Factors Relating to Decision Delay in the Emergency Department: Effects of Diagnostic Tests and Consultations

Purpose

The purpose of this study is to investigate the factors increasing waiting time (WT) and length of stay (LOS) in patients, which may cause delays in decision-making in the emergency departments (ED).

Patients and Methods

Patients who arrived at a training hospital in the central region of Izmir City, Turkey, during the first quarter of 2020 were retrospectively analyzed. WT and LOS were the outcome variables of the study, and gender, age, arrival type, triage level determined based on the clinical acuity, diagnosis encoded based on International Classification of Diseases-10 (ICD-10), the existence of diagnostic tests or consultation status were the identified factors. The significance of the differences in WT and LOS values based on each level of these factors was analyzed using independent sample t-tests and ANOVA.

Results

While patients for which no diagnostic testing or consultation was requested had a significantly higher WT in EDs, their LOS values were substantially lower than those for which at least one diagnostic test or consultation was ordered (p≤0.001). Besides, elderly and red zone patients and those who arrived by ambulance had significantly lower WT and higher LOS values than other levels for all groups of patients for which laboratory-type or imaging-type diagnostic test or consultation was requested (p≤0.001 for each comparison).

Conclusion

Besides ordering diagnostic tests or consultation in EDs, different factors may extend patients' WT and LOS values and cause significant decision-making delays. Understanding the patient characteristics associated with longer waiting times and LOS values and, thus, delayed decisions will enable practitioners to improve operations management in EDs.

The diagnosis of pulmonary embolism without contrastis not always Challenging: be aware of hyperdense lumen sign

Acute pulmonary embolism (PE) diagnosis is a challenging task, despite the advanced diagnostic methods for both clinicians and radiologists. Awareness of the “hyperdense lumen sign” in patients obtained un-enhanced computarized tomography (CT) of chest mayhelp to establish an acute PE diagnosis, especially in clinically non suspected PE patients. A 78-year-old woman was brought to our emergency department (ED) with an aphasia complaint. The patient's dizziness improved in ED. Neurological examination returned to base line status but sinus tachycardia and low saturation value on room air were continuing. Un-enhanced CT of the chest demonstrates hyperdense material within the right main pulmonary artery. Contrast-enhanced CTPA demonstrated hypodense filling defect within the rigth main pulmonary artery consistent with PE. Independent of the patient's complaint, the measurement of all vital signs is important especially in elderly patients. Emergency physicians have to be aware of that the “hyperdense lumen sign” may point out PE and should be prevented from delayed recognition.

Urine Dipstick of Sputum for the Rapid Diagnosis of Community Acquired Pneumonia

INTRODUCTION

Community acquired pneumonia (CAP) is responsible for an important part of treatment costs across the world. Even though posterior-anterior lung radiography (PALG) and direct sputum smear microscopy are required or routine diagnoses. The purpose of this study is to determine the diagnostic value of the bedside urine strip tests in CAP.

METHODS

Patients who attended the emergency department (ED) between from February 2016 to September 2016 with expectoration complaints and suspicion of pneumonia. The sensitivity, specificity, and accuracy rate of the urine strip tests, direct sputum smear microscopy, and PALG were calculated and analyzed using SPSS 15.0.

RESULTS

During the study period, 100 patients with pneumonia suspicion were evaluated in the ED. The sample was divided into two groups: negative and positive diagnosis of CAP. The leukocytes detecting by urine strip tests are statistical differences between the two groups (p: 0.003). The results show that the sensitivity, specificity, and accuracy rate of leukocytes detected in sputum with urine strip tests in the pneumonia diagnosis were 83.3%, 44.2% and 63% respectively.

CONCLUSION

According to the study, it is believed that the method of determination of leukocytes with urine strip tests in sputum combined with more detailed results. They can become part of CAP diagnosis methods.

