Addition of a general practitioner to the accident and emergency department: a cost-effec…

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Does integrated emergency care reduce mortality and non-elective admissions? A retrospect…

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Comparison of two clinical scoring systems in risk stratification of non-ST elevation acu…

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Features of odontogenic infections in hospitalised and non-hospitalised settings.
…

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Individual care plans can reduce hospital admission rate for patients who frequently attend the emergency department.
Emerg Med J. 2011 Aug;28(8):654-7
Authors: Newton A, Sarker SJ, Parfitt A, Henderson K, Jaye P, Drake N
…

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The prevalence and characteristics of alcohol-related presentations to emergency departments in rural Australia.
Emerg Med J. 2011 Apr;28(4):290-5
Authors: Havard A, Shakeshaft AP, Conigrave KM, Sanson-Fisher RW
The bu…

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Formal medicine reconciliation within the emergency department reduces the medication error rates for emergency admissions.
Emerg Med J. 2010 Dec;27(12):911-5
Authors: Mills PR, McGuffie AC
To improve medication histor…

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Related Articles

Clinical diagnosis of acute coronary syndrome in patients with chest pain and a normal or non-diagnostic electrocardiogram.

Emerg Med J. 2009 Dec;26(12):866-70

Authors: Goodacre S, Pett P, Arnold J, Chawla A, Hollingsworth J, Roe D, Crowder S, Mann C, Pitcher D, Brett C

BACKGROUND: Clinical features may be used to determine which patients with suspected acute coronary syndrome (ACS), but a normal or non-diagnostic ECG, should be selected for further investigation or inpatient care. We aimed to measure the diagnostic value of clinical features for ACS. METHODS: Standardised data relating to presenting characteristics, associated features and risk factors were collected at seven chest pain units established for the ESCAPE trial. All patients received troponin measurement at least 6 h after last significant symptoms, creatine kinase MB(mass) gradient over 2 h and, if appropriate, treadmill exercise testing. The reference standard of ACS was defined as troponin >0.03 ng/ml, creatine kinase MB(mass) gradient >3.0 ng/ml or early positive treadmill exercise test. RESULTS: 1576 patients were analysed, including 132 (8.4%) with ACS. Patients with ACS were older, had longer symptom duration, were more likely to be a man, hypertensive and an ex-smoker or have pain radiating to their right arm. On multivariate analysis, only age, duration, sex and radiation of pain to the right arm were independently associated with ACS. Likelihood ratios (95% CI) were radiation of pain to the right arm, 2.9 (95% CI 1.4 to 6.3), male sex 1.2 (95% CI 1.0 to 1.3) and female sex 0.79 (95% CI 0.62 to 1.0). The area under the receiver operator characteristic curve for age was 0.629 (95% CI 0.573 to 0.686) and for duration was 0.546 (95% CI 0.481 to 0.610). CONCLUSION: Clinical features have very limited value for diagnosing ACS in patients with a normal or non-diagnostic ECG. Radiation of pain to the right arm increases the likelihood of ACS.

PMID: 19934131 [PubMed - indexed for MEDLINE]

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Interobserver variability in CT scan interpretation for suspected acute appendicitis.

Emerg Med J. 2009 Feb;26(2):92-4

Authors: in’t Hof KH, Krestin GP, Steijerberg EW, Bonjer HJ, Lange JF, Becking WB, Kazemier G

OBJECTIVE: A prospective study was undertaken to assess the interobserver variability in CT scan interpretation in patients with suspected acute appendicitis. METHODS: 103 adult patients with suspected acute appendicitis underwent unenhanced helical multislice CT scanning of the abdomen. All patients subsequently underwent laparoscopy by a surgeon who was blind to the diagnosis suggested by the CT scan. All CT scans were interpreted by group A, B and C radiologists with different levels of expertise. RESULTS: Acute appendicitis was diagnosed on multislice CT scans in 69%, 74% and 80% by group A, B, and C radiologists, respectively. At laparoscopy, 83% of patients were diagnosed with acute appendicitis. For group A, B and C radiologists, the specificity of CT scanning for the diagnosis of acute appendicitis was 94%, 94% and 100%, respectively, the sensitivity was 81%, 88% and 95%, the positive predictive value was 98.6%, 98.7% and 100%, and the negative predictive value was 50%, 68% and 81%. The difference in the proportion of positive outcomes between observer groups A and C was significant. During laparoscopy, 12 patients were diagnosed with other diseases. These were all correctly diagnosed by group C radiologists; groups A and B radiologists missed the diagnosis of colitis in one patient. All other disorders were diagnosed correctly. CONCLUSIONS: The sensitivity of CT interpretations for the diagnosis of acute appendicitis differs considerably between radiologists. This interobserver variability has to be taken into account during implementation of routine CT scanning in patients with suspected acute appendicitis. Only in centres with expert CT radiologists is the implementation of routine CT scanning in patients with suspected acute appendicitis justified.

