Prevalence of information gaps for seniors transferred from nursing homes to the emergency department

ABSTRACTObjective:Information gaps, defined as previously collected information that is not available to the treating physician, have implications for patient safety and system efficiency. For patients transferred to an emergency department (ED) from a nursing home or seniors residence, we determined the frequency and type of clinically important information gaps and the impact of a regional transfer form.Methods:During a 6-month period, we studied consecutive patients who were identified through the National Ambulatory Care Reporting System database. Patients were over 60 years of age, lived in a nursing home or seniors residence, and arrived by ambulance to a tertiary care ED. We abstracted data from original transfer and ED records using a structured data collection tool. We measured the frequency of prespecified information gaps, which we defined as the failure to communicate information usually required by an emergency physician (EP). We also determined the use of the standardized patient transfer form that is used in Ontario and its impact on the rate of information gaps that occur in our community.Results:We studied 457 transfers for 384 patients. Baseline dementia was present in 34.1% of patients. Important information gaps occurred in 85.5% (95% confidence interval [CI] 82.0%–88.0%) of cases. Specific information gaps along with their relative frequency included the following: the reason for transfer (12.9%), the baseline cognitive function and communication ability (36.5%), vital signs (37.6%), advanced directives (46.4%), medication (20.4%), activities of daily living (53.0%) and mobility (47.7%). A standardized transfer form was used in 42.7% of transfers. When the form was used, information gaps were present in 74.9% of transfers compared with 93.5% of the transfers when the form was not used (p< 0.001). Descriptors of the patient's chief complaint were frequently absent (81.0% for head injury [any information about loss of consciousness], 42.4% for abdominal pain and 47.1% for chest pain [any information on location, severity and duration]).Conclusion:Information gaps occur commonly when elderly patients are transferred from a nursing home or seniors residence to the ED. A standardized transfer form was associated with a limited reduction in the prevalence of information gaps; even when the form was used, a large percentage of the transfers were missing information. We also determined that the lack of descriptive detail regarding the presenting problem was common. We believe this represents a previously unidentified information gap in the literature about nursing home transfers. Future research should focus on the clinical impact of information gaps. System improvements should focus on educational and regulatory interventions, as well as adjustments to the transfer form.

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Effects of Full-Moon Definition on Psychiatric Emergency Department Presentations

ISRN Emergency Medicine ◽

10.1155/2014/398791 ◽

2014 ◽

Vol 2014 ◽

pp. 1-6

Author(s):

Varinder S. Parmar ◽

Ewa Talikowska-Szymczak ◽

Emily Downs ◽

Peter Szymczak ◽

Erin Meiklejohn ◽

...

Keyword(s):

Emergency Department ◽

Mental Health Professionals ◽

Full Moon ◽

Tertiary Care ◽

Lunar Cycle ◽

Future Research ◽

Before And After ◽

Definition Of ◽

Tertiary Care Hospitals ◽

The Impact

Objectives. The lunar cycle is believed to be related to psychiatric episodes and emergency department (ED) admissions. This belief is held by both mental health professionals and the general population. Previous studies analyzing the lunar effect have yielded inconsistent results. Methods. ED records from two tertiary care hospitals were used to assess the impact of three different definitions of the full-moon period, commonly found in the literature. The full-moon definitions used in this study were 6 hours before and 6 hours after the full moon (a 12-hour model); 12 hours before and 12 hours after the full moon (a 24-hour model); and 24 hours before and after the day of the full moon (a 3-day model). Results. Different significant results were found for each full-moon model. Significantly fewer patients with anxiety disorders presented during the 12-hour and 24-hour models; however, this was not true of the 3-day model. For the 24-hour model, significantly, more patients presented with a diagnosis of personality disorders. Patients also presented with more urgent triage scores during this period. In the 3-day model, no significant differences were found between the full-moon presentations and the non-full-moon presentations. Conclusions. The discrepancies in the findings of full moon studies may relate to different definitions of “full moon.” The definition of the “full moon” should be standardized for future research.

