scholarly journals Characteristics and outcomes of older emergency department patients assigned a low acuity triage score

CJEM ◽  
2018 ◽  
Vol 20 (5) ◽  
pp. 762-769 ◽  
Author(s):  
Ariel Hendin ◽  
Debra Eagles ◽  
Victoria Myers ◽  
Ian G. Stiell
Keyword(s):  
Emergency Department ◽  
Older Patients ◽  
Admission Rate ◽  
High Risk Population ◽  
Chi Square ◽  
Patients Âgés ◽  
Patient Demographics ◽  
Included Patient ◽  
Emergency Department Patients ◽  
Stratified Analysis

AbstractObjectiveAlthough older patients are a high-risk population in the emergency department (ED), little is known about those identified as “less acute” at triage. We aimed to describe the outcomes of patients ages 65 years and older who receive low acuity triage scores.MethodsThis health records review assessed ED patients who were ages 65 years and above or ages 40 to 55 years (controls) who received a Canadian Triage Acuity Scale score of 4 or 5. Data collected included patient demographics, ED management, disposition, and a return visit or hospital admission at 14 days. Data were analysed descriptively and chi-square testing performed. A pre-planned stratified analysis of patients ages 65 to 74, 75 to 84, and 85 and older was conducted.ResultsThree hundred fifty older patients with a mean age of 76.5 years and 150 control patients were included. Most patients presented with musculoskeletal or skin complaints and were triaged to the ambulatory care area. Older patients were significantly more likely than controls to be admitted on the index visit (5.0% v. 0.3%, p=0.016) and on re-presentation (4.0% v. 0.7%, p=0.045). In a subgroup analysis, patients ages 85 years and above were most likely to be admitted (8.9%, p=0.003).ConclusionsOlder patients who present to the ED with issues labelled as “less acute” at triage are 16 times more likely to be admitted than younger controls. Patients ages 85 years and up are the primary drivers of this higher admission rate. Our study indicates that even “low acuity” elders presenting to the ED are at risk for re-presentation and admission within 14 days.

scholarly journals Is computed tomography-defined obstruction a predictor of urological intervention in emergency department patients presenting with renal colic?

2017 ◽  
Vol 11 (3-4) ◽  
pp. 88 ◽  
Author(s):  
Peter Alexander Massaro ◽  
Avinash Kanji ◽  
Paul Atkinson ◽  
Ryan Pawsey ◽  
Tom Whelan
Keyword(s):  
Computed Tomography ◽  
Emergency Department ◽  
Urinary Calculi ◽  
Signs And Symptoms ◽  
Helical Ct ◽  
Opioid Dose ◽  
Patient Demographics ◽  
Included Patient ◽  
Emergency Department Patients ◽  
Urological Intervention

Introduction: Our objective was to determine whether unilateral calculus-induced ureteric obstruction on computed tomography (CT) was independently associated with the need for urological intervention and 30-day return to the emergency department (ED).Methods: We performed a retrospective cohort study of patients with symptomatic urinary calculi diagnosed by unenhanced helical CT. Stepwise regression analysis was used to determine the predictors of urological intervention and 30-day return to the ED. Potential predictors assessed included: patient demographics, calculus size, calculus location, degree of obstruction, analgesic doses, signs and symptoms of infection, serum creatinine, cumulative intravenous fluid administered, and the prescription of medical expulsive therapy.Results: Of 195 patients, 81 (41.5%) underwent urological intervention. The size of the calculus, its location, and the cumulative opioid dose were all independent predictors for urological intervention. Every 1 mm increase in calculus size increased the likelihood of intervention 2.2 times (odds ratio [OR] 2.17; 95% confidence interval [CI] 1.67‒2.85). Proximal stones were 4.7 times more likely to require intervention than distal calculi (OR 0.21; 95% CI 0.09‒0.49). Every 10 mg increase in morphine was associated with a 30% increase in the odds of intervention (OR 1.30; 95% CI 1.07‒1.58). Degree of obstruction was not associated with the need for urological intervention. Finally, none of the variables were predictors for 30-day return to the ED.Conclusions: Although stone size, proximal location, and severe pain, as indicated by higher opioid doses, were associated with the need for intervention, the degree of obstruction did not influence the management of patients with CT-defined urinary calculi.

CT Abdominal Tomography Indications: Are We All Sticking to the Plan?

