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Terhalle L, Arntz L, Hoffmann F, Arnold I, Hafner L, Picking-Pitasch L, Zuppinger J, Delport Lehnen K, Leuppi J, Somasundaram R, Nickel CH, Bingisser R. Nonspecific stress biomarkers for mortality prediction in older emergency department patients presenting with falls: a prospective multicenter observational study. Intern Emerg Med 2024:10.1007/s11739-024-03693-6. [PMID: 38960969 DOI: 10.1007/s11739-024-03693-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 06/21/2024] [Indexed: 07/05/2024]
Abstract
BACKGROUND Older patients presenting to the emergency department (ED) after falling are increasingly prevalent. Falls are associated with functional decline and death. Biomarkers predicting short-term mortality might facilitate decisions regarding resource allocation and disposition. D-dimer levels are used to rule out thromboembolic disease, while copeptin and adrenomedullin (MR-proADM) may be used as measures of the patient`s stress level. These nonspecific biomarkers were selected as potential predictors for mortality. METHODS Prospective, international, multicenter, cross-sectional observation was performed in two tertiary and two regional hospitals in Germany and Switzerland. Patients aged 65 years or older presenting to the ED after a fall were enrolled. Demographic data, Activities of Daily Living (ADL), and D-dimers were collected upon presentation. Copeptin and MR-proADM levels were determined from frozen samples. Primary outcome was 30-day mortality; and secondary outcomes were mortality at 90, 180, and 365 days. RESULTS Five hundred and seventy-two patients were included. Median age was 83 [IQR 78, 89] years, 236 (67.7%) were female. Mortality overall was 3.1% (30 d), 5.4% (90 d), 7.5% (180 d), and 13.8% (365 d), respectively. Non-survivors were older, had a lower ADL index and higher levels of all three biomarkers. Elevated levels of MR-proADM and D-dimer were associated with higher risk of mortality. MR-proADM and D-dimer showed high sensitivity and low negative likelihood ratio regarding short-term mortality, whereas copeptin did not. CONCLUSION D-dimer and MR-proADM levels might be useful as prognostic markers in older patients presenting to the ED after a fall, by identifying patients at low risk of short-term mortality. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02244983.
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Affiliation(s)
- Lukas Terhalle
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland.
| | - Laura Arntz
- Emergency Department, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Felix Hoffmann
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Isabelle Arnold
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Livia Hafner
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | | | - Joanna Zuppinger
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
- Emergency Department, Cantonal Hospital Basel-Landschaft, Liestal, Switzerland
| | - Karen Delport Lehnen
- Emergency Department, Cantonal Hospital Basel-Landschaft Campus Bruderholz, Binningen, Switzerland
| | - Jörg Leuppi
- Medical Faculty, University of Basel and Cantonal Hospital Baselland, Liestal, Switzerland
| | - Rajan Somasundaram
- Emergency Department, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Christian H Nickel
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Roland Bingisser
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
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2
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van Dam CS, Peters MJL, Hoogendijk EO, Nanayakkara PWB, Muller M, Trappenburg MC. Older patients with nonspecific complaints at the Emergency Department are at risk of adverse health outcomes. Eur J Intern Med 2023; 112:86-92. [PMID: 37002150 DOI: 10.1016/j.ejim.2023.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 03/13/2023] [Accepted: 03/18/2023] [Indexed: 03/31/2023]
Abstract
OBJECTIVE Older adults at the Emergency Department (ED) often present with nonspecific complaints (NSC) such as 'weakness' or 'feeling unwell'. Health care workers may underestimate illness in patients with NSC, leading to adverse health outcomes. This study compares characteristics and outcomes of NSC-patients versus specific complaints (SC) patients. METHODS Cohort study in patients ≥ 70 years in two Dutch EDs. NSC was classified according to the BANC-study-framework based on the medical history in the ED letter, before additional diagnostics took place. A second classification was performed at the end of the ED visit/hospital admission. Primary outcomes were functional decline, institutionalization, and mortality at 30 days. RESULTS 26% (n = 228) of a total of 888 included patients presented with NSC. Compared with SC-patients, NSC-patients were older, more frail, and more frequently female. NSC-patients had a higher risk of functional decline and institutionalization at 30 days (adjusted ORs 1.84, 95% CI 1.27 - 2.72, and 2.46, 95% CI 1.51-4.00, respectively), but not mortality (adjusted OR 1.26, 95% CI 0.58 - 2.73). Reclassification to a specific complaint after the ED visit or hospital admission occurred in 54% of NSC-patients. CONCLUSION NSC occur especially in older, frail female patients and are associated with an increased risk of functional decline and institutionalization, even after adjustment for worse baseline status. In half of the patients, a specific complaint revealed during ED or hospital stay. Physicians at the ED should consider NSC as a red flag needing appropriate observation and evaluation of underlying serious conditions and needs of this vulnerable patient group.
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Affiliation(s)
- C S van Dam
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Internal Medicine and Geriatrics, Amsterdam Cardiovascular Sciences research institute, De Boelelaan 1117, Amsterdam, the Netherlands.
| | - M J L Peters
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Internal Medicine and Geriatrics, Amsterdam Cardiovascular Sciences research institute, De Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Internal Medicine and Vascular Medicine, De Boelelaan 1117, Amsterdam, the Netherlands; Department of Internal Medicine and Geriatrics, UMC Utrecht, the Netherlands
| | - E O Hoogendijk
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Epidemiology and Data Science, Amsterdam Public Health research institute, De Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam UMC, Vrije Universiteit Amsterdam, Department of General Practice, Amsterdam Public Health research institute, De Boelelaan 1117, Amsterdam, the Netherlands
| | - P W B Nanayakkara
- Amsterdam UMC, Vrije Universiteit Amsterdam, Section General Internal Medicine, Amsterdam Public Health Research Institute, De Boelelaan 1117, Amsterdam, the Netherlands
| | - M Muller
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Internal Medicine and Geriatrics, Amsterdam Cardiovascular Sciences research institute, De Boelelaan 1117, Amsterdam, the Netherlands
| | - M C Trappenburg
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Internal Medicine and Geriatrics, Amsterdam Cardiovascular Sciences research institute, De Boelelaan 1117, Amsterdam, the Netherlands; Department of Internal Medicine and Geriatrics, Amstelland Hospital, Amstelveen, the Netherlands
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3
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Arnold I, Busch JM, Terhalle L, Nickel CH, Bingisser R. Throughput delays: causes, predictors, and outcomes - observational cohort in a Swiss emergency department. Swiss Med Wkly 2023; 153:40084. [PMID: 37245118 DOI: 10.57187/smw.2023.40084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023] Open
Abstract
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.
