Leaving Against Medical Advice: Current Problems and Plausible Solutions.

Leave against medical advice (LAMA) is defined as 'a decision to leave the hospital before the treating physician recommends discharge', and is associated with higher rates of readmission, longer subsequent hospitalization, and worse health outcomes. In addition to this, they also contribute to poor healthcare resource utilization. We conducted a single-center audit to establish patient demographics and contributing factors of patients leaving against medical advice from our emergency department (ED). We benchmarked our data against locally available clinical policy guidelines. We interrogated our electronic health record system (known as Salamtak®), which is a Cerner-based platform (Cerner Corporation, Kansas City, MO 64138) for patients who signed LAMA from ED from 2018 to 2023. We selected a convenience pilot sample of 120 subjects. Based on a literature review, we identified patient demographics (age, gender, nationality, socioeconomic status, marital status, religion), possible contributing factors (time of attendance, insurance status, length of ED stay), and patient outcomes (reattendances within 1 week and mortality) to evaluate. Based on locally available guidance, we formulated six criteria to audit with a standard set at 100% for each. A team of emergency medicine residents collected data that was anonymized on an Excel spreadsheet (Microsoft Excel, Microsoft Corporation. (2018). Basic descriptive statistics were used to collate results. About 93 patients (77.5%) were 16 years and above, and 27 patients (22.5%) were below 16 years. There was a slight preponderance of males (64 patients, 53.3%) than females (56 patients, 46.6%). The majority of LAMA cases presented in the evening and night (97 patients, 80.8%). About 57 (47.5%) patients had an ED length of stay of 3 hours or more. The average ED length of stay for these patients was 3.4 hours. About 73 patients (60.3%) were insured. Out of 120 patients, only 12 (10%) had a mental capacity assessment documented. The commonest reason for signing LAMA was a social reason in 45 (37.5%) cases. In the remaining cases, the causes were a combination of family, financial, waiting, or other/undocumented reasons). When faced with a decision to LAMA, the involvement of a Public Relationship Officer (PRO) was only documented to be consulted in seven (5.8%) cases. About 14 cases were re-attended within 1 week (11.6%) and no mortalities were reported in any of the reattendances. LAMA is a not-so-rare phenomenon often occurring in EDs, and often a cause of trepidation for healthcare workers. Treating this as an aberrant behavior on the part of the patient, or laying the responsibility for this action on the healthcare provider is primitive, counter-productive, and not patient-centric. Familiarity with local guidelines around this contentious area is essential. Revised nomenclature like 'premature discharge' may be less stigmatizing for the patient. Where possible, a harm reduction approach should be used and frontline healthcare workers must be prepared with an escalation plan. In the United Arab Emirates, familiarity with Wadeema's Law as a child protection measure is essential.

Procedural Sedation in a UAE Emergency Department: Encouraging Informed Decision-Making Through a Patient Information Leaflet.

