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1.
MMWR Morb Mortal Wkly Rep ; 69(13): 371-376, 2020 Apr 03.
Artículo en Inglés | MEDLINE | ID: mdl-32240125

RESUMEN

In 2017, drug overdoses caused 70,237 deaths in the United States, a 9.6% rate increase from 2016 (1). Monitoring nonfatal drug overdoses treated in emergency departments (EDs) is also important to inform community prevention and response activities. Analysis of discharge data provides insights into the prevalence and trends of nonfatal drug overdoses, highlighting opportunities for public health action to prevent overdoses. Using discharge data from the Healthcare Cost and Utilization Project's (HCUP) Nationwide Emergency Department Sample (NEDS), CDC identified nonfatal overdoses for all drugs, all opioids, nonheroin opioids, heroin, benzodiazepines, and cocaine and examined changes from 2016 to 2017, stratified by drug type and by patient, facility, and visit characteristics. In 2017, the most recent year for which population-level estimates of nonfatal overdoses can be generated, a total of 967,615 nonfatal drug overdoses were treated in EDs, an increase of 4.3% from 2016, which included 305,623 opioid-involved overdoses, a 3.1% increase from 2016. From 2016 to 2017, the nonfatal overdose rates for all drug types increased significantly except for those involving benzodiazepines. These findings highlight the importance of continued surveillance of nonfatal drug overdoses treated in EDs to inform public health actions and, working collaboratively with clinical and public safety partners, to link patients to needed recovery and treatment resources (e.g., medication-assisted treatment).


Asunto(s)
Sobredosis de Droga/terapia , Servicio de Urgencia en Hospital/estadística & datos numéricos , Adolescente , Adulto , Anciano , Niño , Preescolar , Sobredosis de Droga/mortalidad , Femenino , Humanos , Lactante , Recién Nacido , Masculino , Persona de Mediana Edad , Estados Unidos/epidemiología , Adulto Joven
2.
Minerva Med ; 111(2): 120-132, 2020 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-32338841

RESUMEN

BACKGROUND: The aim of this study was to describe the population of patients arriving in several Italian Emergency Departments (EDs) complaining of chest pain suggestive of acute coronary syndrome (ACS) in order to evaluate the incidence of ACS in this cohort and the association between ACS and different clinical parameters and risk factors. METHODS: This is an observational prospective study, conducted from the 1st January to the 31st December 2014 in 11 EDs in Italy. Patients presenting to ED with chest pain, suggestive of ACS, were consecutively enrolled. RESULTS: Patients with a diagnosis of ACS (N.=1800) resulted to be statistically significant older than those without ACS (NO ACS; N.=4630) (median age: 70 vs. 59, P<0.001), and with a higher prevalence of males (66.1% in ACS vs. 57.5% in NO ACS, P<0.001). ECG evaluation, obtained at ED admission, showed new onset alterations in 6.2% of NO ACS and 67.4% of ACS patients. Multiple logistic regression analysis showed that the following parameters were predictive for ACS: age, gender, to be on therapy for cardio-vascular disease (CVD), current smoke, hypertension, hypercholesterolemia, heart rate, ECG alterations, increased BMI, reduced SaO2. CONCLUSIONS: Results from this observational study strengthen the importance of the role of the EDs in ruling in and out chest pain patients for the diagnosis of ACS. The analysis put in light important clinical and risk factors that, if promptly recognized, can help Emergency Physicians to identify patients who are more likely to be suffering from ACS.


Asunto(s)
Síndrome Coronario Agudo/epidemiología , Dolor en el Pecho/epidemiología , Servicio de Urgencia en Hospital/estadística & datos numéricos , Sistema de Registros/estadística & datos numéricos , Síndrome Coronario Agudo/diagnóstico , Factores de Edad , Anciano , Femenino , Humanos , Italia/epidemiología , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Análisis de Regresión , Factores de Riesgo , Factores Sexuales
3.
Epidemiol Psychiatr Sci ; 29: e108, 2020 Mar 12.
Artículo en Inglés | MEDLINE | ID: mdl-32160934

RESUMEN

AIMS: The aim of this study was to estimate incidence of self-harm presentations to hospitals and their associated hospital costs across England. METHODS: We used individual patient data from the Multicentre Study of Self-harm in England of all self-harm presentations to the emergency departments of five general hospitals in Oxford, Manchester and Derby in 2013. We also obtained cost data for each self-harm presentation from the hospitals in Oxford and Derby, as well as population and geographical estimates from the Office for National Statistics. First, we estimated the rate of self-harm presentations by age and gender in the Multicentre Study and multiplied this with the respective populations to estimate the number of self-harm presentations by age and gender for each local Clinical Commissioning Group (CCG) area in England. Second, we performed a regression analysis on the cost data from Oxford and Derby to predict the hospital costs of self-harm in Manchester by age, gender, receipt of psychosocial assessment, hospital admission and type of self-harm. Third, the mean hospital cost per age year and gender were combined with the respective number of self-harm presentations to estimate the total hospital costs for each CCG in England. Sensitivity analysis was performed to address uncertainty in the results due to the extrapolation of self-harm incidence and cost from the Multicentre Study to England. RESULTS: There were 228 075 estimated self-harm presentations (61% were female) by 159 857 patients in 2013 in England. The largest proportions of self-harm presentations were in the age group 40-49 years (30%) for men and 19-29 years (28%) for women. Associated hospital costs were approximately £128.6 (95% CI 117.8-140.9) million in 2013. The estimated incidence of self-harm and associated hospital costs were lower in the majority of English coastal areas compared to inland regions but the highest costs were in Greater London. Costs were also higher in more socio-economically deprived areas of the country compared with areas that are more affluent. The sensitivity analyses provided similar results. CONCLUSIONS: The results of this study highlight the extent, hospital costs and distribution of self-harm presentations to hospitals in England and identify potential sub-populations that might benefit from targeted actions to help prevent self-harm and assist those who have self-harmed. They can support national as well as local health stakeholders in allocating funds and prioritising interventions in areas with the greatest need for preventing and managing self-harm.