2020 ◽  
pp. 084653712095107
Author(s):  
Michael Pyper ◽  
Abdulwahab Sidiqi ◽  
Patrik Rogalla ◽  
Sam Sabbah ◽  
Ania Kielar
Keyword(s):  
Emergency Department ◽  
Radiation Dose ◽  
Patient Outcomes ◽  
Abdominal Radiography ◽  
Low Radiation Dose ◽  
Patient Demographics ◽  
Included Patient ◽  
Significant Difference ◽  
Quality Assurance Project ◽  
Emergency Department Patients

Objective: Ultra-low radiation dose computed tomography (CT) abdominal tomography was introduced in our institution in 2016 to replace standard abdominal radiography in the investigation of emergency department patients. This project aims to ascertain whether investigation of emergency department patients using ultra-low radiation dose CT abdominal tomography complies with original indication guidelines and/or if there has been any “indication creep” 3 years after inception. Methods: Retrospective, quality assurance project with research ethics waiver. A review of 200 consecutive patients investigated with CT abdominal tomography between February and May 2017 was performed. This was compared with 200 consecutive patients investigated between February and May 2019. Data analyzed included patient demographics, indication for scan, as well as scan and patient outcomes. Results: In the 2017 group, 29/200 scans were noncompliant with approved indication guidelines. In the 2019 group, 30/200 scans were also noncompliant. There was no statistically significant difference between groups ( P < .05) regarding the use of approved indications. Forty of 200 scans performed in 2017 revealed additional findings which are not specifically addressed on the reporting template. Forty-one of 200 scans in 2019 revealed these findings. Conclusions: There has been no “indication creep” for CT abdominal tomography over time.

scholarly journals MP13: Characteristics and outcomes of older emergency department patients assigned a low acuity triage score

CJEM ◽  
2017 ◽  
Vol 19 (S1) ◽  
pp. S69
Author(s):  
A. Hendin ◽  
D. Eagles ◽  
V.R. Myers ◽  
I.G. Stiell
Keyword(s):  
Emergency Department ◽  
High Risk ◽  
Hospital Admission ◽  
Older Patients ◽  
Tertiary Care ◽  
Group Analysis ◽  
Control Group ◽  
High Risk Population ◽  
Chi Square ◽  
Admission Rates

Introduction: Older patients are a high-risk population in the Emergency Department (ED) for poor outcomes after ED visit, including return presentation and hospital admission. Little is known however about outcomes in older patients identified as “low acuity” by triage. We aim to describe the characteristics, ED workup, disposition, and 14-day outcomes of ED patients 65 years and up who are triaged as low acuity and compare them to a younger cohort. Methods: This health records review was done in a Canadian tertiary care ED. Included patients received a Canadian Triage Acuity score (CTAS) of 4 or 5 and were either 65 years and up (“older” group), or 40-55 years (controls). Data collected included patient demographics, tests and services involved in ED, and disposition. Return ED visit and hospital admission rates at 14 days were tracked. Data were analyzed descriptively and chi-square testing conducted to assess for differences (p &lt; 0.05) between groups. A pre-planned stratified analysis of patients 65-74 years, 75-84, and 85 and older was conducted. Results: 350 patients (mean age 76.5, 56.6% female) were included in the older group and 150 in the control group (mean age 47.3, 55.3% female). Most patients presented with musculoskeletal or skin complaints (older cohort: 28.6% extremity pain/injury, 10% rash, 8.9% laceration, versus control 30% extremity pain/injury, 14.7% rash, 14.0% laceration) and were triaged to the ambulatory care area (88.6% elderly, 99.3% control). Older patients were significantly more likely than younger controls to be admitted on index visit (5.0% vs 0.3% admit rate, p=0.016). They had a trend towards increased re-presentation rates within 14 days (13.7% vs 8.7% control, p=0.11) and were more likely to be admitted on re-presentation (4.0% vs 0.7%, p=0.045). In sub-group analysis, very elderly patients (85 years and up, n=79) were more likely to be admitted (8.9%, p=0.003). Conclusion: Patients 65 years of age and older who present to the ED with issues labelled as “less acute” at triage are 16 times more likely to be admitted than younger controls. Patients 85 years and up are the primary drivers of this higher admit rate. This study characterizes “low acuity” elders presenting to ED and indicates these patients are high risk for re-presentation and admission within 14 days.

scholarly journals Implementation of the acutely presenting older patient (APOP) screening program in routine emergency department care

2021 ◽  
Author(s):  
Laura C. Blomaard ◽  
Bas de Groot ◽  
Jacinta A. Lucke ◽  
Jelle de Gelder ◽  
Anja M. Booijen ◽  
...  
Keyword(s):  
Emergency Department ◽  
High Risk ◽  
Older Patients ◽  
Screening Program ◽  
Admission Rate ◽  
Older Patient ◽  
Hospital Admission Rate ◽  
High Risk Patients ◽  
Risk Patients

