Emergency Department Crowding in Relation to In-hospital Adverse Medical Events: A Large Prospective Observational Cohort Study.

BACKGROUND: Emergency department (ED) crowding has been linked with adverse medical events. However, this association was inadequately controlled for potential confounding variables. OBJECTIVES: To investigate whether ED crowding is independently associated with risk of in-hospital death and morbidity, and longer total hospital stay. METHODS: Prospective observational cohort study of all patients (≥ 18 years) presenting to the ED of an academic teaching hospital in Leuven, Belgium from June 21, 2010 to July 20, 2012. Multivariate logistic regression and proportional hazard analysis was used to control for risk factors. ED occupancy was determined for 108,229 included patients and labeled "ED crowding" when occupancy was within the highest quartile of occupancy. Outcomes within 10 days of ED admission included in-hospital death, hospital-acquired morbidities, and total hospital stay. RESULTS: During ED crowding, a median of 58 (interquartile range 55-63) patients were present for 40 licensed treatment bays. After controlling for all baseline risk factors and as compared with the lowest quartile of ED occupancy (30 [26-32] patients), ED crowding was not independently associated with mortality (odds ratio [OR] 0.94, 95% confidence interval [CI] 0.74-1.19; p = 0.6), but tended to be associated with higher incidence of hospital-acquired pneumonia (OR 1.24, 95% CI 0.96-1.62; p = 0.09). CONCLUSIONS: Failing to control for baseline risk factors may have led to false-positive associations between ED crowding and mortality in previous studies. After controlling for risk factors, we showed that ED crowding was associated with longer hospital stays but not with increased mortality.

Short-term unscheduled return visits of adult patients to the emergency department.

BACKGROUND: Emergency department (ED) crowding is a major international concern that affects patients and providers. STUDY OBJECTIVE: We describe the characteristics of patients who had an unscheduled related return visit to the ED and investigate its relation to ED crowding. METHODS: Retrospective medical record review of all unscheduled related ED return visits by patients older than 16 years of age over a 1-year period. The top quartile of ED occupancy rates was defined as ED crowding. RESULTS: Eight hundred thirty-seven patients (1.9%) made an unscheduled related return visit. Length of stay (LOS) at the ED for the index visit and the LOS for the return visit (5 h, 54 min vs. 6 h, 51 min) were significantly different, as were the percent admitted (11.6% vs. 46.1%). Of these patients, 85.1% and 12.0% returned due to persistence or a wrong initial diagnosis, of their initial illness, respectively, and 2.9% returned due to an adverse event related to the treatment initially received. Patients presented the least frequently with an alcohol-related complaint during the index visit (480 patients), but they had the highest number of unscheduled return visits (45 patients; 9.4%). Unscheduled related return visits were not associated with ED crowding. CONCLUSION: Return visits impose additional pressure on the ED, because return patients have a significantly longer LOS at the ED. However, the rate of unscheduled return visits and ED crowding was not related. Because this parameter serves as an essential quality assurance tool, we can assume that the studied hospital scores well on this particular parameter.

Evaluating implementation of the emergency severity index in a Belgian hospital.

INTRODUCTION: Triage aims to categorize patients based on their clinical need and the available departmental resources. To accomplish this goal, one needs to ensure that the implemented triage system is reliable and that staff use it correctly. Therefore this study assessed the ability of Belgium nurses to apply the Emergency Severity Index (ESI), version 4, to hypothetical case scenarios after an educational intervention. METHODS: An ESI educational intervention was implemented in accordance with the ESI manual. Using paper case scenarios, nurses' interrater agreement was assessed by comparing triage nurse ESI levels with the reference answers noted in the implementation manual. Interrater agreement was measured by the percentage of agreement and Cohen's κ coefficient using different weighting schemes. RESULTS: Overall, 77.5% of the scenario cases were coded according the ESI guidelines, resulting in a good interrater agreement (κ = 0.72, linear weighted κ = 0.84, quadratic weighted κ = 0.92, and triage-weighted scheme = 0.79). Interrater agreement varied when evaluating each ESI level separately. Undertriage was more common than overtriage. The highest misclassification range (37.8%) occurred in ESI level 2 scenarios, with 99.2% of the misclassifications being undertriaged. DISCUSSION: Implementation of the ESI into a novel setting guided by a locally developed training program resulted in suboptimal interrater agreement. Existing weighted κ schemes overestimated the interrater agreement between the triage nurse-assigned ESI level and the reference standard. By providing an aggregated measure of agreement, which allows partial agreement, clinically significant misclassification was masked by a misleading "good" interrater agreement.