Asunto(s)
Servicio de Urgencia en Hospital/estadística & datos numéricos , Costos de Hospital/estadística & datos numéricos , Conducta Autodestructiva/epidemiología , Suicidio/estadística & datos numéricos , Adolescente , Adulto , Distribución por Edad , Anciano , Inglaterra/epidemiología , Femenino , Hospitalización , Hospitales Generales , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Conducta Autodestructiva/psicología , Distribución por Sexo , Factores Socioeconómicos , Adulto Joven
4.
West Afr J Med ; 37(2): 131-137, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-32150631

RESUMEN

BACKGROUND: Trauma in developing countries has assumed an epidemic proportion and is now a public health problem. This is largely due to the rising incidence of road traffic crashes (RTC), increasing urbanization, industrialization and armed conflicts including terrorism fuelled by political, ethnic and religious factors in most developing countries. Unfortunately, this public health menace has not gotten the attention it deserves from the governments of the low-income countries, global non-governmental organisations and the mass media compared to the infectious diseases. METHODS: This was a 2-year retrospective cohort study of trauma patients who presented to our emergency department and died within 72 hours of admission. RESULTS: Within the period, a total of 6,858 patients, consisting of 2,228 trauma patients were admitted into our emergency department. Out of the trauma admissions, 256 patients died; giving a mortality rate of 11.5%. However, only 237 of the dead patients' case files could be reviewed. There were 195 (82.3%) males and 42 (17.7%) females. Majority of the deaths were in the age group 31 years - 45 years, with a mean age of 33.6 years. Road traffic crash was the most common cause of trauma deaths, 194 (81.9%); followed by flame burn, 15 (6.3%). Traumatic brain injury with or without other associated lesser injuries was the predominant diagnosis at presentation, 157 (66.2%). Most of the patients presented within 4 hours of their injuries, 136 (57.4%). Majority of the patients were brought to hospital by other road users, 133 (56.1%); and commercial bus was the commonest mode of transportation of the patients to the hospital, 102 (43.1%). CONCLUSION: The trauma mortality rate in our emergency department calls for urgent intervention measures. Critical amongst them is the need for establishment of a trauma system with an efficient pre-hospital emergency medical service component in our region.


Asunto(s)
Accidentes de Tránsito/mortalidad , Accidentes/mortalidad , Urgencias Médicas/epidemiología , Servicio de Urgencia en Hospital/estadística & datos numéricos , Mortalidad Hospitalaria , Heridas y Traumatismos/epidemiología , Accidentes de Tránsito/estadística & datos numéricos , Adulto , Causas de Muerte , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Nigeria/epidemiología , Estudios Retrospectivos , Factores de Riesgo , Centros de Atención Terciaria
6.
Med Care ; 58(4): 336-343, 2020 04.
Artículo en Inglés | MEDLINE | ID: mdl-32197028

RESUMEN

BACKGROUND: Heart failure patients have high rates of repeat acute care use. Current efforts for risk prediction often ignore postdischarge data. OBJECTIVE: To identify postdischarge patient-reported clinical factors associated with repeat acute care use. RESEARCH DESIGN: In a prospective cohort study that followed patients with chronic heart failure for 30 days postdischarge, for 7 days after discharge (or fewer days if patients used acute care within 7 days postdischarge), patients reported health status, heart failure symptoms, medication management, knowledge of follow-up plans, and other issues using a daily interactive automatic phone call. SUBJECTS: A total of 156 patients who had responded to phone surveys. MEASURES: The outcome variable was dichotomous 30-day acute care use (rehospitalization or emergency department visit). We examined the association between each patient-reported issue and the outcome, using multivariable logistic regression to adjust for confounders. RESULTS: Patients were 63 years old (SD=12.4), with 51% African-American and 53% women. Within 30 days postdischarge, 30 (19%) patients used acute care. After adjustment, poor health status [odds ratio (OR)=3.53; 95% confidence interval (CI), 1.06-11.76], pain (OR=2.44; 95% CI, 1.02-5.84), and poor appetite (OR=3.05; 95% CI, 1.13-8.23) were positively associated with 30-day acute care utilization. Among 58 reports of pain in follow-up nursing notes, 39 (67%) were noncardiac, 2 (3%) were cardiac, and 17 (29%) were indeterminate. CONCLUSIONS: Patient-reported poor health status, pain, and poor appetite were positively associated with 30-day acute care utilization. These novel postdischarge markers require further study before incorporation into risk prediction to drive quality improvement efforts.


