Recurrent Emergency Department Users: Two Categories with Different Risk Profiles

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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Health care provided to recent asylum-seeking and non-asylum-seeking pediatric patients in 2016 and 2017 at a Swiss tertiary hospital - a retrospective study

10.21203/rs.3.rs-22231/v3 ◽

2020 ◽

Author(s):

Julia Brandenberger ◽

Christian Pohl ◽

Florian Vogt ◽

Thorkild Tylleskär ◽

Nicole Ritz

Keyword(s):

Health Care ◽

Emergency Department ◽

Retrospective Study ◽

Hospital Admissions ◽

Tertiary Care ◽

Median Number ◽

Care Hospital ◽

Children With Medical Complexity ◽

Cross Sectional ◽

Number Of Visits

Abstract BackgroundAsylum-seeking children represent an increasing and vulnerable group of patients whose health needs are largely unmet. Data on the health care provision to asylum-seeking children in European contexts is scarce. In this study we compare the health care provided to recent asylum-seeking and non-asylum-seeking children at a Swiss tertiary hospital.MethodsWe performed a cross-sectional retrospective study in a pediatric tertiary care hospital in Basel, Switzerland. All patients and visits from January 2016 to December 2017 were identified, using administrative and medical electronic health records. The asylum-seeking status was systematically assessed and the patients were allocated accordingly in the two study groups.Results A total of 202,316 visits by 55,789 patients were included, of which asylum-seeking patients accounted for 1674 (1%) visits by 439 (1%) individuals. The emergency department recorded the highest number of visits in both groups with a lower proportion in asylum-seeking compared to non-asylum-seeking children: 19% (317/1674) and 32% (64,315/200,642) respectively. The median number of visits per patient was 1 (IQR 1-2) in the asylum-seeking and 2 (IQR 1-4) in the non-asylum-seeking children. Hospital admissions were more common in asylum-seeking compared to non-asylum-seeking patients with 11% (184/1674) and 7% (14,692/200,642). Frequent visits (>15 visits per patient) accounted for 48% (807/1674) of total visits in asylum-seeking and 25% (49,886/200,642) of total visits in non-asylum-seeking patients. ConclusionsHospital visits by asylum-seeking children represented a small proportion of all visits. The emergency department had the highest number of visits in all patients but was less frequently used by asylum-seeking children. Frequent care suggests that asylum-seeking patients also present with more complex diseases. Further studies are needed, focusing on asylum-seeking children with medical complexity.

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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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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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Clinical characteristics and factors influencing the outcome of hospitalised COVID-19 patients in a semi-urban primary healthcare center

IMC Journal of Medical Science ◽

10.3329/imcjms.v14i2.52829 ◽

2021 ◽

Vol 14 (2) ◽

pp. 42-54

Author(s):

Wasim Md Mohosin Ul Haque ◽

Chinmay Saha Podder ◽

Nandini Chowdhury ◽

Md Mohim Ibne Sina ◽

SKM Shameem Kawser ◽

...

Keyword(s):

Risk Factors ◽

Adverse Outcome ◽

Severe Disease ◽

Tertiary Care ◽

Chronic Obstructive ◽

Care Hospital ◽

Rt Pcr ◽

District Health ◽

Factors Associated ◽

Negative Outcome

Background and objectives: Various new manifestations and risk factors for COVID-19 have been unveiled in the course of the current pandemic. Understanding the clinical spectrums as well as the risk factors associated with the adverse outcome of the disease is critical to combat this pandemic. This study was conducted to identify the clinical features, overall outcome and the factors associated with adverse outcome of the hospitalised COVID-19 patients in a semi-urban healthcare setting. Methods: This study was conducted at Debidwar Upazila (sub-district) Health Complex under the Cumilla district from April 2020 to October 2020. Reverse transcriptase-polymerase chain reaction (RT-PCR) positive COVID-19 patients, aged 18 years and above, admitted at the Health Complex were enrolled in the study. All patients were followed till their recovery, referral or death. The data were collected in a pre-designed semi-structured questionnaire that included demographic, epidemiological, clinical and laboratory parameters. Result: Out of 50 RT-PCR positiveCOVID-19 adult participants, 30 (60%) were males and 20 (40%) were females. Twenty-four percent, 36%, and 40% of the patients had mild, moderate and severe disease respectively. The most common clinical symptom was fever (96%), followed by cough (86%) and shortness of breath (60%). Hypertension (54%), diabetes mellitus (40%), bronchial asthma (20%) and chronic obstructive pulmonary disease (COPD, 14%) were the major co-morbid conditions. Of the total cases, 2 (4%) died and 8 (16%) required referral to tertiary care hospital while 40 (80%) recovered. COPD was associated with poor outcome (OR 19; 95% CI: 2.88, 125.31; p < 0.05). Smokers were 7 times more likely to exhibit the negative outcome than non-smokers (95% CI: 1.52, 32.33; p < 0.05). Conclusion: In this study, COPD was associated with a negative outcome. Further study with larger sample should be carried out to determine the spectrum of risk factors. Ibrahim Med. Coll. J. 2020; 14(2): 42-54