Abstract Objective The aim of this study was to evaluate the effects of implementation of the acutely presenting older patient (APOP) screening program for older patients in routine emergency department (ED) care shortly after implementation. Methods We conducted an implementation study with before-after design, using the plan-do-study-act (PDSA) model for quality improvement, in the ED of a Dutch academic hospital. All consecutive patients ≥ 70 years during 2 months before and after implementation were included. The APOP program comprises screening for risk of functional decline, mortality and cognitive impairment, targeted interventions for high-risk patients and education of professionals. Outcome measures were compliance with interventions and impact on ED process, length of stay (LOS) and hospital admission rate. Results Two comparable groups of patients (median age 77 years) were included before (n = 920) and after (n = 953) implementation. After implementation 560 (59%) patients were screened of which 190 (34%) were high-risk patients. Some of the program interventions for high-risk patients in the ED were adhered to, some were not. More hospitalized patients received comprehensive geriatric assessment (CGA) after implementation (21% before vs. 31% after; p = 0.002). In 89% of high-risk patients who were discharged to home, telephone follow-up was initiated. Implementation did not influence median ED LOS (202 min before vs. 196 min after; p = 0.152) or hospital admission rate (40% before vs. 39% after; p = 0.410). Conclusion Implementation of the APOP screening program in routine ED care did not negatively impact the ED process and resulted in an increase of CGA and telephone follow-up in older patients. Future studies should investigate whether sustainable changes in management and patient outcomes occur after more PDSA cycles.

scholarly journals Impact of a nurse practitioner on patient care in a Canadian emergency department

CJEM ◽  
2009 ◽  
Vol 11 (03) ◽  
pp. 207-214 ◽  
Author(s):  
Ivan P. Steiner ◽  
Darren N. Nichols ◽  
Sandra Blitz ◽  
Lloyd Tapper ◽  
Andrew P. Stagg ◽  
...  
Keyword(s):  
Emergency Department ◽  
Nurse Practitioner ◽  
Wait Times ◽  
Free Standing ◽  
Patient Demographics ◽  
Lengths Of Stay ◽  
Broad Scope ◽  
Triage Category ◽  
Included Patient ◽  
And Control

ABSTRACTObjective:Our objective was to determine whether the addition of a broad-scope nurse practitioner (NP) would improve emergency department (ED) wait times, ED lengths of stay (LOS) and left-without-treatment (LWOT) rates. We hypothesized that the addition of a broad-scope NP during weekday ED shifts would result in shorter patient wait times, reduced LOS and fewer patients leaving the ED without treatment.Methods:This prospective observational study was conducted in a busy urban free-standing community ED. Intervention shifts, with NP coverage, were compared with control shifts (similar shifts with emergency physicians [EPs] working independently). Primary outcomes included patient wait times, ED LOS and LWOT rates. Patient demographics, triage category, the provider seen, the time to provider and ED LOS were captured using an electronic database.Results:The addition of an NP was associated with a 12% increase in patient volume per shift and a 7-minute reduction in mean wait times for low-acuity patients. However, overall patient wait times and ED LOS did not differ between intervention and control shifts. During intervention shifts, EPs saw a smaller proportion of low-acuity patients and there was a trend toward a lower proportion of LWOT patients (11.9% v. 13.7%,p= 0.10).Conclusion:Adding a broad-scope NP to the ED staff may lower the proportion of patients who leave without treatment, reduce the proportion of low-acuity patients seen by EPs and expedite throughput for a subgroup of less urgent patients. However, it did not reduce overall wait times or ED LOS in this setting.

scholarly journals LO37: Prevalence of cigarette smoking amongst adult emergency department patients

CJEM ◽  
2019 ◽  
Vol 21 (S1) ◽  
pp. S20-S21
Author(s):  
A. Tolmie ◽  
R. Erker ◽  
T. Oyedokun ◽  
E. Sullivan ◽  
T. Graham ◽  
...  
Keyword(s):  
Emergency Department ◽  
Cigarette Smoking ◽  
Intervention Program ◽  
Smoking Prevalence ◽  
Health Concern ◽  
Chi Square ◽  
Smoking Cessation Counselling ◽  
Chief Complaints ◽  
Statistics Canada ◽  
Emergency Department Patients

