[Impact in the quality of health care and cost-effectiveness analysis of the reform of an emergency medicine service]

Acute Kidney Injury Facilitates Hypocalcemia by Exacerbating the Hyperphosphatemic Effect of Muscle Damage in Rhabdomyolysis

BACKGROUND/AIMS

Hypocalcemia is an important complication of rhabdomyolysis for which several pathogenic factors, including acute kidney injury (AKI), have been proposed. To gain insight regarding the hypocalcemic roles of AKI in rhabdomyolysis, we retrospectively examined patients with rhabdomyolysis.

METHODS

Of 28,387 patients admitted to the Department of Internal Medicine, 51 patients met the inclusion criteria for the study. Serum calcium was analyzed based on laboratory data including indicators of AKI, serum creatine kinase (CK) and serum inorganic phosphate (iP).

RESULTS

Twenty-two patients (43%) had hypocalcemia. Compared with patients without hypocalcemia, they had a higher prevalence of AKI (82 vs. 55%; p = 0.046), higher levels of peak CK (39,100 ± 50,600 vs. 9,800 ± 11,900 IU/l; p = 0.003) and higher levels of peak iP (1.77 ± 1.10 vs. 1.10 ± 0.35 mmol/l; p = 0.007). Indicators of AKI were correlated with peak CK and peak iP and were not significant variables in the regression analysis for hypocalcemia. Peak CK and peak iP were not correlated with each other. Impaired phosphate use by muscle contributed to the increased iP.

CONCLUSION

These findings indicate that muscle damage is the primary hypocalcemic factor in rhabdomyolysis. AKI facilitated hypocalcemia by exacerbating the hyperphosphatemic effects of muscle damage. Aggressive hydration, which could increase oxygen supply and subsequently repair phosphate use in muscle, might reduce the incidence of hypocalcemia in rhabdomyolysis.

Effectiveness and safety of an emergency department short-stay unit as an alternative to standard inpatient hospitalisation

BACKGROUND

Emergency department short-stay units (EDSSUs) are currently emerging worldwide as an alternative to standard inpatient hospitalisation. In our hospital, a 960-bed teaching tertiary institution in Barcelona, Spain, an EDSSU has been in operation during winter periods (November-March) since 1997.

AIM

To determine the efficacy and safety of our EDSSU.

METHODS

Retrospective analysis of activity and quality outcomes, assessment of patient satisfaction levels and determination of the diagnostic-related groups that were mainly responsible for admissions to the EDSSU, comparing the clinical characteristics of those patients with the characteristics of patients with similar clinical diagnoses admitted to standard hospitalisation units.

RESULTS

5666 patients were treated in the EDSSU, with a progressive increase in the number of patients admitted per period, ranging from 707 in 1997-8 to 1227 in 2003-4 (73.5% increase). The mean length of stay ranged from 3.1 to 2.8 days, mortality from 2.5% to 5.1%, home discharge rate from 84% to 90%, and hospital readmission rate within the first week after discharge from 3.9% to 6.2%. In all, 98% of patients were satisfied with their stay at the EDSSU. The main diagnostic-related groups were chronic obstructive pulmonary disease (COPD = 50%) and acute heart failure (28%). Patients with COPD admitted at the EDSSU (n = 545) showed significantly (p = 0.05) lower mean length of stay (3.4 v 12 days) and mortality (1.7% v 8.1%), but a higher hospital readmission rate (9.9% v 7%) than those admitted to standard inpatient units (n = 1961).

CONCLUSIONS

In our experience, the EDSSU proved to be an effective and safe alternative to standard inpatient hospitalisation.

Repercusión de la falta de camas de hospitalización en la actividad de un servicio de urgencias hospitalario

BACKGROUND AND OBJECTIVE

To determine the effect that the lack of inhospital beds exerts on emergency department performance.

MATERIAL AND METHOD

Two different time periods with comparable daily census, but significantly different bed availability. Variables assessed were general emergency department performance markers, emergency department effectiveness markers and objective and subjective quality markers.

RESULTS

All variables got worse within lower bed availability period, and reached a change magnitude between 0% and 300% when compared with control period. However, a statistical difference was only achieved in emergency department occupation rate (+14%; p < 0.001), rate of patients waiting to be admitted (+100%; p < 0.001), patients waiting to be seen (+60%; p < 0.01), waiting time to be seen (+83%; p < 0.001), time to employed for first medical assessment and treatment (+44%; p < 0.01), and patients left without being seen (+90%; p < 0.05).