Introduction Procedural sedation is a common procedure conducted in emergency departments (ED) across the world, which requires patients to receive anesthesia/sedation medication in a controlled environment in order to alleviate pain, anxiety, and suffering, thereby allowing multiple procedures to be completed in a safe and timely manner. We deploy this technique for joint reductions, burns dressings, wound repairs, etc. in our ED. As a large tertiary referral hospital ED, we aimed to benchmark our practice for this high-acuity procedure against international standards. The main objective of our audit was to benchmark our current practice of procedural sedation against international standards from the Royal College of Emergency Medicine (RCEM), United Kingdom, and American College of Emergency Physicians (ACEP) guidelines. As a secondary objective, we aimed to design and implement a multi-lingual procedural sedation leaflet for our patients and their carers. Methods A retrospective electronic healthcare records review was conducted from January 2019 to August 2022 following which a convenience sample of 100 patients was selected. Records audited were obtained from the Hospital Quality and Pharmacy departments. We selected patients from the data provided by selecting sedation medication used (ketamine, midazolam, propofol) and frequency documented as 'pre-procedure' (Pre-Proc). We included patients of all age groups who received procedural sedation in the emergency department and excluded inpatient encounters. After reviewing RCEM and ACEP guidance, we studied 14 criteria and standards. A team comprising physicians and hospital interpreters was set up to draft a procedural sedation leaflet. After hospital marketing team approval, these were published in Arabic, English, Urdu, Hindi, Bengali, and Malayalam. Results Compliance percentages of the 14 criteria were calculated. A "traffic light" color scheme was used to inform the reader of areas of good practice and areas for improvement. Percentages of 90-100% (green) were considered compliant, 80-89% (amber) were partially compliant, and 79% or less (red) were non-compliant. Of the 14 criteria, 10 were fully compliant. One criterion was partially compliant and three criteria were non-compliant. Conclusion Overall, we performed well in in this audit with 100% compliance rates in many areas. We identified that we had no written discharge information leaflet for our patients and carers. We drafted a multi-lingual procedural sedation leaflet and stocked this in the department. Through face-to-face education, we re-trained physicians on the importance of documentation when adhering to safe practices around procedural sedation.

An Interesting Case of Weakness and Atrial Tachycardia in the Emergency Department: Thinking Beyond Hearts and Minds.

Thyrotoxic periodic paralysis is a rare but life-threatening presentation of hyperthyroidism that manifests with sudden, painless episodes of muscle weakness due to hypokalemia. We present the case of a middle-aged Middle Eastern female who attended our Emergency Department with sudden onset weakness to the lower limbs, resulting in her inability to walk. She had a power of 1/5 in the lower limbs, and subsequent investigations showed a low potassium level, and primary hyperthyroidism secondary to Grave's disease was diagnosed. A 12-lead electrocardiogram showed atrial flutter with a variable block, along with U waves. The patient reverted to sinus rhythm following administration of potassium replacement and was also treated with Propanalol and Carbimazole. The patient made a full neurological recovery.  Emergency physicians and all frontline healthcare workers should be aware that electrolyte problems can cause paralysis. Furthermore, hypokalemic periodic paralysis can be caused by an undiagnosed thyrotoxic state. Be aware that if left untreated, hypokalemia can cause serious atrial and ventricular arrhythmias. Achieving a euthyroid state and blunting hyperadrenergic stimulation, in addition to replacing potassium, all help to fully reverse muscle weakness.

Facial Swelling Mimicking Anaphylaxis: A Case of Superior Vena Cava Syndrome in the Emergency Department.

Superior vena cava (SVC) syndrome represents clinical manifestations from obstruction of the SVC. It is an uncommon medical emergency that is commonly missed. SVC obstruction is usually caused by extraluminal compression by an intrathoracic mass or intraluminal obstruction from a thrombus. The latter is more common in patients with indwelling central venous catheters and pacemaker leads. Here, we present the case of a 53-year-old woman who presented to the emergency department (ED) with clinical features which were initially diagnosed as anaphylaxis and subsequently diagnosed as a case of SVC syndrome. In this case, diagnostic challenges in the ED and the potential role of cognitive bias are highlighted. In addition, we discuss the clinical manifestations and management of SVC syndrome.

Chest Pain and Electrocardiographic Changes in a Child With Duchenne Muscular Dystrophy.

A 12-year-old boy known to have Duchenne muscular dystrophy presented to our Emergency Department with acute onset central chest pain. A 12-lead electrocardiogram (ECG) was performed showing ST-segment elevation with reciprocal changes. An echocardiogram showed reduced left ventricular systolic function with an ejection fraction of 45%. Initial cardiac biomarkers were significantly elevated, with troponin-T result recorded at 7,065 ng/L (reference range: 0-14 ng/L). The patient was admitted to the pediatric intensive care unit with a differential diagnosis of acute myocardial infarction or acute myocardial injury related to cardiomyopathy and commenced on an ACE (angiotensin-converting enzyme) inhibitor. Computed tomography (CT) of the coronary arteries was performed, which showed normal coronary arteries and cardiac anatomy. The patient was discharged on day 5 and continues to follow up in the pediatric cardiology clinic. He was commenced on a beta blocker at one-month follow-up when he was asymptomatic.