Impact of temperature exposure on stability of drugs in a real-world out-of-hospital setting.

STUDY OBJECTIVE: The aim of this study is to determine the content of 5 important emergency medical services (EMS) drugs after being stored at the recommended refrigerated temperature, room temperature, or in an emergency physician transport vehicle operating under real-world working conditions. METHODS: Adrenaline hydrochloride, cisatracurium besylate, lorazepam, methylergonovine maleate, and succinylcholine chloride were stored for 1 year under the 3 conditions. For each storage condition, samples of the drugs were taken after 1, 2, 3, and 4 weeks and after 2, 4, 6, 8, 10, and 12 months. For adrenaline hydrochloride, however, the samples were taken after 1, 2, 4, 6, 8, 10, and 12 months. The samples were analyzed with a validated high-performance liquid chromatography assay. A drug was considered stable if its content was above 90%. RESULTS: Adrenaline hydrochloride and methylergonovine maleate remained stable for 1 year at room temperature and in the emergency physician transport vehicle. At room temperature and in the emergency physician transport vehicle, lorazepam became unstable within 4 weeks. Succinylcholine chloride was stable for 2 months at room temperature and for 1 month in the emergency physician transport vehicle. Cisatracurium besylate became unstable within 4 months at room temperature. However, it remained stable for 4 months in the emergency physician transport vehicle. CONCLUSION: When stored at room temperature or in the emergency physician transport vehicle, lorazepam became unstable within weeks, whereas succinylcholine chloride and cisatracurium besylate became unstable within months. Adrenaline hydrochloride and methylergonovine maleate remained stable for several months, even under room temperature and emergency physician transport vehicle conditions. Thus, real-world EMS working conditions pose challenges for maintaining optimal efficacy of these important EMS drugs.

Validity and timeliness of syndromic influenza surveillance during the autumn/winter wave of A (H1N1) influenza 2009: results of emergency medical dispatch, ambulance and emergency department data from three European regions.

BACKGROUND: Emergency medical service (EMS) data, particularly from the emergency department (ED), is a common source of information for syndromic surveillance. However, the entire EMS chain, consists of both out-of-hospital and in-hospital services. Differences in validity and timeliness across these data sources so far have not been studied. Neither have the differences in validity and timeliness of this data from different European countries. In this paper we examine the validity and timeliness of the entire chain of EMS data sources from three European regions for common syndromic influenza surveillance during the A(H1N1) influenza pandemic in 2009. METHODS: We gathered local, regional, or national information on influenza-like illness (ILI) or respiratory syndrome from an Austrian Emergency Medical Dispatch Service (EMD-AT), an Austrian and Belgian ambulance services (EP-AT, EP-BE) and from a Belgian and Spanish emergency department (ED-BE, ED-ES). We examined the timeliness of the EMS data in identifying the beginning of the autumn/winter wave of pandemic A(H1N1) influenza as compared to the reference data. Additionally, we determined the sensitivity and specificity of an aberration detection algorithm (Poisson CUSUM) in EMS data sources for detecting the autumn/winter wave of the A(H1N1) influenza pandemic. RESULTS: The ED-ES data demonstrated the most favourable validity, followed by the ED-BE data. The beginning of the autumn/winter wave of pandemic A(H1N1) influenza was identified eight days in advance in ED-BE data. The EP data performed stronger in data sets for large catchment areas (EP-BE) and identified the beginning of the autumn/winter wave almost at the same time as the reference data (time lag +2 days). EMD data exhibited timely identification of the autumn/winter wave of A(H1N1) but demonstrated weak validity measures. CONCLUSIONS: In this study ED data exhibited the most favourable performance in terms of validity and timeliness for syndromic influenza surveillance, along with EP data for large catchment areas. For the other data sources performance assessment delivered no clear results. The study shows that routinely collected data from EMS providers can augment and enhance public health surveillance of influenza by providing information during health crises in which such information must be both timely and readily obtainable.

Deliberate self-poisoning: characteristics of patients and impact on the emergency department of a large university hospital.

