P085: Remember that patient you saw last week – Characteristics of patients experiencing unanticipated death following emergency department discharge

Background: The emergency department (ED) is an at-risk area for medical error. We measured the frequency and characteristics of patients with unanticipated death within 7 days of ED discharge and whether medical error contributed. Aim Statement: This study aimed to calculate the frequency of patients experiencing death within 7 days after ED discharge and determine whether these deaths were related to their index ED visit, were unanticipated, and whether possible medical error occurred. Measures & Design: We performed a single-centre health records review of 200 consecutive cases from an eligible 458,634 ED visits from 2014-2017 in two urban, academic, tertiary care EDs. We included patients evaluated by an emergency physician who were discharged and died within 7 days. Three trained and blinded reviewers determined if deaths were related to the index visit, anticipated or unanticipated, or due to potential medical error. Reviewers performed content analysis to identify themes. Evaluation/Results: Of the 200 cases, 129 had sufficient information for analysis, translating to 44 deaths per 100,000 ED discharges. We found 13 cases per 100,000 ED discharges were related and unanticipated deaths and 18 of these were due to potential medical errors. Over half (52.7%) of 129 patients displayed abnormal vital signs at discharge. Patients experienced pneumonia (27.1%) as their most common cause of death. Patient characteristic themes were: difficult historian, multiple complaints, multiple comorbidities, acute progression of chronic disease, recurrent falls. Provider themes were: failure to consider infectious etiology, failure to admit high-risk elderly patient, missed diagnosis. System themes included multiple ED visits or recent admission, no repeat vital signs recorded. Discussion/Impact: Though the frequency of related and unanticipated deaths and those due to medical error was low, these results highlight opportunities to potentially enhance ED discharge decisions. These data add to the growing body of ED diagnostic error literature and emphasize the importance of identifying potentially high risk patients as well as being cognizant of the common medical errors leading to patient harm.

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Identification of emergency department patients for referral to rapid-access addiction services

CJEM ◽

10.1017/cem.2019.453 ◽

2020 ◽

Vol 22 (2) ◽

pp. 170-177 ◽

Cited By ~ 1

Author(s):

Jessica Hann ◽

Howie Wu ◽

Aliyah Gauri ◽

Kathryn Dong ◽

Ni Lam ◽

...

Keyword(s):

Health Care ◽

Emergency Department ◽

High Risk ◽

Tertiary Care ◽

Health Care Team ◽

Care Team ◽

Rapid Access ◽

Addiction Services ◽

Ed Visits ◽

Emergency Department Patients

ABSTRACTObjectivesSubstance-related emergency department (ED) visits are rapidly increasing. Despite this finding, many EDs do not have access to on-site addiction services. This study characterized substance-related ED presentations and assessed the ED health care team's perceived need for an on-site rapid-access addiction clinic for direct patient referral from the ED.MethodsThis prospectively enrolled cohort study was conducted at an urban tertiary care ED from June to August 2018. Adult ED patients with problematic or high-risk substance use were enrolled by ED staff using a one-page form. The electronic and paper records from the index ED visit were reviewed. The primary outcome evaluated whether the ED health care team would have referred the patient to an on-site rapid-access addiction clinic, if one were available.ResultsWe received 557 enrolment forms and 458 were included in the analysis. Median age was 35 years, and 64% of included patients were male. Alcohol was the most commonly reported substance of problematic or high-risk use (60%). Previous ED visits within 7 days of the index visit were made by 28% of patients. The ED health care team indicated “Yes” for rapid-access addiction clinic referral from the ED for 66% of patients, with a mean of 4.3 patients referred per day during the study period.ConclusionsAt least four patients per day would have been referred to an on-site rapid-access addiction clinic from the ED, had one been available. This indicates a gap in care and collaborating with other sites that have successfully implemented this clinic model is an important next step.

