Patients presenting at the emergency department with acute abdominal pain are less likely to be admitted to inpatient wards at times of access block: a registry study

Congruency of nurse-patient pain scoring in the emergency department: a cross-sectional observational study

Aim: To examine the congruency between patient self-reporting and nurse assessment of pain in the emergency department (ED) through the use of the numerical rating scale (NRS) and visual analogue scale (VAS). Materials & methods: Patient self-reporting of pain and nurse assessments were concurrently conducted using the NRS and VAS. Results & conclusion: Self-reported pain assessment was collected from 200 ED patients in parallel with their corresponding nurse-reported pain scores, conducted by 67 ED nurses. Although nurse-patient pain scoring was associated with a high congruency using both NRS and VAS (88.2 and 91.5%, respectively), nurses still underestimated patients' pain intensity using both tools (t = 2.37 and 2.60; p = 0.007 and 0.010 and CI: 0.17-1.1 and 0.06-0.46, respectively). Some nurse-patient characteristics showed relationships with a discrepancy in pain scoring.

Acute Pain Assessment Inadequacy in the Emergency Department: Patients' Perspective

For many patients, acute pain is a common cause to seek treatment in an Emergency Department (ED). An inadequate assessment could cause inappropriate pain management. The aim of this study was to describe and explain patients’ perceptions of acute pain assessment in the Emergency Department. The data were collected from ED patients (n = 114). Patients reported that nurses were asking about intensity of pain at rest, but only 52% during movement. According to the patients, the most common tools to assess acute pain were the verbal rating scale (VRS; 54% of patients), numerical rating scale (NRS; 28% of patients), and visual analogue scale (VAS; 9.7% of patients). Over twenty per cent of patients stated that ED nurses did not ask about the intensity of pain after analgesic administration. Twenty-four per cent of the patients were not pleased with nursing pain assessment in the ED. The assessment of acute pain is still inadequate in the ED. Therefore, ED nurses need to be more attentive to systematic acute pain management of patients in the ED.

Likelihood of admission to hospital from the emergency department is not universally associated with hospital bed occupancy at the time of admission

Background

The decision to admit into the hospital from the emergency department (ED) is considered to be important and challenging. The aim was to assess whether previously published results suggesting an association between hospital bed occupancy and likelihood of hospital admission from the ED can be reproduced in a different study population.

Methods

A retrospective cohort study of attendances at two Swedish EDs in 2015 was performed. Admission to hospital was assessed in relation to hospital bed occupancy together with other clinically relevant variables. Hospital bed occupancy was categorized and univariate and multivariate logistic regression were performed.

Results

In total 89,503 patient attendances were included in the final analysis. Of those, 29.1% resulted in admission within 24 h. The mean hospital bed occupancy by the hour of the two hospitals was 87.1% (SD 7.6). In both the univariate and multivariate analysis, odds ratio for admission within 24 h from the ED did not decrease significantly with an increasing hospital bed occupancy.

Conclusions

A negative association between admission to hospital and occupancy level, as reported elsewhere, was not replicated. This suggests that the previously shown association might not be universal but may vary across sites due to setting specific circumstances.

Influence of Overcrowding in the Emergency Department on Return Visit within 72 Hours

This study was conducted to determine whether overcrowding in the emergency department (ED) affects the occurrence of a return visit (RV) within 72 h. The crowding indicator of index visit was the average number of total patients, patients under observation, and boarding patients during the first 1 and 4 h from ED arrival time and the last 1 h before ED departure. Logistic regression analysis was conducted to determine whether each indicator affects the occurrence of RV and post-RV admission. Of the 87,360 discharged patients, 3743 (4.3%) returned to the ED within 72 h. Of the crowding indicators pertaining to total patients, the last 1 h significantly affected decrease in RV (p = 0.0046). Boarding patients were found to increase RV occurrence during the first 1 h (p = 0.0146) and 4 h (p = 0.0326). Crowding indicators that increased the likelihood of admission post-RV were total number of patients during the first 1 h (p = 0.0166) and 4 h (p = 0.0335) and evaluating patients during the first 1 h (p = 0.0059). Overcrowding in the ED increased the incidence of RV and likelihood of post-RV admission. However, overcrowding at the time of ED departure was related to reduced RV.

Pain assessment in the Emergency Department. Correlation between pain rated by the patient and by the nurse. An observational study

BACKGROUND AND AIM OF THE STUDY

Pain is always present in the Emergency Department (ED), but is often underestimated. The primary purpose of this study is to analyze the degree to which the intensity of pain is underestimated or overestimated in the perception of the nurse and the patient in the ED. The secondary objective of this research is to study possible factors that lead to these discrepancies in assessment.