STUDY OBJECTIVE: The epidemiology, management and cost of emergency department (ED) visits for deliberate self-poisoning (DSP) are described. METHODS: In a retrospective study, the medical records of all DSP patients older than 16 years, who presented to the ED from 1 January 2009 to 31 December 2009, were reviewed. RESULTS: 312 episodes of DSP were included, accounting for 0.6% of all ED visits. 190 patients were women, with a female to male ratio of 1.56:1. Mean patient age was 37 years. More than 60% (n=190) of DSP patients were <40 years of age. Most patients presented to the ED between 18:00 and 23:00. A single drug was ingested in 39% (n=121) of patients. Alcohol was co-ingested by 36% of patients who were mostly middle-aged men. Of the overdoses, 50.8% were due to benzodiazepines, 23.2% were due to antidepressants and 16.4% were due to antipsychotics. Two-thirds of patients were treated with oral activated charcoal and 89% were seen by a psychiatrist. Nearly 90% of patients were admitted to the ED observation ward, with a mean length of stay of 16.7 h. The estimated total cost was €;266 134.89, with an average of €;872.57 per patient. CONCLUSION: Self-poisoning cases in Belgium are grossly similar to those in other Western countries. Supportive treatment alone should be considered in the majority of patients presenting with oral drug overdose. Overall, DSP leads to a significant financial burden on the community.

Emergency department visits due to alcohol intoxication: characteristics of patients and impact on the emergency room.

AIMS: The aim of the study was to describe the epidemiology, management and cost of emergency department (ED) visits due to alcohol intoxication. METHODS: A retrospective review of medical records of all episodes of alcohol intoxication was made, excepting those where another diagnosis such as trauma or psychiatric illness was primary, in patients older than 16 years, who presented to the ED of a large university hospital in Belgium over a 12-month period from 1 January 2009. RESULTS: A total of 635 such patients accounted for 1.2% of all ED visits; 429 were males and 48.3% were aged between 41 and 60 years; 63.8% of the patients had a history of alcohol use disorder and 60.3% had a history of psychiatric disorder; 74.3% of the patients received some form of medical treatment and 62% were seen by a psychiatrist. Of the total, 57.5% of the patients were admitted to the ED observation ward, with a mean length of stay of 8.4 h. The estimated total cost was €318 838.25, with an average of €541.32 per patient. CONCLUSION: Alcohol intoxication leads to a financial burden on the community. In addition to imposing physical, social and psychological stress on the community, the often agitated or aggressive patient imposes stress on ED staff. Close surveillance of trends in alcohol abuse is warranted, and the ED should consider implementing a questionnaire method of screening for alcohol abuse.

Can the heartscan be used for diagnosis and monitoring of emergencies in general practice?

INTRODUCTION: Mostly, it is impossible to establish the type of arrhythmias, based on signs and symptoms only. An ECG device is not always within reach. We presumed the heartscan, a handheld wireless device, to be of value to a GP in emergency situations. We therefore studied inter- and intra-observer variability and the accuracy of the screen readings. METHODS: All consecutive patients visiting the emergency department (ED) of the Gasthuisberg University Hospital in Leuven, Belgium, as well as patients hospitalised in three hospital wards on one day, were included. Immediately after the heartscan recording, a standard 12-lead ECG was recorded and read by an experienced hospital-based cardiologist. The recordings were read on the device screen by two general practitioners. All readers were blinded to the 12-lead ECG readings and vice versa, and for each other's ones. We compared both the heartscan reading of the first reader and the automatic reading of the device with the readings of the second GP and to the 12-lead ECG results, used as the gold standard. Intra- and inter-observer agreement was studied using total accuracy and kappa values with their 95% confidence interval (CI). RESULTS: Full data of 177 (73%) patients, 80 men (45%) and 97 women (55%), with a mean age of 55 years (range 18-94 y) were recorded. The specificity of the heartscan reading by a clinician was 88%, the sensitivity between 60 and 69%, PPV < 50% and NPV > 95%. Comparing codes of the heartscan with the ECG readings was difficult but sensitivity for atrial fibrillation was 92.3%. Inter- and intra-observer accuracy were high (> 0.86 and > or = 0.95, respectively), with low kappa values. CONCLUSION: The detection of rhythm disorders by the device is incomplete. However, the heartscan can be a help for the GP. The performance of the heartscan could probably be improved by increasing screen resolution, but, in the future, more sophisticated heart monitors should become available. They should be small, light and affordable.

Incidence and outcome of first syncope in primary care: A retrospective cohort study.

