Improvement of emergency department patient flow using lean thinking.

OBJECTIVE: To apply lean thinking in triage acuity level-3 patients in order to improve emergency department (ED) throughtput and waiting time. DESIGN: A prospective interventional study. SETTING: An ED of a tertiary care hospital. PARTICIPANTS: Triage acuity level-3 patients. INTERVENTION(S): To apply lean techniques such as value stream mapping, workplace organization, reduction of wastes and standardization by the frontline staff. MAIN OUTCOME MEASURE(S): Two periods were compared: (i) pre-lean: April-September, 2015; and (ii) post-lean: April-September, 2016. Variables included: median process time (time from beginning of nurse preparation to the end of nurse finalization after doctor disposition) of both discharged and transferred to observation patients; median length of stay; median waiting time; left without being seen, 72-h revisit and mortality rates, and daily number of visits. There was no additional staff or bed after lean implementation. RESULTS: Despite an increment in the daily number of visits (+8.3%, P < 0.001), significant reductions in process time of discharged (182 vs 160 min, P < 0.001) and transferred to observation (186 vs 176 min, P < 0.001) patients, in length of stay (389 vs 329 min, P < 0.001), and in waiting time (71 vs 48 min, P < 0.001) were achieved after lean implementation. No significant differences were registered in left without being seen rate (5.23% vs 4.95%), 72-h revisit rate (3.41% vs 3.93%), and mortality rate (0.23% vs 0.15%). CONCLUSION: Lean thinking is a methodology that can improve triage acuity level-3 patient flow in the ED, resulting in better throughput along with reduced waiting time.

Changes in the etiology, incidence and prognosis of acute lower respiratory track infections in human immunodeficiency virus patients.

AIM: To describe the incidence, the changes in the etiology and the prognosis of lower respiratory tract infection (LRTI) in HIV infected patients, presenting by the first time to the Emergency Department (ED), during years 2000-2010. STUDY DESIGN: Prospective collection of data. METHODS: Data were collected on the first visit of HIV-infected patients at our ED due to a LRTI, (defined according to the criteria of the European Respiratory Society), between 1/1/2000 and 31/12/2010. A series of epidemiological and laboratory variables as well as the need for admission to the intensive care unit (ICU). LRTI etiology were also collected. The influence ofthe mentioned variables on 30-day mortality were analyzed. RESULTS: One hundred thirty one patients were included. LRTI represented 27% of visits to the ED by HIV-infected patients. Mean age was 39±9 years. 72% of patients were males. 18% required admission to the ICU. The most frequent LRTI was pneumonia by P. jiroveci in 35 cases, bacterial penumonia in 27 and pulmonary tuberculosis in 20. LRTI incidence gradually reduced significantly over time from 6.13 × 1000 patients/year in year 2000 to 0.23 × 1000 patients/year in 2010 (p<0.05). Overall mortality was 14%. Logistic regression analysis showed that admission to ICU (p<0.004) and viral load (p<0.029) were independent variables predicting mortality. CONCLUSION: LRTI is a pathology with a decreasing incidence, probably related to the widespread utilization increased of HAART regimens. lts etiology has also been changing, but with a non negligible mortality, mostly when ICU admission was required.

The utility of copeptin in the emergency department as a predictor of adverse outcomes in non-ST-elevation acute coronary syndrome: the COPED-PAO study.

AIMS: To test the utility of a single copeptin determination at presentation to the emergency department (ED) as a short-term prognosis marker in patients with non-ST-elevation acute coronary syndrome (NSTEACS). To compare the results with those achieved with conventional troponin. METHODS: A multicentric, prospective, observational, longitudinal, cohort study involving 15 Spanish EDs. Inclusion: consecutive patients with chest pain (<12 h) finally diagnosed of NSTEACS. MEASUREMENTS: copeptin and troponin at arrival. Cut-off point for copeptin: 25.9 pmol/l. FOLLOW-UP: within 2 months after ED attendance to identify 30-day adverse events. Discriminatory capacity of copeptin and troponin was compared by receiver operating characteristic (ROC) curves. RESULTS: We included 377 patients with NSTEACS. Adverse events: 11 (2.9%) patients died, 27 (7.2%) had an adverse coronary event, 14 (3.7%) had a stroke, and 48 (12.7%) a composite endpoint. The initial copeptine value was over 25.9 pmol/l in 114 patients, and they presented a higher mortality rate (OR: 4.2, (95% CI 1.2 to 14.8); p=0.03). This association disappeared after adjusting by clinical variables or troponin level. No significant differences were found for the remaining endpoints. The area under the curve of the ROC curve of 30-day mortality was 0.73 (95% CI 0.58 to 0.87) for copeptin, and 0.80 (95% CI 0.73 to 0.87) for troponin. CONCLUSIONS: In patients with NSTEACS, determination of copeptin at presentation to the ED is associated with risk of death during the subsequent month. This association, however, disappears after adjusting by baseline features or troponin level, so copeptin does not add complementary prognostic information over that provided by troponin.

Factors associated with erroneous emergency department noncardiac chest pain classifications in men and women. / Análisis individualizado por sexo de los factores asociados a la clasificación inicial errónea en urgencias del dolor torácico como no coronario.

