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To identify the proportion of high-frequency users of the emergency department (ED) who have chronic pain.
We reviewed medical records of adult patients with ≥ 12 visits to a tertiary-care, academic hospital ED in Canada in 2012-2013. We collected the following demographics: 1) patient age and sex; 2) visit details – number of ED visits, inpatient admissions, length of inpatient admissions, diagnosis, and primary location of pain; 3) current and past substance abuse, mental health and medical conditions. Charts were reviewed independently by two reviewers. ED visits were classified as either “chronic pain” or “not chronic pain” related.
We analyzed 4,646 visits for 247 patients, mean age was 47.2 years (standard deviation = 17.8), and 50.2% were female. This chart review study found 38% of high-frequency users presented with chronic pain to the ED and that women were overrepresented in this group (64.5%). All high-frequency users presented with co-morbidities and/or mental health concerns. High-frequency users with chronic pain had more ED visits than those without and 52.7% were prescribed an opioid. Chronic abdominal pain was the primary concern for 54.8% of high-frequency users presenting with chronic pain.
Chronic pain, specifically chronic abdominal pain, is a significant driver of ED visits among patients who frequently use the ED. Interventions to support high-frequency users with chronic pain that take into account the complexity of patient's physical and mental health needs will likely achieve better clinical outcomes and reduce ED utilization.
One of the many challenges facing emergency departments (EDs) across North America is timely access to emergency radiology services. Academic institutions, which are typically also regional referral centres, frequently require cross-sectional studies to be performed 24 hours a day with expedited final reports to accelerate patient care and ED flow.
The purpose of this study was to determine if the presence of an in-house radiologist, in addition to a radiology resident dedicated to the ED, had a significant impact on report turnaround time.
Preliminary and final report turnaround times, provided by the radiology resident and staff, respectively, for patients undergoing computed tomography or ultrasonography of their abdomen/pelvis in 2008 (before the implementation of emergency radiology in-house staff service) were compared to those performed during the same time frame in 2009 and 2010 (after staffing protocols were changed).
A total of 1,624 reports were reviewed. Overall, there was no statistically significant decrease in the preliminary report turnaround times between 2008 and 2009 (p = 0.1102), 2009 and 2010 (p = 0.6232), or 2008 and 2010 (p = 0.0890), although times consistently decreased from a median of 2.40 hours to 2.08 hours to 2.05 hours (2008 to 2009 to 2010). There was a statistically significant decrease in final report turnaround times between 2008 and 2009 (p < 0.0001), 2009 and 2010 (p < 0.0011), and 2008 and 2010 (p < 0.0001). Median final report times decreased from 5.00 hours to 3.08 hours to 2.75 hours in 2008, 2009, and 2010, respectively. There was also a significant decrease in the time interval between preliminary and final reports between 2008 and 2009 (p < 0.0001) and 2008 and 2010 (p < 0.0001) but no significant change between 2009 and 2010 (p = 0.4144).
Our results indicate that the presence of a dedicated ED radiologist significantly reduces final report turnaround time and thus may positively impact the time to ED patient disposition. Patient care is improved when attending radiologists are immediately available to read complex films, both in terms of health care outcomes and regarding the need for repeat testing. Providing emergency physicians with accurate imaging findings as rapidly as possible facilitates effective and timely management and thus optimizes patient care.
To enhance patient safety, it is important to understand the frequency and causes of adverse events (defined as unintended injuries related to health care management). We performed this study to describe the types and risk of adverse events in high-acuity areas of the emergency department (ED).
This prospective cohort study examined the outcomes of consecutive patients who received treatment at 2 tertiary care EDs. For discharged patients, we conducted a structured telephone interview 14 days after their initial visit; for admitted patients, we reviewed the inpatient charts. Three emergency physicians independently adjudicated flagged outcomes (e.g., death, return visits to the ED) to determine whether an adverse event had occurred.
We enrolled 503 patients; one-half (n = 254) were female and the median age was 57 (range 18–98) years. The majority of patients (n = 369, 73.3%) were discharged home. The most common presenting complaints were chest pain, generalized weakness and abdominal pain. Of the 107 patients with flagged outcomes, 43 (8.5%, 95% confidence interval 8.1%–8.9%) were considered to have had an adverse event through our peer review process, and over half of these (24, 55.8%) were considered preventable. The most common types of adverse events were as follows: management issues (n = 18, 41.9%), procedural complications (n = 13, 30.2%) and diagnostic issues (n = 10, 23.3%). The clinical consequences of these adverse events ranged from minor (urinary tract infection) to serious (delayed diagnosis of aortic dissection).
We detected a higher proportion of preventable adverse events compared with previous inpatient studies and suggest confirmation of these results is warranted among a wider selection of EDs.
Information gaps, defined as previously collected information that is not available to the treating physician, have implications for patient safety and system efficiency. For patients transferred to an emergency department (ED) from a nursing home or seniors residence, we determined the frequency and type of clinically important information gaps and the impact of a regional transfer form.
During a 6-month period, we studied consecutive patients who were identified through the National Ambulatory Care Reporting System database. Patients were over 60 years of age, lived in a nursing home or seniors residence, and arrived by ambulance to a tertiary care ED. We abstracted data from original transfer and ED records using a structured data collection tool. We measured the frequency of prespecified information gaps, which we defined as the failure to communicate information usually required by an emergency physician (EP). We also determined the use of the standardized patient transfer form that is used in Ontario and its impact on the rate of information gaps that occur in our community.
We studied 457 transfers for 384 patients. Baseline dementia was present in 34.1% of patients. Important information gaps occurred in 85.5% (95% confidence interval [CI] 82.0%–88.0%) of cases. Specific information gaps along with their relative frequency included the following: the reason for transfer (12.9%), the baseline cognitive function and communication ability (36.5%), vital signs (37.6%), advanced directives (46.4%), medication (20.4%), activities of daily living (53.0%) and mobility (47.7%). A standardized transfer form was used in 42.7% of transfers. When the form was used, information gaps were present in 74.9% of transfers compared with 93.5% of the transfers when the form was not used (p < 0.001). Descriptors of the patient's chief complaint were frequently absent (81.0% for head injury [any information about loss of consciousness], 42.4% for abdominal pain and 47.1% for chest pain [any information on location, severity and duration]).
Information gaps occur commonly when elderly patients are transferred from a nursing home or seniors residence to the ED. A standardized transfer form was associated with a limited reduction in the prevalence of information gaps; even when the form was used, a large percentage of the transfers were missing information. We also determined that the lack of descriptive detail regarding the presenting problem was common. We believe this represents a previously unidentified information gap in the literature about nursing home transfers. Future research should focus on the clinical impact of information gaps. System improvements should focus on educational and regulatory interventions, as well as adjustments to the transfer form.
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