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LO14: Interdepartmental program to improve outcomes for acute heart failure patients seen in the emergency department

CJEM ◽

10.1017/cem.2020.70 ◽

2020 ◽

Vol 22 (S1) ◽

pp. S11-S12

Author(s):

I. Stiell ◽

M. Taljaard ◽

A. Forster ◽

L. Mielniczuk ◽

G. Wells ◽

...

Keyword(s):

Heart Failure ◽

Emergency Department ◽

Acute Heart Failure ◽

Hospital Admissions ◽

Tertiary Care ◽

Control Period ◽

Care Hospital ◽

Index Visit ◽

Rapid Access

Introduction: An important challenge physicians face when treating acute heart failure (AHF) patients in the emergency department (ED) is deciding whether to admit or discharge, with or without early follow-up. The overall goal of our project was to improve care for AHF patients seen in the ED while avoiding unnecessary hospital admissions. The specific goal was to introduce hospital rapid referral clinics to ensure AHF patients were seen within 7 days of ED discharge. Methods: This prospective before-after study was conducted at two campuses of a large tertiary care hospital, including the EDs and specialty outpatient clinics. We enrolled AHF patients ≥50 years who presented to the ED with shortness of breath (<7 days). The 12-month before (control) period was separated from the 12-month after (intervention) period by a 3-month implementation period. Implementation included creation of rapid access AHF clinics staffed by cardiology and internal medicine, and development of referral procedures. There was extensive in-servicing of all ED staff. The primary outcome measure was hospital admission at the index visit or within 30 days. Secondary outcomes included mortality and actual access to rapid follow-up. We used segmented autoregression analysis of the monthly proportions to determine whether there was a change in admissions coinciding with the introduction of the intervention and estimated a sample size of 700 patients. Results: The patients in the before period (N = 355) and the after period (N = 374) were similar for age (77.8 vs. 78.1 years), arrival by ambulance (48.7% vs 51.1%), comorbidities, current medications, and need for non-invasive ventilation (10.4% vs. 6.7%). Comparing the before to the after periods, we observed a decrease in hospital admissions on index visit (from 57.7% to 42.0%; P <0.01), as well as all admissions within 30 days (from 65.1% to 53.5% (P < 0.01). The autoregression analysis, however, demonstrated a pre-existing trend to fewer admissions and could not attribute this to the intervention (P = 0.91). Attendance at a specialty clinic, amongst those discharged increased from 17.8% to 42.1% (P < 0.01) and the median days to clinic decreased from 13 to 6 days (P < 0.01). 30-day mortality did not change (4.5% vs. 4.0%; P = 0.76). Conclusion: Implementation of rapid-access dedicated AHF clinics led to considerably increased access to specialist care, much reduced follow-up times, and possible reduction in hospital admissions. Widespread use of this approach can improve AHF care in Canada.

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Combination pretest probability assessment and D-dimer did not reduce outpatient imaging for venous thromboembolism in a tertiary care hospital emergency department

CJEM ◽

10.2310/8000.2013.130986 ◽

2014 ◽

Vol 16 (01) ◽

pp. 53-62 ◽

Cited By ~ 1

Author(s):

Sarah Ingber ◽

Rita Selby ◽

Jacques Lee ◽

William Geerts ◽

Elena Brnjac

Keyword(s):