PMID: 19164615 [PubMed - indexed for MEDLINE]

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The use of plain abdominal x rays in the emergency department.

Emerg Med J. 2009 Mar;26(3):160-3

Authors: Smith JE, Hall EJ

Abdominal x rays expose patients to significant doses of radiation and have limited use in emergency medicine. This review explores the evidence supporting the use of abdominal x rays in the emergency department, with particular reference to recent guidelines published by the Royal College of Radiologists. The authors’ recommendations for the use of abdominal x rays in the emergency department are given.

PMID: 19234001 [PubMed - indexed for MEDLINE]

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Use of an admission early warning score to predict patient morbidity and mortality and treatment success.

Emerg Med J. 2008 Dec;25(12):803-6

Authors: Groarke JD, Gallagher J, Stack J, Aftab A, Dwyer C, McGovern R, Courtney G

BACKGROUND: Early warning scores (EWS) are used to identify physiological deterioration in patients. Studies to date have primarily focused on the correlation between trends in serially recorded EWS of inpatients and clinical outcomes. This study examined the predictive value of an EWS calculated immediately on presentation to hospital for acute medical patients. METHOD: A prospective study of 225 consecutive medical admissions. Pulse, systolic blood pressure, respiratory rate, oxygen saturation and neurological status were used to calculate an EWS. Patients were divided into four score categories based on their EWS. The primary endpoints examined were intensive care unit (ICU)/coronary care unit (CCU) admission, death, cardiac arrest and length of hospital stay. RESULTS: For each rise in score category there was an increased risk of admission to ICU (odds ratio (OR) 3.35, CI 1.52 to 7.40, p = 0.003), admission to CCU (OR 1.82, CI 1.07 to 3.09, p = 0.027), death (OR 2.19, CI 1.41 to 3.39, p = 0.000) and reaching the combined endpoint of CCU/ICU admission or death (OR 2.19, CI 1.41 to 3.39, p = 0.000). The higher the score the longer the length of hospital admission (p = 0.04). A decrease in EWS between first presentation to hospital and transfer to the ward was associated with a decreased risk of reaching the combined endpoint of CCU or ICU admission or death (OR 2.56, CI 1.11 to 5.89, p = 0.028). DISCUSSION: Higher admission EWS correlate with increased risk of CCU/ICU admission, death and longer hospital stays independent of patient age. An improvement in serial EWS within 4 h of presentation to hospital predicts improved clinical outcomes. The EWS is a potential triage tool in the emergency department for acute medical patients.

PMID: 19033494 [PubMed - indexed for MEDLINE]

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Can a change in policy reduce emergency hospital admissions? Effect of admission avoidance team, guideline implementation and maximising the observation unit.

Emerg Med J. 2008 Sep;25(9):575-8

Authors: Gonnah R, Hegazi MO, Hmdy I, Shenoda MM

BACKGROUND: Reduction in admissions is an important aim of emergency department working policy to overcome the problems of a shortage of inpatient beds, overcrowding, rising costs and exhausted resources. A new policy was instituted in the emergency department of a hospital in Kuwait with the following components: (1) an admission avoidance team of emergency department doctors; (2) implementation of disease management guidelines; and (3) maximising the use of an emergency department observation unit. METHODS: The effects of this policy on reduction in admission rates for total medical admissions and for chest pain, bronchial asthma, heart failure, pneumonia and pyelonephritis as selected samples of common medical conditions were prospectively studied over a period of 3 years from institution of the policy and compared with the 3-year period before the policy was instituted. RESULTS: There was a significant reduction in admission rates after institution of the new policy, with a relative reduction of 35.9% for total medical admissions, 52.7% for chest pain, 49.2% for bronchial asthma, 34.7% for heart failure, 59.1% for pneumonia and 43.3% for pyelonephritis compared with the period before the policy was instituted. CONCLUSION: A multidisciplinary emergency department policy, using as much available evidence as possible, was successful in significantly reducing medical hospital admissions in spite of the rising numbers of patients visiting the emergency department and observation unit.

