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Helbig L, Stier B, Römer C, Kilian M, Slagman A, Behrens A, Stiehr V, Vollert JO, Bachmann U, Möckel M. [The abdominal pain unit as a treatment pathway : Structured care of patients with atraumatic abdominal pain in the emergency department]. Med Klin Intensivmed Notfmed 2023; 118:132-140. [PMID: 34928407 PMCID: PMC9992050 DOI: 10.1007/s00063-021-00887-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 08/30/2021] [Accepted: 09/14/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Patients with atraumatic abdominal pain are common in the emergency department and have a relatively high hospital mortality, with a very wide spectrum of different causes. Rapid, goal-directed diagnosis is essential in this context. METHODS In a Delphi process with representatives of different disciplines, a diagnostic treatment pathway was designed, which is called the Abdominal Pain Unit (APU). RESULTS The treatment pathway was designed as an extended event process chain. Crucial decision points were specified using standard operating procedures. DISCUSSION The APU treatment pathway establishes a consistent treatment structure for patients with atraumatic abdominal pain. It has the potential to improve the quality of care and reduce intrahospital mortality over the long term.
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Affiliation(s)
- Lukas Helbig
- Akut- und Notfallmedizin, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland.
| | - Britta Stier
- Akut- und Notfallmedizin, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland
| | - Claudia Römer
- Akut- und Notfallmedizin, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland
| | - Maik Kilian
- Abteilung für Allgemein- und Viszeralchirurgie, Evangelische Elisabeth Klinik Berlin, Lützowstraße 26, 10785, Berlin, Deutschland
| | - Anna Slagman
- Akut- und Notfallmedizin, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland
| | - Angelika Behrens
- Abteilung für Innere Medizin, Gastroenterologie und Pneumologie, Evangelische Elisabeth Klinik Berlin, Lützowstraße 26, 10785, Berlin, Deutschland
| | - Vera Stiehr
- Abteilung für Innere Medizin, Gastroenterologie und Pneumologie, Evangelische Elisabeth Klinik Berlin, Lützowstraße 26, 10785, Berlin, Deutschland
| | - Jörn Ole Vollert
- Akut- und Notfallmedizin, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland
| | - Ulrike Bachmann
- Akut- und Notfallmedizin, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland
| | - Martin Möckel
- Akut- und Notfallmedizin, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland.
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Mihalj M, Corona A, Andereggen L, Urman RD, Luedi MM, Bello C. Managing bottlenecks in the perioperative setting: Optimizing patient care and reducing costs. Best Pract Res Clin Anaesthesiol 2022; 36:299-310. [DOI: 10.1016/j.bpa.2022.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 05/27/2022] [Indexed: 10/18/2022]
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Oh BY, Kim K. Factors associated with the undertriage of patients with abdominal pain in an emergency room. Int Emerg Nurs 2020; 54:100933. [PMID: 33221695 DOI: 10.1016/j.ienj.2020.100933] [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] [Received: 05/05/2020] [Revised: 08/21/2020] [Accepted: 09/21/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION The triage process lasts for a very short time, which can result in over-triage and under-triage. Studies have explored factors related to under-triage among trauma patients. In Korea, the clinical characteristics and severity of cases of under-triaged patients have been investigated. However, there is limited research on the under-triage of patients experiencing abdominal pain. Therefore, this study aimed to determine the under-triage rate of emergency department (ED) patients with abdominal pain, as well as the factors associated with their under-triage. METHODS The participants of this retrospective cohort study were 3,030 adult patients at a single tertiary hospital in Korea, who were brought to the ED for abdominal pain as the chief complaint. Participants' general characteristics, pain-related information, and environmental information were obtained from their electronic medical records. RESULTS The under-triage rate of ED patients with abdominal pain was 31.0%. Factors related to the under-triage of these patients were sex, age, visit route, time from the onset of the pain to the visit, location of pain, and intensity of pain. CONCLUSION These findings provide a foundation for the understanding and mitigation of under-triage in EDs through the identification of factors associated with under-triage in patients with abdominal pain.
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Affiliation(s)
- Boo Young Oh
- Department of Emergency, Kangbuk Samsung Hospital, Seoul, Republic of Korea.
| | - Kisook Kim
- Department of Nursing, Chung-Ang University, Seoul, Republic of Korea.