CONCLUSIONS

The lack of inhospital beds for patients admitted from the emergency department leads to a remarkable worsening in its function and performance.

[Effect of the incorporation of a general practitioner on emergency department effectiveness]

BACKGROUND AND OBJECTIVES

To know the effect that the presence of a general practitioner (GP) has on emergency department's effectiveness, efficiency and health care.

PATIENTS AND METHOD

Prospective interventional study carried out in the emergency medicine unit fast track area (FTA), which is ideally opened from 8 am to 12 am, and staffed by 2 residents.

INTERVENTION

8 resident hours (from 4 pm to 12 am) were substituted by 8 GP hours. The study period was August 2002 (GP presence), and the control period, October 2002. From each period, 10 days and 100 patients were randomly selected. From each day, FTA census (P), percentage of revisits and patients leaving without being seen, elapsed time to FTA actual closing (OT), percentage of patients moved to the observation area, and percentage of admissions were recorded. From each patient, epidemiological and clinical characteristics, waiting time to be seen (WT), number of tests performed, elapsed time to treatment (TT), and length of stay (LOS) were collected along with the number of patients finally discharged without hospital specialist consultation and those discharged with no test ordered. To assess perceived care quality, a telephone survey was performed. Three effectiveness indexes were defined and determined: P/WT (E1), P/OT (E2), and perceived care quality/perceived WT (E3). Finally, fixed and variables costs (C) from both periods were calculated, and cost-effectiveness analysis for each effectiveness index and period performed.

RESULTS

Periods showed no differences regarding daily census and patient characteristics. In the study period (GP presence), all time variables significantly improved: 20% reduction in WT, 25% in TT, 36% in LOS, and 17.5% in OT. A decrease in the number of tests ordered (41% less), in the percentage of patients moved to the observation area (78% less), and in the revisit rate (75% less) was also noted. Finally, E1 improved in 77% and E2 in 51%. Cost-effectiveness analysis clearly supported the study period, showing a decrease in C/E1 (55% less), in C/E2 (33% less), and in C/E3 (6% less). From the telephone survey, no differences between periods were detected except a perceived WT in the study period lower than that in the control period.

CONCLUSIONS

The presence of a GP in a FTA leads to an improvement in the effectiveness and quality of care received by attended patients. In addition of these important features, this presence is also efficient. Therefore, it is an intervention that could be taken into account by administrators to better manage emergency departments.

Trends in illicit drug emergencies: the emerging role of gamma-hydroxybutyrate

BACKGROUND

Previously used as a general anesthetic, gamma-hydroxybutyrate is now used as a recreational drug. Not surprisingly, an increasing number of acute overdose cases requiring emergency medical care have been reported and described, especially in the United States.

OBJECTIVES

To determine the number and percentage of gamma-hydroxybutyrate overdoses over a 15-month period and to describe the clinical hallmarks and course of this new drug in overdose.

METHODS

All toxicological emergencies, including those caused by illicit drug consumption, were recorded for 15 months in an urban public hospital emergency department. Accurate toxicological history was obtained from the patients and, if gamma-hydroxybutyrate was suspected, confirmation was performed by urine mass spectrometry. The study data were compared with data recorded in the same emergency department in 1989.

RESULTS

The total number of toxicological emergencies attended in our emergency department have remained unchanged during the last decade, with a significant decrease in number of opiate overdoses and an increase in the number of cocaine, amphetamine, and gamma-hydroxybutyrate overdoses. During the study period, 104 gamma-hydroxybutyrate overdoses presented to the emergency department (3.1% of all toxicological emergencies), ranking second in illicit drugs requiring emergency consultation. The profile of a patient with gamma-hydroxybutyrate intoxication is well defined: a young individual (23 +/- 5 years), male (64%), emergency department presentation on weekends (90%), with simultaneous ethanol consumption (73%) and ingestion of additional illicit drugs (86%), decrease of consciousness being the main complaint in all cases [16% with Glasgow Coma Scale (GCS) = 3]. Complete recovery without sequelae occurred in all cases.

CONCLUSION

Health authorities must be aware of the hazards of recreational gamma-hydroxybutyrate, and physicians must be cognizant of this recent cause of coma among youths presenting to the emergency departments.