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Frequent users of an inner-city emergency department

CJEM ◽

10.2310/8000.2012.120670 ◽

2012 ◽

Vol 14 (05) ◽

pp. 306-313 ◽

Cited By ~ 11

Author(s):

Jill Geurts ◽

Wes Palatnick ◽

Trevor Strome ◽

Erin Weldon

Keyword(s):

Emergency Department ◽

Substance Use ◽

General Population ◽

Tertiary Care ◽

Vital Signs ◽

Female Gender ◽

Tertiary Care Centre ◽

Lengths Of Stay ◽

Ed Visits ◽

Marginally Housed

ABSTRACTBackground:Within the emergency department (ED) patient population there is a subset of patients who make frequent visits. This chart review sought to characterize this population and identify strategies to reduce frequent ED visits.Methods:Frequent use at an urban tertiary care centre was defined as 15 or more visits over 1 year. The details of each visit—demographics, entrance complaint, discharge diagnosis, arrival method, Canadian Triage and Acuity Scale (CTAS) score, and length of stay—were analyzed and compared to data from the entire ED population for the same period.Results:Ninety-two patients generated 2,390 ED visits (of 25,523 patients and 44,204 visits). This population was predominantly male (66%) and middle-aged (median 42 years), with no fixed address (27.2%). Patients arrived by ambulance in 59.3% of visits with less acute CTAS scores than the general population. Substance use accounted for 26.9% of entrance complaints. Increased lengths of stay were associated with female gender and abnormal vital signs, whereas shorter stays were associated with no fixed address and substance use (p< 0.05). Admissions were lower than the general population, and women were twice as likely as men to be admitted (p< 0.05). Patients left without being seen in 15.8% of visits.Conclusions:High-frequency ED users are more likely to be male, younger, and marginally housed and to present secondary to substance use. Although admissions among this population are low, the costs associated with these presentations are high. Interventions designed to decrease visits and improve the health of this population appear warranted.

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Identifying children at high risk for infection-related decompensation using a predictive emergency department-based electronic assessment tool

Diagnosis ◽

10.1515/dx-2020-0030 ◽

2020 ◽

Vol 0 (0) ◽

Author(s):

Robert J. Sepanski ◽

Arno L. Zaritsky ◽

Sandip A. Godambe

Keyword(s):

Emergency Department ◽

High Risk ◽

Positive Predictive Value ◽

Firing Rate ◽

Predictive Value ◽

Assessment Tool ◽

Predictive Tool ◽

High Severity ◽

Electronic Assessment ◽

Ed Visits

AbstractObjectivesElectronic alert systems to identify potential sepsis in children presenting to the emergency department (ED) often either alert too frequently or fail to detect earlier stages of decompensation where timely treatment might prevent serious outcomes.MethodsWe created a predictive tool that continuously monitors our hospital’s electronic health record during ED visits. The tool incorporates new standards for normal/abnormal vital signs based on data from ∼1.2 million children at 169 hospitals. Eighty-two gold standard (GS) sepsis cases arising within 48 h were identified through retrospective chart review of cases sampled from 35,586 ED visits during 2012 and 2014–2015. An additional 1,027 cases with high severity of illness (SOI) based on 3 M’s All Patient Refined – Diagnosis-Related Groups (APR-DRG) were identified from these and 26,026 additional visits during 2017. An iterative process assigned weights to main factors and interactions significantly associated with GS cases, creating an overall “score” that maximized the sensitivity for GS cases and positive predictive value for high SOI outcomes.ResultsTool implementation began August 2017; subsequent improvements resulted in 77% sensitivity for identifying GS sepsis within 48 h, 22.5% positive predictive value for major/extreme SOI outcomes, and 2% overall firing rate of ED patients. The incidence of high-severity outcomes increased rapidly with tool score. Admitted alert positive patients were hospitalized nearly twice as long as alert negative patients.ConclusionsOur ED-based electronic tool combines high sensitivity in predicting GS sepsis, high predictive value for physiologic decompensation, and a low firing rate. The tool can help optimize critical treatments for these high-risk children.

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P060: Cannabinoid hyperemesis syndrome presentation to the emergency department: a two-year multi-centre retrospective study

CJEM ◽

10.1017/cem.2016.236 ◽

2016 ◽

Vol 18 (S1) ◽

pp. S98-S99 ◽

Cited By ~ 2

Author(s):

J.M. Hernandez ◽

J. Paty ◽

I. Price

Keyword(s):

