Disagreements between emergency patients and physicians regarding chief complaint - Patient factors and prognostic implications

Emergency Presentations for Dizziness-Radiological Findings, Final Diagnoses, and Mortality

Background

Dizziness is a frequent presentation in patients presenting to emergency departments (EDs), often triggering extensive work-up, including neuroimaging. Therefore, gathering knowledge on final diagnoses and outcomes is important. We aimed to describe the incidence of dizziness as primary or secondary complaint, to list final diagnoses, and to determine the use and yield of neuroimaging and outcomes in these patients.

Methods

Secondary analysis of two observational cohort studies, including all patients presenting to the ED of the University Hospital of Basel from 30th January 2017-19th February 2017 and from 18th March 2019-20th May 2019. Baseline demographics, Emergency Severity Index (ESI), hospitalization, admission to Intensive Care Units (ICUs), and mortality were extracted from the electronic health record database. At presentation, patients underwent a structured interview about their symptoms, defining their primary and secondary complaints. Neuroimaging results were obtained from the picture archiving and communication system (PACS). Patients were categorized into three non-overlapping groups: dizziness as primary complaint, dizziness as secondary complaint, and absence of dizziness.

Results

Of 10076 presentations, 232 (2.3%) indicated dizziness as their primary and 984 (9.8%) as their secondary complaint. In dizziness as primary complaint, the three (out of 73 main conditions defined) main diagnoses were nonspecific dizziness (47, 20.3%), dysfunction of the peripheral vestibular system (37, 15.9%), as well as somatization, depression, and anxiety (20, 8.6%). 104 of 232 patients (44.8%) underwent neuroimaging, with relevant findings in 5 (4.8%). In dizziness as primary complaint 30-day mortality was 0%.

Conclusion

Work-up for dizziness in emergency presentations has to consider a broad differential diagnosis, but due to the low yield, it should include neuroimaging only in few and selected cases, particularly with additional neurological abnormalities. Presentation with primary dizziness carries a generally favorable prognosis lacking short-term mortality. .

Throughput delays: causes, predictors, and outcomes - observational cohort in a Swiss emergency department

BACKGROUND

Optimal throughput times in emergency departments can be adjudicated by emergency physicians. Emergency physicians can also define causes of delays during work-up, such as waiting for imaging, clinical chemistry, consultations, or exit blocks. For adequate streaming, the identification of predictors of delays is important, as the attribution of resources depends on acuity, resources, and expected throughput times.

OBJECTIVE

This observational study aimed to identify the causes, predictors, and outcomes of emergency physician-adjudicated throughput delays.

METHODS

Two prospective emergency department cohorts from January to February 2017 and from March to May 2019 around the clock in a tertiary care centre in Switzerland were investigated. All consenting patients were included. Delay was defined as the subjective adjudication of the responsible emergency physician regarding delay during emergency department work-up. Emergency physicians were interviewed for the occurrence and cause of delays. Baseline demographics, predictor values, and outcomes were recorded. The primary outcome - delay - was presented using descriptive statistics. Univariable and multivariable logistic regression analyses were performed to assess the associations between possible predictors and delays and hospitalization, intensive care, and death with delay.

RESULTS

In 3656 (37.3%) of 9818 patients, delays were adjudicated. The patients with delays were older (59 years, interquartile range [IQR]: 39-76 years vs 49 years, IQR: 33-68 years) and more likely had impaired mobility, nonspecific complaints (weakness or fatigue), and frailty than the patients without delays. The main causes of delays were resident work-up (20.4%), consultations (20.2%), and imaging (19.4%). The predictors of delays were an Emergency Severity Index of 2 or 3 at triage (odds ratio [OR]: 3.00; confidence interval [CI]: 2.21-4.16; OR: 3.25; CI: 2.40-4.48), nonspecific complaints (OR: 1.70; CI: 1.41-2.04), and consultation and imaging (OR: 2.89; CI: 2.62-3.19). The patients with delays had an increased risk for admission (OR: 1.56; CI: 1.41-1.73) but not for mortality than those without delays.

CONCLUSION

At triage, simple predictors such as age, immobility, nonspecific complaints, and frailty may help to identify patients at risk of delay, with the main reasons being resident work-up, imaging, and consultations. This hypothesis-generating observation will allow the design of studies aimed at the identification and elimination of possible throughput obstacles.

Emergency presentations of older patients living with frailty: Presenting symptoms compared with non-frail patients

BACKGROUND AND OBJECTIVE

Symptoms may differ between frail and non-frail patients presenting to Emergency Departments (ED). However, the association between frailty status and type of presenting symptoms has not been investigated. We aimed to systematically analyse presenting symptoms in frail and non-frail older emergency patients and hypothesized that frailty may be associated with nonspecific complaints (NSC), such as generalised weakness.

METHODS

Secondary analysis of a prospective, single centre, observational all-comer cohort study conducted in the ED of a Swiss tertiary care hospital. All presentations of patients aged 65 years and older were analysed. At triage, presenting symptoms and frailty were systematically assessed using a questionnaire. Patients with a Clinical Frailty Scale (CFS) > 4 were considered frail. Presenting symptoms, stratified by frailty status, were analysed. The association between frailty and generalised weakness was tested by logistic regression.

