Frequent users of an inner-city emergency department

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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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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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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Substance-related problems in patients visiting an urban Canadian emergency department

CJEM ◽

10.1017/s1481803500010101 ◽

2008 ◽

Vol 10 (03) ◽

pp. 198-204 ◽

Cited By ~ 10

Author(s):

Jeffrey R. Brubacher ◽

Amy Mabie ◽

Michelle Ngo ◽

Riyad B. Abu-Laban ◽

Jan Buchanan ◽

...

Keyword(s):

Emergency Department ◽

Substance Use ◽

Intervention Program ◽

Hospital Admissions ◽

Screening Program ◽

Tertiary Care ◽

Admission Rate ◽

Problematic Substance Use ◽

Problematic Substance ◽

Ed Visits

ABSTRACTObjective:For many patients with addiction and other substance problems, the emergency department (ED) is the sole provider of medical care. This study sought to determine the prevalence and characteristics of substance-related medical problems in ED patients, as defined by documentation in the medical record. We also sought to compare the ED resource use (length of ED stay and number of revisits) of patients with and without substance problems.Methods:Trained evaluators using explicit criteria reviewed all ED charts during a 6-week period at a Canadian tertiary care teaching centre. Data was collected on demographics, documentation of problematic substance use and whether the ED visit was due to substance problems. Using a computerized database, we determined how many patients with and without substance problems had 1 or more subsequent ED visits during the 1-year period from Sept. 1, 2002, to Aug. 31, 2003.Results:Of 6064 visits made by 5194 patients, 6026 visits (99.4%) representing 5188 patients (99.9%) were captured for review. Of those visits, 674 (11.2%, 95% confidence interval [CI] 10.4%–12.0%), made by 600 patients, had documentation of problematic substance use and 521 visits (8.6%, 95% CI 7.9%–9.4%) by 469 patients were caused by substance problems. The mean age of patients with a visit due to a substance problem was 39.2 years, compared with 48.5 years for those with other visits (p< 0.001). The admission rate for substance-related visits was 25.3%, compared with 17.6% for other visits (p< 0.001). For discharged patients, the median length of the ED visit owing to substance-related problems lasted 232 minutes (IQR [interquartile range] 267 min), compared with 164 minutes (IQR 167 min) for other visits (p< 0.001). In 1 year of follow-up, 161 of 600 patients (26.8%) with a substance problem made 466 revisits (mean 0.78 revisits/patient), compared with 975 of 4588 patients (21.3%) without a substance problem who made a total of 2150 revisits (mean 0.47 revisits/patient,p< 0.001).Conclusion:Substance problems contribute significantly to ED visits, hospital admissions and duration of ED stay at a tertiary centre. It is likely that our methodology underestimates the scope of the problem and that a universal screening program would find a higher prevalence. The magnitude of this problem supports the need for an interdisciplinary identification and intervention program for ED patients with substance-related issues.

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

PLoS ONE ◽

10.1371/journal.pone.0261977 ◽

2021 ◽

Vol 16 (12) ◽

pp. e0261977

Author(s):

M. S. A. Niemantsverdriet ◽

T. T. Pieters ◽

I. E. Hoefer ◽

M. C. Verhaar ◽

J. A. Joles ◽

...

Keyword(s):

Emergency Department ◽

Steady State ◽

Serum Creatinine ◽

Tertiary Care ◽

Reliable Estimate ◽

Tertiary Care Centre ◽

Creatinine Concentration ◽

Reference Change Value ◽

Ed Visits ◽

Significant Change

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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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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A Sample of The Relationship Between The Non-Integrated Healthcare System And National Epidemic of Emergency Department Overcrowding In Turkey

10.21203/rs.3.rs-818815/v1 ◽

2021 ◽

Author(s):

Cihad Dundar ◽

Seydanur Dal Yaylaoglu

Keyword(s):