Emergency Department ◽

Tertiary Care ◽

Case Series ◽

Kappa Statistic ◽

Cannabis Use ◽

Data Abstraction ◽

Tertiary Care Centre ◽

Associated Symptoms ◽

Cannabinoid Hyperemesis Syndrome ◽

Ed Visits

Introduction: Cannabinoid hyperemesis syndrome (CHS) is a paradoxical side effect of cannabis use. Patients with CHS often present multiple times to the Emergency Department (ED) with cyclical nausea, vomiting and abdominal pain, and are discharged with various misdiagnoses. CHS studies to date are limited to case series. We examined the epidemiology of CHS cases presenting to two major urban Tertiary Care Centre EDs. Methods: Using explicit variables, trained abstractors, and standardized abstraction forms, we abstracted data for all adults (18-55 years) with a presenting complaint of vomiting, and/or a discharge diagnosis of vomiting and/or cyclical vomiting, during a 2-year period. Inter-rater agreement was measured using a kappa statistic. Results: We identified 494 cases: mean age 31 years; 36% male; only 19.4% of charts specifically reported cannabis use. Among the regular cannabis users (>3 times per week), 43% had repeat ED visits for similar complaints. Interestingly, of these patients, 92% had bloodwork done in the ED, 92% received IV fluids, 89% received anti-emetics, 27% received opiates, 19% underwent imaging, 8% were admitted to hospital, and 8% were referred to the Gastroentorology service. Inter-rater reliability for data abstraction was kappa = 1. Conclusion: This study suggests CHS may be an overlooked diagnosis for nausea and vomiting, a factor which can possibly contribute to unnecessary investigations and treatment in the ED. Additionally, this indicates a lack of screening for CHS on ED history, especially in quantifying cannabis use and eliciting associated symptoms of CHS.

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Opioid prescription practices for patients discharged from the emergency department with acute musculoskeletal fractures

CJEM ◽

10.1017/cem.2020.50 ◽

2020 ◽

Vol 22 (4) ◽

pp. 486-493

Author(s):

Garrick Mok ◽

Hailey Newton ◽

Lisa Thurgur ◽

Marie-Joe Nemnom ◽

Ian G. Stiell

Keyword(s):

Emergency Department ◽

Tertiary Care ◽

Multivariable Analysis ◽

Prescription Data ◽

Care Hospital ◽

Total Dosage ◽

Opioid Prescription ◽

Prescription Practices ◽

Ed Visits

ABSTRACTBackgroundOpioid related mortality rate has increased 200% over the past decade. Studies show variable emergency department (ED) opioid prescription practices and a correlation with increased long-term use. ED physicians may be contributing to this problem. Our objective was to analyze ED opioid prescription practices for patients with acute fractures.MethodsWe conducted a review of ED patients seen at two campuses of a tertiary care hospital. We evaluated a consecutive sample of patients with acute fractures (January 2016–April 2016) seen by ED physicians. Patients admitted or discharged by consultant services were excluded. The primary outcome was the proportion of patients discharged with an opioid prescription. Data were collected using screening lists, electronic records, and interobserver agreement. We calculated simple descriptive statistics and a multivariable analysis.ResultsWe enrolled 816 patients, including 441 females (54.0%). Most common fracture was wrist/hand (35.2%). 260 patients (31.8%) were discharged with an opioid; hydromorphone (N = 115, range 1–120 mg) was most common. 35 patients (4.3%) had pain related ED visits <1 month after discharge. Fractures of the lumbar spine (OR 10.78 [95% CI: 3.15–36.90]) and rib(s)/sternum/thoracic spine (OR 5.46 [95% CI: 2.88–10.35)] had a significantly higher likelihood of opioid prescriptions.ConclusionsThe majority of patients presenting to the ED with acute fractures were not discharged with an opioid. Hydromorphone was the most common opioid prescribed, with large variations in total dosage. Overall, there were few return to ED visits. We recommend standardization of ED opioid prescribing, with attention to limiting total dosage.

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Recurrent Emergency Department Users: Two Categories with Different Risk Profiles

Journal of Clinical Medicine ◽

10.3390/jcm8030333 ◽

2019 ◽

Vol 8 (3) ◽

pp. 333 ◽

Cited By ~ 4

Author(s):

Ksenija Slankamenac ◽

Meret Zehnder ◽

Tim Langner ◽

Kathrin Krähenmann ◽

Dagmar Keller

Keyword(s):