Introduction: Tobacco smoking is a priority public health concern, and a leading cause of death and disability globally. While the smoking prevalence in Canada is approximately 13-18%, the proportion of smokers among emergency department (ED) patients has been found to be significantly higher. This disparity primes the emergency department as a critical environment to provide smoking cessation counselling and support. Methods: A verbal questionnaire was administered to adult patients (18+) presenting to Royal University, Saskatoon City, and St. Paul's Hospital ED's. Patients were excluded if they were underage, too ill, or physically/mentally unable to complete the questionnaire independently. Patients’ smoking habits were also correlated with Fagerstrom tobacco dependence scores, chief complaints, Canadian Triage Acuity Scale (CTAS) scores, and willingness to partake in ED specific cessation counselling. Data were analyzed using IBM SPSS software to determine smoking prevalence and compared to Statistics Canada data using chi-square tests. Results: In total, 1190 eligible patients were approached, and 1078 completed the questionnaire. Adult Saskatoon ED patients demonstrated a cigarette smoking prevalence of 19.6%, which is significantly higher than the general adult Saskatchewan public at 15.1% (p &lt; 0.0001). Comparing smoking and non-smoking cohorts, there are no significant differences in CTAS scores (p = 0.60). Of the proposed cessation interventions, ED cessation counselling was most popular among patients (62.4%), followed by receiving a pamphlet (56.2%), and being contacted by a smokers’ quit line (49.5%). Out of the smoking cohort, 51.4% indicated they want to quit smoking, and would be willing to partake in ED-specific cessation counselling, if available. Additionally, 88.1% of current smokers started smoking when they were less than 19 years old. Conclusion: The higher smoking prevalence demonstrated in ED patients highlights the need for a targeted intervention program that is feasible for the fast-paced environment. Quit attempts have been demonstrated to be more efficacious with repeated interventions, which could be achieved by training ED staff to conduct brief motivational interviews and faxing referrals to a smokers' quit line for follow-up. Furthermore, pediatric ED's could be a valuable location for cigarette smoking screening, as the majority began smoking in their adolescence.

scholarly journals Adherence of older emergency department patients to community-based specialized geriatric services

CJEM ◽  
2019 ◽  
Vol 21 (5) ◽  
pp. 659-666
Author(s):  
Zachary MacDonald ◽  
Ian G. Stiell ◽  
Ioanna Genovezos ◽  
Debra Eagles
Keyword(s):  
Emergency Department ◽  
Patient Adherence ◽  
Cognitively Impaired ◽  
Study Participation ◽  
Convenience Sample ◽  
Home Based ◽  
Included Patient ◽  
Emergency Department Patients ◽  
Future Work

ABSTRACTObjectivesOur objective was to determine emergency department (ED) patient adherence to outpatient specialized geriatric services (SGS) following ED evaluation by the geriatric emergency management (GEM) nurse, and identify barriers and facilitators to attendance.MethodsWe conducted a prospective cohort study at two academic EDs between July and December 2016, enrolling a convenience sample of patients ≥ 65 years, seen by a GEM nurse, referred to outpatient SGS, and consented to study participation. We completed a chart review and a structured telephone follow-up at 6 weeks. Descriptive statistics were used.ResultsWe enrolled 103/285 eligible patients (86 eligible but not enrolled, 86 declined specialized geriatric referrals, and 10 declined study participation). Patients were mean age of 83.1 years, 59.2% female, and 73.2% cognitively impaired. Reasons for referral included mobility (86.4%), cognition (56.3%), pain (38.8%), mood (35.0%), medications (33.0%), and nutrition (31.1%). Referrals were to Geriatric Day Hospital (GDH) programs (50.5%), geriatric outreach (26.2%), falls clinic (12.6%), and geriatric psychiatry (8.7%). Adherence with follow-up was 59.2%. Barriers to attendance included patient did not feel SGS were needed (52.1%), inability to recall GEM consultation (53.4%), and dependence on family for transportation (72.6%). Home-based assessments had the highest adherence (81.5%).ConclusionAdherence of older ED patients referred by the GEM team to SGS is suboptimal, and a large proportion of patients decline these referrals in the ED. Future work should examine the efficacy of home-based assessments in a larger confirmatory setting and focus on interventions to increase referral acceptance and address barriers to attendance.

scholarly journals P068: Patient satisfaction following educational ultrasounds in the emergency department