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Affiliation(s)
- Isabelle Arnold
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Jeannette-Marie Busch
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Lukas Terhalle
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Christian H Nickel
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Roland Bingisser
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
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4
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Furlong KR, O'Donnell K, Farrell A, Mercer S, Norman P, Parsons M, Patey C. Older Adults, the "Social Admission," and Nonspecific Complaints in the Emergency Department: Protocol for a Scoping Review. JMIR Res Protoc 2023; 12:e38246. [PMID: 36920467 PMCID: PMC10132007 DOI: 10.2196/38246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 11/09/2022] [Accepted: 12/21/2022] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND Older adults have a higher visit rate and poorer health outcomes in the emergency department (ED) compared to their younger counterparts. Older adults are more likely to require additional resources and hospital admission. The nonspecific, atypical, and complex nature of disease presentation in older adults challenges current ED triage systems. Acute illness in older adults is often missed or commonly disguised in the ED as a social or functional issue. If diagnostic clarity is lacking or safe discharge from the ED is not feasible, then older adults may be labelled a "social admission" (or another synonymous term), often leading to negative health consequences. OBJECTIVE This scoping review aims to describe and synthesize the available evidence on patient characteristics, adverse events, and health outcomes for older adults labelled as "social admission" (and other synonymously used terms), as well as those with nonacute or nonspecific complaints in the ED or hospital setting. METHODS A literature search of MEDLINE, Embase, Scopus, PsycINFO, and CINAHL was completed. Relevant reference lists were screened. Data have been managed using EndNote software and the Covidence web application. Original data have been included if patients are aged ≥65 years and are considered a "social admission" (or other synonymously used term) or if they present to the ED with a nonacute or nonspecific complaint. Two review team members have reviewed titles and abstracts and will review full-text articles. Disagreements are resolved by consensus or in discussion with a third reviewer. This review does not require research ethics approval. RESULTS As of January 2023, we have completed the title and abstract screening and have started the full-text screening. Some remaining full-text articles are being retrieved and/or translated. We are extracting data from included studies. Data will be presented in a narrative and descriptive manner, summarizing key concepts, patient characteristics, and health outcomes of patients labelled as a "social admission" (and other synonymously used terms) and of those with nonacute and nonspecific complaints. We expect the first results for publication in Spring 2023. CONCLUSIONS Acute illness in the older adult is not always easily identified. We hope to better understand patient characteristics, adverse events, and health outcomes of older adults labelled as a "social admission," as well as those with nonacute or nonspecific complaints. We aim to identify priorities for future research and identify knowledge gaps that may inform health care providers caring for these vulnerable patients. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/38246.
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Affiliation(s)
- Kayla Rose Furlong
- Discipline of Family Medicine, Faculty of Medicine, Memorial University, St John's, NL, Canada.,Discipline of Emergency Medicine, Faculty of Medicine, Memorial University, St John's, NL, Canada.,Carbonear Institute for Rural Reach and Innovation by the Sea, Carbonear, NL, Canada
| | - Kathleen O'Donnell
- Discipline of Family Medicine, Faculty of Medicine, Memorial University, St John's, NL, Canada
| | - Alison Farrell
- Health Sciences Library, Memorial University Libraries, Memorial University, St John's, NL, Canada
| | - Susan Mercer
- Discipline of Family Medicine, Faculty of Medicine, Memorial University, St John's, NL, Canada
| | - Paul Norman
- Carbonear Institute for Rural Reach and Innovation by the Sea, Carbonear, NL, Canada
| | - Michael Parsons
- Discipline of Family Medicine, Faculty of Medicine, Memorial University, St John's, NL, Canada.,Discipline of Emergency Medicine, Faculty of Medicine, Memorial University, St John's, NL, Canada
| | - Christopher Patey
- Discipline of Family Medicine, Faculty of Medicine, Memorial University, St John's, NL, Canada.,Discipline of Emergency Medicine, Faculty of Medicine, Memorial University, St John's, NL, Canada.,Carbonear Institute for Rural Reach and Innovation by the Sea, Carbonear, NL, Canada
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5
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Messmer AS, Elmer A, Ludwig R, Pfortmueller CA, Cioccari L, Schefold JC. Characteristics and outcomes of medical emergency team calls in a Swiss tertiary centre - a retrospective observational study. Swiss Med Wkly 2022; 152:40006. [PMID: 36455160 DOI: 10.57187/smw.2022.40006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
AIMS OF THE STUDY To describe reasons for medical emergency team (MET) activation over time, to analyse outcomes, and to describe the circadian distribution of MET calls and Intensive Care Unit (ICU) admissions following MET activation. METHODS Monocentric retrospective observational study of prospectively collected data on all MET calls between 1st of January 2012 until 31st of May 2019. We analysed data on baselines, referring wards, and disposition of all MET patients. In addition, we allocated all MET calls to the hourly intervals over the 24-hour cycle of the day in order to identify peak times of team activation. RESULTS A total of 4068 calls in 3277 patients (37% female, n = 1210) were analysed. The mean age was 65.9 years (± 15.7). The MET dose (defined as MET calls/1000 hospital admissions) remained relatively stable over the years with a median of 8.0 calls/1000 hospitalisations (interquartile range [IQR] 7.0-10.0). A total of 2526 calls (62%) occurred out of hours (17:00 to 8:00). The hourly rate of MET activations was greatest during the evening shift (33.8% of calls in seven hours), followed by the day shift (35.8% calls in nine hours) and night shift (30.4% in eight hours). Over the years, staff concern was the main reason for a MET call (n = 1192, 34%), followed by low peripheral oxygen saturation (SpO2) not responding to oxygen therapy (n = 776, 22%). Abnormal respiratory rate was a trigger to call the MET in 44 cases (1.3%), and was not documented prior to 2017. Overall, in-hospital mortality was 22%. CONCLUSION While most common reasons for MET calls over the years were staff concern and low SpO2, abnormal respiratory rate was the least frequent, but increased after the introduction of the quick sequential organ failure assessment (qSOFA) in 2016. Most MET calls occurred out of hours with peak hours during the evening shift, highlighting the importance of resource allocation during this shift when planning to introduce a MET system in a hospital. In-hospital mortality after a MET call was 22%.
