most patients (73.5%) were discharged; however, more subjects with type 2 diabetes required admission (30.3 vs. 8.8%). Discharge instructions were documented in only 55.5% of patients, and referral to diabetes services occurred in fewer than 20% of cases. Considerable variation existed in the management of hypoglycemia across EDs. CONCLUSIONS: Patients with diabetes presenting to an ED with hypoglycemia consume considerable healthcare resources, and practice variation exists. Emergency departments should develop protocols for the management of hypoglycemia, with attention to discharge planning to reduce recurrence.

Evaluating the Effectiveness of a Nurse Practitioner-Led Outreach Program for Long-Term-Care Homes.

An observational prospective cohort study was conducted on 1,353 observations from a convenience sample of 311 long-term-care (LTC) residents to evaluate the effectiveness of a nurse practitioner-led outreach program on the health outcomes, emergency department (ED) transfers, and hospital admissions of LTC residents. The results show that ED transfers by the NPs were 27% less likely to be non-urgent than transfers made by MDs (OR = .73; 95% CI .54-.97) and that ED transfers by the NPs were 3.23 times more likely to be admitted to hospital than transfers by MDs (OR = 3.23; 95% CI 1.17-8.90). These findings highlight the potential benefits of the NP-led outreach program for LTC residents and for the health-care system.

Dans le cadre d'une étude de cohorte prospective observationnelle, 1 353 observations provenant d'un échantillon de commodité composé de 311 bénéficiaires de soins de longue durée ont été soumises à un examen visant à évaluer l'efficacité d'un programme d'extension des services dirigé par des infirmières praticiennes en ce qui a trait aux résultats sur la santé, aux transferts vers le service des urgences et à l'hospitalisation des bénéficiaires de soins de longue durée. Les résultats indiquent que les patients transférés au service des urgences par des infirmières praticiennes étaient dans une proportion de 27 % moins susceptibles d'être non urgents que ceux transférés par des médecins (rapport de cotes = 0,73; intervalle de confiance à 95 % de 0,54 à 0,97), et 3,23 fois plus susceptibles d'être admis à l'hôpital que ceux transférés par des médecins (rapport de cotes = 3,23; intervalle de confiance à 95 % de 1,17 à 8,90). Ces constatations ont permis de mettre en évidence les avantages possibles d'un programme d'extension des services dirigé par des infirmières praticiennes pour les bénéficiaires de soins de longue durée et le système de soins de santé.

Acute management and outcomes of patients with diabetes mellitus presenting to Canadian emergency departments with hypoglycemia.

OBJECTIVES: This retrospective chart audit examined the demographics, investigations, management and outcomes of adult patients with diabetes mellitus presenting to Canadian emergency departments (EDs). METHODS: All sites conducted a search of their electronic medical records using International Classification of Diseases, Tenth Revision, codes to identify ED visits for hypoglycemia between 2008 and 2010. Patient characteristics, demographics, ED management, ED resources and outcome are reported. RESULTS: A total of 1039 patients over the age of 17 years were included in the study; 347 (33.4%) were classified as type 1 diabetes and 692 (66.6%) were classified as type 2 diabetes. Type 2 diabetes patients were significantly older (73 vs. 49 years; p<0.0001) and had more chronic conditions recorded on their chart (all p<0.001). Most subjects arrived by ambulance, and triage scores revealed severe presentations in 39% of cases. Treatments for hypoglycemia were common (75.7%) during prehospital transport; 38.5% received intravenous glucose and 40.1% received glucagon. Hypoglycemia treatments in the ED included oral (76.8%), intravenous (29.6%) and continuous infusion (27.7%) of glucose. Diagnostic testing (81.9%) commonly included electrocardiograms (51.9%), chest radiography (37.5%) and head computed tomography scans (14.5%). Most patients (73.5%) were discharged; however, more subjects with type 2 diabetes required admission (30.3 vs. 8.8%). Discharge instructions were documented in only 55.5% of patients, and referral to diabetes services occurred in fewer than 20% of cases. Considerable variation existed in the management of hypoglycemia across EDs. CONCLUSIONS: Patients with diabetes presenting to an ED with hypoglycemia consume considerable healthcare resources, and practice variation exists. Emergency departments should develop protocols for the management of hypoglycemia, with attention to discharge planning to reduce recurrence.

Patient transfer from a rehabilitation hospital to an emergency department : a retrospective study of an American trauma center.

OBJECTIVE: To analyze medical indications and conditions for patients transferred from a rehabilitation hospital to an emergency department (ED). Are there differences in terms of which patients go to the ED during their stay and which do not? Specifically, what type of patient is most likely to be transferred? METHODOLOGY: A retrospective study was conducted at an American adult and pediatric urban trauma center that serves 40,000 patients per year. This study compared randomly selected samples of 534 patients having been transferred to the ED from a rehabilitation hospital and 500 patients who were directly admitted to the ED from the community. Variables examined were: demographics, ED diagnosis and level of care, length of hospital stay, costs, discharge condition and return within 60days to the ED. RESULTS: The patients transferred from the rehabilitation hospital were older (P<0.01), differed with regard to ethnicity (83% African American; P<0.01), the reason for hospitalization (P<0.01; the majority presented with cardiovascular disease, respiratory disease or altered mental status), had longer and more expensive stays (average: 4-8days, P<0.01), required a higher level of care (P<0.01), were more often admitted to surgery or telemetry, and, lastly, were more likely to be discharged in a frail or poor condition (P<0.01). CONCLUSIONS: The patients transferred from a rehabilitation hospital had complex, intense medical (and often psychological) issues. These patients' medical needs required a high level of resources in the ED. They frequently left the hospital in sub-optimal conditions, making it likely that they would return to the hospital via the ED prior to completing their treatment within the rehabilitation hospital.