GFR estimation is complicated by a high incidence of non-steady-state serum creatinine concentrations at the emergency department

Background Acquiring a reliable estimate of glomerular filtration rate (eGFR) at the emergency department (ED) is important for clinical management and for dosing renally excreted drugs. However, renal function formulas such as CKD-EPI can give biased results when serum creatinine (SCr) is not in steady-state because the assumption that urinary creatinine excretion is constant is then invalid. We assessed the extent of this by analysing variability in SCr in patients who visited the ED of a tertiary care centre. Methods Data from ED visits at the University Medical Centre Utrecht, the Netherlands between 2012 and 2019 were extracted from the Utrecht Patient Oriented Database. Three measurement time points were defined for each visit: last SCr measurement before visit as baseline (SCr-BL), first measurement during visit (SCr-ED) and a subsequent measurement between 6 and 24 hours during admission (SCr-H1). Non-steady-state SCr was defined as exceeding the Reference Change Value (RCV), with 15% decrease or 18% increase between successive SCr measurements. Exceeding the RCV was deemed as a significant change. Results Of visits where SCr-BL and SCr-ED were measured (N = 47,540), 28.0% showed significant change in SCr. Of 17,928 visits admitted to the hospital with a SCr-H1 after SCr-ED, 27,7% showed significant change. More than half (55%) of the patients with SCr values available at all three timepoints (11,054) showed at least one significant change in SCr over time. Conclusion One third of ED visits preceded and/or followed by creatinine measurement show non-stable serum creatinine concentration. At the ED automatically calculated eGFR should therefore be interpreted with great caution when assessing kidney function.

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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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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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Two-year Longitudinal Evaluation of Amphotericin B Lipid Complex Injection in a Tertiary Care Medical Center

Hospital Pharmacy ◽

10.1177/001857870003500215 ◽

2000 ◽

Vol 35 (2) ◽

pp. 176-181 ◽

Cited By ~ 1

Author(s):

Leanne D. Kennedy ◽

Julie F. Connelly ◽

Kevin M. Kuzma

Keyword(s):

Serum Creatinine ◽

Amphotericin B ◽

Fungal Infections ◽

Tertiary Care ◽

Serum Creatinine Concentration ◽

Creatinine Concentration ◽

Lipid Complex ◽

Tertiary Care Medical Center ◽

Amphotericin B Lipid Complex ◽

The Mean

A 2-year concurrent drug use evaluation was conducted in 156 patients to determine whether Abelcet (amphotericin B lipid complex injection) was being prescribed according to institution-approved guidelines and to characterize the patient population receiving Abelcet. Eighty-nine patients (57%) had fungal infections documented by chest x-ray, computed tomography, or fungal cultures. Sixty-seven (43%) had clinically suspected fungal infections. The Abelcet mean dose by weight was 5 mg/kg/day (actual body weight). Seventy-one patients (46%) met the established guidelines for use; 85 (54%) did not. Premedication was given to 64% of the patients; only 15 patients (10%) experienced documented fever and chills. A total of 72 patients (46%) died during therapy. Of the 75 patients who completed therapy in the hospital, 41 were switched to conventional amphotericin B, fluconazole, or itraconazole following a decrease in serum creatinine concentration, and 34 did not receive further antifungal therapy. The mean length of Abelcet therapy was 11 days. The mean increase in serum creatinine concentration at discontinuation of therapy was 0.2 mg/dL. Continued monitoring of Abelcet use was recommended and established guidelines were reaffirmed. Hydration with normal saline before and after dosing was suggested to help improve renal function, and dopamine was recommended to increase renal blood flow.