PMID: 18723706 [PubMed - indexed for MEDLINE]

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Initial risk stratification and presenting characteristics of patients with evolving myocardial infarctions.

Emerg Med J. 2008 Aug;25(8):492-7

Authors: Miller CD, Fermann GJ, Lindsell CJ, Mahaffey KW, Peacock WF, Pollack CV, Hollander JE, Diercks DB, Gibler WB, Hoekstra JW,

OBJECTIVES: To describe the presenting characteristics and risk stratification of patients presenting to the emergency department with chest pain who have a normal initial troponin level followed by a raised troponin level within 12 h (evolving myocardial infarction (EMI)). METHODS: Data from the Internet Tracking Registry for Acute Coronary Syndromes (i*trACS), a registry of patients presenting with undifferentiated chest pain, were used. This analysis included patients without ST segment elevation with at least two troponin assay results < or = 12 h apart. Patients were stratified into three groups: EMI (initial troponin assay negative, second troponin assay positive), non-ST elevation myocardial infarction (NSTEMI) (initial troponin assay positive) and no MI (all troponin assays negative). RESULTS: Of 4136 eligible patients, 5% had EMI, 8% had NSTEMI and 87% had no MI. Patients with EMI were more similar to those with NSTEMI than those with no MI with respect to demographic characteristics, presentation, admission patterns and revascularisation. The initial ECG in patients with EMI was most commonly non-diagnostic (51%), but physicians' initial impressions commonly reflected MI, unstable angina or high-risk chest pain (76%). This risk assessment was followed by a high rate of critical care admissions (32%) and revascularisation (percutaneous coronary intervention 17%) among patients with EMI. CONCLUSION: Patients with EMI appear similar at presentation to those with NSTEMI. Patients with EMI are perceived as being at high risk, evidenced by similar diagnostic impressions, admission practices and revascularisation rates to patients with NSTEMI.

PMID: 18660397 [PubMed - indexed for MEDLINE]

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Impact of helical computed tomography in clinically evident appendicitis.

Emerg Med J. 2008 Aug;25(8):477-81

Authors: Kim K, Rhee JE, Lee CC, Kim KS, Shin JH, Kwak MJ, Kim JH, Suh GJ, Hahn SK, Singer AJ

OBJECTIVES: To determine the utility of multidetector computed tomography (MDCT) in patients with clinically evident acute appendicitis and to compare the test characteristics of overall clinical impression, Alvarado scores, and MDCT in suspected appendicitis. METHODS: A prospective observational cohort study was conducted in two urban emergency departments (ED). Consecutive patients with suspected acute appendicitis were clinically evaluated by an emergency physician who was asked to determine whether appendicitis was clinically evident or not. Elements of the Alvarado scores were collected and all patients then underwent MDCT and a decision to operate, observe, or discharge the patients was made by a surgeon. The final diagnosis was based on surgical pathology or clinical follow-up. The test characteristics of clinical impression, Alvarado scores and MDCT were then calculated and the rates at which acute appendicitis was falsely diagnosed based on clinical impression and MDCT were compared using McNemar's test. RESULTS: Of 157 study patients, 71 were considered to have clinically evident appendicitis before MDCT and 91 had findings of acute appendicitis on MDCT. 19 of the 71 patients with clinically evident appendicitis did not have appendicitis. 14 of 52 patients with an Alvarado score > or = 8 also did not have appendicitis. Three of 91 patients with acute appendicitis based on MDCT did not have appendicitis. The specificities of clinical impression and Alvarado score > or = 8 were 71.6% and 79.1%, respectively, and these were significantly lower than that of MDCT (95.5%, p<0.05). CONCLUSION: The performance of abdominal MDCT in patients with a high degree of clinical suspicion for acute appendicitis reduces the number of false positives and has the potential to reduce negative appendectomies.

PMID: 18660392 [PubMed - indexed for MEDLINE]

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