Jejunojejunal intussusception in an adult: a rare presentation of abdominal pain in the emergency department.

Abdominal pain is a common presentation to the emergency department (ED) and the differential diagnoses is broad. Intussusception is more common in children, with only 5% of cases reported in adults. 80%-90% of adult intussusception is due to a well-defined lesion resulting in a lead point, whereas in children, most cases are idiopathic. The most common site of involvement in adults is the small bowel. Treatment in adults is generally operative management whereas in children, a more conservative approach is taken with non-operative reduction. We present a case of a 54-year-old woman who presented to our ED with severe abdominal pain and vomiting. CT of the abdomen revealed a jejunojejunal intussusception. The patient had an urgent laparoscopy and small bowel resection of the intussusception segment was performed. Histopathological examination of the resected specimen found no pathologic lead point and, therefore, the intussusception was determined to be idiopathic.

Incidental diagnosis of situs inversus totalis: a perspective from an emergency department attendance.

A 30-year-old man of African origin presented to our emergency department (ED) with subjective fever and abdominal pain which started on the day of attendance. Vital signs and systemical examination were within normal limits. As part of his evaluation in ED, a 12-lead electrocardiogram was performed which showed features consistent with dextrocardia later confirmed on a chest X-ray as well. An ultrasound scan of the abdomen was performed which showed mirror imaging of the abdominal viscera, all of which were otherwise structurally normal. A diagnosis of situs inversus totalis was made. The patient's symptoms resolved with analgesia and he was discharged with advice to follow-up in our hospital's outpatient department. The diagnosis of situs inversus in the ED is a tricky one to make and most cases of this condition are discovered incidentally, as in our case. The mirror-imaged arrangement of viscera can have implications on the site of localised complaints, the physical examination, future health problems for the patient including anaesthesia risks, chronic lung conditions, cardiac complications and specialised trauma management. This anatomical variation can pose diagnostic challenges in such patients. Based on meticulous examination and readily accessible investigations including X-rays, 12-lead ECG and ultrasound, a timely diagnosis can be made.

Diagnostic accuracy of the magnetocardiograph for patients with suspected acute coronary syndrome.

BACKGROUND: We aimed to estimate the diagnostic accuracy of the VitalScan magnetocardiograph (MCG) for suspected acute coronary syndrome (ACS). METHODS: We undertook a prospective cohort study evaluating the diagnostic accuracy of the MCG in adults with suspected ACS. The reference standard of ACS was determined by an independent adjudication committee based on 30-day investigations and events. The cohort was split into a training sample, to derive the MCG algorithm and an algorithm combining MCG with a modified Manchester Acute Coronary Syndrome (MACS) clinical probability score, and a validation sample, to estimate diagnostic accuracy. RESULTS: We recruited 756 participants and analysed data from 680 (293 training, 387 validation), of whom 96 (14%) had ACS. In the training sample, the respective area under the receiver operating characteristic (AUROC) curves were the following: MCG 0.66 (95% CI 0.58 to 0.74), MACS 0.64 (95% CI 0.54 to 0.73) and MCG+MACS 0.70 (95% CI 0.63 to 0.77). MCG specificity was 0.16 (95% CI 0.12 to 0.21) at the threshold achieving acceptable sensitivity for rule-out (>0.98). In the validation sample (n=387), the respective AUROCs were the following: MCG 0.56 (95% CI 0.48 to 0.64), MACS 0.69 (95% CI 0.61 to 0.77) and MCG+MACS 0.64 (95% CI 0.56 to 0.72). MCG sensitivity was 0.89 (95% CI 0.77 to 0.95) and specificity 0.15 (95% CI 0.12 to 0.20) at the rule-out threshold. MCG+MACS sensitivity was 0.85 (95% CI 0.73 to 0.92) and specificity 0.30 (95% CI 0.25 to 0.35). CONCLUSION: The VitalScan MCG is currently unable to accurately rule out ACS and is not yet ready for use in clinical practice. Further developmental research is required.