Asunto(s)
Servicio de Urgencia en Hospital/estadística & datos numéricos , Insuficiencia Cardíaca/terapia , Readmisión del Paciente/estadística & datos numéricos , Retratamiento/estadística & datos numéricos , Apetito , Enfermedad Crónica , Femenino , Estado de Salud , Humanos , Masculino , Persona de Mediana Edad , Dimensión del Dolor , Educación del Paciente como Asunto , Estudios Prospectivos , Factores de Riesgo , Encuestas y Cuestionarios
7.
J Forensic Leg Med ; 69: 101887, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-32056804

RESUMEN

BACKGROUND: Few studies address the demographics/epidemiology of patients presenting to emergency departments (ED) for evaluation of sexual assault across an entire nation. It was the purpose of this study to analyze the demographics of sexual assault using a national data base. METHODS: This was a retrospective study of prospectively collected data from National Electronic Injury Surveillance System - All Injury Program for years 2005-2013. Patients presenting for sexual assault were analyzed. Descriptive and logistic regression statistical analyses were performed with SUDAAN 11.0.01™ software. A p < 0.05 was considered statistically significant. RESULTS: Sexual assault accounted for an estimated 657,719 ED visits (0.24% of all injuries, and 3.4% of injuries due to violence). When an assault victim presented to the ED, a sexual assault was most likely when the patient was 0-14 years old (OR = 19.48 [12.02, 31.57]), White (OR = 2.12 [1.30, 3.47]), the perpetrator being a stranger (OR = 10.51 [8.21, 13.46]), and occurring at home (OR = 10.05 [6.61, 15.27]). The average annual incidence of ED visits for sexual assault per 10,000 US population was 2.39; 0.47 for males and 4.92 for females. The average was 19.6 years; 90.3% were female. Assaults occurred in the home in 45.6%, and were more common in the summer. The perpetrator was unknown in 37.5%, a friend/acquaintance in 24.8%, other relative in 9.4%, multiple perpetrators in 9.3%, spouse/partner in 6.8%, with the remaining 12.7% from other groups. Racial composition was White in 60.9%, Black in 25.9%, Amerindian in 12.5%, and Asian in 0.5%. The perpetrator was a close relative nearly twice as frequently for male victims compared to female victims. Hospital admission overall was 2.7%: 7.1% when the assault occurred on the street, 1.8% when at school or sporting locations, 4.9% for males and 1.5% for females. Nearly all (98.2%) extremity injuries occurred in females. CONCLUSIONS: Sexual assaults account for 4.4% of ED visits for violence. There was a decrease in the number of sexual assaults occurring on the street and at school/sporting locations over time while the number of assaults by strangers increased. For males, 54.1% occurred in those <10 years of age. The differences between patients by demographic and event characteristics is important information for health care providers.


Asunto(s)
Víctimas de Crimen/estadística & datos numéricos , Servicio de Urgencia en Hospital/estadística & datos numéricos , Delitos Sexuales/estadística & datos numéricos , Adolescente , Adulto , Distribución por Edad , Anciano , Anciano de 80 o más Años , Niño , Preescolar , Grupos de Población Continentales/estadística & datos numéricos , Femenino , Humanos , Lactante , Recién Nacido , Masculino , Persona de Mediana Edad , Admisión del Paciente/estadística & datos numéricos , Vigilancia en Salud Pública , Estudios Retrospectivos , Distribución por Sexo , Estados Unidos/epidemiología , Heridas y Traumatismos/epidemiología , Adulto Joven
8.
Crit Care Resusc ; 22(1): 6-14, 2020 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-32102638

RESUMEN

OBJECTIVE: To determine patient and perioperative characteristics associated with unexpected postoperative clinical deterioration as determined for the need of a postoperative emergency response team (ERT) activation. DESIGN: Retrospective case-control study. SETTING: Tertiary academic hospital. PARTICIPANTS: Patients who underwent general anaesthesia discharged to regular wards between 1 January 2013 and 31 December 2015 and required ERT activation within 48 postoperative hours. Controls were matched based on age, sex and procedure. MAIN OUTCOME MEASURES: Baseline patient and perioperative characteristics were abstracted to develop a multiple logistic regression model to assess for potential associations for increased risk for postoperative ERT. RESULTS: Among 105 345 patients, 797 had ERT calls, with a rate of 7.6 (95% CI, 7.1-8.1) calls per 1000 anaesthetics (0.76%). Multiple logistic regression analysis showed the following risk factors for postoperative ERT: cardiovascular disease (odds ratio [OR], 1.61; 95% CI, 1.18-2.18), neurological disease (OR, 1.57; 95% CI, 1.11-2.22), preoperative gabapentin (OR, 1.60; 95% CI, 1.17-2.20), longer surgical duration (OR, 1.06; 95% CI, 1.02-1.11, per 30 min), emergency procedure (OR, 1.54; 95% CI, 1.09-2.18), and intraoperative use of colloids (OR, 1.50; 95% CI, 1.17-1.92). Compared with control participants, ERT patients had a longer hospital stay, a higher rate of admissions to critical care (55.5%), increased postoperative complications, and a higher 30-day mortality rate (OR, 3.36; 95% CI, 1.73-6.54). CONCLUSION: We identified several patient and procedural characteristics associated with increased likelihood of postoperative ERT activation. ERT intervention is a marker for increased rates of postoperative complications and death.