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Affiliation(s)
- Anna S Messmer
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Annina Elmer
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Roger Ludwig
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Carmen A Pfortmueller
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luca Cioccari
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Department of Intensive Care Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Joerg C Schefold
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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6
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Werner NE, Rutkowski RA, Krause S, Barton HJ, Wust K, Hoonakker P, King B, Shah MN, Pulia MS, Brenny-Fitzpatrick M, Smith M, Carayon P. Disparate perspectives: Exploring healthcare professionals' misaligned mental models of older adults' transitions of care between the emergency department and skilled nursing facility. APPLIED ERGONOMICS 2021; 96:103509. [PMID: 34157478 PMCID: PMC8320066 DOI: 10.1016/j.apergo.2021.103509] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 05/28/2021] [Accepted: 06/13/2021] [Indexed: 06/13/2023]
Abstract
Care transitions that occur across healthcare system boundaries represent a unique challenge for maintaining high quality care and patient safety, as these systems are typically not aligned to perform the care transition process. We explored healthcare professionals' mental models of older adults' transitions between the emergency department (ED) and skilled nursing facility (SNF). We conducted a thematic analysis of interviews with ED and SNF healthcare professionals and identified three themes: 1) ED and SNF healthcare professionals had misaligned mental models regarding communication processes and tools used during care transitions, 2) ED and SNF healthcare professionals had misaligned mental models regarding healthcare system capability, and 3) Misalignments led to individual and organizational consequences. Overall, we found that SNF and ED healthcare professionals are part of the same process but have different perceptions of the process. Future work must take steps to redesign and realign these distinct work systems such that those involved conceptualize themselves as part of a joint process.
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Affiliation(s)
- Nicole E Werner
- University of Wisconsin-Madison Industrial and Systems, 1513 University Avenue WI Madison, Wisconsin 53706, United States.
| | - Rachel A Rutkowski
- University of Wisconsin-Madison Industrial and Systems, 1513 University Avenue WI Madison, Wisconsin 53706, United States
| | - Sheryl Krause
- University of Wisconsin-Madison Industrial and Systems, 1513 University Avenue WI Madison, Wisconsin 53706, United States
| | - Hanna J Barton
- University of Wisconsin-Madison Industrial and Systems, 1513 University Avenue WI Madison, Wisconsin 53706, United States
| | - Kathryn Wust
- University of Wisconsin-Madison Industrial and Systems, 1513 University Avenue WI Madison, Wisconsin 53706, United States
| | - Peter Hoonakker
- University of Wisconsin-Madison Industrial and Systems, 1513 University Avenue WI Madison, Wisconsin 53706, United States
| | - Barbara King
- University of Wisconsin-Madison Industrial and Systems, 1513 University Avenue WI Madison, Wisconsin 53706, United States
| | - Manish N Shah
- University of Wisconsin-Madison Industrial and Systems, 1513 University Avenue WI Madison, Wisconsin 53706, United States
| | - Michael S Pulia
- University of Wisconsin-Madison Industrial and Systems, 1513 University Avenue WI Madison, Wisconsin 53706, United States
| | - Maria Brenny-Fitzpatrick
- University of Wisconsin-Madison Industrial and Systems, 1513 University Avenue WI Madison, Wisconsin 53706, United States
| | - Maureen Smith
- University of Wisconsin-Madison Industrial and Systems, 1513 University Avenue WI Madison, Wisconsin 53706, United States
| | - Pascale Carayon
- University of Wisconsin-Madison Industrial and Systems, 1513 University Avenue WI Madison, Wisconsin 53706, United States
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7
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The presentational flow chart "unwell adult" of the Manchester Triage System-Curse or blessing? PLoS One 2021; 16:e0252730. [PMID: 34081753 PMCID: PMC8174732 DOI: 10.1371/journal.pone.0252730] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 05/21/2021] [Indexed: 11/19/2022] Open
Abstract
Background The presentational flow chart “unwell adult” of the Manchester Triage System (MTS) occupies a special role in this triage system, defined as the nonspecific presentation of an emergency patient. Current scientific studies show that a considerable proportion of emergency room patients present with so-called "nonspecific complaints". The aim of the present study is to investigate in detail the initial assessment of emergency patients triaged according to the presentational flow chart "unwell adult". Methods Monocentric, retrospective observational study. Results Data on 14,636 emergency department visits between March 12th and August 12th, 2019 were included. During the observation period, the presentational flow chart "unwell adult" was used 1,143 times and it was the third most frequently used presentational flow chart. Patients triaged with this flow chart often had unspecific complaints upon admission to the emergency department. Patients triaged with the “unwell adult” chart were often classified with a lower triage level. Notably, patients who died in hospital during the observation period frequently received low triage levels. The AUC for the MTS flow chart “unwell adult” and hospitalization in general for older patients (age ≥ 65 years) was 0.639 (95% CI 0.578–0.701), and 0.730 (95% CI 0.714–0.746) in patients triaged with more specific charts. The AUC for the MTS flow chart “unwell adult” and admission to ICU for older patients (age ≥65 years) was 0.631 (95% CI 0.547–0.715) and 0.807 (95% CI 0.790–0.824) for patients triaged with more specific flow charts. Comparison of the predictive ability of the MTS for in-hospital mortality in the group triaged with the presentational flow chart “unwell adult” revealed an AUC of 0.682 (95% CI 0.595–0.769) vs. 0.834 (95% CI 0.799–0.869) in the other presentational flow charts. Conclusion The presentational flow chart "unwell adult" is frequently used by triage nurses for initial assessment of patients. Patient characteristics assessed with the presentational flow chart "unwell adult" differ significantly from those assessed with MTS presentational flow charts for more specific symptoms. The quality of the initial assessment in terms of a well-functioning triage priority assessment tool is less accurate than the performance of the MTS described in the literature.
