Nurse-administered early warning score system can be used for emergency department triage.

INTRODUCTION: Studies have shown that early warning score systems can identify in-patients at high risk of catastrophic deterioration and this may possibly be used for an emergency department (ED) triage. Bispebjerg Hospital has introduced a multidisciplinary team (MT) in the ED activated by the Bispebjerg Early Warning Score (BEWS). The BEWS is calculated on the basis of respiratory frequency, pulse, systolic blood pressure, temperature and level of consciousness. The aim of this study is to evaluate the ability of the BEWS to identify critically ill patients in the ED and to examine the feasibility of using the BEWS to activate an MT response. MATERIAL AND METHODS: This study is based on an evaluation of retrospective data from a random sample of 300 emergency patients. On the basis of documented vital signs, a BEWS was calculated retrospectively. The primary end points were admission to an intensive care unit (ICU) and death within 48 hours of arrival at the ED. This study was registered at clinicaltrials.gov (NCT01243021). RESULTS: A BEWS ≥ 5 is associated with a significantly increased risk of ICU admission within 48 hours of arrival (relative risk (RR) 4.1; 95% confidence interval (CI) 1.5-10.9) and death within 48 hours of arrival (RR 20.3; 95% CI 6.9-60.1). The sensitivity of the BEWS in identifying patients who were admitted to the ICU or who died within 48 hours of arrival was 63%. The positive predictive value of the BEWS was 16% and the negative predictive value 98% for identification of patients who were admitted to the ICU or who died within 48 hours of arrival. CONCLUSION: The BEWS is a simple scoring system based on readily available vital signs. It is a sensitive tool for detecting critically ill patients and may be used for ED triage and activation of an MT response.

Quality of care using a multidisciplinary team in the emergency room.

INTRODUCTION: Bispebjerg Hospital has implemented a multidisciplinary team reception of critically ill and severely injured patients at the Emergency Department (ED), termed emergency call (EC) and trauma call (TC). The aim of this study was to describe the course, medical treatment and outcome for patients received by this multidisciplinary team and to evaluate the quality of acute medical treatment of these patients. MATERIAL AND METHODS: A retrospective evaluation was made of all ECs and TCs registered during a six-month period. Information on sex, age, interventions at the ED, time spent at the ED and outcome measures (admission, Intensive Care Unit (ICU) admission and death) were obtained. The quality of the acute medical treatment during the ED stay and the first 48 hours of admission were evaluated by senior consultants from the departments receiving the patients. RESULTS: A total of 150 ECs and 47 TCs were included. The median time spent at the ED was 65 minutes for ECs and 95 minutes for TCs. In EC patients a median of eight interventions were performed at the ED, while a median of five interventions were performed in TC patients. A total of 137 EC patients were admitted to hospital including 32 patients admitted to the ICU. In all, 49 EC patients died during admission. Forty percent of TC patients were discharged to their homes. Only one trauma patient died and none were admitted to the ICU. The acute medical treatment was found to be satisfactory in 87% of EC patients and 96% of TC patients. CONCLUSION: A multidisciplinary team reception ensures early initiation of diagnostic procedures and treatment, short ED stays and admission to relevant departments in critically ill and severely injured patients.

Low compliance with a validated system for emergency department triage.

INTRODUCTION: Bispebjerg Hospital has introduced a triage system at the Emergency Department (ED) based on "primary criteria" and a physiological scoring system named the Bispebjerg Early Warning Score (BEWS). A BEWS is calculated on the basis of five vital signs which are accessible bedside. Patients who have a "primary criterion" or a BEWS ≥ 5 are presumed to be critically ill or severely injured and should be received by a multidisciplinary team, termed the Emergency Call (EC) and Trauma Call (TC), respectively. The aim of this study was to examine compliance with this triage system at Bispebjerg Hospital. MATERIAL AND METHODS: Retrospective evaluation of the triage of a random sample of 300 ED patients. ED medical charts were searched for "primary criteria", documentation of vital signs and a BEWS score. If a BEWS score had not been calculated, this was done retrospectively by the author. An evaluation was made to determine whether ECs or TCs had been correctly activated. RESULTS: In 47 patients, all five vital signs for calculation of a BEWS had been documented. A BEWS had been calculated in 22 patients. Nine patients had a TC activation criterion, and in all these cases a TC was activated. A total of 48 patients had an EC activation criterion, but an EC had only been activated in 24 patients. Among the 24 patients for whom an EC had not been activated, eight had a "primary criterion" and 16 patients had a retrospective BEWS ≥ 5. CONCLUSION: The triage system is not being used systematically and documentation of vital signs is insufficient at Bispebjerg Hospital. As a consequence, many patients who are presumed to be critically ill are not allocated to an EC. Initiatives have been taken to raise compliance with the system.