OBJECTIVES: To analyze the frequency and clinical characteristics associated with erroneous initial classifications of noncardiac chest pain (NCP) in men and women. MATERIAL AND METHODS: We analyzed all case records in which chest pain was initially classified as noncardiac in origin according to clinical signs and electrocardiograms evaluated in our emergency department between 2008 and 2017. We considered the initial evaluation of NCP to be in error if the final diagnosis was acute coronary syndrome. A risk model for an erroneous initial classification of NCP was developed based on multivariable analysis of our patient data. We also used multivariable analysis to explore associations between 10 clinical signs of chest pain and an erroneous initial NCP classification. The data for men and women were analyzed separately. RESULTS: NCP was the initial classification for 8093 women; their median (interquartile range) age was 54 (38-73) years. The classification was in error for 72 women (0.9%). Odds ratios (ORs) showed that patient risk factors associated with an erroneous NCP classification in the women in our series were obesity (OR, 0.40; 95% CI, 0.17- 0.97) and cocaine consumption (OR, 5.18; 95% CI, 1.16-23.2). Clinical risk factors associated with erroneous NCP classification in women were recent physical exertion (OR, 2.01; 95% CI, 1.21-3.33), radiation exposure (OR, 2.05; 95% CI, 1.23-3.41), and vegetative symptoms (OR, 1.86; 95% CI, 1.02-3.41). For 9979 men with a median age of 47 (33-64) years, NCP was the initial classification; in 83 of the men (0.8%) the classification was erroneous. Patient factors associated with erroneous NCP classification in men were age over 40 years (OR, 1.74; 95% CI, 1.04-2.91) and hypertension (OR, 0.45; 95% CI, 0.24-0.84). No clinical signs of chest pain in men were associated with error. CONCLUSION: More clinical characteristics are associated with an erroneous classification of NCP in women. Our findings underline the need to assess the possibility of acute coronary syndrome differently in women, in whom the signs have usually been considered to be atypical.

OBJETIVO: Analizar de forma independiente en mujeres y hombres la frecuencia y las características clínicas asociadas a una clasificación inicial errónea (CIE) en urgencias del dolor torácico (DT) como no coronario. METODO: Se analizan todas las consultas por DT atendidas en urgencias entre 2008 y 2017 clasificadas inicialmente (historia clínica y ECG) como DT no coronario. Se consideró como CIE si el diagnóstico final fue síndrome coronario agudo (SCA). Se crearon dos modelos multivariable, uno con 10 factores de riesgo, y otro con 10 características clínicas del DT, en los que se investigó la asociación de estas variables con una CIE. Se analizaron independientemente mujeres y hombres. RESULTADOS: Se analizaron 8.093 mujeres con DT clasificado inicialmente como no coronario (edad mediana: 54 años, RIC: 38-73), 72 con CIE (0,9%). Los factores de riesgo asociados independientemente a CIE fueron obesidad (OR = 0,40; IC 95% = 0,17-0,97) y consumo de cocaína (5,18; 1,16-23,2), y las características clínicas fueron relación con el esfuerzo (2,01; 1,21-3,33), existencia de irradiación (2,05; 1,23-3,41) y síntomas vegetativos acompañantes (1,86; 1,02-3,41). Se analizaron 9.979 hombres (edad mediana: 47 años, RIC: 33-64), 83 con CIE (0,8%). Los factores de riesgo asociados a CIE fueron edad > 40 años (1,74; 1,04-2,91) e hipertensión (0,45; 0,24-0,84). No hubo características clínicas del DT asociadas a CIE. CONCLUSIONES: En las mujeres con dolor torácico, se idenfitican más características asociadas al error de clasificación que en los hombres. Este estudio remarca la necesidad de análisis independiente por sexo en el SCA, en el que clásicamente se ha considerado la clínica en las mujeres como atípica.

WtsWrng Interim Comparative Effectiveness Evaluation and Description of the Challenges to Develop, Assess, and Introduce This Novel Digital Application in a Traditional Health System.

Science and technology have evolved quickly during the two decades of the 21st century, but healthcare systems are grounded in last century's structure and processes. Changes in the way health care is provided are demanded; digital transformation is a key driver making healthcare systems more accessible, agile, efficient, and citizen-centered. Nevertheless, the way healthcare systems function challenges the development (Innovation + Development and regulatory requirements), assessment (methodological guidance weaknesses), and adoption of digital applications (DAs). WtsWrng (WW), an innovative DA which uses images to interact with citizens for symptom triage and monitoring, is used as an example to show the challenges faced in its development and clinical validation and how these are being overcome. To prove WW's value from inception, novel approaches for evidence generation that allows for an agile and patient-centered development have been applied. Early scientific advice from NICE (UK) was sought for study design, an iterative development and interim analysis was performed, and different statistical parameters (Kappa, B statistic) were explored to face development and assessment challenges. WW triage accuracy at cutoff time ranged from 0.62 to 0.94 for the most frequent symptoms attending the Emergency Department (ED), with the observed concordance for the 12 most frequent diagnostics at hospital discharge fluctuating between 0.4 to 0.97; 8 of the diagnostics had a concordance greater than 0.8. This experience should provoke reflective thinking for DA developers, digital health scientists, regulators, health technology assessors, and payers.

Factors associated with late presentation to the emergency department in patients complaining of chest pain.

OBJECTIVE: We investigated which factors predict late presentation (LP) to the emergency department (ED) in patients with non-traumatic chest pain (CP). METHODS: All CP cases attended at a single ED (2008-2017) were included. LP was considered if time from CP onset to ED arrival was>6 h. We analyzed associations between 42 patient/CP-related characteristics and LP in the whole cohort and in patients with CP due to acute coronary syndrome (ACS). RESULTS: The cohort included 25,693 cases (LP=50.6%; ACS=19.0%). Twenty factors were associated with LP, and 8 were also found in patients with ACS: CP of short-duration, aggravated by exertion or breathing/movement, undulating or recurrent CP increased the risk of LP, whereas CP accompanied by diaphoresis, irradiated to the throat, and chronic treatment with nitrates decreased the risk of LP. Exertional and recurrent CP were associated with both, LP and ACS. CONCLUSION: Some characteristics, mainly CP-related, may lead to LP to the ED. CP aggravated by exercise and recurrent CP were associated with both LP and a final diagnosis of ACS. PRACTICE IMPLICATIONS: Patient educational initiatives should consider these two features as potential warnings for ACS and thereby encourage patients to seek early medical consultation.