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8
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Disposition Decision Support by Laboratory Based Outcome Prediction. J Clin Med 2021; 10:jcm10050939. [PMID: 33804332 PMCID: PMC7957752 DOI: 10.3390/jcm10050939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 02/13/2021] [Accepted: 02/23/2021] [Indexed: 12/05/2022] Open
Abstract
Disposition is one of the main tasks in the emergency department. However, there is a lack of objective and reliable disposition criteria, and diagnosis-based risk prediction is not feasible at early time points. The aim was to derive a risk score (TRIAL) based on routinely collected baseline (TRIage level and Age) and Laboratory data—supporting disposition decisions by risk stratification based on mortality. We prospectively included consecutive patients presenting to the emergency department over 18 weeks. Data sets of routinely collected baseline (triage level and age) and laboratory data were used for multivariable logistic regression to develop the TRIAL risk score predicting mortality. Routine laboratory variables and disposition cut-offs were chosen beforehand by expert consensus. Risk stratification was based on low risk (<1%), intermediate risk (1–10%), and high risk (>10%) of in-hospital mortality. In total, 8687 data sets were analyzed. Variables identified to develop the TRIAL risk score were triage level (Emergency Severity Index), age, lactate dehydrogenase, creatinine, albumin, bilirubin, and leukocyte count. The area under the ROC curve for in-hospital mortality was 0.93. Stratification according to the TRIAL score showed that 67.5% of all patients were in the low-risk category. Mortality was 0.1% in low-risk, 3.5% in intermediate-risk, and 26.2% in high-risk patients. The TRIAL risk score based on routinely available baseline and laboratory data provides prognostic information for disposition decisions. TRIAL could be used to minimize admission in low-risk and to maximize observation in high-risk patients.
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9
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Rutkowski RA, Salwei M, Barton H, Wust K, Hoonakker P, Brenny-Fitzpatrick M, King B, Shah MN, Pulia MS, Patterson BW, Dáil PVW, Smith M, Carayon P, Werner NE. Physician Perceptions of Disposition Decision-making for Older Adults in the Emergency Department: A Preliminary Analysis. ACTA ACUST UNITED AC 2021; 64:648-652. [PMID: 34234398 DOI: 10.1177/1071181320641148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Disposition decision-making in the emergency department (ED) is critical to patient safety and quality of care. Disposition decision-making has particularly important implications for older adults who comprise a significant portion of ED visits annually and are vulnerable to suboptimal outcomes throughout ED care transitions. We conducted a secondary inductive content analysis of interviews with ED physicians (N= 11) to explore their perceptions of who they involve in disposition decision-making and what information they use to make disposition decisions for older adults. ED physicians cited 7 roles (5 types of clinicians, patients and families) and 11 information types, both clinical (e.g. test/lab results) and non-clinical (e.g. family's preference). Our preliminary findings represent a key first step toward the development of interventions that promote patient safety and quality of care for older adults in the ED by supporting the cognitive and communicative aspects of disposition decision-making.
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Affiliation(s)
- Rachel A Rutkowski
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison
| | - Megan Salwei
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison
| | - Hanna Barton
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison
| | - Kathryn Wust
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison
| | - Peter Hoonakker
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison
| | | | - Barbara King
- School of Nursing, University of Wisconsin-Madison
| | - Manish N Shah
- Berbee Walsh Department of Emergency Medicine, University of Wisconsin-Madison
| | - Michael S Pulia
- Berbee Walsh Department of Emergency Medicine, University of Wisconsin-Madison
| | - Brian W Patterson
- Berbee Walsh Department of Emergency Medicine, University of Wisconsin-Madison
| | - Paula vW Dáil
- University of Wisconsin-Madison Health Sciences Patient and Family Advisory Council member
| | - Maureen Smith
- University of Wisconsin-Madison School of Medicine and Public Health, Departments of Population Health Sciences and Family Medicine & Community Health.,University of Wisconsin Institute of Clinical and Translational Research Health Innovation Program
| | - Pascale Carayon
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison
| | - Nicole E Werner
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison
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10
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Heeren P, Hendrikx A, Ceyssens J, Devriendt E, Deschodt M, Desruelles D, Flamaing J, Sabbe M, Milisen K. Structure and processes of emergency observation units with a geriatric focus: a scoping review. BMC Geriatr 2021; 21:95. [PMID: 33526029 PMCID: PMC7852183 DOI: 10.1186/s12877-021-02029-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 01/13/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Combining observation principles and geriatric care concepts is considered a promising strategy for risk-stratification of older patients with emergency care needs. We aimed to map the structure and processes of emergency observation units (EOUs) with a geriatric focus and explore to what extent the comprehensive geriatric assessment (CGA) approach was implemented in EOUs. METHODS The revised scoping methodology framework of Arksey and O'Malley was applied. Manuscripts reporting on dedicated areas within hospitals for observation of older patients with emergency care needs were eligible for inclusion. Electronic database searches were performed in MEDLINE, EMBASE and CINAHL in combination with backward snowballing. Two researchers conducted data charting independently. Data-charting forms were developed and iteratively refined. Data inconsistencies were judged by a third researcher or discussed in the research team. Quality assessment was conducted with the Methodological Index for Non-Randomized Studies. RESULTS Sixteen quantitative studies were included reporting on fifteen EOUs in seven countries across three continents. These units were located in the ED, immediately next to the ED or remote from the ED (i.e. hospital-based). All studies reported that staffing consisted of at least three healthcare professions. Observation duration varied between 4 and 72 h. Most studies focused on medical and functional assessment. Four studies reported to assess a patients' medical, functional, cognitive and social capabilities. If deemed necessary, post-discharge follow-up (e.g. community/primary care services and/or outpatient clinics) was provided in eleven studies. CONCLUSION This scoping review documented that the structure and processes of EOUs with a geriatric focus are very heterogeneous and rarely cover all elements of CGA. Further research is necessary to determine how complex care principles of 'observation medicine' and 'CGA' can ideally be merged and successfully implemented in clinical care.