CJEM ◽  
2017 ◽  
Vol 19 (S1) ◽  
pp. S101
Author(s):  
P. Kapur ◽  
M. Betz ◽  
J. Chenkin ◽  
C. Brick
Keyword(s):  
Emergency Department ◽  
Patient Satisfaction ◽  
Point Of Care ◽  
Point Of Care Ultrasound ◽  
Negative Experiences ◽  
Patient Demographics ◽  
Included Patient ◽  
Survey Results ◽  
Age Range ◽  
Do So

Introduction: Development of point-of-care ultrasound (POCUS) image-generating skills requires residents to practice on patients awaiting care in the emergency department (ED) for unrelated reasons. While patients are almost universally agreeable to the scans, there is the possibility that they feel pressured to do so and may have negative experiences that go unreported. The objective of this study was to determine the self-reported patient satisfaction and identify any concerns after educational ultrasounds performed in the ED. Methods: We conducted a survey of patients at a single academic ED. Patients were eligible for enrollment if they had volunteered for an ultrasound when study personnel were available. The survey was administered by a representative from the Patient Affairs Department who advised the patients that the results would remain anonymous and would have no impact on their care. The survey included patient demographics, questions about the consent process, communication by the trainee, adverse reactions and patient satisfaction. The primary outcome was the overall satisfaction level reported by the volunteer patients on a 5-point Likert scale. Secondary outcomes included identification of any discomfort or concerns about the process as expressed by patients. Simple descriptive statistics were used to report survey results. Results: Ninety-nine patients fully completed the questionnaire. Fifty (50%) were women. The age range was 18 to 99 years. Satisfaction among volunteers was high, with 94% of respondents giving a rating of 4 or 5 (five being an excellent experience). No patients gave a negative rating (1 or 2). Three (3%) patients felt “somewhat” pressured to volunteer. A majority of patients (72%) experienced no discomfort during the scan however 16% experienced some physical discomfort. Comments indicated that too much pressure applied with the ultrasound probe or cold ultrasound gel were the main sources of discomfort. Despite some discomfort 95 (95%) patients stated they would likely volunteer again if asked in the future. Conclusion: ED patients volunteering as models for residents learning POCUS expressed generally positive perceptions of their experience. While only a small minority of patients experienced some discomfort or felt pressured into participating, it is important to ensure that patients have a process to communicate any concerns about educational ultrasounds in the ED.

scholarly journals Management of Discharged Emergency Department Patients with a Primary Diagnosis of Hypertension: A Multicentre Study

CJEM ◽  
2015 ◽  
Vol 17 (5) ◽  
pp. 523-531 ◽  
Author(s):  
Dennis D. Cho ◽  
Peter C. Austin ◽  
Clare L. Atzema
Keyword(s):  
Emergency Department ◽  
Primary Outcome Measure ◽  
Primary Diagnosis ◽  
Emergency Physicians ◽  
Physician Characteristics ◽  
Included Patient ◽  
Follow Up Care ◽  
Emergency Department Patients ◽  
Certification Type

AbstractIntroductionMany patients are seen in the emergency department (ED) for hypertension, and the numbers will likely increase in the future. Given limited evidence to guide the management of such patients, the practice of one’s peers provides a de facto standard.MethodsA survey was distributed to emergency physicians during academic rounds at three community and four tertiary EDs. The primary outcome measure was the proportion of participants who had a blood pressure (BP) threshold at which they would offer a new antihypertensive prescription to patients they were sending home from the ED. Secondary outcomes included patient- and provider-level factors associated with initiating an antihypertensive based on clinical vignettes of a 69-year-old man with two levels of hypertension (160/100 vs 200/110 mm Hg), as well as the recommended number of days after which to follow up with a primary care provider following ED discharge.ResultsAll 81 surveys were completed (100%). Half (51.9%; 95% CI 40.5-63.1) of participants indicated that they had a systolic BP threshold for initiating an antihypertensive, and 55.6% (95% CI 44.1-66.6) had a diastolic threshold: mean systolic threshold was 199 mm Hg (SD 19) while diastolic was 111 mm Hg (SD 8). A higher BP (OR 12.9; 95% CI 7.5-22.2) and more patient comorbidities (OR 3.0; 95% CI 2.1-4.3) were associated with offering an antihypertensive prescription, while physician years of practice, certification type, and hospital type were not. Participants recommended follow-up care within a median 7.0 and 3.0 days for the patient with lower and higher BP levels, respectively.ConclusionsHalf of surveyed emergency physicians report having a BP threshold to start an antihypertensive; BP levels and number of patient comorbidities were associated with a modification of the decision, while physician characteristics were not. Most physicians recommended follow-up care within seven days of ED discharge.

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