An Exploratory Analysis of Referrals to a major Emergency Department in a developing country

Background: Hospital crowding, ED waiting times and high demand for unscheduled care all place significant burdens on secondary care services. This impacts on patient care, staff morale and overall functioning of the whole healthcare system. Patient referrals from other healthcare providers often is a result of limited access to resources, specialists or because of acuity. However, some referrals may be more suitable for lower acuity settings, with the benefit of better overall patient experience. In addition, duplication of contacts with a healthcare professional may not result in additional benefit to patients, but may necessarily add to the patient journey and contribute to crowding. Objectives: We aimed to determine the originator of referrals to the ED. We also aimed to determine the proportion of referred patients who received any meaningful intervention at the ED. Finally, we aimed to estimate the proportion of patients referred who may have been suitable for direct inpatient referral or management in a lower acuity setting. Methods: We conducted a prospective evaluation of all referrals to the ED of a large urban hospital over 7 days. Routine anonymised demographic, diagnosis and intervention data were collected and simple descriptive analysis was undertaken using Microsoft Excel®. A validated algorithm was applied to determine suitability for lower acuity settings, and contextual secondary analysis was applied to determine choice of altResults: There were 168 formal referrals during the period evaluated (mean 24/day), of which data was available for 151. Most referrals were on Monday and Thursday. 39.7% were referred from the four regional District Health Facilities (DHF). 12 % were referred by specialists. There were significantly higher referrals from Local Health Centres located more than 5km of the hospital compared with those closer, although this could have been due to greater numbers outside the 5 km radius. 5.5% were thought suitable for primary care management and 31% could have been referred directly to an inpatient team if this were available. The majority (51.3%) of referred patients received no significant intervention in the ED, with almost 1 in 7 suitable for outpatient management. Conclusions: A significant number of patients referred to the ED may have been more appropriately directed. Direct special admission, access to outpatient referral slots or telephone advice from senior ED or specialty clinicians may prevent up to a half of referrals being seen by an ED clinician. This may reduce unnecessary transport, improve time and resource utilization and decongest the ED and hospital. Further large scale evaluation is warranted to investigate the predictors of referral, control for seniority, and make more robust recommendations for improving the patient journey ernate pathways.

Decision-making in the scheduling of endovascular treatment after brain arteriovenous malformation haemorrhage: a retrospective single centre study.

The appropriate timing for endovascular intervention after brain arteriovenous malformation (bAVM) rupture is not known. This paper aims to determine factors that lead to early endovascular intervention and to investigate whether early intervention has the same complication rate as late intervention in a single centre. All patients who underwent endovascular treatment for a ruptured bAVM at our institution in the period January 2007 and July 2010 were included in this retrospective observational study. Of 50 patients, 33 had early endovascular intervention, defined as within 30 days of haemorrhage and the remaining 17 patients had endovascular treatment at day 30 or beyond. A greater proportion of patients treated within the first 30 days were in neuro-intensive care preoperatively (51.5% vs. 23.5%, p=0.07). A 'high-risk' angioarchitectural feature was identified in more patients who had acute intervention (78.8% vs. 11.8%, p<0.0001) and targeted embolization was also more frequent in this group (48.5% vs. 5.9%, p=0.004). Nidal aneurysms, venous varices and impaired venous outflow (venous stenosis) were the principal 'high risk' features. Clinically apparent complications occurred in 10.8% of procedures with permanent neurological deficit in 3.6%. There was no directly procedure-related mortality. There was no statistically significant difference in the complication rate of early procedures compared with delayed interventions (12.5% vs. 7.4%, p=0.71). Greater initial injury severity and the presence of high-risk lesion characteristics are the factors that lead to early endovascular intervention. Early intervention is associated with a higher complication rate, but this difference is not statistically significant.

Idiopathic aneurysms of distal cerebellar arteries: endovascular treatment after rupture.