'See and Treat' Clinic Service Evaluation at a Tertiary Care Hospital in Abu Dhabi.

OBJECTIVES: We sought to evaluate the performance provided at a 'See and Treat' (ST) clinic at a tertiary hospital emergency department (ED) in Abu Dhabi, UAE, and to assess its impact on ED crowding. METHODS: We conducted a retrospective electronic medical chart review and database analyses. We included patients triaged as triage level 4 (T4) and triage level 5 (T5) as per the Emergency Severity Index treated at ED in the ST clinic and other ED areas, including the off-site Urgent Care Centre (UCC) between 1 June 2016 and 30 June 2017. We analyzed a group of process and outcome measures at our ST clinic and compared them to the same measures in other areas of our ED and the co-located UCC. The process measure analyzed was the door-to-doctor time. In addition, the outcome measures analyzed were the door-to-door time, unplanned return within 72 hours, and feedback from T4 and T5 triaged patients treated at the clinic. RESULTS: The number of patients enrolled in the study was 43 109. Of these, 11 329 (26.3%) patients were treated at the ST clinic, 6328 (14.7%) were treated at the UCC, and 25 452 (59.0%) were treated at the main ED. The door-to-doctor time was within 30 minutes for 89.0% of ST clinic patients, and 94.0% of patients experienced a door-to-door time of within two hours; 2.1% of these patients returned within 72 hours. Among these, 78.7% returned for an issue related to their first visit. However, none of the patients were admitted on their return visit. For patients presenting to UCC and other parts of our ED, we recorded a door-to-doctor time of within 30 minutes for 80.5% of patients and a door-to-door time of within two hours for 73.0% of patients. We found the difference in waiting times (i.e., door-to-doctor times between ST clinic patients and the rest of ED) to be statistically significant (p < 0.001, 95% confidence interval (CI): 0.56-0.63). However, on comparing door-to-door times, we found the difference between ST clinic patients and the rest of ED patients was not statistically significant. CONCLUSIONS: Door-to-doctor times were shorter in ST clinics compared to other parts of our ED, but there was no statistically significant difference in door-to-door times when comparing ST clinics to the rest of the ED. ST clinic patients had a lower rate of unplanned return within 72 hours, of which, none required admission on the return attendance. We believe ST clinics have a positive impact on reducing ED crowding but acknowledge they are one of the many plausible solutions attributing to optimized patient flow in the ED.

Recognising the de Winter ECG pattern - A time critical electrocardiographic diagnosis in the Emergency Department.

The de Winter ECG pattern is associated with proximal left anterior descending artery occlusion, being a significant risk factor for anterior wall ST elevation myocardial infarction. We present a case of a patient who attended our Emergency Department with chest pain and a prehospital ECG demonstrating transient infero-lateral lead ST segment elevation, which changed to the de Winter ECG pattern in our Emergency Department. She subsequently underwent primary PCI of the culprit lesion within the left anterior descending artery (LAD). Recognition of de Winter ECG pattern in the Emergency Department results in a time critical diagnosis for acute coronary occlusion and should be followed by emergency coronary revascularization.

Occupational stress in the ED: a systematic literature review.

