THE ASSOCIATION BETWEEN SYSTOLIC BLOOD PRESSURE AND HEART RATE IN EMERGENCY DEPARTMENT PATIENTS: A MULTICENTER COHORT STUDY.

BACKGROUND: Guidelines and textbooks assert that tachycardia is an early and reliable sign of hypotension, and an increased heart rate (HR) is believed to be an early warning sign for the development of shock, although this response may change by aging, pain, and stress. OBJECTIVE: To assess the unadjusted and adjusted associations between systolic blood pressure (SBP) and HR in emergency department (ED) patients of different age categories (18-50 years; 50-80 years; > 80 years). METHODS: A multicenter cohort study using the Netherlands Emergency department Evaluation Database (NEED) including all ED patients ≥ 18 years from three hospitals in whom HR and SBP were registered at arrival to the ED. Findings were validated in a Danish cohort including ED patients. In addition, a separate cohort was used including ED patients with a suspected infection who were hospitalized from whom measurement of SBP and HR were available prior to, during, and after ED treatment. Associations between SBP and HR were visualized and quantified with scatterplots and regression coefficients (95% confidence interval [CI]). RESULTS: A total of 81,750 ED patients were included from the NEED, and a total of 2358 patients with a suspected infection. No associations were found between SBP and HR in any age category (18-50 years: -0.03 beats/min/10 mm Hg, 95% CI -0.13-0.07, 51-80 years: -0.43 beats/min/10 mm Hg, 95% CI -0.38 to -0.50, > 80 years: -0.61 beats/min/10 mm Hg, 95% CI -0.53 to -0.71), nor in different subgroups of ED patient. No increase in HR existed with a decreasing SBP during ED treatment in ED patients with a suspected infection. CONCLUSION: No association between SBP and HR existed in ED patients of any age category, nor in ED patients who were hospitalized with a suspected infection, even during and after ED treatment. Emergency physicians may be misled by traditional concepts about HR disturbances because tachycardia may be absent in hypotension.

Using case vignettes to study the presence of outcome, hindsight, and implicit bias in acute unplanned medical care: a cross-sectional study.

BACKGROUND AND IMPORTANCE: Various biases can impact decision-making and judgment of case quality in the Emergency Department (ED). Outcome and hindsight bias can lead to wrong retrospective judgment of care quality, and implicit bias can result in unjust treatment differences in the ED based on irrelevant patient characteristics. OBJECTIVES: First, to evaluate the extent to which knowledge of an outcome influences physicians' quality of care assessment. Secondly, to examine whether patients with functional disorders receive different treatment compared to patients with a somatic past medical history. DESIGN: A web-based cross-sectional study in which physicians received case vignettes with a case description and care provided. Physicians were informed about vignette outcomes in a randomized way (no, good, or bad outcome). Physicians rated quality of care for four case vignettes with different outcomes. Subsequently, they received two more case vignettes. Physicians were informed about the past medical history of the patient in a randomized way (somatic or functional). Physicians made treatment and diagnostic decisions for both cases. SETTING AND PARTICIPANTS: One hundred ninety-one Dutch emergency physicians (EPs) and general practitioners (GPs) participated. OUTCOME MEASURES AND ANALYSIS: Quality of care was rated on a Likert scale (0-5) and dichotomized as adequate (yes/no). Physicians estimated the likelihood of patients experiencing a bad outcome for hindsight bias. For the second objective, physicians decided on prescribing analgesics and additional diagnostic tests. MAIN RESULTS: Large differences existed in rated quality of care for three out of four vignettes based on different case outcomes. For example, physicians rated the quality of care as adequate in 44% (95% CI 33-57%) for an abdominal pain case with a bad outcome, compared to 88% (95% CI 78-94%) for a good outcome, and 84% (95% CI 73-91%) for no outcome ( P  < 0.01). The estimated likelihood of a bad outcome was higher if physicians received a vignette with a bad patient outcome. Fewer diagnostic tests were performed and fewer opioids were prescribed for patients with a functional disorder. CONCLUSION: Outcome, hindsight, and implicit bias significantly influence decision-making and care quality assessment by Dutch EPs and GPs.

[Hardly any objection from patients against medical information feedback among healthcare workers in the acute care]. / Nauwelijks bezwaar van SEH-patiënten tegen terugkoppeling medische gegevens.

OBJECTIVE: Feedback of patients' medical information among healthcare workers within the acute care could improve the quality of care during an Emergency Department (ED) visit. However, in practice, feedback among healthcare workers leads to juridical discussions. Therefore, this study explores whether ED patients agree with medical information feedback among healthcare workers in the acute care, such as the ambulance staff and ED physicians, and whether this was different from permission for feedback to the general practitioner. METHOD: Multicenter cross-sectional study in three EDs in the Netherlands. Patients ≥18 years old, presented per ambulance between May 3rd and June 12th 2021, filled in a questionnaire asking whether they agree with medical information feedback to ambulance staff and reviewing medical files for follow-up by ED physicians. RESULTS: A total of 369 patients were included with a mean age of 68 years (SD 18). In total, 98,9% of patients agreed with medical information feedback to ambulance staff, which was not significantly different from the 99,2% of patients who agreed with feedback to the general practitioner (p=1.00). CONCLUSION: All but a few ED patients agreed with medical information exchange to ambulance personnel and follow-up by ED-physicians. During ED-visits, medical information feedback to the general practitioner is a standard procedure, with the possibility of an opt-out. In our opinion, feedback and exchange of medical information within the acute care should be arranged similarly.