INTRODUCTION: Idiopathic ruptured aneurysms of distal cerebellar arteries (DCAAs) are rare, and their endovascular therapy (EVT) has as yet not been extensively reported. They are usually assumed to result from local arterial wall disruption rather than infection, unlike distal supratentorial artery aneurysms. This study was performed to audit their frequency, potential aetiology and results of EVT. PATIENTS AND METHODS: Using strict inclusion criteria and a database of 1715 EVT patients, we identified ten idiopathic ruptured DCAAs (0.6%) over a 13-year period (1993-2006). The series comprised six males and four females with mean age of 64 years and solitary aneurysms located on posterior inferior cerebellar artery (five patients), anterior inferior cerebellar artery (three patients) and superior cerebellar artery (two patients). Nine aneurysms were fusiform and were treated by endovascular parent artery occlusion, and one was saccular and treated by endosaccular packing. Endovascular therapy was performed with coils in seven cases, n-butyl-2-cyanoacrylate (NBCA) in two cases and with both in one case. RESULTS: Primary EVT was successful in eight patients. One patient died following a procedure-related re-bleeding and one patient required re-treatment after failed endosaccular packing. Nine patients made good or excellent clinical recoveries (modified Rankin Scale 2 or less). Focal cerebellar infarctions were seen on computed tomography images after EVT in three patients, only one of whom was symptomatic with transient dysmetria, which resolved completely during follow up. No aneurysm recanalisation was detected on late follow-up imaging up to 24 months. CONCLUSION: Ruptured DCAAs are rare. The majority are fusiform in shape and their aetiology remains uncertain. Endovascular treatment is feasible and effective. It usually requires parent artery occlusion.

Embolisation of metachronous pseudoaneurysms complicating chronic pancreatitis.

BACKGROUND: Pseudoaneurysm bleeding is a well-described complication of chronic pancreatitis. Reports of embolisation therapy for metachronous pseudoaneurysms in this condition are rare. We present such a patient and describe his management. CASE OUTLINE: A 5 1-year-old man with chronic pancreatitis who presented with recurrent occult major gastrointestinal bleeding underwent angiography on two separate occasions, 2 years apart. Initial intervention revealed the origin of the coeliac axis to be occluded or absent, and a splenic artery (SA) aneurysm, feeding via the superior mesenteric artery, was embolised. Subsequent angiography after a major bleed showed a new pseudoaneurysm in the head of pancreas feeding from an aberrant hepatic artery, which was embolised. The second angiogram confirmed persistent occlusion of the SA aneurysm and 6 months follow-up showed no evidence of recurrence of the second aneurysm. DISCUSSION: The resolution of these metachronous pseudoaneurysms by angiographic embolisation attests to the validity of this approach as potentially definitive and repeatable therapy.

Case report: abdominal cocoon associated with tuberculous pelvic inflammatory disease.

Abdominal cocoon is a rare acquired condition in which there is encapsulation of the small bowel by a fibrous membrane. The authors describe a case wherein an organism was identified for the first time. The clinical, pathological and radiological features of this unusual disease are reviewed. Peritoneal encapsulation, a related subject, is also discussed.

Non-operative management of haemobilia.

BACKGROUND: The aim was to evaluate a non-operative approach to the management of haemobilia. METHODS: This was a retrospective analysis of patients presenting over 10 years with haemobilia. All patients had upper gastrointestinal endoscopy, abdominal ultrasonography and digital subtraction angiography. Superselective coil and/or Gelfoam embolization was done as close as possible to the bleeding site. Completion angiography was performed routinely to confirm adequate embolization. RESULTS: There were 23 patients with liver trauma and six with inflammatory conditions. All patients required resuscitation with fluids and blood transfusion, and had the haemobilia controlled successfully by angiographic embolization. There was one death from fulminant hepatic sepsis. CONCLUSION: This series attests to the efficacy of a non-operative approach to haemobilia using radiological diagnosis and intervention.

Clinics in diagnostic imaging (68). Intradural extramedullary spinal paraganglioma.

Paragangliomas rarely present as spine tumours. The correct diagnosis is generally not suspected pre-operatively and initial imaging is often non-specific. A 36-year-old man with low back pain, and progressive leg numbness and weakness, was found to have an expansile intradural extramedullary spinal tumour on radiographs and magnetic resonance imaging. Surgery revealed a paraganglioma. The features of spinal paraganglioma and differential diagnosis of intradural extramedullary tumours are discussed.