Emergency Department ◽

Venous Thromboembolism ◽

False Positive Rate ◽

Tertiary Care ◽

Real Life ◽

Pretest Probability ◽

Care Hospital ◽

Ed Visits ◽

The Impact ◽

D Dimer

ABSTRACTIntroduction:Venous thromboembolism (VTE) is difficult to diagnose yet potentially life threatening. A low-risk pretest probability (PTP) assessment combined with a negative Ddimer can rule out VTE in two-thirds of outpatients, reducing the need for imaging. Real-life implementation of this strategy is associated with several challenges.Methods:We evaluated the impact of introducing a standardized diagnostic algorithm including a mandatory PTP assessment and D-dimer on radiologic test use for VTE in our emergency department (ED). A retrospective review of all ED visits for suspected VTE in the year prior to and following the introduction of this algorithm was conducted. VTE diagnosis was based on imaging. Guideline compliance was also assessed.Results:ED visits were investigated for suspected VTE in the pre- and postintervention periods (n 5 1,785). Most D-dimers (95%) ordered were associated with a PTP assessment, and 50% of visits assigned a low PTP had a negative D-dimer. The proportion of imaging tests ordered for VTE in all ED visits was unchanged postintervention (1.9% v. 2.0%). The proportion of patients with suspected VTE in whom VTE was confirmed on imaging decreased postintervention (10.2% v. 14.1%).Conclusion:In spite of excellent compliance with our algorithm, we were unable to reduce imaging for VTE. This may be due to a lower threshold for suspecting VTE and an increase in investigation for VTE combined with a high false positive rate of our D-dimer assay in low–pretest probability patients. This study highlights two common real-life challenges with adopting this strategy for VTE investigation.

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Health care provided to recent asylum-seeking and non-asylum-seeking pediatric patients in 2016 and 2017 at a Swiss tertiary hospital - a retrospective study

BMC Public Health ◽

10.1186/s12889-020-10082-z ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Julia Brandenberger ◽

Christian Pohl ◽

Florian Vogt ◽

Thorkild Tylleskär ◽

Nicole Ritz

Keyword(s):

Health Care ◽

Emergency Department ◽

Retrospective Study ◽

Hospital Admissions ◽

Tertiary Care ◽

Tertiary Hospital ◽

Care Hospital ◽

Children With Medical Complexity ◽

Cross Sectional ◽

Number Of Visits

Abstract Background Asylum-seeking children represent an increasing and vulnerable group of patients whose health needs are largely unmet. Data on the health care provision to asylum-seeking children in European contexts is scarce. In this study we compare the health care provided to recent asylum-seeking and non-asylum-seeking children at a Swiss tertiary hospital. Methods We performed a cross-sectional retrospective study in a pediatric tertiary care hospital in Basel, Switzerland. All patients and visits from January 2016 to December 2017 were identified, using administrative and medical electronic health records. The asylum-seeking status was systematically assessed and the patients were allocated accordingly in the two study groups. Results A total of 202,316 visits by 55,789 patients were included, of which asylum-seeking patients accounted for 1674 (1%) visits by 439 (1%) individuals. The emergency department recorded the highest number of visits in both groups with a lower proportion in asylum-seeking compared to non-asylum-seeking children: 19% (317/1674) and 32% (64,315/200,642) respectively. The median number of visits per patient was 1 (IQR 1–2) in the asylum-seeking and 2 (IQR 1–4) in the non-asylum-seeking children. Hospital admissions were more common in asylum-seeking compared to non-asylum-seeking patients with 11% (184/1674) and 7% (14,692/200,642). Frequent visits (> 15 visits per patient) accounted for 48% (807/1674) of total visits in asylum-seeking and 25% (49,886/200,642) of total visits in non-asylum-seeking patients. Conclusions Hospital visits by asylum-seeking children represented a small proportion of all visits. The emergency department had the highest number of visits in all patients but was less frequently used by asylum-seeking children. Frequent care suggests that asylum-seeking patients also present with more complex diseases. Further studies are needed, focusing on asylum-seeking children with medical complexity.

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Clinical Profile of Stroke Patients Presenting to the Emergency Department of a Major Stroke Centre in Oman

Sultan Qaboos University Medical Journal [SQUMJ] ◽

10.18295/squmj.4.2021.062 ◽

2021 ◽

Author(s):

Hasina A. Al Harthi ◽

Ammar Al Kashmiri ◽

Lubna M. Zakaryia ◽

Jawad A. Al-Lawati ◽

Omar M. Najem ◽

...

Keyword(s):