A bedside ultrasound technique for fluid therapy monitoring in severe hypovolemia: Tissue Doppler imaging of the right ventricle

Fluid therapy is one of the main issues for hemodynamic resuscitation. Tissue Doppler imaging (TDI) of the right ventricle (RV) with bedside ultrasound (BUS) technique is a new dynamic method to identify fluid responsiveness in patients with hypotension. Here, we present the case of a hypotensive patient monitored with TDI measurements of RV. A 75-year-old male patient was admitted to the emergency department (ED) with the complaint of diarrhea. He was in severe hypovolemia, with hypotension, tachycardia, and tachypnea. His laboratory results were normal. BUS was performed on the patient by the ED physician. The velocity of the excursion of the tricuspid valve measured at presentation was 14.47 cm/s and, together with collapsed inferior vena cava (IVC), this finding led to the decision to begin fluid therapy immediately. The patient underwent 2 L of fluid therapy with 0.9% NaCl in a 2-h period. Control BUS after fluid therapy revealed decreased TDI velocity of tricuspid annulus to 11.81 cm/s and dilated IVC not collapsing sufficiently with respiration. The patient received his maintenance therapy after admission to the internal medicine department and was discharged from the service after 3 days. TDI in fluid responsiveness may find a clinical role in the future by the clinical studies.

Bedside lung ultrasonography for diagnosis of pneumonia

Objective

The aim of this study was to investigate the accuracy of bedside lung ultrasound (BUS) in the diagnosis of community-acquired pneumonia (CAP) in patients with dyspnoea presenting to the emergency department (ED) and to analyse the characteristic sonographic findings of CAP.

Methods

After a six-hour training program, BUS procedures were performed between October 2011 and February 2012 to prospectively evaluate patients presenting to the ED with dyspnoea. Chest X-ray (CXR) or computerised tomography (CT) were ordered, depending on the presence of consolidation signs on CXR. The outcome was determined by consolidation findings on CXR or CT. BUS results were compared using Chi-squared testing.

Results

Of the 112 enrolled patients with dyspnoea, 40 patients were excluded and 72 were included in the study. Thirty-four patients were BUS positive. Of these, CXR or CT findings agreed with the BUS findings in 27 patients. In 38 cases, BUS was negative, and one patient was diagnosed with pneumonia based on the CT report. The sensitivity, specificity, PPV, NPV, and the positive and negative likelihood ratios for BUS were 96.4%, 84.1%, 79.4%, 97.4%, 6.1 and 0.042, respectively. The diagnostic accuracy of BUS was 89%. The presence of consolidation signs, either shred or hepatisation, were the most frequent sonographic findings in our study.

Conclusions

Acute alveolar consolidation can be diagnosed easily by performing BUS with high degree of accuracy in EDs.

An Unexpected Reason for Isolated Foot Drop: Acute Stroke

The differential diagnosis of acute weakness (AW) in emergency departments (ED) is broad and includes both neurological and medical reasons. We describe an 81-year-old female patient with cortical infarct presenting with sudden onset isolated foot drop, which to the best of our knowledge, was the third case in English literature. An 81-year-old female was admitted to our ED with a 12-hour history of left-sided foot drop. Her motor strength was normal throughout the upper and lower extremities, except for weakness in the left ankle and toe dorsiflexors. Other examination findings were unremarkable. Diffusion-weighted magnetic resonance imaging (DWI-MR) revealed a focal high intensity signal in the right precentral gyrus at high convexity with a cerebral infarct. Detailed physical examinations and histories are extremely important for exact diagnosis and differentials of patients with AW. This case reminds us that a small infarct area of central nervous system may mimic peripheral nerve lesions, especially in elderly patients. Although the presentation of such complaints may play a distracting role to emergency physicians, strokes must always be taught regarding elderly patients and, if necessary, infarct areas should be confirmed with DWI-MR.