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Affiliation(s)
- Pieter Heeren
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Kapucijnenvoer 35/4, 3000, Leuven, Belgium
- Department of Geriatric Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
- Research Foundation Flanders, Egmontstraat 5, 1000, Brussels, Belgium
| | - Annabelle Hendrikx
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Kapucijnenvoer 35/4, 3000, Leuven, Belgium
| | - Janne Ceyssens
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Kapucijnenvoer 35/4, 3000, Leuven, Belgium
| | - Els Devriendt
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Kapucijnenvoer 35/4, 3000, Leuven, Belgium
- Department of Geriatric Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Mieke Deschodt
- Department of Public Health and Primary Care, Gerontology and Geriatrics, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
- Department of Public Health, Nursing Science, University of Basel, Bernoullistrasse 28, 4056, Basel, Switzerland
- Faculty of Medicine and Life Sciences, Healthcare and Ethics, UHasselt, Martelarenlaan 42, 3500, Hasselt, Belgium
| | - Didier Desruelles
- Department of Emergency Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Johan Flamaing
- Department of Geriatric Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
- Department of Public Health and Primary Care, Gerontology and Geriatrics, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Marc Sabbe
- Department of Emergency Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
- Department of Public Health and Primary Care, Emergency Medicine, KU Leuven, Kapucijnenvoer 35/4, 3000, Leuven, Belgium
| | - Koen Milisen
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Kapucijnenvoer 35/4, 3000, Leuven, Belgium.
- Department of Geriatric Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
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Oliveira J E Silva L, Jeffery MM, Campbell RL, Mullan AF, Takahashi PY, Bellolio F. Predictors of return visits to the emergency department among different age groups of older adults. Am J Emerg Med 2020; 46:241-246. [PMID: 33071094 DOI: 10.1016/j.ajem.2020.07.042] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 06/24/2020] [Accepted: 07/16/2020] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVE To identify predictors of 30-day emergency department (ED) return visits in patients age 65-79 years and age ≥ 80 years. METHODS This was a cohort study of older adults who presented to the ED over a 1-year period. A mixed-effects logistic regression model was used to identify predictors for returning to the ED within 30 days. We stratified the cohort into those aged 65-79 years and aged ≥80 years. Adjusted odds ratios (aORs) with 95% confidence intervals (CI) were reported. This study adhered to the STROBE reporting guidelines. RESULTS A total of 21,460 ED visits representing 14,528 unique patients were included. The overall return rate was 15% (1998/13,300 visits) for age 65-79 years, and 16% (1306/8160 visits) for age ≥ 80 years. A history of congestive heart failure (CHF), dementia, or prior hospitalization within 2 years were associated with increased odds of returning in both age groups (for age 65-79: CHF aOR 1.36 [CI 1.16-1.59], dementia aOR 1.27 [CI 1.07-1.49], prior hospitalization aOR 1.36 [CI 1.19-1.56]; for age ≥ 80: CHF aOR 1.32 [CI 1.13-1.55], dementia aOR 1.22 [CI 1.04-1.42], and prior hospitalization aOR 1.27 [CI 1.09-1.47]). Being admitted from the ED was associated with decreased odds of returning to the ED within 30 days (aOR 0.72 [CI 0.64-0.80] for age 65-79 years and 0.72 [CI 0.63-0.82] for age ≥ 80). CONCLUSION Age alone was not an independent predictor of return visits. Prior hospitalization, dementia and CHF were predictors of 30-day ED return. The identification of predictors of return visits may help to optimize care transition in the ED.
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Affiliation(s)
| | - Molly M Jeffery
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA; Department of Health Science Research, Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, USA
| | - Ronna L Campbell
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA
| | - Aidan F Mullan
- Department of Biostatistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Paul Y Takahashi
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Fernanda Bellolio
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA; Department of Health Science Research, Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, USA.
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Haag E, Molitor A, Gregoriano C, Müller B, Schuetz P. The value of biomarker-guided antibiotic therapy. Expert Rev Mol Diagn 2020; 20:829-840. [PMID: 32529871 DOI: 10.1080/14737159.2020.1782193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
INTRODUCTION There is an increasing interest to individualize patient management and decisions regarding antibiotic treatment. Biomarkers may provide relevant information for this purpose. AREAS COVERED Despite a growing number of clinical trials investigating several biomarkers, there remain open questions regarding the best type of biomarker, timing or frequency of testing, and optimal cutoffs among others. The most promising results in regard to diagnosis of bacterial infection and therapy monitoring are found for procalcitonin (PCT), although some recent trials were not able to validate the promising earlier findings. Furthermore, less specific markers like C-reactive protein (CRP) and new prognostic biomarkers such as proadrenomedullin (MR-proADM) may improve the prognostic assessment of patients and proteomics may help shorten time to microbiological results. The aim of this review is to summarize the current concept of biomarker-guided management and provide an outlook of promising ongoing investigations. EXPERT OPINION 'Antibiotic stewardship' is complex and needs more than just the measurement of one single biomarker. However, when integrated into the context of a thorough clinical examination, standard blood parameters and a well done risk stratification by clinical scores such as the SOFA-score, biomarkers have great potential to improve the diagnostic and prognostic assessment of patients.
