From symptom onset to ED departure: understanding the acute care chain for patients with undifferentiated complaints: a prospective observational study.

BACKGROUND: For most acute conditions, the phase prior to emergency department (ED) arrival is largely unexplored. However, this prehospital phase has proven an important part of the acute care chain (ACC) for specific time-sensitive conditions, such as stroke and myocardial infarction. For patients with undifferentiated complaints, exploration of the prehospital phase of the ACC may also offer a window of opportunity for improvement of care. This study aims to explore the ACC of ED patients with undifferentiated complaints, with specific emphasis on time in ACC and patient experience. METHODS: This Dutch prospective observational study, included all adult (≥ 18 years) ED patients with undifferentiated complaints over a 4-week period. We investigated the patients' journey through the ACC, focusing on time in ACC and patient experience. Additionally, a multivariable linear regression analysis was employed to identify factors independently associated with time in ACC. RESULTS: Among the 286 ED patients with undifferentiated complaints, the median symptom duration prior to ED visit was 6 days (IQR 2-10), during which 58.6% of patients had contact with a healthcare provider before referral. General Practitioners (GPs) referred 80.4% of the patients, with the predominant patient journey (51.7%) involving GP referral followed by self-transportation to the ED. The median time in ACC was 5.5 (IQR 4.0-8.4) hours of which 40% was spent before the ED visit. GP referral and referral to pulmonology were associated with a longer time in ACC, while referral during evenings was associated with a shorter time in ACC. Patients scored both quality and duration of the provided care an 8/10. CONCLUSION: Dutch ED patients with undifferentiated complaints consulted a healthcare provider in over half of the cases before their ED visit. The median time in ACC is 5.5 h of which 40% is spent in the prehospital phase. Those referred by a GP and to pulmonology had a longer, and those in the evening a shorter time in ACC. The acute care journey starts hours before patients arrive at the ED and 6 days of complaints precede this journey. This timeframe could serve as a window of opportunity to optimise care.

Vital signs, clinical rules, and gut feeling: an observational study among patients with fever.

BACKGROUND: GPs decide which patients with fever need referral to the emergency department (ED). Vital signs, clinical rules, and gut feeling can influence this critical management decision. AIM: To investigate which vital signs are measured by GPs, and whether referral is associated with vital signs, clinical rules, or gut feeling. DESIGN & SETTING: Prospective observational study at two out-of-hours (OOH) GP cooperatives in the Netherlands. METHOD: During two 9-day periods, GPs performed their regular work-up in patients aged ≥18 years with fever (≥38.0°C). Subsequently, researchers measured missing vital signs for completion of the systemic inflammatory response syndrome (SIRS) criteria and the quick Sequential Organ Failure Assessment (qSOFA) score. Associations between the number of referrals, positive SIRS and qSOFA scores, and GPs' gut feelings were investigated. RESULTS: GPs measured and recorded all vital signs required for SIRS criteria and qSOFA score calculations in 24 of 108 (22.2%) assessed patients, and referred 45 (41.7%) to the ED. Higher respiratory rates, temperatures, clinical rules, and gut feeling were associated with referral. During 7-day follow-up, nine (14.3%) of 63 patients who were initially not referred were admitted to hospital. CONCLUSION: GPs measured and recorded all vital signs for SIRS criteria and qSOFA score in one-in-five patients with fever, and referred half of 63 patients who were SIRS-positive and almost all of 22 patients who were qSOFA-positive. Some vital signs and gut feeling were associated with referral, but none were consistently present in all patients who were referred. The vast majority of patients who were not initially referred remained at home during follow-up.

A Rare Case of Hemorrhagic Shock: Morel-Lavallée Lesion.

Hemorrhage is a major cause of death among trauma patients. Controlling the bleeding is essential but can be difficult when the source of bleeding remains unidentified. We present a 67-year-old healthy male with a hypovolemic shock after a suicide attempt by jumping from a height. Apart from a bilateral pneumothorax with multiple rib fractures, a femur fracture and spine fractures, computer tomography (CT) revealed a closed, degloving injury of the back, also known as a Morel-Lavallée lesion. Hemodynamic instability due to hemorrhage caused by a Morel-Lavallée lesion in the lumbar region is very rare and easily overlooked. This case demonstrates the importance of clinical signs of Morel-Lavallée, and illustrates the need for total body CTs to exclude other locations of bleeding and to detect contrast extravasation. This report also discusses the possible treatment options for Morel-Lavallée lesions.

Characteristics of the prehospital phase of adult emergency department patients with an infection: A prospective pilot study.

OBJECTIVE: Research on serious infections/sepsis has focused on the hospital environment, while potentially the most delay, and therefore possibly the best opportunity to improve quality of care, lies in the prehospital setting. In this study we investigated the prehospital phase of adult emergency department (ED) patients with an infection. METHODS: In this prospective pilot study all adult (≥18y) patients with a suspected/proven infection, based on the notes in the patient's ED chart, were included during a 4-week period in 2017. Prehospital course, ED findings, presence of sepsis and 30-day outcomes were registered. RESULTS: A total of 440 patients were identified, with a median symptom duration before ED visit of 3 days (IQR 1-7 days). Before arrival in the ED, 23.9% of patients had used antibiotics. Most patients (83.0%) had been referred by a general practitioner (GP), while 41.1% of patients had visited their GP previously during the current disease episode. Patients referred by a GP were triaged as high-urgency less often, while vital parameters were similar. Emergency Medical Services (EMS) transported 268 (60.9%) of patients. Twenty-two patients (5.0%) experienced an adverse outcome (30-day all-cause mortality and/or admission to intensive care). CONCLUSIONS: Patients with a suspected infection had symptoms for 3 (IQR 1-7) days at the moment of presentation to the ED. During this prehospital phase patients often had consulted, and were treated by, their GP. Many were transported to the ED by EMS. Future research on severe infections should focus on the prehospital phase, targeting patients and primary care professionals.