Frequency of serious outcomes in patients with hypertension as a chief complaint in the emergency department.

CONTEXT: Hypertension is a common incidental finding in the emergency department (ED). However, the authors noticed a segment of patients who present to the ED specifically because their blood pressure is found to be elevated outside of the hospital. Emergency medicine physicians are often unsure of the level of intervention that is required for these patients. OBJECTIVE: To determine if these patients have serious outcomes (ie, final diagnosis of myocardial infarction, angina, coronary syndrome, congestive heart failure, pulmonary edema, hypertensive encephalopathy, malignant hypertension, stroke, transient ischemic attack, subarachnoid hemorrhage, loss of vision, kidney failure, or aortic dissection) within 7 days of the initial ED visit. METHODS: The authors retrospectively reviewed ED medical records from 2008 with a chief complaint of high blood pressure or hypertension in the physician or nursing notes. Age, sex, blood pressure, history of hypertension, associated symptoms, tests, medications, admission or discharge information, final diagnoses, and return visits within 7 days were recorded. RESULTS: Of the 316 medical records that were reviewed, 149 met the study criteria and were included in analysis. Patient age range was 19 to 94 years (mean, 59.8 years; median, 61 years). Sixty patients (40%) were men and 89 (60%) were women. Of the 149 patients, 121 (81%) had a previous diagnosis of hypertension and 28 (19%) did not. Five patients (3%) had a normal initial blood pressure in the ED. Sixteen patients (11%) did not undergo diagnostic tests, and 77 patients (52%) received medication in the ED. Twenty-six patients (17%) were admitted to the hospital, and 123 (83%) were discharged or eloped. Four patients (2.7%; 95% confidence interval, 0.7-6.7) had a serious outcome noted within 7 days of initial presentation to the ED. CONCLUSION: Among patients presenting to the ED with a chief complaint of hypertension or high blood pressure and no serious associated complaint, the risk of serious outcome within 7 days is low.

Validation of a triage algorithm for psychiatric screening (TAPS) for patients with psychiatric chief complaints.

CONTEXT: The process of medical clearance screening for patients with psychiatric chief complaints has not been standardized. OBJECTIVE: To investigate the validity of a triage algorithm for psychiatric screening (TAPS) as a method to screen for the absence of acute medical illness in these patients. METHODS: The current study was a structured, retrospective medical record review in a suburban community teaching hospital with 37,000 emergency department visits per year. All ambulatory patients presenting to triage with a psychiatric chief complaint from January 31, 2001, to June 21, 2002, were assessed with TAPS. Patients with a completed TAPS and a negative assessment were identified and included in the study. A negative TAPS assessment comprised age younger than 65 years, normal vital signs, no medical complaints, no evidence of recent substance use, and no history of schizophrenia, mental retardation, or hallucinations. Emergency department records, return visit records, and inpatient admission records were reviewed for the diagnosis or management of acute medical illness. RESULTS: A total of 1179 patients were assessed with TAPS, of whom 825 (70%) had negative TAPS assessment and were eligible for inclusion. A random sample of 100 patients was selected from this group, with 7 exclusions. Sixty-six (71%) had a history of mental illness and 51 (55%) were admitted. Further, 25 (27%) had laboratory tests ordered, and none of the laboratory results required medical intervention. Twenty-nine patients (31%) received medication, mostly previously prescribed medications or sleep aids. None of the medications were for treating patients with violent or aggressive behavior. The average length of stay was 409 minutes. No patients (95% confidence interval, 0%-3%; P<.05) received a diagnosis of or treatment for acute medical illness. CONCLUSION: The TAPS form is potentially an effective tool in screening for the absence of acute medical illness.

Is early analgesia associated with delayed treatment of appendicitis?

PURPOSE: We sought to investigate the relationship between delay in treatment of appendicitis and early use of analgesia. BASIC PROCEDURES: We designed a matched case-control study, with patients having delayed treatment of appendicitis as the cases and patients with no delay in treatment of appendicitis as controls matched for age, sex, Alvarado score, and date of diagnosis. Of 957 patients with appendicitis, there were 103 delayed cases. Matching patients were identified yielding 103 controls. MAIN FINDINGS: In comparing cases and controls for early opiate use (26/103 cases, 24/103 controls), there was no association with delayed treatment (odds ratio, 1.11; P = .745; 95% confidence interval, 0.59-3.89). When comparing cases and controls for early NSAID use (29/103 cases, 17/103 controls), an association was found with delayed treatment (odds ratio, 1.98; P = .045; 95% confidence interval, 1.01-3.89). CONCLUSION: For early analgesia in appendicitis, we did not find an association with delayed treatment for opiate analgesia, but there did appear to be an association with nonsteroidal anti-inflammatory analgesia.

Appendicitis outcomes with increasing computed tomographic scanning.

PURPOSE: The purpose of the study was to examine appendicitis outcomes over time as computed tomographic (CT) scanning was incorporated into practice. BASIC PROCEDURES: Using chart review, appendectomy cases from 1998 to 2004 were analyzed by year for CT scanning rate, delay in treatment, complications, negative appendectomies, and time to surgery. Delay in treatment was defined as discharge from the ED at first visit or more than 20 hours from examination until surgery. MAIN FINDINGS: Computed tomographic scanning increased from 12.3% in 1998 to 84.4% in 2004. Delay in treatment decreased from 7.8% in 1998 to 3.0% in 2004. Complications decreased from 33.3% in 1998 to 21.3% in 2004. Negative appendectomy rate did not change significantly over time. There was a slight decrease that may have resulted from chances, variation (p=.087) for the line trend. Median time to surgery increased from 250 minutes in 1998 to 426 minutes in 2002, decreasing to 370 minutes by 2004. CONCLUSION: During the period when CT scanning increased dramatically, delays in treatment and complications decreased significantly, but negative appendectomy rates decreased only slightly, if at all. Median time to surgery increased.