Validation of a triage flowchart to rule out acute coronary syndrome.

OBJECTIVE: To validate a triage flowchart to rule out acute coronary syndrome (ACS) in chest pain patients attending the emergency department (ED). METHODS: An observational cohort study of consecutive patients. In all cases, a previously derived five-step triage flowchart (age ≤ 40 years, absence of diabetes, not previously known coronary artery disease, non-oppressive and non-retrosternal pain) was applied. Patients meeting all five discriminators were grouped as 'five-step triage non-ACS', the rest as 'five-step triage ACS'. The same strategy was used with a four-step model (without age ≤ 40 years). After ED study and 1-month follow-up, patients were definitively classified as 'true ACS' or 'true non-ACS'. Validity indexes and receiver operating characteristics curves were calculated. RESULTS: 4231 patients were included: 918 (21.7%) were 'true ACS', 3303 (78.1%) 'true non-ACS'; 10 (0.2%) were lost to follow-up. The five-step triage flowchart classified 4000 (94.8%) as 'triage ACS' and 221 (5.2%) as 'triage non-ACS'; none of the latter was 'true ACS'. The four-step model classified 3194 (75.6%) as 'triage ACS' and 1027 (24.4%) as 'triage non-ACS'. A 'true ACS' was seen in 26 patients from the latter group. Accordingly, five-step triage flowchart specificity and positive predictive value (PPV) to rule out ACS were 100% (95% CI 100% to 100%). For the four-step model specificity and PPV were 97% (95% CI 96% to 98%). CONCLUSION: The five-step triage flowchart identifies chest pain patients without an ACS. However, only 5% of these patients meet these five criteria. A simpler model allows greater patient inclusion but a higher risk of misclassification of true ACS.

Influence of previous coronary artery bypass grafting in the difficulty of acute coronary syndrome diagnosis.

OBJECTIVES: To investigate whether the diagnosis of acute coronary syndrome (ACS) in coronary artery bypass grafting (CABG) patients with chest pain (CP) is more difficult based on the initial clinical and electrocardiogram (ECG) findings. METHODS: We included consecutive CP patients attended at a single emergency department (ED) during a 10-year period. CABG status and the final diagnosis of ACS were considered as stated in the ED discharge report. We evaluated the frequency of 21 CP characteristics (CPC) and four ECG signatures, their individual and collective association with ACS, and ED length of stay (LOS) in CABG and non-CABG patients. RESULTS: We included 34 429 patients [median age: 61 years; female: 41.8%; CABG: 2204 patients (6.4%)], and ACS was diagnosed in 6727 (19.5%; CABG/non-CABG 37.2%/18.3%; P < 0.001). CABG patients more frequently had CPC and ECG findings typically associated with ACS, but their final association with ACS was weaker than in non-CABG patients (only significant after adjustment for attendant diaphoresis, throat irradiation, ST-segment elevation and T-wave inversion). The collective discriminative capacity was significantly lower in CABG patients (area under the curve 0.710 vs. 0.793; P < 0.001), even after adjustment (0.708 vs. 0.790; P < 0.001). ED LOS was longer for CABG patients, overall (P < 0.001) and for patients diagnosed with ACS (P = 0.008) and non-ACS (P < 0.001), but these differences disappeared after adjustment. CONCLUSION: CABG substantially reduces the diagnostic performance of CPC and ECG findings to suggest ACS. A longer LOS in the ED in CABG patients is more related to their baseline characteristics than to CABG itself.

Predicting bacteremic pneumonia in HIV-1-infected patients consulting the ED.

INTRODUCTION: HIV-1-infected patients have higher incidence of community-acquired pneumonia (CAP) and risk of complications. Bacteremia has been associated with a higher risk of complications in such patients. We investigated factors associated with bacteremia in HIV-1-infected patients with CAP presenting at the emergency department. METHODS: We included HIV-1-infected patients with CAP for 3 years (March 2005-February 2008). Only patients in whom blood cultures were performed were finally included. Clinical data (age; sex; CD4(+) count; serum HIV viral load; previous or current intravenous drug use and antiretroviral treatment; systolic blood pressure; and cardiac and respiratory rates), analytical data (leukocyte count, arterial oxygen content, C-reactive protein value, and urgent Streptococcus pneumoniae and Legionella spp antigen urine detection), and APACHE-II (Acute Physiology and Chronic Health Evaluation) score were compiled. The need for intensive care unit admission, mechanical ventilation, mortality, and for patients finally discharged, duration of admission were retrospectively obtained from the clinical history. A multivariate analysis using logistic regression was performed to find independent predictors of bacteremia. RESULTS: We diagnosed 129 HIV-1-infected patients with CAP. Blood cultures were performed in 118 cases (91%). Bacteremia was present in 28 (24%). Independent predictors of bacteremia were the detection of S pneumoniae antigen in urine (odds ratio, 9.0; 95% confidence interval, 1.9-42.0) and the absence of current antiretroviral treatment (odds ratio, 7.1; 95% confidence interval, 1.4-33.3). In-hospital mortality was higher in patients with bacteremia (15% vs 0%). CONCLUSION: HIV-1-infected patients with CAP who are not on current antiretroviral therapy and have positive S pneumoniae antigenuria are at increased risk of having bacteremia. Bacteremic patients have a poor outcome.