ABSTRACT: BACKGROUND: Assessment of risk for serious cardiovascular outcome after syncope is difficult. OBJECTIVES: To determine the incidence of first syncope in primary care. To investigate the relation between syncope and serious cardiovascular (CV) outcome and serious injury. METHODS: Retrospective cohort study using data from the Intego general practice-based registration network, collecting data from 55 general practices (90 GP's). All patients with a first syncope from 1994 to 2008 were included; five participants without syncope were matched for age and gender for every patient with syncope. The main outcome measures were incidence of first syncope by age and gender and one year risk of serious CV outcome or injury after syncope. RESULTS: 2785 patients with syncope and 13909 matched patients without syncope were included. The overall incidence of a first syncope was 1.91 per 1000 person-years (95% CI 1.83-1.98). The incidence was higher in females (2.42 (95% CI 2.32-2.55) per 1000 person-years) compared to males (1.4 (95% CI 1.32-1.49) per 1000 person-years) and follows a biphasic pattern according to age: a first peak at the age of 15-24 years is followed by a sharp rise above the age of 45. One year serious outcome after syncope was recorded in 12.3% of patients. Increasing age (HR 1.04 (1.03-1.04)), CV comorbidity (HR 3.48 (95% CI 2.48-4.90) and CV risk factors (HR 1.65 (95% CI 1.24-2.18) are associated with serious outcome. Cox regression, adjusting for age, gender, CV comorbidity and risk factors, showed that syncope was an independent risk factor for serious CV outcome or injury (HR 3.99 (95% CI 3.44-4.63)). The other independent risk factors were CV comorbidity (HR 1.81 (95% CI 1.51-2.17)) and age (HR 1.03 (95% CI 1.03-1.04)). CONCLUSIONS: Incidence rate of first syncope in primary care was 1.91 per 1000 person-years. One year risk of serious outcome after syncope was 12.3%. Increasing age, CV comorbidity and risk factors are associated with serious outcome. Compared to a control group, syncope on itself is an independent risk factor for serious outcome (adjusted for age, gender, CV comorbidity and risk factors).

Admission hyperglycaemia is associated with higher mortality in patients with hip fracture.

OBJECTIVE: To determine the proportion of hip-fracture patients with admission hyperglycaemia, and, when present, whether it was associated with a worse outcome (i.e. increased length of hospital stay, admission to ICU, or mortality). PATIENTS AND METHODS: Over a 2-year period, we retrospectively analysed records of patients with a primary diagnosis of hip fracture (ICD-9-CM 820.x). The records were retrieved from an electronic hospital database. RESULTS: An admission blood sugar level (aBSL) greater than 140 mg/dl was observed in 34% of the patients and was associated with a higher in-hospital mortality (P=0.042). ICU admissions and length of stay did not differ for patients having an aBSL above or below the 140 mg/dl cut-off. CONCLUSION: Hyperglycaemia is common in hip-fracture patients. A high aBSL might serve as a prognostic indicator in hip-fracture patients. To our knowledge, this is the first report of hyperglycaemia-associated mortality in less severely traumatised patients, who generally are not admitted to an ICU.

Exacerbation of atopic dermatitis in the emergency department.

A 38-year-old man was admitted to the Emergency Department suffering from an exacerbation of atopic dermatitis, fever and a burning sensation in the eyes. He was first treated with systemic corticosteroids. A subsequent dermatological and ophthalmological examination established the diagnosis of Kaposi-Juliusberg disease or eczema herpeticum with bilateral herpetic keratitis. Eczema herpeticum is an uncommon herpes simplex virus infection that occurs in patients with atopic dermatitis. Because it is a possible life-threatening condition, this disease must be recognized by all emergency physicians. The association with herpetic keratitis is not frequent but is a major ophthalmological problem. Treatment consists of the administration of high-dose intravenous acyclovir and acyclovir ophthalmic ointment.

The number of patients simultaneously present at the emergency department as an indicator of unsafe waiting times: a receiver operated curve-based evaluation.