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A Study on Shock Index in Early Diagnosis of Sepsis in Emergency Department of Tertiary Care Centre of Nepal

Nepal Medical Journal ◽

10.37080/nmj.68 ◽

2019 ◽

Vol 2 (2) ◽

pp. 37-42

Author(s):

Manish Nath Pant ◽

Subash Dawadi ◽

Ashish Thapa

Keyword(s):

Emergency Department ◽

Heart Rate ◽

Severe Sepsis ◽

Early Diagnosis ◽

Blood Lactate ◽

Lactate Level ◽

Tertiary Care ◽

Serum Lactate ◽

Shock Index ◽

Tertiary Care Centre

Introduction: Sepsis and its consequences, severe sepsis and septic shock is at menace in country like ours where infectious disease are at toll. Early diagnosis and treatment is very important to decrease the morbidity and mortality. Shock index is one of such tool that is very handy in these situations as this is just a mathematical calculation using heart rate(HR) and systolic blood pressure(SBP). The main aim of this study was to find the effectiveness of using SI as an adjunct to blood lactate in diagnosing patients in sepsis. Methods: This was an observational hospital-based study conducted at Emergency Department of TUTH, Maharajgunj on 104 patients, obtained by purposive sampling method, who had presented to the “Red Area”, aged between 18 to 65 years. These patients were screened for severe sepsis using triage vital signs, basic laboratory tests and an initial serum lactate level. Test characteristics were calculated for hyperlactatemia. I considered the following covariates in our analysis: heart rate >90 beats/min; mean arterial pressure <65 mmHg; respiratory rate > 20 breaths/min; ≥2 SIRS including white blood cell count; SI <0.6; SI 0.6 to 1; SI 1 to 1.4and SI ≥ 1.4. Results: There was a positive correlation between shock index and blood lactate level, r=0.2, n=104, p=0.042. No relationship was found between SI>=1 and hyperlactemia, X2 (.285, N = 104) = 1, p =.594 and relationship was found between SI >=0.7 and hyperlactemia, X2 (4.1, N = 104) = 1, p =.04. sensitivity and specificity for detecting hyperlactemia of SI>=1, SI.=0.7, SIRS was 84% and 20%, 93% and 0%, 79% and 20% respectively. Conclusions: There was weak correlation between the lactate level and shock index with statistically significant correlation between the shock index grouped >=0.7 and hyperlactatemia with high sensitivity and very low specificity.

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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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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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Emergency Department Management of Children with Sickle Cell Disease.

Blood ◽

10.1182/blood.v104.11.1660.1660 ◽

2004 ◽

Vol 104 (11) ◽

pp. 1660-1660

Author(s):

Melissa J. Frei-Jones ◽

Amy L. Baxter ◽

Charles T. Quinn ◽

George R. Buchanan

Keyword(s):