METHODS

The observational study was carried out in two Hospitals in Central Italy. The sample population was based on 130 patients and 26 nurses. A questionnaire was given to the patients who provided personal data followed by information regarding their pain, including an assessment of the intensity of pain on a scale from 0 to 10. A similar questionnaire was given to the nurses.

RESULTS

The average score based on the numeric rating scale (NRS) to assess the intensity of pain perceived by the patients is 6.16, while the numerical average estimated by the nurses based on their assessment is 5. Using the t test we found that the average between nurse and patient assessments was very significant. The analysis of the nurses' characteristics and professional experiences, age, years of employment and years of service in the ED are all significant variables affecting the discrepancy between the nurses' and patients' assessments of pain. As previous studies have shown, nurses tend to underestimate the degree of pain. In fact, in only 55.5% of the cases was there a correspondence in the evaluations of the intensity of pain done by nurses and patients, and in no case did the nurses' evaluation exceed that of the patients.

CONCLUSIONS

This study reveals the persistent difficulty in pain management, while attempting contemporaneously to communicate the importance of the assessment, since adequate understanding of pain renders it possible to recognize and treat it.

Patients with acute stroke are less likely to be admitted directly to a stroke unit when hospital beds are scarce: A Swedish multicenter register study

Introduction

It is well established that managing patients with acute stroke in dedicated stroke units is associated with improved functioning and survival. The objectives of this study are to investigate whether patients with acute stroke are less likely to be directly admitted to a stroke unit from the Emergency Department when hospital beds are scarce and to measure variation across hospitals in terms of this outcome.

Patients and methods

This register study comprised data on patients with acute stroke admitted to 14 out of 72 Swedish hospitals in 2011-2014. Data from the Swedish stroke register were linked to administrative daily data on hospital bed occupancy (measured at 6 a.m.). Logistic regression analysis was used to analyse the association between bed occupancy and direct stroke unit admission.

Results

A total of 13,955 hospital admissions were included; 79.6% were directly admitted to a stroke unit from the Emergency Department. Each percentage increase in hospital bed occupancy was associated with a 1.5% decrease in odds of direct admission to a stroke unit (odds ratio = 0.985, 95% confidence interval = 0.978-0.992). The best-performing hospital exhibited an odds ratio of 3.8 (95% confidence interval = 2.6-5.5) for direct admission to a stroke unit versus the reference hospital.

Discussion and conclusion

We found an association between hospital crowding and reduced quality of care in acute stroke, portrayed by a lower likelihood of patients being directly admitted to a stroke unit from the Emergency Department. The magnitude of the effect varied considerably across hospitals.

Primary triage nurses do not divert patients away from the emergency department at times of high in-hospital bed occupancy - a retrospective cohort study

BACKGROUND

Emergency department (ED) overcrowding is frequently described in terms of input- throughput and output. In order to reduce ED input, a concept called primary triage has been introduced in several Swedish EDs. In short, primary triage means that a nurse separately evaluates patients who present in the Emergency Department (ED) and either refers them to primary care or discharges them home, if their complaints are perceived as being of low acuity. The aim of the present study is to elucidate whether high levels of in-hospital bed occupancy are associated with decreased permeability in primary triage. The appropriateness of discharges from primary triage is assessed by 72-h revisits to the ED.

METHODS

The study is a retrospective cohort study on administrative data from the ED at a 420-bed hospital in southern Sweden from 2011-2012. In addition to crude comparisons of proportions experiencing each outcome across strata of in-hospital bed occupancy, multivariate models are constructed in order to adjust for age, sex and other factors.

RESULTS

A total of 37,129 visits to primary triage were included in the study. 53.4 % of these were admitted to the ED. Among the cases referred to another level of care, 8.8 % made an unplanned revisit to the ED within 72 h. The permeability of primary triage was not decreased at higher levels of in-hospital bed occupancy. Rather, the permeability was slightly higher at occupancy of 100-105 % compared to <95 % (OR 1.09 95 % CI 1.02-1.16). No significant association between in-hospital bed occupancy and the probability of 72-h revisits was observed.

CONCLUSIONS

The absence of a decreased permeability of primary triage at times of high in-hospital bed occupancy is reassuring, as the opposite would have implied that patients might be denied entry not only to the hospital, but also to the ED, when in-hospital beds are scarce.