Prehospital emergency services in Catalonia: the SEPHCAT analysis. / Estudio SEPHCAT: análisis de los servicios de emergencias prehospitalarios en Cataluña.

OBJECTIVES: To describe the main characteristics of all prehospital emergency services (SEPHs, the Catalan acronym) in Catalonia (the SEPHCAT study). MATERIAL AND METHODS: A professional survey researcher interviewed the medical directors of all services in Catalonia, using a questionnaire prepared by the authors. Questions covered aspects related to organization, professional staffing and employment conditions, as well as the staff's training, instructional activity and research. Only closed answers were collected. The survey reflected the situation in 2015. RESULTS: We identified 13 SEPHs (11 in the public health service and 2 private companies). Together they received 2 482 627 calls (16.4% to private services) and attended 943 849 emergencies (11.8% attended by private companies). Three hundred thirty-six basic life support units and 73 advanced life support units were reported. They were mostly considered to be of sufficient size and quality. The SEPHs contracted 1374845 person-hours/y (753995 physician-hours and 620 850 nurse-hours; 23.4% in private companies). These figures correspond to 815 full-time staff positions (447 for physicians and 368 for nurses). The numbers of physicians and nurses working were relatively stable during the morning, afternoon and evening shifts but decreased during the midnight-to-early-morning shift (physicians, by 31%; nurses, by 9%). A majority of the physicians employed were trained in family and community medicine (56.8%), but 21.3% had no specialized training; 6.5% had PhD degrees. SEPH physicians (61.5%) and nurses (46.2%) also taught undergraduate medical students; 46.2% of physicians and 84.6% of nurses taught postgraduate medical courses. Both undergraduate medical and nursing students were received in the same measure for practical training by 15.4% of the SEPHs; 69.2% also offered practical training for physicians at the postgraduate level and 76.9% trained postgraduate nurses. CONCLUSION: SEPHs in Catalonia are very active, and private companies account for nearly 12% of the activity. Together the public and private sectors employ a large number of physicians and nurses. Staff members are involved in training others but are less involved in research.

OBJETIVO: Describir las principales características de todos los servicios de emergencias prehospitalarios (SEPH) existentes en Cataluña. METODO: Una encuestadora profesional entrevistó a los responsables clínicos de todos los SEPH de Cataluña. La encuesta fue preparada por los autores, y abordaba diversos aspectos organizativos, profesionales, laborales, formativos, docentes y de investigación. Las preguntas contenidas en la encuesta solo permitían respuestas cerradas, y hacían referencia a la situación en 2015. RESULTADOS: Se identificaron 13 SEPH (11 públicos, 2 privados), que recibieron 2.482.627 consultas (16,4% a SEPH privados) y realizaron 943.849 atenciones (11,8% por SEPH privados). Había 336 bases de soporte vital básico y 73 de avanzado, con instalaciones mayoritariamente consideradas de tamaño suficiente y calidad buena. Se contrataron 1.374.845 horas anuales (753.995 de médico y 620.850 de enfermero), el 23,4% de ellas por SEPH privados, que globalmente corresponderían a 815 puestos de trabajo a jornada completa (447 de médico, 368 de enfermero). La dotación de médicos/enfermeros era relativamente estable durante el día, pero decaía un 31%/9% de madrugada. La especialidad médica mayoritaria era medicina familiar y comunitaria (56,8%), el 21,3% no tenía formación especializada, y el 6,5% tenía título de doctor. Había médicos/enfermeros profesores universitarios de grado en el 61,5%/46,2% de los SEPH; y de postgrado en el 46,2%/84,6%. Recibían estudiantes de medicina/enfermería en prácticas de grado el 15,4%/15,4% de los SEPH, y de postgrado el 69,2%/76,9%. CONCLUSIONES: La actividad de los SEPH en Cataluña es elevada; un 12% la desarrollan SEPH privados, y globalmente implica a un número alto de médicos y enfermeros, los cuales además desarrollan un rol docente y, en menor medida, investigador.

External validation of an emergency department triage algorithm for chest pain patients.

BACKGROUND: We aimed to externally validate an emergency department triage algorithm including five hierarchical clinical variables developed to identify chest pain patients at low risk of having an acute coronary syndrome justifying delayed rather than immediate evaluation. METHODS: In a single-centre cohort enrolling 29,269 consecutive patients presenting with chest pain, the performance of the algorithm was compared against the emergency department discharge diagnosis. In an international multicentre study enrolling 4069 patients, central adjudication by two independent cardiologists using all data derived from cardiac work-up including follow-up served as the reference. Triage towards 'low-risk' required absence of all five clinical 'high-risk' variables: history of coronary artery disease, diabetes, pressure-like chest pain, retrosternal chest pain and age above 40 years. Safety (sensitivity and negative predictive value (NPV)) and efficacy (percentage of patients classified as low risk) was tested in this initial proposal (Model A) and in two additional models: omitting age criteria (Model B) and allowing up to one (any) of the five high-risk variables (Model C). RESULTS: The prevalence of acute coronary syndrome was 9.4% in the single-centre and 28.4% in the multicentre study. The triage algorithm had very high sensitivity/NPV in both cohorts (99.4%/99.1% and 99.9%/99.1%, respectively), but very low efficacy (6.2% and 2.7%, respectively). Model B resulted in sensitivity/NPV of 97.5%/98.3% and 96.1%/89.4%, while efficacy increased to 14.2% and 10.4%, respectively. Model C resulted in sensitivity/NPV of 96.7%/98.6% and 95.2%/91.3%, with a further increase in efficacy to 23.1% and 15.5%, respectively. CONCLUSION: A triage algorithm for the identification of low-risk chest pain patients exclusively based on simple clinical variables provided reasonable performance characteristics possibly justifying delayed rather than immediate evaluation in the emergency department.