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Affiliation(s)
- Ellen Haag
- University Department of Medicine, Kantonsspital Aarau , Aarau, Switzerland
| | - Alexandra Molitor
- University Department of Medicine, Kantonsspital Aarau , Aarau, Switzerland
| | - Claudia Gregoriano
- University Department of Medicine, Kantonsspital Aarau , Aarau, Switzerland
| | - Beat Müller
- University Department of Medicine, Kantonsspital Aarau , Aarau, Switzerland
| | - Philipp Schuetz
- University Department of Medicine, Kantonsspital Aarau , Aarau, Switzerland
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13
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Sailer JM, Bleckwenn M. [Non specific complaints. Somatization disorder or somatic disease?]. MMW Fortschr Med 2020; 162:34-37. [PMID: 31960307 DOI: 10.1007/s15006-020-0057-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Johann Michael Sailer
- Instituts für Hausarztmedizin der Universität Bonn, Venusberg Campus 1, D-53127, Bonn, Deutschland.
| | - Markus Bleckwenn
- Medizinische Faktultät der Universität Leipzig, Leipzig, Deutschland
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Why are we misdiagnosing urinary tract infection in older patients? A qualitative inquiry and roadmap for staff behaviour change in the emergency department. Eur Geriatr Med 2019; 10:585-593. [DOI: 10.1007/s41999-019-00191-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 04/03/2019] [Indexed: 11/26/2022]
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15
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Schmid F, Malinovska A, Weigel K, Bosia T, Nickel CH, Bingisser R. Construct validity of acute morbidity as a novel outcome for emergency patients. PLoS One 2019; 14:e0207906. [PMID: 30601812 PMCID: PMC6314600 DOI: 10.1371/journal.pone.0207906] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 11/08/2018] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES Validation of acute morbidity as a novel outcome in emergency medicine. METHODS Construct validity of acute morbidity was established by comparison to other outcomes using linear and logistic regression models. RESULTS Data of 4608 patients were analysed. 1869 patients (40.6%) fulfilled the criteria for acute morbidity. Using multivariate analyses, acute morbidity was associated with outcomes such as hospitalisation (OR: 11, 95%-CI 9-13), mortality (OR 15, 95%-CI 6-49), and ICU admission (OR: 46, 95%-CI 25-96). Reliability of the construct "acute morbidity" was estimated using Cohens Kappa, which was 0.96 for intra-rater and 0.94 for inter-rater reliability. CONCLUSION Reliability of the framework for acute morbidity was high. Construct validity was shown by associations with hospitalisation, mortality, and ICU admission.
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Affiliation(s)
- Fabrizia Schmid
- Emergency Department, University Hospital Basel, Basel, Switzerland
| | | | - Karin Weigel
- Joint Practice Boettcher and Hoeller, Laufenburg, Germany
| | - Tito Bosia
- Emergency Department, University Hospital Basel, Basel, Switzerland
| | | | - Roland Bingisser
- Emergency Department, University Hospital Basel, Basel, Switzerland
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16
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Wachelder JJH, van Galen LS, Kellett J, Nickel CH, Haak HR. Unplanned readmissions among patients presenting with nonspecific complaints. Eur J Intern Med 2018; 54:e36-e37. [PMID: 29885755 DOI: 10.1016/j.ejim.2018.05.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Accepted: 05/14/2018] [Indexed: 11/17/2022]
Affiliation(s)
- J J H Wachelder
- Department of Internal Medicine, Máxima Medical Centre, 5631 BM Eindhoven/Veldhoven, The Netherlands; Maastricht University, CAPHRI School for Public Health and Primary Care, Ageing and Long-Term Care, Maastricht, The Netherlands; Dept. of Internal Medicine, Division of General Medicine, Maastricht University Medical Centre, 6229 HX Maastricht, the Netherlands.
| | - L S van Galen
- Section Acute Medicine, Department of Internal Medicine, VU Medical Centre, Amsterdam, The Netherlands; Centre for Population Health Sciences, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - J Kellett
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
| | - C H Nickel
- Emergency Department, University Hospital Basel, Switzerland
| | - H R Haak
- Department of Internal Medicine, Máxima Medical Centre, 5631 BM Eindhoven/Veldhoven, The Netherlands; Maastricht University, CAPHRI School for Public Health and Primary Care, Ageing and Long-Term Care, Maastricht, The Netherlands; Dept. of Internal Medicine, Division of General Medicine, Maastricht University Medical Centre, 6229 HX Maastricht, the Netherlands
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Abstract
This article reviews 10 best practices that integrate geriatric principles into emergency department processes of care. These best practices are grouped around ten words: complexity; clinician education; geriatric-specific; atypical; medication; variability; cognitive impairment; psychosocial issues; end-of-life care; and interdisciplinary.
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18
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Andrade LASD, Santos SDP, Corpolato RC, Willig MH, Mantovani MDF, Aguilera AL. Elderly care in the emergency department: an integrative review. REVISTA BRASILEIRA DE GERIATRIA E GERONTOLOGIA 2018. [DOI: 10.1590/1981-22562018021.170144] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Abstract Objective: To identify the care practices of nurses for the elderly in emergency departments. Method: An integrative review was carried out in the CAPES database, selecting publications in English, Portuguese and Spanish published between January 2011 and October 2016. The descriptors used were: "Emergency nursing"; "Geriatric nursing"; "Health services for the elderly"; "Elderly person"; "Nursing care". Results: Sixteen articles were analyzed in English, the majority of which had a qualitative approach (56.2%). Australia had the largest number of publications (31.2%). After reading the studies in full, the common themes were organized and classified into three categories: Challenges/difficulties in the care of the elderly in the emergency department, Positive experiences of elderly care in the emergency department and The emergency department as a space of death and dying. Conclusion: The care practices of nurses are focused on identifying the main problems regarding elderly care, adaptation and the planning of their work routine. Another strategy is the implementation of instruments of evaluation specific to elderly patients and the involvement of the family in all stages of care.