RESULTS

Overall, 2'416 presentations of patients 65 years and older were analysed. Mean age was 78.9 (SD 8.4) years, 1'228 (50.8%) patients were female, and 885 (36.6%) patients were frail (CFS > 4). Generalised weakness, dyspnea, localised weakness, speech disorder, loss of consciousness and gait disturbance were recorded more often in frail patients, whereas chest pain was reported more often by non-frail patients. Generalised weakness was reported as presenting symptom in 166 (18.8%) frail patients and in 153 (10.0%) non-frail patients. Frailty was associated with generalised weakness after adjusting for age, gender and elevated National Early Warning Score 2 (NEWS) ≥ 3 (OR 1.19, CI 1.10-1.29, p < 0.001).

CONCLUSION

Presenting symptoms differ in frail and non-frail patients. Frailty is associated with generalised weakness at ED presentation.

Prevalence and Prognosis of Fever Symptoms, Hypo-, and Hyperthermia in Unselected Emergency Patients

Assessments of history and body temperature are cornerstones of the diagnostic workup in all patients presenting to emergency departments (ED). Yet, the objective measurement of temperature and the subjective perception of fever can differ. This is a secondary exploratory analysis of a consecutive all-comer study, performed at an adult ED in Switzerland. Trained medical students interviewed all patients if fever was present. Altered temperature (>38.0 °C/<36.0 °C) measured at triage using an ear thermometer was used as the reference standard for diagnostic performance. In case of a disagreement between fever symptoms and altered temperature, discordance was noted. Outcome measures for case severity (acute morbidity, hospitalization, intensive care, and in-hospital mortality) were extracted from the electronic health records. Odds ratios (OR) for discordance between signs and symptoms and outcomes were calculated. Among 2183 patients, 325 patients reported fever symptoms. The sensitivity of fever symptoms as a test for altered temperature was 36.3%. Specificity was 91.5%. The negative predictive value was 84.1%, positive likelihood ratio was 4.2 and negative likelihood ratio was 0.7. The adjusted OR for discordance between fever symptoms and altered temperature was 1.71 (95% CI: 1.2–2.44) for acute morbidity, 1.56 (95% CI: 1.13–2.15) for hospitalization, and 1.12 (95% CI: 0.64–1.59) for intensive care. Unadjusted OR for mortality was 1.5 (95% CI: 0.69–3.25). Fever symptoms and altered temperature broadly overlap, but presentations can be stratified according to concordance between signs and symptoms. In case of discordance, the odds for acute morbidity and hospitalization are increased. Discordance may therefore be further investigated as a red flag for a serious outcome.

The association between the degree of fever as measured in the emergency department and clinical outcomes of hospitalized adult patients

BACKGROUND

Fever is a physiologic response to a wide range of pathologies and one of the most common complaints and clinical signs in the emergency medicine department (ED). The association between fever magnitude and clinical outcomes has been evaluated in specific populations with inconsistent results.

OBJECTIVES

In this study we aimed to investigate the association between the degree of fever in the ED and clinical outcomes of hospitalized febrile adult patients.

METHODS

This was a retrospective single-center cohort study of all the patients with maximal body temperature (BT) ≥ 38.0 °C, as recorded during the ED evaluation, who were hospitalized between January 2015 and December 2020. Patients with heatstroke were excluded. The primary outcome was 30-day all-cause mortality and secondary outcomes were intensive care unit (ICU) admission and development of acute kidney injury (AKI).

RESULTS

Fever was recorded among 8.1% of patients evaluated in the ED. Elevated BT was associated with increased risk of hospital admission (70.3% vs. 49.4%, p < 0.001), 30-day mortality (12.3% vs. 2.6%, p < 0.001), ICU admission (5.7% vs. 2.8%, p < 0.001), and AKI 11.7% vs. 3.8%, p < 0.001). After exclusion of nine patients with heatstroke, 21,252 hospitalized febrile patients were included in the final analysis. BT > 39.7 °C was progressively associated with increased mortality (OR 1.64-2.22, 95% CI 1.16-2.81, p < 0.005) as compared to BT 38.0-38.1 °C. More AKI events were observed in patients with BT > 39.5 °C (OR 1.48-2.91, 95% CI 1.11-3.66, p < 0.007). Temperature between 39.2 and 39.5 °C was associated with lower mortality (OR 0.62-0.71, 95% CI 0.51-0.87, p < 0.001). In a multiple logistic regression analysis BT > 39.9 °C was independently associated with increased mortality and AKI. BT > 39.7 °C was progressively associated with an increased risk of ICU admission.

CONCLUSION

Among febrile patients admitted to the hospital, BT > 39.5 °C was associated with adverse clinical course, as compared to patients with lower-grade fever (38.0-38.1 °C). These patients should be flagged on arrival to the ED and likely warrant more aggressive evaluation and treatment.