Nontraumatic chest pain and suspicion of acute coronary syndrome: associated clinical and electrocardiographic findings on initial evaluation. / Asociación entre los datos clínicos y electrocardiográficos iniciales en pacientes con dolor torácico no traumático y la sospecha inicial y el diagnóstico final de síndrome coronario agudo.

OBJECTIVES: To analyze clinical data and electrocardiographic (ECG) findings obtained during the initial evaluation of patients with nontraumatic chest pain (NTCP). To explore associations between these findings and the initial and final diagnoses of acute coronary syndrome (ACS). To assess which variables initially over- or underestimate risk ACS. MATERIAL AND METHODS: Consecutive patients with NTCP attended in a chest pain unit during the 10-year period of 2008-2017 were included if the suspected and discharge diagnoses of interest (ACS or non-ACS) had been recorded. Thirtythree independent variables (demographic, 2; cardiovascular, 5; chest pain, 22; ECG, 4). We included all variables in models to calculate crude and adjusted odds ratios (ORs) between each independent variable and the initial and final diagnoses. The adjusted ORs were compared to determine whether the initial and final diagnoses of ACS differed significantly in relation to the variables. RESULTS: A total of 34 552 patient visits were attended. The ORs for the 33 variables were significantly associated with initial and final NTCP classification as ACS or non-ACS, and in many cases the association was confirmed by the adjusted ORs. The adjusted ORs for 19 variables were significantly different in their relation to the initial and final diagnoses of ACS: 10 overpredicted the probability of the diagnosis and 9 underpredicted it. CONCLUSION: The variables traditionally used to warn of ACS in emergency patients with NTCP identify individuals likely to be initially and finally diagnosed with ACS. However, some of these variables overestimate or underestimate the risk of a final ACS diagnosis. Emergency medicine physicians should be aware of variables associated with underestimation of risk.

OBJETIVO: Evaluar la utilidad del cuestionario COPD Asessment Test (CAT) para valorar la recuperación de la exacerbación de la enfermedad pulmonar obstructiva crónica (EA-EPOC). Evaluar si la puntuación CAT aumenta la capacidad predictiva de mala evolución de una escala de gravedad para EA-EPOC. METODO: Se incluyeron las consultas consecutivas por DTNT en una unidad de dolor torácico durante 10 años (2008-2017) en las que se disponía de los diagnósticos inicial de sospecha (SCA/no SCA) y final de alta de urgencias (SCA/no SCA). Se incluyeron 33 variables independientes (2 demográficas, 5 comorbilidad cardiovascular, 22 dolor torácico, 4 datos ECG). Se calcularon las odds ratio (OR) para la clasificación (inicial y final) como SCA para cada variable independiente, crudas y ajustadas en modelos globales que incluían todas ellas. En estos modelos ajustados se comparó si las OR para la clasificación inicial y final como SCA eran significativamente diferentes. RESULTADOS: Se incluyeron 34.552 visitas. Las 33 variables analizadas mostraron asociación significativa para la clasificación inicial y final del DTNT como SCA, y en muchos casos esta asociación se mantuvo en el modelo ajustado. Diecinueve variables mostraron OR significativamente diferentes para la sospecha inicial de SCA que para el diagnóstico final de SCA: 10 sobrestimaban la asociación final y 9 la subestimaban. CONCLUSIONES: Los datos clínicos iniciales clásicamente utilizados para sospechar SCA pacientes con DTNT en urgencias identifican todos ellos individualmente a pacientes con riesgo incrementado de ser clasificado inicial y finalmente como SCA; sin embargo, algunos de ellos sobreestiman y otros subestiman inicialmente el riesgo final. Los urgenciólogos debieran sensibilizarse más con estos datos subestimados.

Predictors and outcomes of frequent chest pain unit users.

AIM: To determine predictors of frequent chest pain unit (CPU) users and to identify characteristics and outcomes of their CPU visits. PATIENTS AND METHODS: Observational prospective case-control study. Frequent CPU user was defined by 3 or more CPU visits within the study year. A control patient and a control visit were randomly selected for each case patient and case visit. Demographic, clinical, and outcome variables were collected from medical record and phone interview performed in a 30-day interval. A multivariate logistic regression analysis was used to identify frequent CPU users' predictors. RESULTS: Of 1934 patients presenting during the year, 80 (4.1%) met the definition for case patient. They accounted for 352 (13%) of 2709 CPU visits. Sixty-seven (83.7%) case patients and 71 (88.7%) control patients were contacted. The final predictors were the following: Karnofsky Performance Scale of 70 or lesser (odds ratio [OR], 5.24 [95% confidence interval {CI}, 1.71-16.06]), previous hospitalization (OR, 3.76 [95% CI, 1.49-9.49]), previously known coronary artery disease (OR, 3.72 [95% CI, 1.32-10.52]), and symptoms of depression (OR, 2.98 [95% CI, 1.14-7.78]). Case visits were more likely at night (OR, 2.41 [95% CI, 1.64- 3.52]), generated more diagnostic uncertainty (OR, 2.39 [95% CI, 1.71-3.35]), but did not increase the need of hospital admission. CONCLUSIONS: Frequent CPU user is associated with previously known coronary artery disease, previous hospitalization, impaired performance status, and presence of symptoms of depression. They are more likely to arrive on CPU at night and generate more diagnostic uncertainty.