Emergency Department ◽

Female Gender ◽

Tertiary Hospital ◽

Emergency Department Visits ◽

Work Hours ◽

Diagnostic Code ◽

Diagnostic Codes ◽

Logistic Analysis ◽

Ed Visits ◽

Negative Impacts

Abstract Background: The use of EDs has significantly increased, and a majority of this increase is attributed to non-urgent visits, which has negative impacts. We aim to explore the frequency of non-urgent emergency department (ED) visits and to identify risk factors for non-urgent ED visits. Methods: This retrospective, the record-based study was conducted at a tertiary hospital in Samsun province of Turkey. The records of all adult patients who visited to the ED between January 1 and December 31, 2017, were included in this study. All emergency department visits were evaluated according to age, gender, time of visit, means of arrival, ICD diagnostic codes, and the number of repeated non-urgent ED visits. The number of ED visits was 87,528 for the year 2017. Results: The non-urgent emergency visit rate was 9.9%. According to binary logistic analysis, non-urgent visits were associated with young age (OR = 2.75), female gender (OR = 1.11) and non-ambulance transportation (OR = 9.86). The prevalence of non-emergent visits was very similar between weekends and weekdays but was significantly higher in work hours on weekdays than non-work hours (p<0.001). The most frequent diagnostic code was “Pain, unspecified” (R52) and the rate of repeated visits was 14.8% of non-urgent ED visits. Conclusions: Harmonization of various databases at the primary level in terms of design and connectivity and integration with hospital information systems will contribute to the identification of problems and the generation of solutions. The next step is establishing an integrated health care system that can benefit emergency care organizations in Turkey.

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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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LO84: Experiences of youth and family presenting to the emergency department for addiction and mental health

CJEM ◽

10.1017/cem.2018.146 ◽

2018 ◽

Vol 20 (S1) ◽

pp. S36-S37

Author(s):

H. Hair ◽

M. Bercov ◽

S. Hastings

Keyword(s):

Mental Health ◽

Emergency Department ◽

Substance Use ◽

Family Involvement ◽

Online Survey ◽

Wait Times ◽

Youth Survey ◽

The Family ◽

Social Media Platforms ◽

Ed Visits

Introduction: The Canadian Institute for Health Information reports the rate of child and youth emergency department (ED) visits for mental health complaints increased by 50% between 2007 and 2015. Improving care for these patients is a major priority of Alberta Health Services (AHS). As part of a multi-phased approach to improving care, the Emergency and the Addiction and Mental Health Strategic Clinical Networks (SCNs) surveyed youth who had presented to an ED for mental health or substance use concerns and their families/caregivers. Methods: The online survey contained closed- and open-ended questions on reasons for ED visits, expectations about and experiences during their visits, and areas for improvement. An ethics approved survey was conducted for 4 weeks. Participants were recruited across the province using an extensive array of social media platforms. For each survey, we randomly selected a sample of open-ended responses to thematically analyze to the point of informational redundancy. Results: The Youth survey received 992 responses and the Family survey received 553. A small number of overarching themes emerged. For both surveys, the major themes were 1) Wait times and access: participants were disappointed with lengthy wait times and services in the community. Youth said this made them question their decision to seek help and left them feeling hopeless. 2) Care provider training: participants were unhappy with the quality of care provided (e.g., lack of compassion, minimizing symptoms). They felt better training would improve care and attitudes towards mental health patients. 3) Environment: participants were uncomfortable with the lack of privacy for discussing sensitive topics; youth also requested items such as pens/paper and phone chargers to make the stay more comfortable and provide distractions. An additional theme emerged in the Youth survey regarding family involvement; participants wanted to decide how much/what information is shared with their families. Youth noted they were less likely to be honest with family present. Communication and navigation were mentioned frequently in the Family survey; participants noted the complexity of the mental health care system and felt frustrated by the lack of information to help them access additional resources. Conclusion: There are a number of areas in need of improvement to provide high-quality, patient-centred care to youth with mental health or substance use concerns that present to the Emergency Department. Phase II of this project will involve a review of the themes and determine priorities and strategies to address the themes that could be implemented into the workflow.

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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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