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Analysis of factors influencing length of stay in the emergency department

CJEM ◽

10.1017/s1481803500006539 ◽

2003 ◽

Vol 5 (03) ◽

pp. 155-161 ◽

Cited By ~ 94

Author(s):

Philip Yoon ◽

Ivan Steiner ◽

Gilles Reinhardt

Keyword(s):

Emergency Department ◽

Length Of Stay ◽

Patient Care ◽

Linear Regression Analysis ◽

Tertiary Care ◽

Future Research ◽

Consultation Rate ◽

Lengths Of Stay ◽

The Impact ◽

Triage Level

ABSTRACTObjectives:Length of stay (LOS) is a key measure of emergency department (ED) throughput and a marker of overcrowding. Time studies that assess key ED processes will help clarify the causes of patient care delays and prolonged LOS. The objectives of this study were to identify and quantify the principal ED patient care time intervals, and to measure the impact of important service processes (laboratory testing, imaging and consultation) on LOS for patients in different triage levels.Methods:In this retrospective review, conducted at a large urban tertiary care teaching hospital and trauma centre, investigators reviewed the records of 1047 consecutive patients treated during a continuous 7-day period in January 1999. Key data were recorded, including patient characteristics, ED process times, tests performed, consultations and overall ED LOS. Of the 1047 patient records, 153 (14.6%) were excluded from detailed analysis because of incomplete documentation. Process times were determined and stratified by triage level, using theCanadian Emergency Department Triage and Acuity Scale(CTAS). Multiple linear regression analysis was performed to determine which factors were most strongly associated with prolonged LOS.Results:Patients in intermediate triage Levels III and IV generally had the longest waiting times to nurse and physician assessment, and the longest ED lengths of stay. CTAS triage levels predicted laboratory and imaging utilization as well as consultation rate. The use of diagnostic imaging and laboratory tests was associated with longer LOS, varying with the specific tests ordered. Specialty consultation was also associated with prolonged LOS, and this effect was highly variable depending on the service consulted.Conclusions:Triage level, investigations and consultations are important independent variables that influence ED LOS. Future research is necessary to determine how these and other factors can be incorporated into a model for predicting LOS. Improved information systems will facilitate similar ED time studies to assess key processes, lengths of stay and clinical efficiency.

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LO28: Emergency department gastrointestinal presentations related to marijuana ingestion: a single centre retrospective study

CJEM ◽

10.1017/cem.2019.71 ◽

2019 ◽

Vol 21 (S1) ◽

pp. S17

Author(s):

J. Teefy ◽

J. Blom ◽

K. Woolfrey ◽

M. Riggan ◽

J. Yan

Keyword(s):