BACKGROUND: Emergency department (ED) crowding and prolonged waiting times have been associated with adverse consequences towards quality and patient safety. OBJECTIVE: This study investigates whether the number of patients simultaneously present at the ED might be an indicator of unsafe waiting and at what threshold hospital-wide measures to improve patient outflow could be justified. METHODS: Data were retrospectively collected during a 1-year period; all ED patients aged ≥16 years, and triaged as ESI-1 or ESI-2 were eligible for inclusion. The number of patients simultaneously present was used as occupancy rate. Waiting time was considered unsafe if it was longer than 10 min for ESI-1 patients, or longer than 30 min for ESI-2 patients. Differences in waiting time and occupancy between patients with safe and unsafe waiting times were analysed using the Mann-Whitney U test. The ability of the occupancy rate to discriminate unsafe waiting times was analysed using a receiver operating characteristic curve. RESULTS: The overall median waiting time was 5 min (IQR=4-8) for ESI-1, and 12 min (IQR=6-24) for ESI-2 patients. Unsafe waiting times occurred in 16.0% of ESI-1 patients (median waiting time=17 min, IQR=13-23), and in 18.9% of ESI-2 patients (median waiting time=48 min, IQR=37-68). The occupancy rate was a weak indicator for unsafe waiting times in ESI-1 patients (AUC=0.625, 95%CI 0.537-0.713) but a fair indicator for unsafe waiting times in ESI-2 patients (AUC=0.740, 95%CI 0.727-0.753) for which the threshold to predict unsafe waiting times with 90% sensitivity was 51 patients. CONCLUSION: The number of patients simultaneously present is a moderate indicator of unsafe waiting times. Future initiatives to improve safe waiting times should not focus solely on occupancy, and expand their focus towards other factors affecting waiting time.

Pharmacist- versus physician-acquired medication history: a prospective study at the emergency department.

BACKGROUND: Recent literature revealed that medication histories obtained by physicians and nurses are often incomplete. However, the number of patients included was often low. Study objective In this study, the authors compare medication histories obtained in the Emergency Department (ED) by pharmacists versus physicians and identify characteristics contributing to discrepancies. METHODS: Medication histories were acquired by the pharmacist from patients admitted to the ED, planned to be hospitalised. A structured form was used to guide the pharmacist or technician to ensure a standardised approach. Discrepancies, defined as any difference between the pharmacist-acquired medication history and that obtained by the physician, were analysed. RESULTS: 3594 medication histories were acquired by pharmacy staff. 59% (95% CI 58.2% to 59.8%) of medication histories recorded by physicians were different from those obtained by the pharmacy staff. Within these inaccurate medication histories, 5963 discrepancies were identified. The most common type of error was omission of a drug (61%; 95% CI 60.4% to 61.6%), followed by omission of dose (18%; 95% CI 17.6% to 18.4%). Drugs belonging to the class of psycholeptics, acid suppressors and beta blocking agents were related to the highest discrepancy rate. Acetylsalicylic acid, omeprazole and zolpidem were most commonly forgotten. CONCLUSION: This large prospective study demonstrates that medication history acquisition is very often incomplete in the ED. A structured form and a standardised method is necessary. Pharmacists are especially suited to acquire and supervise accurate medication histories, as they are educated and familiar with commonly used drugs.

Early evaluation of the risk of functional decline following hospitalization of older patients: development of a predictive tool.

OBJECTIVE: To develop a predictive tool that could be used on admission to identify older hospitalized people at risk of functional decline 3 months after discharge. METHODS: This was a prospective cohort study that included 625 patients aged 70 years and older (mean age 80.0 +/- 5.6 years) hospitalized by the way of the emergency room, for at least 48 h, in two academic hospitals. Three months after discharge, 550 patients remained for analysis. On admission, people were assessed for premorbid functional status with the activities of daily living (ADL) scale and instrumental ADL scale. Demographic and medical data, including cognitive function, falls, polypharmacy, comorbidity, continence, mobility and self-rated health, were collected. ADL functioning was re-assessed at discharge and 1 and 3 months later. Functional decline was defined as the loss of at least one point on the ADL scale between the premorbid and 3-month evaluation. Univariate analyses were used to select variables associated with functional decline. A logistic regression model was then constructed to predict functional status 3 months after discharge. RESULTS: Three months after discharge, 165 (31.5%) patients had declined. The predictive tool SHERPA includes five factors: age, impairment in premorbid instrumental ADLs, falls in the year before hospitalization, cognitive impairment (Abbreviated Mini Mental State below 15/21) and poor self-rated health. Sensitivity and specificity were 67.9% and 70.8%, respectively. CONCLUSIONS: Older people are at high risk of functional decline following hospitalization. On admission, a simple instrument can easily identify these patients, even though the performance of this instrument is moderate.