Asunto(s)
Servicio de Urgencia en Hospital/estadística & datos numéricos , Complicaciones Posoperatorias , Estudios de Casos y Controles , Humanos , Tiempo de Internación , Estudios Retrospectivos , Factores de Riesgo
9.
South Med J ; 113(2): 55-58, 2020 02.
Artículo en Inglés | MEDLINE | ID: mdl-32016433

RESUMEN

OBJECTIVES: Out-of-hospital cardiac arrest (OHCA) is rare in infants, with the cause of arrest often unknown upon presentation. Nonaccidental trauma is a potential etiology of OHCA among infants, but its occult presentation makes this etiology challenging to diagnose. In the absence of apparent injuries, identifying the need for trauma team activation is difficult during the initial resuscitation of infants with OHCA. METHODS: We performed a retrospective chart review of infants younger than 1 year old who presented to Children's National Health System from 2012 to 2016 with cardiopulmonary resuscitation in progress. Medical records and the trauma registry were reviewed for relevant resuscitation information. Autopsy records provided the cause and manner of death, contributing factors to death, and evidence of injury. RESULTS: Among 592 infants undergoing resuscitation during the study period, 34 infants (5.7%) presented in cardiac arrest. The average age on presentation was 101.2 days (standard deviation 78.7). Most of the patients (n = 32, 94.1%) died in the emergency department, with none surviving to discharge. Among the 32 infants for whom autopsy records were available, the cause of death was nonaccidental trauma in one patient (3.1%). CONCLUSIONS: Infant OHCA had poor outcomes, with trauma as a rare etiology. In the absence of external signs of injury or known injury mechanism, immediate trauma team presence was not beneficial for these infants during the initial resuscitation phase.


Asunto(s)
Reanimación Cardiopulmonar/estadística & datos numéricos , Servicios Médicos de Urgencia/estadística & datos numéricos , Paro Cardíaco Extrahospitalario/etiología , Traumatología/estadística & datos numéricos , Servicio de Urgencia en Hospital/estadística & datos numéricos , Femenino , Humanos , Lactante , Recién Nacido , Masculino , Evaluación de Necesidades , Paro Cardíaco Extrahospitalario/mortalidad , Sistema de Registros , Estudios Retrospectivos
10.
Lancet ; 395(10221): 339-349, 2020 02 01.
Artículo en Inglés | MEDLINE | ID: mdl-32007169

RESUMEN

BACKGROUND: Acute atrial fibrillation is the most common arrythmia treated in the emergency department. Our primary aim was to compare conversion to sinus rhythm between pharmacological cardioversion followed by electrical cardioversion (drug-shock), and electrical cardioversion alone (shock-only). Our secondary aim was to compare the effectiveness of two pad positions for electrical cardioversion. METHODS: We did a partial factorial trial of two protocols for patients with acute atrial fibrillation at 11 academic hospital emergency departments in Canada. We enrolled adult patients with acute atrial fibrillation. Protocol 1 was a randomised, blinded, placebo-controlled comparison of attempted pharmacological cardioversion with intravenous procainamide (15 mg/kg over 30 min) followed by electrical cardioversion if necessary (up to three shocks, each of ≥200 J), and placebo infusion followed by electrical cardioversion. For patients having electrical cardioversion, we used Protocol 2, a randomised, open-label, nested comparison of anteroposterior versus anterolateral pad positions. Patients were randomly assigned (1:1, stratified by study site) for Protocol 1 by on-site research personnel using an online electronic data capture system. Randomisation for Protocol 2 occurred 30 min after drug infusion for patients who had not converted and was stratified by site and Protocol 1 allocation. Patients and all research and emergency department staff were masked to treatment allocation for Protocol 1. The primary outcome was conversion to normal sinus rhythm for at least 30 min at any time after randomisation and up to a point immediately after three shocks. Protocol 1 was analysed by intention to treat and Protocol 2 excluded patients who did not receive electrical cardioversion. This study is registered at ClinicalTrials.gov, number NCT01891058. FINDINGS: Between July 18, 2013, and Oct 17, 2018, we enrolled 396 patients, and none were lost to follow-up. In the drug-shock group (n=204), conversion to sinus rhythm occurred in 196 (96%) patients and in the shock-only group (n=192), conversion occurred in 176 (92%) patients (absolute difference 4%; 95% CI 0-9; p=0·07). The proportion of patients discharged home was 97% (n=198) versus 95% (n=183; p=0·60). 106 (52%) patients in the drug-shock group converted after drug infusion only. No patients had serious adverse events in follow-up. The different pad positions in Protocol 2 (n=244), had similar conversions to sinus rhythm (119 [94%] of 127 in anterolateral group vs 108 [92%] of 117 in anteroposterior group; p=0·68). INTERPRETATION: Both the drug-shock and shock-only strategies were highly effective, rapid, and safe in restoring sinus rhythm for patients in the emergency department with acute atrial fibrillation, avoiding the need for return to hospital. The drug infusion worked for about half of patients and avoided the resource intensive procedural sedation required for electrical cardioversion. We also found no significant difference between the anterolateral and anteroposterior pad positions for electrical cardioversion. Immediate rhythm control for patients in the emergency department with acute atrial fibrillation leads to excellent outcomes. FUNDING: Heart and Stroke Foundation of Canada and the Canadian Institutes of Health Research.


