Neuroleptic malignant syndrome after overdose of haloperidol - A case report.

Introduction: The Neuroleptic Malignant Syndrome (NMS), alternatively referred to as the Antipsychotic Malignant Syndrome, is a potentially fatal condition that is infrequently observed and is linked to the administration of antipsychotic medications. This syndrome is characterized by a disturbance in consciousness, autonomic instability manifesting as hyperthermia, and muscular rigidity. The onset of this syndrome is typically within the initial month of treatment or following an escalation in the dosage of an antipsychotic medication. This case report delineates a case where NMS was precipitated by an excessive intake of haloperidol, a typical antipsychotic drug. Case description: In the Emergency Department (ED), a 23-year-old male was admitted following an overdose of haloperidol, a typical antipsychotic drug. The patient exhibited symptoms of tachypnea and tachycardia, and initially presented with hypotension. His level of consciousness was variable, but maximal upon stimulation. Notably, there was a significant increase in muscle tension, characterized by cogwheel rigidity. His body temperature rose to 38.6 degrees Celsius. Laboratory findings revealed a substantial high anion gap metabolic acidosis, with a lactate level of 21.2 mmol/L. Additionally, his creatine kinase level was elevated, measuring 1347 U/L. The therapeutic approach encompassed the intravenous administration of midazolam (2.5 mg), lorazepam (2.5 mg), and biperiden (5 mg), in conjunction with resuscitation involving 2 liters of 0.9% NaCl. The patient demonstrated a positive response to this regimen, leading to his admission to the ward. Following a full recovery, he was discharged from the hospital the subsequent day. Discussion: The patient in our case fulfilled all the diagnostic criteria for NMS as stipulated in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V). NMS is not contingent on the dosage, although an increased dosage does elevate the risk. A thorough review of existing literature did not yield any cases mirroring ours. Conclusion: In conclusion, we present a case where NMS developed after an overdose of haloperidol.

The PIRATE mnemonic: providing a structured approach in the care for intoxicated patients at the emergency department.

BACKGROUND: Expertise in toxicology is essential for acute care providers, as intoxicated patients frequently present to Emergency Departments. These patients can be challenging for care providers because they often present with uncertain substance exposure and unknown dose and timing of these exposures. METHODS: The Dutch Society of Emergency Physicians has developed an mnemonic to support treating physicians in a structured approach for the management of (undifferentiated) intoxicated patients. RESULTS: The PIRATE mnemonic was developed, which includes the following aspects and sequence of care for the intoxicated patient: primary survey, investigation & identification, risk assessment, ADME (comprising pharmacokinetic therapeutic targets: absorption, distribution, metabolism, elimination), therapy and evaluation. CONCLUSION: The toxicology section of the Dutch Society of Emergency Physicians developed the PIRATE mnemonic to provide a structured approach in the management of patients presenting with acute intoxications to Emergency Departments. It summarizes the essential steps and priorities required in the care of intoxicated patients. Further, it provides a common strategy for all specialties involved in the care of the acutely intoxicated patient, contributing to developing greater competence in poisoning management.

The prevalence of prescription opioid use and misuse among emergency department patients in The Netherlands.

RATIONALE: Prescription opioid use and misuse have increased rapidly in many Western countries in the past decade. Patients (mis)using opioids are at risk of presenting to the emergency department (ED) with opioid-related problems. European data concerning prescription opioid (mis)use among the ED population is lacking. AIMS AND OBJECTIVES: This study aims to determine prevalence of prescription opioid use, misuse, and opioid use disorder (OUD) among Dutch ED patients. Secondary objectives were to explore factors associated with prescription opioid misuse and the number of patients discharged with a new opioid prescription. METHODS: In a cross-sectional multicenter study at three hospitals in the Netherlands, adult ED patients were screened for current prescription opioid use. Opioid users filled out questionnaires regarding opioid (mis)use, and underwent a structured interview to assess OUD criteria. The primary outcomes were prevalence rates of (1) current prescription opioid use, (2) prescription opioid misuse (based on a Current Opioid Misuse Measure [COMM] score > 8), (3) OUD, based on DSM-5 criteria. Independent T-tests, Pearson χ2 and Fisher's Exact tests were used to analyse differences in characteristics between groups. RESULTS: A total of 997 patients were screened, of which 15% (n = 150) used prescription opioids. Out of 93 patients assessed, 22.6% (n = 21) showed signs of prescription opioid misuse, and 9.8% (n = 9, 95% CI: 4.5-17.8) fulfilled criteria for OUD. A medical history of psychiatric disorder was significantly more common in patients with prescription opioid misuse and OUD. CONCLUSION: This study shows that prescription opioid use is relatively common in ED patients in the Netherlands, compared to the overall population. Over one fifth of these patients shows signs of opioid misuse or OUD. Awareness among ED personnel about the high prevalence of prescription opioid (mis)use in their population is critical for signalling opioid-related problems.