Bedside Echocardiography in Acute Myocardial Infarction Patients with Hemodynamic Deterioration

Ventricular septal (VS) rupture after acute myocardial infarction (AMI) is an uncommon complication in the reperfusion era. Bedside echocardiography (BECH) continues to be a strong diagnostic tool for emergency physicians treating dyspneic patients, especially for decision-making on the management strategies to use with these unstable patients. In the case we present here, a patient is diagnosed with a delayed mechanical complication after AMI, and a swift management plan is made with the aid of point-of-care BECH. The patient is a 72-year-old man with dyspnea who was admitted to the ED 5 days after receiving a primary percutaneous coronary intervention with stent implantation for AMI; in the ED, the patient was diagnosed, via BECH, with a VS rupture. On arrival, his vital signs and the results of his physical examination depicted shock and low perfusion with wet lung. A cardiac examination revealed a new 2/6 harsh holosystolic murmur along the left sternal border without pretibial oedema. Emergency physicians performed BECH, and subcostal views of the heart revealed a wide interventricular septal rupture and left-to-right shunting with minimal pericardial effusion. The patient underwent surgery immediately to repair the defect. The post-operative course was uneventful, and he was discharged in stable condition on the seventh day after the surgery. The use of BECH to recognize a VS rupture is critical because such a defect may be the most important determinant of mortality in AMI patients who are in shock. BECH thus can influence clinicians' acute management and disposition decisions.

An unusual cause of death: spontaneous urinary bladder perforation

Spontaneous urinary bladder perforation is a rare and life-threatening condition similar to traumatic and iatrogenic perforation. The connection with the underlying bladder damage due to previous radiotherapy, inflammation, malignancy, obstruction, or other causes can be found in almost all cases. The symptoms are often nonspecific, and misdiagnosis is common. Here, we present a case of spontaneous urinary bladder perforation due to bladder necrosis in a diabetic woman. She presented to the emergency department with abdominal pain. Exploratory laparotomy was performed by surgeons and revealed necrosis of the anterior and lateral walls of the urinary bladder. Microscopic examination revealed necrotic changes throughout the bladder wall. Ghost-like cellular outlines were compatible with coagulative necrosis. Clusters of bacteria were also present in some necrobiotic tissues. Malignant cells were not present. It appears probable that the infection was due to local interference with the blood supply (arterial, capillary, or venous) combined with the systemic metabolic upset that led to the bladder condition. In our case, we observed partial necrosis of the bladder rather than distortion of the entire blood supply to the bladder as consequences of the microvascular effects of diabetes. Urinary bladder perforation must be considered in the differential diagnosis of patients presenting with free fluid in the abdomen/peritonitis, decreased urine output, and hematuria, and in whom increased levels of urea/creatinine are detected in serum and/ or peritoneal fluid aspirate.

Comparison of existing syncope rules and newly proposed anatolian syncope rule to predict short-term serious outcomes after syncope in the Turkish population

Background

We wished to compare the San Francisco Syncope Rule (SFSR), Evaluation of Guidelines in Syncope Study (EGSYS) and the Osservatorio Epidemiologico sulla Sincope nel Lazio (OESIL) risk scores and to assess their efficacy in recognising patients with syncope at high risk for short-term adverse events (death, the need for major therapeutic procedures, and early readmission to the hospital). We also wanted to test those variables to designate a local risk score, the Anatolian Syncope Rule (ASR).

Methods

This prospective, cohort study was conducted at the emergency department of a tertiary care centre. Between December 1 2009 and December 31 2010, we prospectively collected data on patients of ages 18 and over who presented to the emergency department with syncope.

Results

We enrolled 231 patients to the study. A univariate analysis found 23 variables that predicted syncope with adverse events. Dyspnoea, orthostatic hypotension, precipitating cause of syncope, age over 58 years, congestive heart failure, and electrocardiogram abnormality (termed DO-PACE) were found to predict short-term serious outcomes by logistic regression analysis and these were used to compose the ASR. The sensitivity of ASR, OESIL, EGSYS and SFSR for mortality were 100% (0.66 to 1.00); 90% (0.54 to 0.99), 80% (0.44 to 0.97) and 100% (0.66 to 1.00), respectively. The specificity of ASR, OESIL, EGSYS and SFSR for mortality were 78% (0.72 to 0.83); 76% (0.70 to 0.82); 80% (0.74 to 0.85) and 70% (0.63 to 0.76). The sensitivity of ASR, OESIL, EGSYS and SFSR for any adverse event were 97% (0.85 to 1.00); 70% (0.52 to 0.82); 56% (0.40 to 0.72) and 87% (0.72 to 0.95). The specificity of ASR, OESIL, EGSYS and SFSR for any adverse event were 72% (0.64 to 0.78); 82% (0.76 to 0.87); 84% (0.78 to 0.89); 78% (0.71 to 0.83), respectively.