Emergency Department ◽

Abdominal Pain ◽

Tertiary Care ◽

Retrospective Chart Review ◽

Clinical History ◽

Cannabis Use ◽

Future Research ◽

Discharge Diagnosis ◽

Marijuana Consumption ◽

The Impact

Introduction: Cannabis Hyperemesis Syndrome (CHS) is a poorly understood phenomenon with a subset of patients presenting to the emergency department (ED) for symptomatic control of refractory nausea and vomiting. As legalization of marijuana commenced on October 2018, it is important to recognize the presentation of patients related to marijuana consumption. The objective of this study was to describe demographic and ED visit data of patients presenting to the ED with cannabis-related sequelae. Methods: This was a health records review of patients ≥18 years presenting to one of two tertiary care EDs (annual census 150,000 visits) with a discharge diagnosis including cannabis use with one of abdominal pain or nausea/vomiting using ICD-10 codes. Trained research personnel collected data from medical records including demographics, clinical history, results of investigations within the ED. Descriptive statistics including means and standard deviations are presented where appropriate. Results: From April 2014 to June 2016, 203 unique ED patients had a discharge diagnosis including cannabis use with abdominal pain or nausea/vomiting. Mean (SD) age was 30 (13.04) years and 120 (59.1%) were male. Patients presented to the ED independently 84 (41.4%), via EMS with 104 (51.23%) and 15 (7.39%) by police. The majority of patients were triaged as CTAS-2 in 27 (33%) and CTAS-3 in 106 (52.2%) of all cases. Of patients disclosing their method of consumption, 31 (15.3%) had used combustion methods and 30 (14.8%) had edible marijuana. Mean (SD) serum potassium was 3.71 (0.48) mmol/l. 162 (79.8%) were discharged home and 9 (4.4%) were given follow up (all psychiatric). Twenty-nine (14.3%) were admitted to hospital with 28 (13.8%) admitted to psychiatry and 1 (0.5%) admitted to medicine. Conclusion: This ED-based retrospective chart review reports a description of cannabis-related presentations to the ED. Clinicians should be aware of CHS in patients presenting to the ED, especially as Canada enters the era of legalization. Future research should focus on the impact of federal legalization of marijuana on ED utilization for CHS-related presentations.

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Emergency Department Referral Profile of Traumatic Brain Injury Records at a Tertiary Care Hospital of Pakistan

10.21203/rs.3.rs-84330/v3 ◽

2021 ◽

Author(s):

Maria Khan ◽

Uzair Yaqoob ◽

Zair Hassan ◽

Muhammad Muizz Uddin

Keyword(s):

Traumatic Brain Injury ◽

Emergency Department ◽

Brain Injury ◽

Road Traffic ◽

Tertiary Care ◽

Initial Assessment ◽

Care Hospital ◽

Mild Tbi ◽

Epidemiological Characteristics ◽

The Impact

Abstract Background: Traumatic Brain Injury (TBI) is the leading cause of morbidity and mortality all over the world and the impact is much worse in Pakistan. The objective here is to describe the epidemiological characteristics of patients with TBI in our country and to determine the immediate outcomes of patients with TBI after the presentation.Method: This was a cross-sectional study conducted at the Lady Reading Hospital, Peshawar, Pakistan. Data were extracted from the medical records from January 1st to December 31st, 2019. Patient age, sex, type of trauma, and immediate outcome of the referral to the Emergency Department were recorded. The severity of TBI was categorized based on Glasgow Coma Scale (GCS) in mild (GCS 13-15), moderate (GCS 9-12), and severe (GCS <8) classes. The Emergency Department referral profile was classified as admissions, disposed, detained and disposed, referred.Results: Out of 5047 patients, 3689 (73.1%) males and 1358 (26.9%) females. The most commonly affected age group was 0-10 years (25.6%) and 21-30 years (20.1%). Road Traffic accident was the predominant cause of injury (38.8%, n=1960) followed by fall (32.7%, n=1649). Most (93.6%, n=4710) of the TBIs were mild. After the full initial assessment and workup, and completing all first-aid management, the immediate outcome was divided into four, most frequent (67.2%, n=3393) of which was “disposed (discharged)”, and 9.3% (n=470) were admitted for further management.Conclusion: Our study represents a relatively commonplace picture of epidemiological data on the burden of TBI in Pakistan. As a large proportion of patients had a mild TBI, and there is a high risk of mild TBI being under-diagnosed, we warrant further investigation of mild TBI in population-based studies.

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

CJEM ◽

10.1017/cem.2020.291 ◽

2020 ◽

Vol 22 (S1) ◽

pp. S95-S95

Author(s):

R. Hoang ◽

K. Sampsel ◽

A. Willmore ◽

K. Yelle-Labre ◽

V. Thiruganasambandamoorthy ◽

...