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Effect of a split-flow physician in triage model on abdominal CT ordering rate and yield. Am J Emerg Med 2020; 46:160-164. [PMID: 33071089 DOI: 10.1016/j.ajem.2020.05.119] [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: 04/14/2020] [Revised: 05/19/2020] [Accepted: 05/25/2020] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE The objective of this study was to compare the rate and clinical yield of computed tomography (CT) imaging between patients presenting with abdominal pain initially seen by a physician in triage (PIT) versus those seen only by physicians working in the main emergency department (ED). METHODS A retrospective study was conducted of all self-arrivals >18 years old presenting to a single ED with abdominal pain. Nine-hundred patients were randomly selected from both the PIT and traditional patient flow groups and rates and yields of CT imaging were compared, both alone and in a model controlling for potential confounders. Predetermined criteria for CT significance included need for admission, consult, or targeted medications. RESULTS The overall rate of CT imaging (unadjusted) did not differ between the PIT and traditional groups, 48.7% (95% CI 45.4-51.9) vs. 45.1% (95% CI 41.8-48.4), respectively (p = .13). The CT yield for patients seen in in the PIT group was also similar to that of the traditional group: 49.1% (95% CI 44.4-53.8) vs. 50.5% (95% CI 45.6-55.4) (p = .68). In the logistic regression model, when controlling for age, gender, ESI-acuity, race and insurance payor, PIT vs. traditional was not a predictor of CT ordering (OR 1.14, 95% CI 0.94-1.38). CONCLUSIONS For patients with abdominal pain, we found no significant differences in rates of CT ordering or CT yield for patients seen in a PIT vs. traditional models, suggesting the increased efficiencies offered by PIT models do not come at the cost of increased or decreased imaging utilization.
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Schwarzfuchs D, Shashar S, Sagy I, Novack V, Zeldetz V. Does the physician in triage strategy improve door-to-balloon time for patients with STEMI? Emerg Med J 2020; 37:540-545. [DOI: 10.1136/emermed-2019-209241] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 06/09/2020] [Accepted: 06/13/2020] [Indexed: 12/25/2022]
Abstract
BackgroundThe physician in triage (PIT) strategy was implemented in the emergency department (ED) of the Soroka University Medical Center (SUMC) to improve overcrowding and waiting time. Our objective in the current study was to assess the impact of the PIT strategy on door-to-balloon time for the treatment of acute ST-elevation myocardial infarction (STEMI).MethodsThe PIT programme began on January 2016, working weekdays between 8:00 and 23:00 hours. We included patients who visited the ED and were diagnosed with STEMI, from November 2014 to February 2018. The primary outcome was improvement in door-to-balloon (D2B) time <90 min between the preintervention and postintervention period. The analysis included a comparison between the two time periods using univariate tests, a time trend analysis illustrated by the locally weighted scatterplot smoothing curves and a regression analysis using generalised estimating equation models. To determine the impact of the PIT, as opposed to other changes in the department, we stratified the population arriving after January 2016 to patients arriving during PIT hours versus patients arriving on weekends and at nights (23:00–8:00 hours).ResultsIn all, 415 patients met all the inclusion criteria of which 237 (57.1%) visited on weekdays 8:00–23:00 hours. The per cent of patients with D2B <90 min was 13.9% higher for postintervention versus preintervention visits (p=0.006). D2B time was significantly shorter by 9 min for postintervention visits (p=0.001). In the postintervention period, patients arriving between 8:00 and 23:00 hours on weekdays were more likely to have D2B <90 min than those arriving nights and weekends; 90/146 (61.6%) vs 47.2% (51/108), respectively, p=0.02. ORs for D2B <90 min was 2.04 (95% CI 1.06 to 3.91) for weekday visits, and 1.90 (0.88 to 4.12) for weekend and night visits.ConclusionThe PIT model in SUMC is associated with D2B reduction for patients with STEMI. To achieve further reduction, both targeted interventions should be performed and PIT strategy should be applied for full time, including nights and weekends.