Cast-OFF Trial: One Versus 4 to 5 Weeks of Plaster Cast Immobilization for Nonreduced Distal Radius Fractures: A Randomized Clinical Feasibility Trial.

BACKGROUND: Distal radius fracture is a common fracture of which the incidence appears to be increasing worldwide. This pilot study investigated whether 1 week of plaster cast is feasible for nonreduced (stable fractures including nondisplaced and displaced fractures) distal radius fractures. METHODS: The study was a multicenter randomized clinical feasibility trial including patients from regional acute care providers. Patients with a nonreduced distal radius fracture were included in the study. Nonreduced fractures meant intra-articular or extra-articular fractures and including nondisplaced and minimal displaced fractures (dorsal angulation less than 5°-10°, maximum radial shortening of 2 mm, and maximum radial shift of 2 mm) not needing a reduction. Forty Patients were included and randomized. After 1 week of plaster cast, patients were randomized to 1 of the 2 treatment groups: plaster cast removed (intervention group) versus 4 to 5 weeks of plaster cast (control group). RESULTS: The analysis shows no significant differences between the 2 groups in having less pain, better function after 6 weeks, and better overall patient satisfaction. No difference was shown in secondary displacement between the 2 groups (control 1 vs intervention 0). CONCLUSION: One week of plaster cast treatment for nonreduced distal radius fracture is feasible, preferred by patients, with at least the same functional outcome and pain scores. LEVEL OF EVIDENCE: According to the Oxford 2011 level of evidence, the level of evidence of this study is 2.

Development and validation of an admission prediction tool for emergency departments in the Netherlands.

OBJECTIVE: Early prediction of admission has the potential to reduce length of stay in the ED. The aim of this study is to create a computerised tool to predict admission probability. METHODS: The prediction rule was derived from data on all patients who visited the ED of the Rijnstate Hospital over two random weeks. Performing a multivariate logistic regression analysis factors associated with hospitalisation were explored. Using these data, a model was developed to predict admission probability. Prospective validation was performed at Rijnstate Hospital and in two regional hospitals with different baseline admission rates. The model was converted into a computerised tool that reported the admission probability for any patient at the time of triage. RESULTS: Data from 1261 visits were included in the derivation of the rule. Four contributing factors for admission that could be determined at triage were identified: age, triage category, arrival mode and main symptom. Prospective validation showed that this model reliably predicts hospital admission in two community hospitals (area under the curve (AUC) 0.87, 95% CI 0.85 to 0.89) and in an academic hospital (AUC 0.76, 95% CI 0.72 to 0.80). In the community hospitals, using a cut-off of 80% for admission probability resulted in the highest number of true positives (actual admissions) with the greatest specificity (positive predictive value (PPV): 89.6, 95% CI 84.5 to 93.6; negative predictive value (NPV): 70.3, 95% CI 67.6 to 72.9). For the academic hospital, with a higher admission rate, a 90% probability was a better cut-off (PPV: 83.0, 95% CI 73.8 to 90.0; NPV: 59.3, 95% CI 54.2 to 64.2). CONCLUSION: Admission probability for ED patients can be calculated using a prediction tool. Further research must show whether using this tool can improve patient flow in the ED.

Introducing copayments in the emergency department would deter appropriate visits in the Netherlands.