[Chronically-ill patients in emergency care: degree of understanding and agreement with the person accompanying them regarding their possible clinical course]. / Enfermos crónicos en urgencias: grado de conocimiento y concordancia con el acompañante respecto a sus posibilidades evolutivas.

BACKGROUND AND OBJECTIVE: Among patients with chronic diseases attending emergency department (ED), to analyze the level of knowledge of the patient and their companion about the patient's illness. To determine the factors associated to patient's and companion's knowledge and the level of concordance among them. MATERIAL AND METHODS: Patients' demographic and clinical characteristics were recorded. A structured interview was performed to patients and companions. Three dependent variables were considered: the patients' good or bad knowledge about the outcome of their chronic disease; the companions' good or bad knowledge about the outcome of their relatives' chronic disease; and the level of concordance (respect to good knowledge) among them. RESULTS: We included 191 patients; 81% of them subjectively considered themselves to be well informed, but only 54% of patients had objectively a good knowledge, and this fact was only associated with age < or = 70 y-o (P<,001). Instead, up to 79% of companions had objectively a good knowledge about patients' disease (P<.001 respect to patients), which was associated with to have an illness different from chronic pneumopathy (p<0,05) and a previous admission as inhospital (P=,01). Concordance between patient and companion was seen in a 49%, and was associated with age < or =70 y-o (P<.001) and companion filling that patient is well-informed (P<.05). CONCLUSIONS: Among patients with chronic diseases attending ED, a poor knowledge about their disease's characteristics and outcome is seen, as well as about the chance of making a living will. A better level of knowledge is detected among companions. The concordance in the level of knowledge among patients and companions is only seen in a half of interviewed people.

Changes in cases of nontraumatic chest pain treated in a chest pain unit over the 10-year period of 2008-2017. / Evolución de las características de las visitas por dolor torácico no traumático en una unidad de dolor torácico durante un periodo de 10 años (2008-2017).

OBJECTIVES: To analyze changes in the characteristics of consecutively treated patients attended in the chest pain unit of a hospital emergency department over a 10-year period. MATERIAL AND METHODS: All patients presenting with nontraumatic chest pain (NTCP) were included. We analyzed changes over time in epidemiologic characteristics, initial diagnostic classification (on clinical and electrocardiographic evaluation), final diagnosis (on discharge), and time until these diagnoses. RESULTS: A total of 34 552 consecutive patients with a mean (SD) age of 59 (13) years were included; 42% were women. The annual number of visits rose over time. Visits were fewer in summer and more numerous on workdays and between the hours of 8 AM and 4 PM (P<.001, both comparisons). The number of women increased over time (up 0.29% annually, P<.05) as did the number of patients under the age of 50 years (up 0.92% annually, P<.001). With time, patients had fewer cardiovascular risk factors and less often had a history of ischemic heart disease. Fewer cases of NTCP had signs suggestive of acute coronary syndrome (ACS). ACS was ruled out at the time of initial and final diagnoses in 52.2% and 80.4%, respectively, and these percentages which rose over the 10-year period by 1.86% (P<.001) and 0.56% (P=.04). Time to initial diagnosis did not change. However, time to final diagnosis did increase (P<.001), and the delay was longer in patients diagnosed with ACS (P<.001). CONCLUSION: The chest pain unit was more active at the end of the period, in keeping with the increase in patients with NTCP whose characteristics were not typical of coronary disease. The percentages of patients initially and finally diagnosed with ACS decreased with time.

OBJETIVO: Analizar la evolución de las características epidemiológicas de las visitas atendidas de forma consecutiva en una unidad de dolor torácico (UDT) de un servicio de urgencias hospitalario (SUH) durante un periodo de 10 años. METODO: Se incluyeron todas las visitas por dolor torácico no traumático (DTNT), analizándose la evolución temporal de las características epidemiológicas, de la clasificación diagnóstica inicial (evaluación clínica inicial y electrocardiograma) y final (al alta de la UDT), y los tiempos necesarios para alcanzar las mismas. RESULTADOS: Se incluyeron 34.552 pacientes consecutivos con una edad media 59 (DE 13) años, el 42% mujeres. Se observó un incrementó en el número anual de visitas a la UDT (p < 0,001), menor afluencia los meses de verano (p < 0,001), y mayor los días laborables (p < 0,001) y de 8-16 horas (p < 0,001). Se comprobó que progresivamente más pacientes eran mujeres (+0,29% anual, p < 0,05), menores de 50 años (+0,92%, p < 0,001), con más factores de riesgo cardiovascular, menos antecedentes de cardiopatía isquémica y con DTNT menos sugestivo de síndrome coronario agudo (SCA). La clasificación diagnóstica inicial y final descartó SCA en un 52,2% y un 80,4% de pacientes, respectivamente, hecho que aumentó progresivamente durante el periodo evaluado (+1,86%, p < 0,001; y +0,56%, p = 0,04; respectivamente). El tiempo de clasificación inicial no se modificó, pero se incrementó el necesario para la clasificación final (p < 0,001), que resultó superior en pacientes con diagnóstico final de SCA (p < 0,001). CONCLUSIONES: Se observa un mayor uso de la UDT tras su creación, causado por un incremento de pacientes con DTNT de características no típicamente coronarias, disminuyendo el porcentaje de clasificados inicial y finalmente como debidos a SCA.