Asunto(s)
Antiarrítmicos/uso terapéutico , Fibrilación Atrial/terapia , Cardioversión Eléctrica , Enfermedad Aguda , Adulto , Anciano , Anciano de 80 o más Años , Protocolos Clínicos , Servicio de Urgencia en Hospital/estadística & datos numéricos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Resultado del Tratamiento , Adulto Joven
11.
Adv Clin Exp Med ; 29(1): 147-155, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-32011830

RESUMEN

BACKGROUND: Chest pain is one of the most frequent symptoms in patients seeking treatment at emergency departments (ED). These patients differ according to the cause of their reported symptoms and resultant mortality. OBJECTIVES: Evaluation of the influence of hospitalization and biochemical parameters on mortality rates in patients admitted to the ED with chest pain, in whom no cardiovascular emergencies were established. MATERIAL AND METHODS: The study group consisted of 243 patients with chest pain admitted to the ED in the Wroclaw Medical University Clinical Hospital, Poland, between January 1 and March 31, 2015, in whom no specific diagnosis was made at discharge. A retrospective analysis was carried out based on medical documentation, and 60-day and 1-year survival was assessed. RESULTS: In the study group, the 60-day mortality rate was 0.8% (2 persons) while the 1-year mortality rate was 6.6% (16 persons). The stepwise multivariable logistic regression analysis revealed that 1-year mortality was related to increased level of D-dimer (odds ratio (OR) = 8.5, 95% confidence interval (95% CI) = 21.9-37.5, p < 0.005), age (OR (per year) = 1.10, 95% CI = 1.03-1.18, p < 0.03) and lower than 12 g/dL hemoglobin concentration (OR = 18.5, 95% CI = 4.2-80.4, p < 0.001). Troponin I (TNI) levels and hospitalization were not related independently to mortality when other clinical factors were considered. CONCLUSIONS: Hospitalization of patients with chest pain who were not diagnosed with cardiac emergencies is not related with better survival than of those discharged home from the ED. The 60-day mortality is very low and occurs in older patients with numerous comorbidities. In multivariate analysis, survival of the 1-year period depends on the patient's age, hemoglobin levels and D-dimer levels. Risk of death in patients admitted to the ED due to chest pain in whom the cause of the chest pain was not due to cardiovascular emergencies depends on the presence of old age and comorbidities.


Asunto(s)
Dolor en el Pecho/diagnóstico , Dolor en el Pecho/terapia , Urgencias Médicas , Servicio de Urgencia en Hospital/estadística & datos numéricos , Productos de Degradación de Fibrina-Fibrinógeno/análisis , Mortalidad Hospitalaria , Troponina I/sangre , Anciano , Biomarcadores/sangre , Dolor en el Pecho/sangre , Dolor en el Pecho/mortalidad , Hospitalización/estadística & datos numéricos , Humanos , Persona de Mediana Edad , Polonia/epidemiología , Estudios Retrospectivos
12.
BMC Health Serv Res ; 20(1): 77, 2020 Feb 03.
Artículo en Inglés | MEDLINE | ID: mdl-32013969

RESUMEN

BACKGROUND: The Affordable Care Act (ACA) was enacted to enhance access to care primarily among nonelderly and low-income populations; however, several provisions addressed key determinants of emergency department (ED) and inpatient visits among Medicare beneficiaries over age 65 years. We take stock of the overall changes in these visits among older Medicare beneficiaries, focusing on those with multiple chronic conditions (MCCs), and provide a nationally representative post-reform update. METHODS: We analyzed a sample of 32,919 older adults (65+) on Medicare from the 2006-2015 Medical Expenditure Panel Survey (MEPS). Using a survey-weighted two-part model, we examined changes in ED visits, inpatient visits, and length of stay (LOS) by MCC status, before (2006-2010), during (2011-2013), and after the ACA (2014-2015). RESULTS: Prior to the ACA, 18.1% of Medicare older adults had ≥1 ED visit, whereas 17.1% had ≥1 inpatient visits, with an average of 5.1 nights/visit. Following ACA reforms, among those with 2+ chronic conditions, the rate of ever having an ED visit increased by 4.3 percentage points [95% confidence intervals [CI]: 2.5, 6.1, p < 0.01], whereas the rate of inpatient visits decreased by 1.4 percentage points [95%CI: - 2.9, 0.2, p < 0.1], after multivariable adjustment. CONCLUSIONS: We found sizable increases in ED visits and nontrivial decreases in inpatient visits among older Medicare beneficiaries with MCCs, underscoring the continuing need for improving access to and quality of care among older adults with MCCs to decrease reliance on the ED and reduce preventable hospitalizations.


Asunto(s)
Enfermedad Crónica/epidemiología , Enfermedad Crónica/terapia , Servicio de Urgencia en Hospital/estadística & datos numéricos , Utilización de Instalaciones y Servicios/estadística & datos numéricos , Hospitalización/estadística & datos numéricos , Medicare/organización & administración , Multimorbilidad , Anciano , Femenino , Reforma de la Atención de Salud , Humanos , Masculino , Patient Protection and Affordable Care Act , Estados Unidos/epidemiología
13.
Med Care ; 58(3): 248-256, 2020 03.
Artículo en Inglés | MEDLINE | ID: mdl-32049947