OBJECTIVE: To determine what the effects of introduction of copayments for self-referred emergency department (ED) visits would be in the Netherlands and at what amount patients would turn to a GP before visiting an ED. METHODS: This questionnaire study was carried out in the ED of the Rijnstate Hospital, a community teaching hospital in the Netherlands. In the Netherlands, a deductible excess system is in use and this study investigated the effects of a copayment for self-referred patients (SRPs) on top of the deductible excess. A questionnaire was developed and handed out to SRPs. RESULTS: A total of 433 SRPs were included; their average age was 33.1 years and 63% were male. With a copayment of &OV0556;100, 47% of SRPs would choose to visit their GP instead of the ED. A further increase in the copayment amount is largely ineffective in reducing the number of self-referred ED visits. The higher the household income and education level and the more urgent the triage category, the larger the copayment patients are willing to pay. There is no significant relation between appropriateness and the amount of copayment that patients are willing to pay and we found no specific copayment level that resulted in reducing mainly inappropriate ED visits. CONCLUSION: With a copayment of &OV0556;100, 47% of the SRPs would choose to visit their GP instead of the ED. There was no specific copayment level that resulted in reducing mainly inappropriate ED visits.

Why patients self-refer to the Emergency Department: A qualitative interview study.

RATIONALE, AIMS, AND OBJECTIVES: There have been multiple studies investigating reasons for patients to self-refer to the Emergency Department (ED). The majority made use of questionnaires and excluded patients with urgent conditions. The goal of this qualitative study is to explore what motives patients have to self-refer to an ED, also including patients in urgent triage categories. METHODS: In a large teaching hospital in the Netherlands, a qualitative interview study focusing on reasons for self-referring to the ED was performed. Self-referred patients were included until no new reasons for attending the ED were found. Exclusion criteria were as follows: not mentally able to be interviewed or not speaking Dutch. Patients who were in need of urgent care were treated first, before being asked to participate. Interviews followed a predefined topic guide. Practicing cyclic analysis, the interview topic guide was modified during the inclusion period. Interviews were recorded on an audio recorder, transcribed verbatim, and anonymized. Two investigators independently coded the information and combined the codes into meaningful clusters. Subsequently, these were categorized into themes to build a framework of reasons for self-referral to the ED. Characteristic quotes were used to illustrate the acquired theoretical framework. RESULTS: Thirty self-referred patients were interviewed. Most of the participants were male (63%), with a mean age of 46 years. Two main themes emerged from the interviews that are pertinent to the patients' decisions to attend the ED: (1) health concerns and (2) practical issues. CONCLUSIONS: This study found that there are 2 clearly distinctive reasons for self-referral to the ED: health concerns or practical motives. Self-referral because of practical motives is probably most suitable for strategies that aim to reduce inappropriate ED visits.

Motives for self-referral to the emergency department: a systematic review of the literature.

BACKGROUND: In several western countries patients' use of Emergency Departments (EDs) is increasing. A substantial number of patients is self-referred, but does not need emergency care. In order to have more influence on unnecessary self-referral, it is essential to know why patients visit the ED without referral. The goal of this systematic review therefore is to explore what motivates self-referred patients in those countries to visit the ED. METHODS: Recommendations from the PRISMA were used to search and analyze the literature. The following databases; PUBMED, MEDLINE, EMBASE, CINAHL and Cochrane Library, were systematically searched from inception up to the first of February 2015. The reference lists of the included articles were screened for additional relevant articles. All studies that reported on the motives of self-referred patients to visit an ED were selected. The reasons for self-referral were categorized into seven main themes: health concerns, expected investigations; convenience of the ED; lesser accessibility of primary care; no confidence in general practitioner/primary care; advice from others and financial considerations. A random-effects meta-analysis was performed. RESULTS: Thirty publications were identified from the literature studied. The most reported themes for self-referral were 'health concerns' and 'expected investigations': 36% (95% Confidence Interval 23-50%) and 35% (95% CI 20-51%) respectively. Financial considerations most often played a role in the United States with a reported percentage of 33% versus 4% in other countries (p < 0.001). CONCLUSIONS: Worldwide, the most important reasons to self-refer to an ED are health concerns and expected investigations. Financial considerations mainly play a role in the United States.

Impact of a well-developed primary care system on the length of stay in emergency departments in the Netherlands: a multicenter study.