Risk Factors ◽

Emergency Department ◽

Emergency Services ◽

Hospital Admissions ◽

Tertiary Care ◽

Chronic Obstructive ◽

Care Hospital ◽

Co Morbidity ◽

Ed Visits ◽

Morbidity Index

Recurrent emergency department (ED) visits are responsible for an increasing proportion of overcrowding. Therefore, our aim was to investigate the characteristics and prevalence of recurrent ED visitors as well as to determine risk factors associated with multiple ED visits. ED patients visiting the ED of a tertiary care hospital at least four times consecutively in 2015 were enrolled. Of 33,335 primary ED visits, 1921 ED visits (5.8%) were performed by 372 ED patients who presented in the ED at least four times within the one-year period. Two different categories of recurrent ED patients were identified: repeated ED users presenting always with the same symptoms and frequent ED visitors who were suffering from different symptoms on each ED visit. Repeated ED users had more ED visits (p < 0.001) and needed more hospital admissions (p < 0.010) compared to frequent ED users. Repeated ED users visited the ED more likely due to symptoms from chronic obstructive pulmonary diseases (p < 0.001) and mental disorders (p < 0.001). In contrast, frequent ED patients showed to be at risk for multiple ED visits when being disabled (p = 0.001), had an increased Charlson co-morbidity index (p = 0.004) or suffering from rheumatic diseases (p < 0.001). A small number of recurrent ED visitors determines a relevant number of ED visits with a relevance for and impact on patient centred care and emergency services. There are two categories of recurrent ED users with different risk factors for multiple ED visits: repeated and frequent. Therefore, multi-professional follow-up care models for recurrent ED patients are needed to improve patients’ needs, quality of life as well as emergency services.

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Chronic Pain in the Emergency Department: A Pilot Interdisciplinary Program Demonstrates Improvements in Disability, Psychosocial Function, and Healthcare Utilization

Pain Research and Management ◽

10.1155/2018/1875967 ◽

2018 ◽

Vol 2018 ◽

pp. 1-10 ◽

Cited By ~ 5

Author(s):

Joshua A. Rash ◽

Patricia A. Poulin ◽

Yaadwinder Shergill ◽

Heather Romanow ◽

Jeffrey Freeman ◽

...

Keyword(s):

Emergency Department ◽

Chronic Pain ◽

Pain Catastrophizing ◽

Tertiary Care ◽

Care Plan ◽

Care Hospital ◽

Opioid Use ◽

Care Plans ◽

Individualized Care ◽

Ed Visits

Objective. To evaluate the feasibility of an individualized interdisciplinary chronic pain care plan as an intervention to reduce emergency department (ED) visits and improve clinical outcomes among patients who frequented the ED with concerns related to chronic pain. Methods. A prospective cohort design was used in an urban tertiary care hospital. As a pilot program, fourteen patients with chronic pain who frequented the ED (i.e., >12 ED visits within the last year, of which ≥50% were for chronic pain) received a rapid interdisciplinary assessment and individualized care plan that was uploaded to an electronic medical record system (EMR) accessible to the ED and patient’s primary care provider. Patients were assessed at baseline and every three months over a 12-month period. Primary outcomes were self-reported pain and function assessed using psychometrically valid scales. Results. Nine patients completed 12-month follow-up. Missing data and attrition were handled using multiple imputation. Patients who received the intervention reported clinically significant improvements in pain, function, ED visits, symptoms of depression, pain catastrophizing, sleep, health-related quality of life, and risk of future aberrant opioid use. Discussion. Individualized care plans uploaded to an EMR may be worth implementing in hospital EDs for high frequency visitors with chronic pain.

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Emergency department use by CTAS Levels IV and V patients

CJEM ◽

10.1017/s1481803500013968 ◽

2006 ◽

Vol 8 (05) ◽

pp. 317-322 ◽

Cited By ~ 8

Author(s):

Simon Field ◽

Andrea Lantz

Keyword(s):

Emergency Department ◽

Family Physician ◽

Tertiary Care ◽

Patient Survey ◽

Medical Problem ◽

Primary Objective ◽

Specific Service ◽

Timely Access ◽

Emergency Department Triage ◽

Ed Visits

ABSTRACT Introduction: Many emergency department (ED) visits are non-urgent. Postulated reasons for these visits include lack of access to family physicians, convenience and 24/7 access, perceived need for investigations or treatment not available elsewhere, and as a mechanism for expedited referral to other specialists. We conducted a patient survey to determine why non-urgent patients use our tertiary care ED. Our primary objective was to determine how often the lack of a family physician was associated with non-urgent ED use. Methods: The survey was administered to Canadian Emergency Department Triage and Acuity Scale (CTAS) Level IV and V patients who attended the ED of the Queen Elizabeth II Health Sciences Centre in Halifax, NS, from March 7 to March 13, 2005. Results: Of the 352 eligible patients, 235 completed the survey (response rate, 67%). Fifty-six percent (132/235) had an acute medical problem of less than 48 hours, including 48% (114/235) with a recent injury. Thirty-four percent (82/235) had been referred to the ED, 49% (114/235) believed they required a specific service that was unavailable elsewhere (e.g., radiology, suturing, casting) and 43% (100/235) presented because of self-perceived urgency of their condition. Eighty-four percent (198/235) had a family physician; 23% (55/235) used the ED because of limited access to theirfamily physician and 3% (6/235) used the ED because they did not have a family physician. Conclusions: In this setting, most non-urgent ED visits involved patients who required a specific service offered by the ED, patients who believed their condition was urgent, or patients who were referred from the community to the ED. From a patient perspective, relatively few visits would be considered inappropriate. Lack of a family physician was not associated with non-urgent ED use; however, inability to obtain timely access to the FP was a factor in one-quarter of cases.