Keyword(s):

Emergency Department ◽

High Risk ◽

Medical Errors ◽

Medical Error ◽

Tertiary Care ◽

Vital Signs ◽

Diagnostic Error ◽

Sufficient Information ◽

Risk Area ◽

Ed Visits

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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P139: The impact of a pancreatitis admission algorithm on emergency department length of stay in a tertiary care academic hospital

CJEM ◽

10.1017/cem.2020.343 ◽

2020 ◽

Vol 22 (S1) ◽

pp. S114-S115

Author(s):

A. Albina ◽

F. Kegel ◽

F. Dankoff ◽

G. Clark

Keyword(s):

Emergency Department ◽

Length Of Stay ◽

Tertiary Care ◽

Physician Satisfaction ◽

Academic Hospital ◽

Before And After ◽

Potential Applicability ◽

The Mean ◽

Algorithm Implementation ◽

The Impact

Background: Emergency department (ED) overcrowding is associated with a broad spectrum of poor medical outcomes, including medical errors, mortality, higher rates of leaving without being seen, and reduced patient and physician satisfaction. The largest contributor to overcrowding is access block – the inability of admitted patients to access in-patient beds from the ED. One component to addressing access block involves streamlining the decision process to rapidly determine which hospital service will admit the patient. Aim Statement: As of Sep 2011, admission algorithms at our institution were supported and formalised. The pancreatitis algorithm clarified whether general surgery or internal medicine would admit ED patients with pancreatitis. We hypothesize that this prior uncertainty delayed the admission decision and prolonged ED length of stay (LOS) for patients with pancreatitis. Our project evaluates whether implementing a pancreatitis admission algorithm at our institution reduced ED time to disposition (TTD) and LOS. Measures & Design: A retrospective review was conducted in a tertiary care academic hospital in Montreal for all adult ED patients diagnosed with pancreatitis from Apr 2010 to Mar 2014. The data was used to plot separate run charts for ED TTD and LOS. Serial measurements of each outcome were used to monitor change and evaluate for special cause variation. The mean ED LOS and TTD before and after algorithm implementation were also compared using the Student's t test. Evaluation/Results: Over four years, a total of 365 ED patients were diagnosed with pancreatitis and 287 (79%) were admitted. The mean ED LOS for patients with pancreatitis decreased following the implementation of an admission algorithm (1616 vs. 1418 mins, p = 0.05). The mean ED TTD was also reduced (1171 vs. 899 mins, p = 0.0006). A non-random signal of change was suggested by a shift above the median prior to algorithm implementation and one below the median following. Discussion/Impact: This project demonstrates that in a busy tertiary care academic hospital, an admission algorithm helped reduce ED TTD and LOS for patients with pancreatitis. This proves especially valuable when considering the potential applicability of such algorithms to other disease processes, such as gastrointestinal bleeding and congestive heart failure, among others. Future studies demonstrating this external applicability, and the impact of such decision algorithms on physician decision fatigue and within non-academic institutions, proves warranted.

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P144: Sentinel visits in emergency department patients with diabetes mellitus as a warning sign for hyperglycemic emergencies

CJEM ◽

10.1017/cem.2016.318 ◽

2016 ◽

Vol 18 (S1) ◽

pp. S126-S126

Author(s):

J. Yan ◽

K. Gushulak ◽

M. Columbus ◽

A. Hamelin ◽

I.G. Stiell

Keyword(s):