RESUMEN

BACKGROUND: A small fraction of patients use a disproportionately large amount of emergency department (ED) resources. Identifying these patients, especially those with ambulatory care sensitive conditions (ACSC), would allow health care professionals to enhance their outpatient care. OBJECTIVE: The objectives of the study were to determine predictive factors associated with frequent ED use in a Quebec adult population with ACSCs and to compare several models predicting the risk of becoming an ED frequent user following an ED visit. RESEARCH DESIGN: This was an observational population-based cohort study extracted from Quebec's administrative data. SUBJECTS: The cohort included 451,775 adult patients, living in nonremote areas, with an ED visit between January 2012 and December 2013 (index visit), and previously diagnosed with an ACSC but not dementia. MEASURES: The outcome was frequent ED use (≥4 visits) during the year following the index visit. Predictors included sociodemographics, physical and mental comorbidities, and prior use of health services. We developed several logistic models (with different sets of predictors) on a derivation cohort (2012 cohort) and tested them on a validation cohort (2013 cohort). RESULTS: Frequent ED users represented 5% of the cohort and accounted for 36% of all ED visits. A simple 2-variable prediction model incorporating history of hospitalization and number of previous ED use accurately predicted future frequent ED use. The full model with all sets of predictors performed only slightly better than the simple model (area under the receiver-operating characteristic curve: 0.786 vs. 0.759, respectively; similar positive predictive value and number needed to evaluate curves). CONCLUSIONS: The ability to identify frequent ED users based only on previous ED and hospitalization use provides an opportunity to rapidly target this population for appropriate interventions.


Asunto(s)
Atención Ambulatoria , Servicio de Urgencia en Hospital/estadística & datos numéricos , Aceptación de la Atención de Salud/estadística & datos numéricos , Poblaciones Vulnerables , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Comorbilidad , Femenino , Hospitalización , Humanos , Masculino , Persona de Mediana Edad , Modelos Estadísticos , Quebec
14.
PLoS One ; 15(2): e0228719, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-32023302

RESUMEN

BACKGROUND AND OBJECTIVE: Attending physician productivity and efficiency can be affected when working simultaneously with Residents. To gain a better understanding of this effect, we aim to compare productivity, efficiency, and overall performance differences among Attendings working solo versus working with Residents in an Emergency Department (ED). METHODS: Data were extracted from the electronic medical records of all patients seen by ED Attendings and/or Residents during the period July 1, 2014 through June 30, 2017. Attending productivity was measured based on the number of new patients enrolled per hour per provider. Attending efficiency was measured based on the provider-to-disposition time (PDT). Attending overall performance was measured by Attending Performance Index (API). Furthermore, Attending productivity, efficiency, and overall performance metrics were compared between Attendings working solo and Attendings working with Residents. The comparisons were analyzed after adjusting for confounders via propensity score matching. RESULTS: A total of 15 Attendings and 266 Residents managing 111,145 patient encounters over the study period were analyzed. The mean (standard deviation) of Attending productivity and efficiency were 2.9 (1.6) new patients per hour and 2.7 (1.8) hours per patient for Attendings working solo, in comparison to 3.3 (1.9) and 3.0 (2.0) for Attendings working with Residents. When paired with Residents, the API decreased for those Attendings who had a higher API when working solo (average API dropped from 0.21 to 0.19), whereas API increased for those who had a lower API when working solo (average API increased from 0.13 to 0.16). CONCLUSION: In comparison to the Attending working solo staffing model, increased productivity with decreased efficiency occurred among Attendings when working with Residents. The overall performance of Attendings when working with Residents varied inversely against their performance when working solo.


Asunto(s)
Eficiencia , Servicio de Urgencia en Hospital/estadística & datos numéricos , Internado y Residencia , Cuerpo Médico de Hospitales/estadística & datos numéricos , Admisión y Programación de Personal , Femenino , Humanos , Masculino , Cuerpo Médico de Hospitales/psicología , Estudios Retrospectivos
15.
Public Health Rep ; 135(2): 262-269, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-32040923

RESUMEN

OBJECTIVES: Valid opioid poisoning morbidity definitions are essential to the accuracy of national surveillance. The goal of our study was to estimate the positive predictive value (PPV) of case definitions identifying emergency department (ED) visits for heroin or other opioid poisonings, using billing records with International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes. METHODS: We examined billing records for ED visits from 4 health care networks (12 EDs) from October 2015 through December 2016. We conducted medical record reviews of representative samples to estimate the PPVs and 95% confidence intervals (CIs) of (1) first-listed heroin poisoning diagnoses (n = 398), (2) secondary heroin poisoning diagnoses (n = 102), (3) first-listed other opioid poisoning diagnoses (n = 452), and (4) secondary other opioid poisoning diagnoses (n = 103). RESULTS: First-listed heroin poisoning diagnoses had an estimated PPV of 93.2% (95% CI, 90.0%-96.3%), higher than secondary heroin poisoning diagnoses (76.5%; 95% CI, 68.1%-84.8%). Among other opioid poisoning diagnoses, the estimated PPV was 79.4% (95% CI, 75.7%-83.1%) for first-listed diagnoses and 67.0% (95% CI, 57.8%-76.2%) for secondary diagnoses. Naloxone was administered in 867 of 1055 (82.2%) cases; 254 patients received multiple doses. One-third of all patients had a previous drug poisoning. Drug testing was ordered in only 354 cases. CONCLUSIONS: The study findings suggest that heroin or other opioid poisoning surveillance definitions that include multiple diagnoses (first-listed and secondary) would identify a high percentage of true-positive cases.