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Kellett J, Nickel CH. What are nonspecific complaints and what are their causes and outcomes? The common unknown unknowns of medicine. Eur J Intern Med 2018; 47:e12-e13. [PMID: 28964636 DOI: 10.1016/j.ejim.2017.09.032] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2017] [Accepted: 09/25/2017] [Indexed: 01/15/2023]
Affiliation(s)
- John Kellett
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark.
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20
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Wachelder JJH, Stassen PM, Hubens LPAM, Brouns SHA, Lambooij SLE, Dieleman JP, Haak HR. Elderly emergency patients presenting with non-specific complaints: Characteristics and outcomes. PLoS One 2017; 12:e0188954. [PMID: 29190706 PMCID: PMC5708794 DOI: 10.1371/journal.pone.0188954] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 11/12/2017] [Indexed: 12/02/2022] Open
Abstract
Background Non-specific complaints (NSC) are common at the emergency department, but only a few studies have shown evidence that these complaints are associated with a poor prognosis in elderly emergency patients. Objective To describe patient characteristics and outcomes in a cohort of elderly emergency patients presenting with NSC. Outcomes were: patient characteristics, hospitalization, 90-day ED-return visits, and 30-day mortality. Method A retrospective cohort study was conducted amongst elderly patients present to the Internal Medicine Emergency Department (ED) between 01-09-2010 and 31-08-2011. NSC were defined as indefinable complaints that lack a pre-differential diagnosis needed to initiate of a standardized patient evaluation. Cox regression was performed to calculate Hazard Ratios (HR) and corrected for confounders such as comorbidity. Results In total, 1784 patients were enrolled; 244 (13.7%) presented with NSC. Compared to those with SC, comorbidity was higher in the NSC-group (Charlson comorbidity index 3.0 vs. 2.4, p<0.001). The triage level did not differ, but ED-length of stay was longer in the NSC-group (188 vs. 178 minutes, p = 0.004). Hospitalization was more frequent (84.0 vs. 71.1%, p<0.001) and the length of hospital stay (9 vs. 6 days, p<0.001 was longer in the NSC- than in the SC-group. The number of ED-return visits were comparable between both groups (HR 0.8, 95%CI 0.6–1.1). Mortality within 30-days was higher in the NSC- (20.1%) than in the SC-group (11.0%, HR 1.7 95%CI 1.2–2.4). Conclusion Elderly patients present with NSC at the ED regularly. These patients are more often hospitalized and have a substantially higher 30-day mortality than patients with SC.
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Affiliation(s)
- Joyce J. H. Wachelder
- Department of Internal Medicine, Máxima Medical Centre, Eindhoven, the Netherlands
- Department of Health Services Research, and CAPHRI School for Public Health and Primary Care, Maastricht, the Netherlands
- * E-mail:
| | - Patricia M. Stassen
- Department of Health Services Research, and CAPHRI School for Public Health and Primary Care, Maastricht, the Netherlands
- Department of Internal Medicine, Division of General Medicine, Section Acute Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands
| | | | - Steffie H. A. Brouns
- Department of Internal Medicine, Máxima Medical Centre, Eindhoven, the Netherlands
- Department of Health Services Research, and CAPHRI School for Public Health and Primary Care, Maastricht, the Netherlands
| | - Suze L. E. Lambooij
- Department of Internal Medicine, Máxima Medical Centre, Eindhoven, the Netherlands
| | - Jeanne P. Dieleman
- Máxima Medical Centrum Academy, Máxima Medical Centre, Veldhoven, the Netherlands
| | - Harm R. Haak
- Department of Internal Medicine, Máxima Medical Centre, Eindhoven, the Netherlands
- Department of Health Services Research, and CAPHRI School for Public Health and Primary Care, Maastricht, the Netherlands
- Department of Internal Medicine, Division of General Medicine, Section Acute Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands
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Dharmarajan K, Qin L, Bierlein M, Choi JES, Lin Z, Desai NR, Spatz ES, Krumholz HM, Venkatesh AK. Outcomes after observation stays among older adult Medicare beneficiaries in the USA: retrospective cohort study. BMJ 2017. [PMID: 28634181 PMCID: PMC5476173 DOI: 10.1136/bmj.j2616] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Objective To characterize rates and trends over time of emergency department treatment-and-discharge stays, repeat observation stays, inpatient stays, any hospital revisit, and death within 30 days of discharge from observation stays.Design Retrospective cohort study.Setting 4750 hospitals in the USA.Participants Nationally representative sample of Medicare fee for service beneficiaries aged 65 or over discharged after 363 037 index observation stays, 2 540 000 index emergency department treatment-and-discharge stays, and 2 667 525 index inpatient stays from 2006-11.Main outcome measures Rates of emergency department treatment-and-discharge stays, observation stays, inpatient stays, any hospital revisit, and death within 30 days of discharge from index observation stays. Rates were compared with corresponding outcomes within 30 days of discharge from both index emergency department treatment-and-discharge stays and index inpatient stays.Results Among 363 037 index observation stays resulting in discharge from 2006-11, 30 day rates of emergency department treatment-and-discharge stays were 8.4%, repeat observation stays were 2.9%, inpatient stays were 11.2%, any hospital revisit was 20.1%, and death was 1.8%. Of all revisits, 49.7% were for inpatient stays. Revisit rates for emergency department treatment-and-discharge stays, repeat observation stays, and any hospital revisit increased from 2006-11 (P<0.001 for trend), while 30 day rates of inpatient stays (P=0.054 for trend) and 30 day mortality (P=0.091 for trend) were both unchanged. Averaged over the study period, 30 day rates of any hospital revisit were similar after discharge from index emergency department treatment-and-discharge stays (19.9%) and index observation stays (20.1%), as was 30 day mortality (1.8% for both). Rates of any hospital revisit (21.8%) and death (5.2%) were highest after discharge from index inpatient stays.Conclusions Hospital revisits are common after discharge from observation stays, frequently result in inpatient hospitalizations, and have increased over time among Medicare beneficiaries. As revisit rates are similar after emergency department and observation stays, strategies shown to enhance emergency department transitional care may be reasonable starting points to improve post-observation outcomes.