Diabetes Mellitus ◽

Emergency Department ◽

Blood Glucose ◽

Tertiary Care ◽

Clinical History ◽

Future Research ◽

Warning Sign ◽

Discharge Diagnosis ◽

Discharge Instructions ◽

Hyperosmolar Hyperglycemic State

Introduction: Patients with poorly controlled diabetes mellitus (DM) often visit the emergency department (ED) for management of hyperglycemia, diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS). Many of these patients have a “sentinel” ED visit for other medical conditions prior to their hyperglycemic visit, which may worsen their glucose control. The objective of this study was to describe the epidemiology and outcomes of patients presenting with a sentinel ED visit prior to their visit for a hyperglycemic emergency. Methods: This was a health records review of patients ≥18 years presenting to one of four tertiary care EDs (combined annual census 300,000) with a discharge diagnosis of DM, hyperglycemia, DKA or HHS in a one-year period. Visits for hypoglycemia were excluded. Trained research personnel collected data from medical records including demographics, clinical history and results of investigations. Electronic charts were reviewed to determine if the patient came to the ED within the prior 14 days of their index hyperglycemia visit, and the details and outcomes surrounding both visits. Descriptive statistics were used where appropriate to summarize the data. Results: From January-December 2014, 609 ED visits had a discharge diagnosis of hyperglycemia. Mean (SD) age was 50.4 (19.5) years, and 343 (56.3%) were male. 101/609 visitors (16.6%) had an ED presentation within the previous 14 days from their hyperglycemia visit. 71 (70.3%) of these were discharged from this initial visit and 49/71 (69.0%) were discharged either without their blood glucose checked or with an elevated blood glucose (>11.0 mmol/L). Of the sentinel visits, 58 (57.4%) were for hyperglycemia and 15 (14.9%) were for infection. Upon returning to the ED, 45/101 (44.6%) visitors were subsequently admitted for management of severe hyperglycemia, DKA or HHS. Conclusion: This unique ED-based study demonstrates that patients with DM presenting with hyperglycemia or infection often return and may ultimately require admission. Clinicians should be vigilant in checking blood glucose when these patients present to the ED and provide clear discharge instructions for follow-up and glucose management. Future research should focus on improving glycemic control in these patients in order to prevent further hyperglycemic emergencies from occurring.

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Perspectives of Healthcare Professionals on Meaningful Activities for Persons with Dementia in Transition from Home to a Nursing Home: An Explorative Study

Healthcare ◽

10.3390/healthcare7030098 ◽

2019 ◽

Vol 7 (3) ◽

pp. 98 ◽

Cited By ~ 1

Author(s):

Mari Groenendaal ◽

Anne Loor ◽

Manja Trouw ◽

Wilco P. Achterberg ◽

Monique A.A. Caljouw

Keyword(s):

Nursing Home ◽

Focus Groups ◽

Healthcare Professionals ◽

Interdisciplinary Collaboration ◽

Specific Information ◽

Organization Of Care ◽

The Social ◽

Centered Care ◽

Social And Physical Environment ◽

The Impact

Meaningful activities can enhance quality of life, a sense of connectedness, and personhood for persons with dementia. Healthcare professionals play an important role in maintaining meaningful activities, but little is currently known about the impact of the transition from home to nursing home on these activities. This study explored the experiences of professionals in four Dutch nursing homes, identifying facilitators and barriers to the maintenance of meaningful activities during the transition. A qualitative explorative design was used. Data were collected using focus groups and analyzed using thematic analysis. Twenty-two professionals participated in four focus groups, and three themes were identified: (1) a lack of awareness and attention for meaningful activities; (2) activities should be personalized and factors such as person characteristics, interests, the social and physical environment, and specific information such as roles, routines, activities, and personal issues play an important role in maintaining activities; (3) in the organization of care, a person-centered care vision, attitudes of professionals and interdisciplinary collaboration facilitate maintenance of meaningful activities. Healthcare professionals felt that meaningful activities are difficult to maintain and that improvements are needed. Our study provides suggestions on how to maintain meaningful activities for persons with dementia prior, during and after the transition.

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Impact of clinical guidance and rapid molecular pathogen detection on evaluation and outcomes of febrile or hypothermic infants

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.317 ◽

2020 ◽

Vol 41 (11) ◽

pp. 1285-1291

Author(s):

Jennifer Crook ◽

Meng Xu ◽

James C. Slaughter ◽

Jeremy Willis ◽

Whitney Browning ◽

...