[Failure of a special winter programme aimed to alleviate negative effects of winter overload on an emergency department]. / Cuantificación de los efectos negativos de la sobrecarga invernal en urgencias y de la efectividad de las medidas extraordinarias invernales para paliarlos.

BACKGROUND AND OBJECTIVE: We aimed: a) to determine changes in patient flow, and in emergency department (ED) effectiveness and quality that may happen depending on the season (winter/non-winter), and b) to analyze effects on those changes when a special winter programme (SWP) of the Pla Integral d'Urgències de Catalunya (PIUC) is applied. MATERIAL AND METHOD: We studied 4 weeks of each period: non-winter period, winter control period (without SWP), winter period with SWP. Within the 3 periods, the daily census was taken as a proxy of external pressure, and the number of patients admitted to the hospital from the ED as a proxy of internal pressure. In each period, effectiveness markers--ED occupancy rate, rate of ED patients waiting for a bed, waiting time (WT) and number of patients waiting to be seen (PW), length of stay-- objective quality markers -revisit rate, rate of patients left without being seen, rate of patients left against medical advise (LAMA), and mortality rate-, and subjective quality markers -patient satisfaction with the physician, the nurse, the general ED organization, and level of complaint solution- were recorded. RESULTS: Compared to the non-winter period, in the winter period without SWP the daily census rose by 6% (p = 0.07), and the number of patients admitted 10.8% (p = 0.16). These increases went along with a worsening of almost all effectiveness and quality markers, although only PW (+63%; p < 0.01), WT (+130%; p < 0.001), length of stay (+28%; p < 0.05), rate of patients left without being seen (+97%; p < 0.001) and LAMA (+218%; p < 0.05) reached statistical significance. In the winter period with SWP, the daily census kept stable but the number of patients admitted grew by 18% (p < 0.01). The SWP improved some subjective quality markers (patient satisfaction with the physician and the nurse), but failed to improve any effectiveness or objective quality marker. Some of them got even worse within the SWP period: ED occupancy rate, +20% (p = 0.001); PW, +42% (p < 0.05), and WT, +56% (p < 0.05). CONCLUSIONS: In winter, a worsening of ED effectiveness and quality can be expected. Measures from the SWP prepared by the Administration are unable to correct such deterioration. A profound analysis of the SWP is suggested.

Analysis of 15 years of emergency service interaction with schools. / Análisis de una experiencia de 15 años de interacción entre urgencias y la comunidad educativa.

EN: For 15 years without interruption, the emergency department of the Hospital Clínic de Barcelona has been holding annual educational sessions for students in their last year of obligatory secondary school. The sessions are organized in collaboration with 3 other entities: the primary care center affiliated with the hospital and serving the area and adjacent to it (THE CAPSBE), the city's emergency ambulance service, and the University of Barcelona. Each year the session lasts 4 hours and covers such content as the organization of the city's emergency medical care (at primary care centers, in prehospital settings, and at the hospital) and the main reasons adolescents require emergency care (related to drugs, traffic accidents, psychiatric disorders, eating disorders, and gynecologic problems). The project seeks to develop the students' sense of social responsibility and to transfer knowledge to the community where the organizers carry out their usual work. The sessions are educational, providing key information intended to encourage individual reflection as well as debate in the student community outside of school hours. A total of 56 secondary schools and 12 260 students between the ages of 15 and 18 years old have participated thus far. This article presents a basic outline of the sessions, reports feedback from the students and their teachers, and analyzes whether there have been significant changes in their opinions over time. Our purpose is to provide information useful to other emergency health services that might consider starting similar programs in which they can interact with their community schools.

ES: Desde hace 15 años, el Área de Urgencias del Hospital Clínic de Barcelona, en colaboración con CAPSBE (su centro de salud adyacente), el Sistema d'Emergències Mèdiques y la Univesitat de Barcelona, viene realizando ininterrumpidamente unas jornadas anuales dirigidas a alumnos de último curso de enseñanza secundaria obligatoria (ESO), de una duración de 4 horas, y en las que se abordan los aspectos organizativos de la atención médica urgente (en atención primaria, prehospitalaria y hospitalaria) en Barcelona, así como los principales motivos de consulta médica urgente en los adolescentes (drogas, accidentes de tráfico, trastornos psiquiátricos y de conducta alimentaria, y urgencias ginecológicas). La actividad se enmarca dentro del desarrollo de una cultura de responsabilidad social corporativa y de transmisión de conocimiento a la comunidad en la que estos centros sanitarios desarrollan su actividad habitual. Las jornadas tienen una finalidad divulgativa y proporcionan claves que puedan generar tanto la reflexión individual del alumnado como el debate conjunto posterior en la escuela. Durante estos 15 años han participado del curso 56 centros de ESO y 10.260 alumnos de entre 15 y 18 años. El objetivo del presente artículo es recoger los aspectos fundamentales de esta actividad, conocer la opinión de los alumnos y profesores de ESO, y analizar si han existido cambios significativos en estas opiniones durante este periodo de tiempo, con la finalidad de que otros servicios de urgencias puedan plantearse la instauración de actividades similares que les permitan una interacción con la comunidad educativa de su entorno.

Triage level assignment and nurse characteristics and experience. / Relación entre la asignación del nivel de triaje y las características y experiencia del personal de enfermería.