INTRODUCTION: Occupational stress is a major modern health and safety challenges. While the ED is known to be a high-pressure environment, the specific organisational stressors which affect ED staff have not been established. METHODS: We conducted a systematic review of literature examining the sources of organisational stress in the ED, their link to adverse health outcomes and interventions designed to address them. A narrative review of contextual factors that may contribute to occupational stress was also performed. All articles written in English, French or Spanish were eligible for conclusion. Study quality was graded using a modified version of the Newcastle-Ottawa Scale. RESULTS: Twenty-five full-text articles were eligible for inclusion in our systematic review. Most were of moderate quality, with two low-quality and two high-quality studies, respectively. While high demand and low job control were commonly featured, other studies demonstrated the role of insufficient support at work, effort-reward imbalance and organisational injustice in the development of adverse health and occupational outcomes. We found only one intervention in a peer-reviewed journal evaluating a stress reduction programme in ED staff. CONCLUSIONS: Our review provides a guide to developing interventions that target the origins of stress in the ED. It suggests that those which reduce demand and increase workers' control over their job, improve managerial support, establish better working relationships and make workers' feel more valued for their efforts could be beneficial. We have detailed examples of successful interventions from other fields which may be applicable to this setting.

The safety of emergency medicine.

The patient safety movement has been active for over a decade, but the issue of patient safety in emergency care and the emergency department (ED) has only recently been brought into the forefront. The ED environment has traditionally been considered unsafe, but there is little data to support this assertion. This paper reviews the literature on patient safety and highlights the challenges associated with using the current evidence base to inform practice due to the variability in methods of measuring safety. Studies looking at safety in the ED report low rates for adverse events ranging from 3.6 to 32.6 events per 1000 attendances. The wide variation in reported rates on adverse events reflects the significant differences in methods of reporting and classifying safety incidents and harm between departments; standardisation in the ED context is urgently required to allow comparisons to be made between departments and to quantify the impact of specific interventions. We outline the key factors in emergency care which may hinder the provision of safer care and consider solutions which have evolved or been proposed to identify and mitigate against harm. Interventions such as team training, telephone follow-up, ED pharmacist interventions and rounding, all show some evidence of improving safety in the ED. We further highlight the need for a collaborative whole system approach as almost half of safety incidents in the ED are attributable to external factors, particularly those related to information flow, crowding, demand and boarding.

Can ocular ultrasound predict intracranial hypertension? A pilot diagnostic accuracy evaluation in a UK emergency department.

OBJECTIVE: To determine if ultrasound guided measurement of the optic nerve sheath diameter accurately predicted elevated intracranial pressure (ICP) as demonstrated by cranial computed tomography (CT) in at-risk emergency department patients. METHODS: Optic nerve sheath diameters were measured on a convenience sample of adult patients presenting with suspected elevated ICP to the emergency department of a large teaching hospital over a 6-month period. A cut off for optic nerve sheath diameter of 5 mm was considered positive for elevated ICP. All patients had a subsequent cranial CT scan on the same day reported by a radiologist. Signs of elevated ICP on cranial CT include midline shift with a mass effect of at least 3 mm, sulcal effacement with evidence of significant oedema, collapse of ventricles, and cisternal compression. RESULTS: Twenty-four patients were recruited with a sensitivity of 100% [95% confidence interval (CI), 83.8-100] and specificity of 75% (95% CI, 30.1-95.4) with a cut-off of 5 mm for optic nerve sheath diameter to predict elevated ICP on cranial CT scan. The positive predictive value for an increased optic nerve sheath diameter for elevated ICP was 95.4% (95% CI, 74.13-99.75) and negative predictive value was 100% (95% CI, 31-100). The positive likelihood ratio of a wide optic nerve sheath diameter for elevated ICP on cranial CT was calculated to be 4.00 (95% CI, 0.73-21.84). CONCLUSION: This study shows that the ultrasound guided optic nerve sheath diameter is a sensitive and specific test for predicting elevated ICP. A prospective validation study across emergency departments would test applicability of this test. We propose an algorithm for incorporating ultrasound for the management of suspected intracranial hypertension in emergency departments.