Asunto(s)
Analgésicos Opioides/envenenamiento , Sobredosis de Droga/diagnóstico , Servicio de Urgencia en Hospital/estadística & datos numéricos , Heroína/envenenamiento , Adolescente , Adulto , Niño , Registros Electrónicos de Salud , Servicio de Urgencia en Hospital/normas , Femenino , Humanos , Clasificación Internacional de Enfermedades , Kentucky , Masculino , Naloxona/administración & dosificación
16.
Public Health Rep ; 135(2): 238-244, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-32040928

RESUMEN

OBJECTIVE: No studies using national data have evaluated changes in nonfatal dog bite injuries among children, adolescents, and young adults during the past 2 decades. We examined estimates of annual nonfatal dog bite injuries among persons aged 0-19 treated in US emergency departments (EDs) from 2001 through 2017. METHODS: We examined data from the Web-based Injury Statistics Query and Reporting System to compare estimates of the annual rates of nonfatal dog bite injuries in EDs among all persons aged 0-19, by age group (0-4, 5-9, 10-14, and 15-19), and by sex. We determined significance by comparing 95% confidence intervals (CIs), and we standardized rate calculations to the year 2000 population. RESULTS: During 2001-2017, an estimated 2 406 109 (95% CI, 2 102 643-2 709 573) persons aged 0-19 were treated in EDs for nonfatal dog bite injuries (age-adjusted rate of 173.1 per 100 000 persons aged 0-19). The estimated number of nonfatal dog bite injuries declined significantly, from 181 090 (95% CI, 158 315-203 864) in 2001 to 118 800 (95% CI, 97 933-139 667) in 2017. The highest rate was among children aged 5-9. Male children, adolescents, and young adults were significantly more likely than female children, adolescents, and young adults to be treated in the ED for nonfatal dog bite injuries, driven by male-female differences in children and adolescents aged 5-14. CONCLUSIONS: Although the estimated number of nonfatal dog bite injuries among persons aged 0-19 declined significantly in the past 2 decades, additional regulatory and educational efforts specific to age and sex may lead to further reductions in nonfatal dog bite injuries.


Asunto(s)
Mordeduras y Picaduras/epidemiología , Perros , Heridas y Traumatismos/epidemiología , Adolescente , Factores de Edad , Animales , Niño , Preescolar , Servicio de Urgencia en Hospital/estadística & datos numéricos , Femenino , Humanos , Lactante , Recién Nacido , Masculino , Factores Sexuales , Estados Unidos/epidemiología , Adulto Joven
17.
Am Heart J ; 222: 191-198, 2020 04.
Artículo en Inglés | MEDLINE | ID: mdl-32105985

RESUMEN

BACKGROUND: Data regarding emergency department (ED) assessment of acute chest pain (CP) and incidence of myocardial infarction (MI) among adult congenital heart disease (ACHD) patients, relative to the non-congenital population, is lacking. OBJECTIVES: To describe MI risk in ACHD patients presenting to the ED with chest pain and to compare clinical characteristics, diagnostic testing patterns, and outcomes to controls. METHODS: We retrospectively identified a cohort of ACHD patients presenting with acute CP and matched them with non-ACHD controls at a large tertiary-level ED during the period 1998-2018. RESULTS: The congenital and control cohorts comprised 297 patients respectively. While MI was less common among ACHD patients (5.2%) than controls (19.7%), P = .01, arrhythmia (14% vs 6%, P < .001) and acute heart failure (3% vs 0.3%, P = .02) were more often the cause of symptoms. Despite more often presenting with non-anginal CP (81% vs 66%, P < .001) and having fewer CAD risk factors (P = .03), ACHD patients underwent more frequent stress testing (22% vs 14%, P < .001) and underwent invasive coronary angiography with equal frequency (7% vs 8%, P = .99). The trend of greater diagnostic scrutiny for acute coronary disease, in the absence of increased risk, strongly correlated with degree of congenital complexity. Both CP character and HEART Score reliably predicted MI for ACHD patients and controls (both P < .001). CONCLUSION: MI is an uncommon cause of CP among ACHD patients presenting to the ED and occurs less frequently than seen in the general population. Established MI predictors, CP character and HEART Score, can reliably identify MI in ACHD patients.


Asunto(s)
Dolor en el Pecho/etiología , Angiografía Coronaria/métodos , Electrocardiografía , Servicio de Urgencia en Hospital/estadística & datos numéricos , Cardiopatías Congénitas/complicaciones , Infarto del Miocardio/complicaciones , Enfermedad Aguda , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Dolor en el Pecho/diagnóstico , Dolor en el Pecho/epidemiología , Diagnóstico Diferencial , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Infarto del Miocardio/diagnóstico , Infarto del Miocardio/epidemiología , Estudios Retrospectivos , Estados Unidos/epidemiología , Adulto Joven
18.
PLoS One ; 15(1): e0226597, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-32005036

RESUMEN

PURPOSE: To evaluate whether the early identification of patients who may benefit from palliative care impacts on the use of palliative, community and acute-based care services. METHODS: Between 2014 and 2017, physicians from eight sites were encouraged to systematically identify patients who were likely to die within one year and would were thought to benefit from early palliative care. Patients in the INTEGRATE Intervention Group were 1:1 matched to controls selected from provincial healthcare administrative data using propensity score-matching. The use of palliative care, community-based care services (home care, physician home visit, and outpatient opioid use) and acute care (emergency department, hospitalization) was each evaluated within one year after the date of identification. The hazard ratio (HR) in the Intervention Group was calculated for each outcome. RESULTS: Of the 1,185 patients in the Intervention Group, 951 (80.3%) used palliative care services during follow-up, compared to 739 (62.4%) among 1,185 patients in the Control Group [HR of 1.69 (95% CI 1.56 to 1.82)]. The Intervention Group also had higher proportions of patients who used home care [81.4% vs. 55.2%; HR 2.07 (95% CI 1.89 to 2.27)], had physician home visits [35.5% vs. 23.7%; HR 1.63 (95% CI 1.46 to 1.92)] or had increased outpatient opioid use [64.3% vs. 52.1%); HR 1.43 (95% CI 1.30 to 1.57]. The Intervention Group was also more likely to have a hospitalization that was not primarily focused on palliative care (1.42 (95% CI 1.28 to 1.58)) and an unplanned emergency department visit for non-palliative care purpose (1.47 (95% CI 1.32 to 1.64)). CONCLUSION: Physicians actively identifying patients who would benefit from palliative care resulted in increased use of palliative and community-based care services, but also increased use of acute care services.