OBJECTIVES: To study the relation between nursing staff demographics and experience and their assignment of triage level in the emergency department. MATERIAL AND METHODS: One-year retrospective observational study in the triage area of a tertiary care urban university hospital that applies the Andorran-Spanish triage model. Variables studied were age, gender, nursing experience, triage experience, shift, usual level of emergency work the nurse undertakes, number of triage decisions made, and percentage of patients assigned to each level. RESULTS: Fifty nurses (5 men, 45 women) with a mean (SD) age of 45 (9) years triaged 67 803 patients during the year. Nurses classified more patients in level 5 on the morning shift (7.9%) than on the afternoon shift (5.5%) (P=.003). The difference in the rate of level-5 triage classification became significant when nurses were older (ß = 0.092, P=.037) and experience was greater (ß = 0.103, P=.017). The number of triages recorded by a nurse was significantly and directly related to the percentage of patients assigned to level 3 (ß = 0.003, P=.006) and inversely related to the percentages assigned to level 4 (ß = -0.002, P=.008) and level 5 (ß = -0.001, P=.017). CONCLUSION: We found that triage level assignments were related to age, experience, shift, and total number of patients triaged by a nurse.

OBJETIVO: Investigar la relación entre las características demográficas y experiencia de los enfermeros que realizan triaje y la asignación de pacientes a un determinado nivel de urgencia. METODO: Estudio observacional retrospectivo llevado a cabo durante 1 año en el área de triaje de un hospital universitario terciario que usa el Model Andorrà de Triatge/Sistema Español de Triage (MAT/SET). Variables: edad, sexo, experiencia en enfermería, experiencia en triaje, turno de trabajo, nivel asistencial donde trabajaban, número de triajes realizados y porcentaje de pacientes asignados a cada nivel de triaje. RESULTADOS: Se incluyeron 50 enfermeros (5 hombres y 45 mujeres) con una edad de 45 (DE 9) años que efectuaron 67.803 triajes. Los enfermeros del turno mañana clasificaban más pacientes en el nivel 5 que las de turno tarde (7,9% frente a 5,5%, p = 0,003). Este mayor porcentaje en el nivel 5 también se registraba de forma significativa cuanta más edad tenía el enfermero (ß = 0,092, p = 0,037) y cuanta mayor experiencia acumulaba (ß = 0,103, p = 0,017). El número de triajes efectuados por cada enfermero se relacionó, significativa y directamente, con el porcentaje de pacientes clasificados en nivel 3 (ß = 0,003, p = 0,006) e, inversamente, con el porcentaje de pacientes clasificados en nivel 4 (ß = ­0,002, p = 0,008) y en nivel 5 (ß = ­0,001, p = 0,017). CONCLUSIONES: Se ha objetivado una relación entre la edad, la experiencia acumulada, el turno de trabajo y el número total de triajes que efectúa un enfermero con el nivel de triaje asignado.

Triage flowchart to rule out acute coronary syndrome.

AIM: The aim of the study was to establish a triage flowchart to rule out acute coronary syndrome (ACS) among patients with chest pain (CP) arriving on an Emergency Department (ED). PATIENTS AND METHOD: This prospective observational study included 1000 consecutive patients with CP arriving on an ED CP unit. Demographic and clinical characteristics along with vital signs were recorded as independent variables. After CP unit protocol completion and 1-month follow-up, patients were classified as (dependent variable) (1) true non-ACS (all noncoronary patients at the first visit that kept this condition when called 1 month later) or (2) true ACS (all the remaining patients). Relationship among variables was assessed by multiple logistic regression analysis. A triage flowchart was obtained from significant variables and applied to patients with CP who were then grouped in "triage non-ACS" and "triage ACS." Validity indexes to exclude ACS for triage flowchart were measured. RESULTS: Variables significantly associated with non-ACS and included in the triage flowchart were age <40 years (odds ratio 3.61, 95% CI 1.63-7.99), absence of diabetes (2.74, 1.53-4.88), no previously known coronary artery disease (5.46, 3.42-8.71), nonoppressive pain (10.63, 6.04-18.70), and nonretrosternal pain (5.16, 2.82-9.42). For the triage flowchart, both specificity and positive predictive value to rule out ACS were 100%. CONCLUSIONS: The triage flowchart is able to accurately identify patients with CP not having an ACS. It may help triage nurses make quick decisions on who should be immediately seen and who could safely wait when delays in medical attention are unavoidable. Prospective validation is needed.

[Factors associated with revisit and admission in patients complaining of fever that are discharged from the emergency department]. / Factores relacionados con la revisita y el ingreso de los pacientes que consultan a urgencias por fiebre.

BACKGROUND AND OBJECTIVE: To identify factors associated with both emergency department (ED) revisit, and hospital admission of patients complaining of fever that have previously been seen and discharged from the ED. PATIENTS AND METHOD: From September, 2003 to April, 2004, 300 patients complaining of fever were discharged from the ED. Revisit rate and admission rate were calculated. Factors from the first visit associated with revisit, and revisit and admission were assessed by univariate and multivariate regression analysis. RESULTS: Fifty-one (17%) patients were revisit, 26 (9%) of whom were finally admitted. The independent factors associated with revisit were: age greater than 65 (OR = 1.96; p = 0.01), presence of comorbidity (OR = 3.23; p = 0.01), and C-reactive protein higher than 15 mg/dl (OR = 6.67; p = 0.02). The independent factors associated with revisit and admission were: age greater than 65 (OR = 4.51; p = 0.03), and presence of comorbidity (OR = 3.31; p = 0.01). CONCLUSIONS: One-sixth of patients complaining of fever that are discharged from an ED will be seen again. These patients are also more likely to be admitted if they are older than 65 and have any comorbidity present.