Conclusion

The newly proposed ASR appears to be highly sensitive for identifying patients at risk for short-term serious outcomes, with scores at least as good as those provided by existing diagnostic rules, and it is easier to perform at the bedside within the Turkish population. If prospectively validated, it may offer a tool to aid physicians' decision-making.

Outpatient follow-up'' or ''Active clinical observation'' in patients with nonspecific abdominal pain in the Emergency Department. A randomized clinical trial

AIM

The aim of this study was to determine whether it is safe and cost-effective to discharge nonspecific abdominal pain (NSAP) patients from the Emergency Department (ED) and re-evaluate diagnosis later.

METHODS

Patients aged between 18 and 65 years were enrolled into the study. They had been admitted to the ED for acute abdominal pain with an indefinitive diagnosis after clinical examination and base-line investigations. The patients were randomly assigned into two groups: 1) active clinical observation (ACO), comprising those admitted to the ED observation room; 2) outpatient group (OG), comprising those discharged and asked to return for re-evaluation at 8-12 hours intervals over the following three days. Each patient was examined by an ED physician and a consultant general surgeon. Demographics, blood tests, morbidity and mortality, number of operations, together with 6-month follow-up results were noted. Finally, a patient satisfaction questionnaire was administered.

RESULTS

A total of 105 patients were enrolled into the study; 50 were randomized to the ACO group and 55 to the OG. There were no statistically significant differences in demographics and blood parameters between the two groups. Overall agreement of ED diagnosis with final diagnosis was 91.4%. Total morbidity was 10% in the ACO group and 7.2% in the OG. There were no statistically differences in morbidities and usage of diagnostic imaging modalities between the two groups (P>0.05). No deaths occurred in either group during the study period. The patients in the ACO group were more keen on returning for re-evaluation and willing to recommend our hospital services to other people (P< or =0.05).

CONCLUSION

Outpatient evaluation of patients with an ED diagnosis of NSAP may be an option, seems to be safe, is not accompanied by an increased incidence of complications and is efficient if patients are selected properly.

The effect of agmatine on the vascular reactivity in streptozotocin-diabetic rats

AIM

We investigated the vascular effects of agmatine (decarboxylated arginine=AGM), an endogenous ligand for alpha(2)-adrenoceptors and imidazoline receptors, present in endothelium and smooth muscle, using the diabetic rat aortae.

MATERIALS AND METHODS

Studies were performed in control group (0.2 ml i.p. saline, n=10), streptozotocin (STZ)-diabetic control group (60 mg kg(-1) STZ i.p., n=10), agmatine (AGM)-control group (5 mg kg(-1)day(-1) i.p. AGM for 1 month, n=10), citrate-control group (0.2 ml 0.01 M, n=10), insulin-treated diabetic group ((3 U kg(-1) NPH+1 U kg(-1) regular insulin) twice per day, for 1 month, n=10) and AGM-treated diabetic group (5 mg kg(-1)day(-1) i.p. for 1 month, n=10). All values are expressed as means+/-S.E.M. Statistical analysis of the data was performed using ANOVA followed by Tukey multiple comparisons test.

RESULTS

One-month AGM-treatment significantly decreased the blood glucose levels of diabetic rats (502+/-44 mg dl(-1) to 343+/-31 mg dl(-1), P<0.001). Fast, slow and total components of responses to noradrenaline in all the experimental groups were not significantly affected by AGM-treatment. AGM reversed the decreased responses of acetylcholine (pD(2) and Inh.%, P<0.001 and P<0.05) in diabetic rats although it did not affect the responses of sodium nitroprusside in all groups. The contraction values of KCl in all groups were not affected by AGM-treatment.

CONCLUSION

AGM-treatment could improve the increased blood glucose level, reverse the endothelial dysfunction and normalize the endothelium-dependent relaxation responses in STZ-diabetic rats.