Risk Factors ◽

Emergency Department ◽

Heart Diseases ◽

Tertiary Care ◽

Public Health Problem ◽

Large Artery ◽

Care Hospital ◽

Stroke Patients ◽

Vessel Occlusion ◽

Number Of Patients

Objectives: Stroke is a significant public health problem and one of the important preventable non-communicable diseases. Preventive stroke programs are yet to be properly established in Oman, with a better focus on increasing awareness among those who are currently at risk. This study was conducted to describe the characteristics of stroke presenting to a tertiary care hospital in Oman. Methods: This was a cross-sectional hospital-based study. Included 193 stroke cases which were prospectively recruited from the Emergency Department of a tertiary-level hospital. Data was collected from November 2017 to April 2018. Results: The total number of patients was 193. 82.9% of strokes were ischemic strokes. 58% were male. The mean age of stroke patients was 61.05 years. Risk factors included hypertension (72.5%) and diabetes mellitus (54.4%). Dyslipidemia, atrial fibrillation and ischemic heart diseases were not particularly prevalent in our population. 24.4% of ischemic strokes had large artery atherosclerosis and 21.9% had small vessel occlusion. Significantly more patients had lower Glasgow Coma Scale (GCS), required ICU admission and had in-hospital deaths in hemorrhagic stroke compared to ischemic stroke. Conclusions: This study provides essential stroke characteristics data specific to Oman’s population. Most of the information obtained conforms with that described internationally and similar preventive strategies can be implemented. The information can be utilized by health administrators in planning resource allocation. Further research is needed to explore rehabilitation aspects and long-term outcomes. Keywords: Stroke; Ischemic; Hemorrhagic; Young Stroke; Risk Factors; Thrombolysis; Epidemiology; Oman.

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Health care provided to asylum-seeking and non-asylum-seeking paediatric patients at a Swiss tertiary hospital

10.21203/rs.2.19022/v1 ◽

2019 ◽

Author(s):

Julia Regina Brandenberger ◽

Christian Pohl ◽

Florian Vogt ◽

Thorkild Tylleskär ◽

Nicole Ritz

Keyword(s):

Health Care ◽

Emergency Department ◽

Hospital Admissions ◽

Tertiary Care ◽

Tertiary Hospital ◽

Cross Sectional Study ◽

Care Hospital ◽

Cross Sectional ◽

Admission Rates ◽

Number Of Visits

Abstract Background & Methods To compare health care provided to asylum-seeking and non-asylum-seeking children, we performed a cross-sectional study in a paediatric tertiary care hospital in Switzerland. Patients were identified using administrative and medical electronic health records from January 2016 - December 2017. Results A total of 202’316 visits by 55’789 patients were included, of which asylum-seeking patients accounted for 1674 (1%) visits by 439 (1%) patients. The emergency department had the highest number of visits in both groups with a lower proportion in asylum-seeking compared to non-asylum-seeking children: 19% (317/1674) and 32% (64’315/200’642) respectively. Hospital admissions were more common in asylum-seeking patients 11% (184/1674) and 7% (14’692/200’642). Frequent visits accounted for 48% (807/1674) of total visits in asylum-seeking and 25% (49’886/200’642) of total visits in non-asylum-seeking patients. Conclusions Hospital visits by asylum-seeking children represented a small proportion of all visits. The emergency department had the highest number of visits in all patients and was less frequently used in asylum-seeking children. Higher admission rates and a larger proportion of visits from frequently visiting patients suggest that asylum-seeking patients may present with more complex diseases.

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Evaluation of the frequency of patients with cancer presenting to an emergency department

Revista da Associação Médica Brasileira ◽

10.1590/1806-9282.66.10.1402 ◽

2020 ◽

Vol 66 (10) ◽

pp. 1402-1408

Author(s):

Cem Isikber ◽

Muge Gulen ◽

Salim Satar ◽

Akkan Avci ◽

Selen Acehan ◽

...

Keyword(s):

Emergency Department ◽

Emergency Services ◽

Care Center ◽

Tertiary Care ◽

Length Of Hospital Stay ◽

Care Hospital ◽

Oncological Emergency ◽

Frequency Of Use ◽

Hospital Patients ◽

Use Of Emergency Services

SUMMARY OBJECTIVE: This study aims to determine the demographic characteristics of cancer patients admitted to an emergency department and determine the relationship between the frequency of admission to the emergency department and oncological emergencies and their effect on mortality. METHODS: This observational, prospective, diagnostic accuracy study was performed in the ED of a tertiary care hospital. Patients over the age of 18 who were previously diagnosed with cancer and admitted to the emergency service for medical reasons were included in the study. We recorded baseline characteristics including age, gender, complaints, oncological diagnosis, metastasis status, cancer treatments received, the number of ED admissions, structural and metabolic oncological emergency diagnoses in the ED, discharge status, length of hospital stay, and mortality status. RESULTS: In our study, 1205 applications related to the oncological diagnosis of 261 patients were examined. 55.6% of the patients were male, and 44.4% were female. The most common metabolic oncological emergency was anemia (19.5%), and the most common structural oncological emergency was bone metastasis-fracture (4.6%.) The mean score of admission of patients to the emergency department was four times (min: 1 max: 29) during the study period. A total of 49.4% (n: 129) of the patients included in the study died during follow-up, and the median time of death was 13 days after the last ED admission. CONCLUSION: The palliation of patient symptoms in infusion centers that will be established in the palliative care center will contribute to the decrease in the frequency of use of emergency services.

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