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Unscheduled return visits by patients to a german emergency department are a high risk group for initial wrong diagnosis

Acute Medicine Journal ◽

10.52964/amja.0729 ◽

2018 ◽

Vol 17 (4) ◽

pp. 178-181

Author(s):

Felix Ludwig ◽

◽

Wilhelm Behringer ◽

Steffen Herdtle ◽

Christian Hohenstein ◽

...

Keyword(s):

Emergency Department ◽

High Risk ◽

Risk Group ◽

Vital Signs ◽

High Risk Group ◽

Normal Limits ◽

Wrong Diagnosis ◽

Return Visits ◽

Special Patient Population ◽

Special Patient

The aim was to classify patients who returned unscheduled to an emergency department within 7 days. We categorized the patients’ cases arbitrarily according to the underlying cause of the return. The main causes for returning unscheduled were: “patient related” (24,2%), “illness related” (35,4%), “physician related” (18,3%), “system related” (3,8%) and “other” (21,7%). We also analyzed missed diagnoses, as the literature describes this special patient population as a high risk group. 15,4% of all return cases had a wrong diagnosis. No typical risk constellation/symptom could be found. Vital signs or blood values were within normal limits as well.

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MP05: Injuries in refugee children presenting to a paediatric emergency department

CJEM ◽

10.1017/cem.2018.159 ◽

2018 ◽

Vol 20 (S1) ◽

pp. S41-S42

Author(s):

E. Zhang ◽

F. Razik ◽

S. Ratnapalan

Keyword(s):

Primary Care ◽

Emergency Department ◽

Primary Care Physicians ◽

Clinical Care ◽

Tertiary Care ◽

Primary Care Providers ◽

Refugee Children ◽

Medical Attention ◽

Care Providers ◽

Ed Visits

Introduction: The number of refugees accepted to Canada grew from 24,600 in 2014 to 46,700 in 2016. Many of these refugees have young families and the number of child refugees has increased accordingly. Although child refugee health care has been in the forefront of media and medical attention recently, there is limited data on injury patterns in this population. Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) collects data on injuries in children presenting to the emergency department (ED). Our objective is to examine the clinical presentations and outcomes of refugee children with injuries presenting to a tertiary care paediatric ED. Methods: Our paediatric hospital has approximately 70,000 ED visits per year of which 13,000 are due to injuries and/or poisonings. The CHIRPP database was accessed to identify children with injuries presenting to our ED from April 2014 to March 2017 with Interim Federal Health Program (IFHP) registration status. All patient charts were reviewed to extract demographic and clinical care information. Results: There were 74 children with 81 ED visits during the study period of whom 19% were transferred from other facilities. Most of them (72%) were males with a mean age of 8.7 years (standard deviation 4.29). There were significant medical histories in 32% of children. The presentation to our ED (greater than 24 hours post-injury) was seen in 25% of visits. Twenty five percent of injured children were seen in our ED. The distribution of Canadian Triage Acuity Score (CTAS) scores 1, 2, 3, 4, and 5 were 0%, 16%, 37%, 46% and 1% respectively. However, subspecialty consultations were required in 69%, 60% and 27% of CTAS 2, 3 and 4 children respectively. Overall, 46% of all patients required subspecialty consults. The top three categories of injuries include fractures (23%), soft tissue injuries (20%) and lacerations (17%). More than half (56%) required diagnostic imaging. Most (89%) were treated in ED and discharged (average length-of-stay 3 hours 55 minutes) and 11% required admissions. 47% of children lacked primary care physicians. Conclusion: Almost half of refugee children with IFHP status require DI testing, sub-specialty consultations and primary care referrals when presenting to our ED with injuries. Follow up arrangements are needed as many do not have access to primary care providers. This demonstrates a need for securing primary care providers early for this vulnerable population.

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