Emergency Department ◽

Steady State ◽

Sickle Cell Disease ◽

Hospital Admission ◽

Sickle Cell ◽

Admission Rate ◽

Categorical Variables ◽

Continuous Variables ◽

Cell Disease ◽

Ed Visits

Abstract Vaso-occlusive crises (VOC) are a common cause of emergency department (ED) visits for children with sickle cell disease (SCD). To better understand our patient population and compare with reports from other centers, we sought to describe the presentation, management, and disposition of children with VOC at our center’s ED. We also aimed to identify predictors of hospital admission. We retrospectively reviewed hospital records of all patients with SCD, age 8–19 years, who presented to our urban pediatric ED in 2003 with a chief complaint of pain. We identified all subjects diagnosed with VOC and not another cause of pain. We obtained the following data for each: SCD genotype; duration of VOC and treatment prior to ED presentation; the nature of analgesia and use of intravenous fluids (IVF) in the ED; hemoglobin (Hgb) concentration; and disposition (admitted, discharged, discharged with subsequent ED visit for same crisis). Categorical variables were evaluated by the χ2 and Fisher exact tests and continuous variables by the t-test. Odds ratios (OR) and 95% confidence intervals (CI) were calculated where appropriate. In 2003, there were 320 ED visits for patients with SCD and pain. Among these, there were 279 diagnoses of VOC in 105 individual patients: 45 had one visit, 25 two visits, and 16 ≥5 visits. Mean number of visits per patient was 2.7; 23 (22%) patients accounted for 145 (55%) visits. Homozygous sickle cell anemia (Hgb SS) was present in 73/105 patients, accounting for 222 (79%) ED visits. Overall admission rate was 179/279 (64%), with 167/179 admitted on their first visit and 12 on their return visit. Subjects with Hgb SS accounted for 147/179 (82%) admissions. Among those discharged who later returned to the ED during the same VOC, the admission rate was 86% (5 returned in 24 hours, 5 in 48 hours, 3 in 72 hours, and one 4 days later). Pre-ED home opioid use was reported in 75% of visits and was associated with increased likelihood of discharge (OR 1.63, CI 0.94–2.84, p=0.082). Duration of VOC before presentation did not significantly affect admission rate and averaged 53.2 hours for admitted patients and 49.7 hours for those discharged (p=0.689). Patients who received IVF in the ED (219/279; 79%) were less likely to be admitted (31% vs 56%, p<0.001). Hgb concentration was increased in 61%, decreased in 36% and unchanged in 3% of patients from steady-state values and was not associated with admission. After receiving 2 doses of morphine, 31 patients were discharged from the ED, while only 5 patients were discharged after receiving 3 or 4 doses of morphine. A departmental VOC protocol was followed for 25.4% of patients, with no impact on admission rate (p=0.290). In this retrospective analysis of a large series of pediatric sickle cell ED visits, patients presented later in their VOC, and admission rate was higher than previously reported. A small proportion of older patients with SCD accounted for most ED visits and hospitalizations. Hgb variation from steady-state was neither clinically significant nor predictive of admission or discharge. In contrast to previous studies, receiving IVF in the ED was associated with a greater likelihood of discharge. Home opioids prior to ED presentation seemed to decrease hospital admission. Adherence to our center’s VOC protocol did not appear to influence disposition from the ED.

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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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A prospective evaluation of the availability and utility of the Ambulance Call Record in the emergency department

CJEM ◽

10.1017/cem.2016.362 ◽

2016 ◽

Vol 19 (2) ◽

pp. 81-87 ◽

Cited By ~ 1

Author(s):

Natalie Cram ◽

Shelley McLeod ◽

Michael Lewell ◽

Matthew Davis

Keyword(s):

Emergency Department ◽

Patient Management ◽

Treatment Plan ◽

Tertiary Care ◽

Relevant Information ◽

Care Centre ◽

Prospective Evaluation ◽

Tertiary Care Centre ◽

Handover Process ◽

Collection Form

AbstractObjectiveTo determine how often the Ambulance Call Record (ACR) was available to emergency department (ED) physicians and whether it contained information that changed the ED management of patients.MethodsThis was a prospective cohort study of adult patients transported to one of two tertiary care centre EDs. Physicians completed a data collection form for each patient regarding ACR availability and the perceived value of the ACR. This study began shortly after the implementation of a new electronic ACR (eACR) handover process (Round 1). To control for any confounding factors related to this new eACR handover process, the study was repeated 6 months after its implementation (Round 2).ResultsTotal of 869 forms were collected: 545 in Round 1, and 324 in Round 2. The ACR was available at first physician assessment for 82 (15.7%) patients in Round 1, and 76 (24.4%) patients in Round 2 (Δ8.7%, 95% CI: 3.1%, 14.5%). The ACR was available at some point during patients’ ED stay for 154 (28.9%) patients in Round 1, compared to 111 (34.5%) patients in Round 2 (Δ5.6%, 95% CI: 0.0%, 12.1%). When the ACR was available for a patient (n=265), physicians believed that information in the ACR changed their treatment plan in 76 (28.8%) cases.ConclusionPhysicians who review the ACR believe that the ACR contains relevant information that may influence patient management; however, physicians commonly manage patients without reviewing the ACR.

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