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Root BK, Kanter JH, Calnan DC, Reyes‐Zaragosa M, Gill HS, Lanter PL. Emergency department observation of mild traumatic brain injury with minor radiographic findings: shorter stays, less expensive, and no increased risk compared to hospital admission. J Am Coll Emerg Physicians Open 2020; 1:609-617. [PMID: 33000079 PMCID: PMC7493558 DOI: 10.1002/emp2.12124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 03/30/2020] [Accepted: 05/04/2020] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE The management of mild traumatic brain injury (mTBI) with minor radiographic findings traditionally involves hospital admission for monitoring, although this practice is expensive with unclear benefit. We implemented a protocol to manage these patients in our emergency department observation unit (EDOU), hypothesizing that this pathway was cost effective and not associated with any difference in clinical outcome. METHODS mTBI patients with minor radiographic findings were managed under the EDOU protocol over a 3-year period from May 1, 2015 to April 30, 2018 (inclusions: ≥19 years old, isolated acute head trauma, normal neurological exam [except transient alteration in consciousness], and a computed tomography [CT] scan of the head with at least 1 of the following: cerebral contusions <1 cm in maximum extent, convexity subarachnoid hemorrhage, or closed, non-displaced skull fractures). These patients were retrospectively analyzed; clinical outcomes and charges were compared to a control cohort of matched mTBI hospital admissions over the preceding 3 years. RESULTS Sixty patients were observed in the EDOU over the 3-year period, and 85 patients were identified for the control cohort. There were no differences in rate of radiographic progression, neurological exam change, or surgical intervention, and the overall incidence of hemorrhagic expansion was low in both groups. The EDOU group had a significantly faster time to interval CT scan (Mean Difference (MD) 3.92 hours, [95%CI 1.65, 6.19]), P = 0.001), shorter length of stay (MD 0.59 days [95% CI 0.29, 0.89], P = 0.001), and lower encounter charges (MD $3428.51 [95%CI 925.60, 5931.42], P = 0.008). There were no differences in 30-day re-admission, 30-day mortality, or delayed chronic subdural formation, although there was a high rate of loss to follow-up in both groups. CONCLUSIONS Compared to hospital admission, observing mTBI patients with minor radiographic findings in the EDOU was associated with significantly shorter time to interval scanning, shorter length of stay, and lower encounter charges, but no difference in observed clinical outcome. The overall risk of hemorrhagic progression in this subset of mTBI was very low. Using this approach can reduce unnecessary admissions while potentially yielding patient care and economic benefits. When designing a protocol, close attention should be given to clear inclusion criteria and a formal mechanism for patient follow-up.
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Affiliation(s)
- Brandon K. Root
- Section of NeurosurgeryDartmouth‐Hitchcock Medical CenterLebanonNew HampshireUSA
| | - John H. Kanter
- Section of NeurosurgeryDartmouth‐Hitchcock Medical CenterLebanonNew HampshireUSA
| | - Dan C. Calnan
- Section of NeurosurgeryDartmouth‐Hitchcock Medical CenterLebanonNew HampshireUSA
| | | | - Harman S. Gill
- Department of Emergency MedicineDartmouth‐Hitchcock Medical CenterLebanonNew HampshireUSA
| | - Patricia L. Lanter
- Department of Emergency MedicineDartmouth‐Hitchcock Medical CenterLebanonNew HampshireUSA
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Budde J, Agarwal P, Mazumdar M, Yeo J, Braman SS. Can an Emergency Department Observation Unit Reduce Hospital Admissions for COPD Exacerbation? Lung 2018; 196:267-270. [PMID: 29488003 DOI: 10.1007/s00408-018-0102-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 01/04/2018] [Indexed: 10/17/2022]
Abstract
Studies on observation unit (OU) use to avoid a hospital admission from the emergency department (ED) have found variable effects on health care resource utilization, and these effects have not been studied in acute exacerbation of chronic obstruction pulmonary disease (AECOPD). We retrospectively collected data for all AECOPD-related ED visits (age > 40) to an urban, academic medical center between February 2013 and April 2017. We examined the total proportion of visits admitted to the hospital before and after availability of an OU and the proportion of visits discharged directly from the ED using segmented regression analysis. There was a 12.8% reduction in hospital admissions after OU availability (79.6 vs. 66.8%, p = 0.0049) without a change in the proportion discharged directly from the ED (p = 0.65). The availability of an OU can decrease hospital AECOPD admissions without affecting the number of patients discharged directly from the ED.
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Affiliation(s)
- Julia Budde
- Division of Pulmonary, Critical Care, & Sleep Medicine, Icahn School of Medicine at Mount Sinai, 1468 Madison Avenue, Annenberg Building 5th Floor, Room 5-20, New York, NY, 10029, USA
| | - Parul Agarwal
- Institute for Health Care Delivery Science at Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, 1425 Madison Avenue, Icahn Building, Floor L2, New York, NY, 10029, USA
| | - Madhu Mazumdar
- Institute for Health Care Delivery Science at Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, 1425 Madison Avenue, Second Floor, Room, New York, NY, 10029, USA
| | - Jonathan Yeo
- Division of Hospital Medicine, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1149, New York, NY, 10029, USA
| | - Sidney S Braman
- Division of Pulmonary, Critical Care, & Sleep Medicine, Icahn School of Medicine at Mount Sinai, 1468 Madison Avenue, Annenberg Building 5th Floor, Room 5-20, New York, NY, 10029, USA.
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