Asunto(s)
Servicios de Salud Comunitaria/estadística & datos numéricos , Prestación Integrada de Atención de Salud , Servicio de Urgencia en Hospital/estadística & datos numéricos , Hospitalización/estadística & datos numéricos , Cuidados Paliativos/estadística & datos numéricos , Grupo de Atención al Paciente/normas , Anciano , Estudios de Casos y Controles , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Tasa de Supervivencia
19.
J Korean Med Sci ; 35(7): e54, 2020 Feb 24.
Artículo en Inglés | MEDLINE | ID: mdl-32080988

RESUMEN

Point-of-care ultrasound (POCUS) is a useful tool that is widely used in the emergency and intensive care areas. In Korea, insurance coverage of ultrasound examination has been gradually expanding in accordance with measures to enhance Korean National Insurance Coverage since 2017 to 2021, and which will continue until 2021. Full coverage of health insurance for POCUS in the emergency and critical care areas was implemented in July 2019. The National Health Insurance Act classified POCUS as a single or multiple-targeted ultrasound examination (STU vs. MTU). STU scans are conducted of one organ at a time, while MTU includes scanning of multiple organs simultaneously to determine each clinical situation. POCUS can be performed even if a diagnostic ultrasound examination is conducted, based on the physician's decision. However, the Health Insurance Review and Assessment Service plans to monitor the prescription status of whether the POCUS and diagnostic ultrasound examinations are prescribed simultaneously and repeatedly. Additionally, MTU is allowed only in cases of trauma, cardiac arrest, shock, chest pain, and dyspnea and should be performed by a qualified physician. Although physicians should scan all parts of the chest, heart, and abdomen when they prescribe MTU, they are not required to record all findings in the medical record. Therefore, appropriate prescription, application, and recording of POCUS are needed to enhance the quality of patient care and avoid unnecessary cut of medical budget spending. The present article provides background and clinical guidance for POCUS based on the implementation of full health insurance coverage for POCUS that began in July 2019 in Korea.


Asunto(s)
Cuidados Críticos , Servicio de Urgencia en Hospital , Cobertura del Seguro , Sistemas de Atención de Punto , Ultrasonografía , Cuidados Críticos/estadística & datos numéricos , Servicio de Urgencia en Hospital/estadística & datos numéricos , Humanos , Cobertura del Seguro/estadística & datos numéricos , Pautas de la Práctica en Medicina , República de Corea , Ultrasonografía/estadística & datos numéricos
20.
PLoS One ; 15(2): e0229210, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-32078640

RESUMEN

BACKGROUND: To allow early identification of patients at risk of sepsis in the emergency department (ED), a variety of risk stratification scores and/or triage systems are used. The first aim of this study was to develop a risk stratification score for sepsis based upon vital signs and biomarkers using a statistical approach. Second, we aimed to validate the Rapid Emergency Triage and Treatment System (RETTS) for sepsis. RETTS combines vital signs with symptoms for risk stratification. METHODS: We retrospectively analysed data from two prospective, observational, multicentre cohorts of patients from studies of biomarkers in ED. A candidate risk stratification score called Sepsis Heparin-binding protein-based Early Warning Score (SHEWS) was constructed using the Least Absolute Shrinkage and Selector Operator (LASSO) method. SHEWS and RETTS were compared to National Early Warning Score 2 (NEWS2) for infection-related organ dysfunction, intensive care or death within the first 72h after admission (i.e. sepsis). RESULTS: 506 patients with a diagnosed infection constituted cohort A, in which SHEWS was derived and RETTS was validated. 435 patients constituted cohort B of whom 184 had a diagnosed infection where both scores were validated. In both cohorts (A and B), AUC for infection-related organ dysfunction, intensive care or death was higher for NEWS2, 0.80 (95% CI 0.76-0.84) and 0.69 (95% CI 0.63-0.74), than RETTS, 0.74 (95% CI 0.70-0.79) and 0.55 (95% CI 0.49-0.60), p = 0.05 and p <0.01, respectively. SHEWS had the highest AUC, 0.73 (95% CI 0.68-0.79) p = 0.32 in cohort B. CONCLUSIONS: Even with a statistical approach, we could not construct better risk stratification scores for sepsis than NEWS2. RETTS was inferior to NEWS2 for screening for sepsis.


Asunto(s)
Servicio de Urgencia en Hospital/estadística & datos numéricos , Tratamiento de Urgencia/estadística & datos numéricos , Mortalidad Hospitalaria/tendencias , Modelos Estadísticos , Medición de Riesgo/métodos , Sepsis/diagnóstico , Triaje/normas , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Estudios de Seguimiento , Hospitalización/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios Prospectivos , Curva ROC , Estudios Retrospectivos
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