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Affiliation(s)
- Kumar Dharmarajan
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Li Qin
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA
| | | | | | - Zhenqiu Lin
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA
| | - Nihar R Desai
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Erica S Spatz
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Harlan M Krumholz
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Arjun K Venkatesh
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA
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Nickel CH, Messmer AS, Ghanim L, Ilsemann-Karakoumis J, Giersdorf S, Hertel S, Ernst S, Geigy N, Bingisser R. Adrenomedullin for Risk Stratification of Emergency Patients With Nonspecific Complaints: An Interventional Multicenter Pilot Study. Medicine (Baltimore) 2016; 95:e2395. [PMID: 26735540 PMCID: PMC4706260 DOI: 10.1097/md.0000000000002395] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Patients with nonspecific complaints (NSC) presenting to the emergency department (ED) are at risk of life-threatening conditions. New stress biomarkers such as the midregional portion of adrenomedullin (MR-proADM) promise to support decision-making. This study tested the following hypotheses: biomarker-assisted disposition of patients with NSC will not increase mortality. Second, discharge from the ED will increase if clinical risk assessment is combined with low MR-proADM levels. Third, inappropriate disposition to a lower level of care will decrease, if clinical assessment is combined with high MR-proADM levels, and fourth that this algorithm is feasible in the ED setting. Prospective, multicenter, randomized, controlled interventional feasibility study with a 30-day follow-up, including patients with NSC. Patients were randomly assigned to either the standard group (decision-making solely based on clinical assessment) or the Novum group (biomarker-assisted). Regarding disposition, patients were assigned to 1 of 3 risk classes: high-risk (admission to hospital), intermediate risk (community geriatric hospital), and low-risk patients (discharge). In the Novum group, in addition to clinical risk assessment, the information of the MR-proADM level was used. Unless there were overruling criteria, patients were transferred or discharged according to the risk assessment. Primary endpoint was 30-day mortality. Secondary endpoints were comparisons of patient disposition and related mortality rates, ED, and hospital length of stay and readmission. The final study cohort consisted of 398 patients (210 in the Standard group and 188 in the Novum group). Overruling, that is, disposition not according to the result of the proposed algorithm occurred in 51 cases. Baseline characteristics between Standard and Novum groups were similar. The mortality rate in the Novum group was 4.3%, as compared to the Standard group mortality of 6.2%, which was not significantly different (intention-to treat analysis). This was confirmed by the perprotocol analysis as well as by sensitivity analysis. For the secondary endpoints, no significant differences were detected. Biomarker-assisted disposition is safe in patients with NSC. Discharge rates did not increase. Feasibility could only partly be shown due to an unexpectedly high overruling rate. Inappropriate disposition to lower levels of care did not change. ClinicalTrials. gov Identifier: NCT00920491.
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Affiliation(s)
- Christian Hans Nickel
- From the Emergency Department, University Hospital, Basel (CHN, ASM, LG, JI-K, RB); Emergency Department, Kantonsspital Baselland, Liestal, Switzerland (NG); Research Department, Thermo Scientific Biomarkers, Hennigsdorf, Germany (SG, SH); and Emergency Department, Kantonsspital Olten, Olten, Switzerland (SE)
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Yip WL, Fan KL, Lui CT, Leung LP, Ng F, Tsui KL. Utilization of the Accident & Emergency Departments by Chinese elderly in Hong Kong. World J Emerg Med 2015; 6:283-8. [PMID: 26693263 DOI: 10.5847/wjem.j.1920-8642.2015.04.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The epidemiological data on elderly patients attending Accident and Emergency Departments (AEDs) in Hong Kong is lacking. The study aimed to examine the epidemiology of geriatric patient visits to AEDs in Hong Kong, including demographic data and predictors of life-saving interventions (LSI) and admission. METHODS A retrospective cross-sectional study of geriatric patients older than 64 years old attending three AEDs during the year 2012, with a sample of 1 200 patient visits recruited. The data were retrieved from the medical records of the respective hospitals. Descriptive characteristics of the visits were provided. Multivariate logistic regression was performed to evaluate the predictors of LSI and hospital admission. RESULTS The mean age of the patients was 79.1 years. Totally 49.7% of the patients were male. "Diseases of the respiratory system" was the commonest diagnosis in AEDs as well as that required admission. The admission rate was 56.8%. Logistic regression demonstrated that dependent activity of daily living (ADL), arrival by ambulance, and the higher number of co-morbidities were predictors of LSI, while advanced age, dependent ADL, institutionalized patients, arrival by ambulance, and higher number of co-morbidities were predictors of hospital admission. CONCLUSIONS Ageing population is creating an imminent burden on the emergency service in Hong Kong. Previously unavailable epidemiological information about geriatric attendance to AEDs was described. This forms the basis for development of future studies concerning the medical services on this specific group of patients.
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Affiliation(s)
- Wai Lam Yip
- Accident & Emergency Department, Queen Mary Hospital, Hong Kong, China
| | - Kit Ling Fan
- Emergency Medicine Unit, The University of Hong Kong, Hong Kong, China
| | - Chun Tat Lui
- Accident & Emergency Department, Tuen Mun Hospital, Hong Kong, China
| | - Ling Pong Leung
- Emergency Medicine Unit, The University of Hong Kong, Hong Kong, China
| | - Fu Ng
- Accident & Emergency Department, Caritas Medical Centre, Hong Kong, China
| | - Kwok Leung Tsui
- Accident & Emergency Department, Tuen Mun Hospital, Hong Kong, China
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