emergency department

Editorial Volume 17 Issue 4 – Assessing, treating and prognosticating from the front door

Editorials, Volume 17, Issue 4, Pages 173 – 240 (2018)

In our daily working lives, acute physicians strive to provide the best holistic care to our patients from the moment they arrive in hospital. Experienced healthcare professionals develop a gut feeling (generally recognised as the nagging internal voice of professional experience) about patients who may be more unwell than appearances suggest, or who may deteriorate despite showing signs of physiologically compensating quite well. The papers in this issue challenge us to examine how we prioritise, prognosticate and risk-stratify the patients we treat in acute medicine, how we remain cognisant and skilled in treating patients with more unusual acute medical conditions, and how we allocate resources in the NHS.

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Mortality outcomes and emergency department wait times – the paradox in the capacity limited system

Original Articles, Volume 17, Issue 3, Pages 117 – 172 (2018)

Abstract

Background: There is concern that undue ED wait times may result in adverse outcomes.

Methods: We studied 30-day in-hospital mortality (2002-2017) for all medical admissions (106,586 episodes; 54,928 patients) focusing on clinical risk profile

Results: Comparing 2002-09 vs. 2010-17, median ED waits > 6 hours (hr) increased 10h (95% CI: 8,13) to 15h (95% CI: 9,19). 30-day mortality declined 6.2% to 4.9%- (RRR- 20.8%/ NNT- 78). 30-day-mortality by ED wait: - < 4hr 6.6% (95% CI: 6.3%, 6.9%), 4-8hr 4.8% (95% CI: 4.6%, 5.0%), 8-12hr 4.3% (95% CI: 4.1%, 4.5%) or >=12hr 4.2% (95% CI: 3.9%, 4.5%).

Conclusion: Admissions with shorter waits are overrepresented with high clinical acuity. Higher Risk Score patient with extended wait times had worse clinical outcomes.

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Screening instruments for identification of vulnerable older adults at the emergency department: a critical appraisal

Original Articles, Volume 17, Issue 3, Pages 117 – 172 (2018)

Abstract

Background: Early detection of vulnerable older adults at the emergency department (ED) and implementation of targeted interventions to prevent functional decline may lead to better patient outcomes.

Objective: To assess the level of agreement between four frequently used screening instruments: ISAR-HP, VMS, InterRAI ED Screener and APOP.

Methods: Observational prospective cohort study in patients ≥ 70 years attending Dutch ED.

Results: The prevalence of vulnerability ranged from 19% (APOP) to 45% (ISAR-HP). Overall there was a moderate agreement between the screening instruments (Fleiss Kappa of 0.42 (p<0.001)). Conclusion: Depending on the screening instrument used, either only a small percentage or almost as many as half of the presenting patients will be eligible for targeted interventions, leading to large dissimilarities in working processes, resources and costs.

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