Keyword(s):

Emergency Department ◽

Clinical Guideline ◽

Young Infant ◽

Tertiary Care ◽

Admission Rate ◽

Entire Study ◽

Clinical Guidance ◽

Period 2 ◽

Ancillary Test ◽

The Impact

AbstractObjective:To quantify the impact of clinical guidance and rapid respiratory and meningitis/encephalitis multiplex polymerase chain reaction (mPCR) testing on the management of infants.Design:Before-and-after intervention study.Setting:Tertiary-care children’s hospital.Patients:Infants ≤90 days old presenting with fever or hypothermia to the emergency department (ED).Methods:The study spanned 3 periods: period 1, January 1, 2011, through December 31, 2014; period 2, January 1, 2015, through April 30, 2018; and period 3, May 1, 2018, through June 15, 2019. During period 1, no standardized clinical guideline had been established and no rapid pathogen testing was available. During period 2, a clinical guideline was implemented, but no rapid testing was available. During period 3, a guideline was in effect, plus mPCR testing using the BioFire FilmArray respiratory panel 2 (RP 2) and the meningitis encephalitis panel (MEP). Outcomes included antimicrobial and ancillary test utilization, length of stay (LOS), admission rate, 30-day mortality. Outcomes were compared across periods using Kruskal-Wallis and Pearson tests and interrupted time series analysis.Results:Overall 5,317 patients were included: 2,514 in period 1, 2,082 in period 2, and 721 in period 3. Over the entire study period, we detected reductions in the use of chest radiographs, lumbar punctures, LOS, and median antibiotic duration. After adjusting for temporal trends, we observed that the introduction of the guideline was associated with reductions in ancillary tests and lumbar punctures. Use of mPCR testing with the febrile infant clinical guideline was associated with additional reductions in ancillary testing for all patients and a higher proportion of infants 29–60 days old being managed without antibiotics.Conclusions:Use of mPCR testing plus a guideline for young infant evaluation in the emergency department was associated with less antimicrobial and ancillary test utilization compared to the use of a guideline alone.

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Initial evaluation of patients diagnosed with pancreatic cancer within a community health system.

Journal of Clinical Oncology ◽

10.1200/jco.2015.33.3_suppl.269 ◽

2015 ◽

Vol 33 (3_suppl) ◽

pp. 269-269

Author(s):

Kathryn Tzung-Kai Chen

Keyword(s):

Pancreatic Cancer ◽

Emergency Department ◽

Health System ◽

Community Health ◽

Outpatient Clinic ◽

Care Center ◽

Tertiary Care ◽

Initial Evaluation ◽

Entire Cohort ◽

The Impact

269 Background: The management of pancreatic patients who are referred to a tertiary care center is well described. However, many patients receive their initial evaluation and care at community health systems. We sought to describe how patients present within the community, the patterns of initial evaluation, and the impact on management. Methods: In a period spanning 3 years (2010-2013), 82 patients were newly diagnosed with pancreatic cancer, as identified by a cancer registry at a community health system. Under IRB approval, data regarding patient characteristics, initial evaluation, and management were retrospectively collected from the electronic medical record (EMR) and analyzed. Results: Of the 82 patients, 68 patients had sufficient data available in the EMR for analysis. Thirty-two patients (47%) initially presented to outpatient clinic, and 36 patients (53%) presented to the emergency department. The presenting complaint was identified as abdominal pain in 33 patients (49%), jaundice in 20 patients (29%), and general malaise in 9 patients (13%). Patients who presented through outpatient clinic vs. emergency department received similar initial imaging studies upfront, including CT of the abdomen and pelvis (61% vs. 72%) and abdominal ultrasound (27% vs. 17%). Sixteen percent of those patients evaluated in outpatient clinic were subsequently admitted, compared to 94% of those patients evaluated in the emergency department. Finally, 31% of those presenting in outpatient clinic eventually underwent surgical resection, compared to 8% of those presenting through the ER, and the median time to surgery for the entire cohort was 1.1 months. Conclusions: Within the community, half of all patients present through the emergency department, and the majority of these are admitted for work up and management of symptoms. In contrast, those patients who present through outpatient clinic are less likely to be admitted, and are more likely to undergo definitive resection. This likely represents a disparity on several levels: the acuity of patients presenting to the emergency department vs. clinic, and how they are managed in each setting.

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