BACKGROUND: The Netherlands has a well-developed primary care system, which increasingly collaborates with hospital emergency departments (EDs). In this setting, insight into crowding in EDs is limited. This study explored links between patients' ED Length of Stay (LOS) and their care pathways. METHODS: Observational multicenter study of 7000 ED patient records from 1 February 2013. Seven EDs spread over the Netherlands, representing overall Dutch EDs, were included. This included three EDs with and four EDs without an integrated primary-care-physician (PCP) cooperative, forming one Emergency Care Access Point (ECAP). The main outcome was LOS of patients comparing different care pathways (origin and destination of ED attenders). RESULTS: The median LOS of ED attenders was 130.0 min (IQR 79.0-140.0), which increased with patients' age. Random coefficient regression analysis showed that LOS for patients referred by medical professionals was 32.9 min longer compared to self-referred patients (95% CI 27.7-38.2 min). LOS for patients admitted to hospital was 41.2 min longer compared to patients followed-up at the outpatient clinic (95% CI 35.3-46.6 min), 49.9 min longer compared to patients followed-up at the PCP (95% CI 41.5-58.3 min) and 44.6 min longer compared to patients who did not receive follow-up (95% CI 38.3-51.0 min). There was no difference in LOS between hospitals with or without an ECAP. CONCLUSIONS: With 130 min, the median LOS in Dutch EDs is relatively short, comparing to other Western countries, which ranges from 176 to 480 min. Although integration of EDs with out-of-hours primary care was not related to LOS, the strong primary care system probably contributed to the overall short LOS of ED patients in the Netherlands.

Self-referrals in a Dutch Emergency Department: how appropriate are they?

OBJECTIVE: Self-referred visits account for an average of 30% of all Emergency Department (ED) visits in the Netherlands. Some of these are considered inappropriate, because patients receive care that a GP can provide. Worldwide, studies have used various methods to determine the proportion of inappropriate visits by self-referred patients, resulting in diverging percentages. The aim of this study was to find a reliable percentage of appropriate visits to the ED by self-referred patients in the Netherlands. METHODS: This observational, prospective study was performed in the ED of a hospital in the Netherlands. Data were collected on all self-referred patients in four separate months over 1 year. The appropriateness of an ED visit was determined at two time points: first, after primary assessment of the patient, using predefined criteria, and second the moment the patient left the ED, on the basis of the diagnosis and treatment received. Finally, the perspective of the patients was taken into account using a questionnaire. RESULTS: In 4 months 3196 self-referred patients were included. In all, 1862 (58.8%) visits were classified as appropriate according to the predefined criteria. When the second time point was taken into consideration, 48.1% of the patients had a secondary care diagnosis and/or needed secondary care treatment, classifying their visits as appropriate. According to the opinion of the patients 76.7% classified their visit as appropriate. CONCLUSION: The percentage of appropriate ED visits by self-referred patients in the Netherlands ranges from 48.1 to 58.8%, as determined using two different methods.

Self-referrals in the emergency department: reasons why patients attend the emergency department without consulting a general practitioner first-a questionnaire study.

BACKGROUND: To influence self-referral, it is crucial to know a patient's motives to directly visit the emergency department (ED). The goal of this study is to examine motives for self-referral to the ED and compare these motives in relation to appropriateness. METHODS: All self-referred patients visiting the ED of a Dutch hospital over four separate months in a 1-year period were included. Patients were handed questionnaires that included questions on their reasons to visit the ED directly and where they would seek medical help next time. Additionally, the motives of patients that either appropriately or inappropriately visited the ED were compared. In a previous study on the same patient cohort, the appropriateness of the ED visits was determined using predefined criteria. RESULTS: A total of 3196 self-referred patients were included, and 48.9 % completed the questionnaires. The majority of patients (28.0 %) attended the ED without a referral because they thought they would get help faster; the next reason was the easier access to radiologic and laboratory investigations (answered by 23.8 %); and the third was the symptoms were considered too severe to visit a general practitioner (GP) (answered by 22.7 %). The majority (78.5 %) would attend the ED the next time they are faced with similar symptoms. Appropriate visits were significantly more seen in females, elderly, and patients in higher triage categories. Patients who expect investigations are necessary, think their symptoms are too severe to visit a GP, or would return to the ED next time were more often appropriately visiting the ED. CONCLUSIONS: The choice of patients to self-refer to an ED is often an explicate decision. Patients are looking for specialist help and want fast and easy access to radiologic and laboratory investigations. Even though the primary care network is well developed in the Netherlands, the reasons for self-referral are similar to the reasons found in previous literature based in other countries. Patients who visit the ED because of health concerns visit the ED more often appropriately than patients visiting for practical reasons.