Diagnosis and treatment of unexplained anemia with iron deficiency without overt bleeding.

A general overview is given of the causes of anemia with iron deficiency as well as the pathogenesis of anemia and the para-clinical diagnosis of anemia. Anemia with iron deficiency but without overt GI bleeding is associated with a risk of malignant disease of the gastrointestinal tract; upper gastrointestinal cancer is 1/7 as common as colon cancer. Benign gastrointestinal causes of anemia are iron malabsorption (atrophic gastritis, celiac disease, chronic inflammation, and bariatric surgery) and chronic blood loss due to gastrointestinal ulcerations. The following diagnostic strategy is recommended for unexplained anemia with iron deficiency: conduct serological celiac disease screening with transglutaminase antibody (IgA type) and IgA testing and perform bidirectional endoscopy (gastroscopy and colonoscopy). Bidirectional endoscopy is not required in premenopausal women < 40 years of age. Small intestine investigation (capsule endoscopy, CT, or MRI enterography) is not recommended routinely after negative bidirectional endoscopy but should be conducted if there are red flags indicating malignant or inflammatory small bowel disease (e.g., involuntary weight loss, abdominal pain or increased CRP). Targeted treatment of any cause of anemia with iron deficiency found on diagnostic assessment should be initiated. In addition, iron supplementation should be administered, with the goal of normalizing hemoglobin levels and replenishing iron stores. Oral treatment with a 100-200 mg daily dose of elemental iron is recommended (lower dose if side effects), but 3-6 months of oral iron therapy is often required to achieve therapeutic goals. Intravenous iron therapy is used if oral treatment lacks efficacy or causes side effects or in the presence of intestinal malabsorption or prolonged inflammation. Three algorithms are given for the following conditions: a) the paraclinical diagnosis of anemia with iron deficiency; b) the diagnostic work-up for unexplained anemia with iron deficiency without overt bleeding; and c) how to proceed after negative bidirectional endoscopy of the gastrointestinal tract.

Rehabilitation for cirrhotic patients discharged after hepatic encephalopathy improves survival.

INTRODUCTION: The 1-year mortality of cirrhotic patients with hepatic encephalopathy (HE) is approximately 60-80% in recent studies. We aimed to establish a rehabilitation out-patient clinic (RC) for alcoholic cirrhotic patients sur-viving HE. MATERIAL AND METHODS: Prospectively, patients surviving HE were offered participation in the RC and were seen by a nurse for a one-hour interview with 1-3 weeks' interval after discharge and by a physician, if needed. Clinical, psychological and social problems were identified and addressed. Alcohol consumption was recorded and alcohol cessation was encouraged at each visit. Minimal or overt HE prompted referral to the Liver Unit. The patients were compared with HE patients discharged in 2008 (the control group). RESULTS: A total of 19 patients were included in the RC group and compared with the 14 patients of the control group. The Child-Pugh score was higher in the RC group (median 13; range 8-14) than in the control group (median 11; range 7-13) (p = 0.033), whereas other clinical, demographic and biochemical parameters did not differ between the two groups. One-year survival was higher in the RC group (16/19; 84%) than in the control group versus (5/14; 36%) (p = 0.012). The log-rank test confirmed an improved survival for the RC group (p = 0.008). The economic costs of subsequent hospital admissions did not differ between the two groups. In the RC group, alcohol consumption was reduced in all but two patients. CONCLUSION: Survival was significantly improved for patients in the rehabilitation clinic. The improved survival did not subsequently cause higher hospital admission costs. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.