OBJECTIVEThe objective of this study was to describe the type of interconsultations carried out in the Emergency Department (ED) to hospital specialists and analyze their pattern over time.
...METHODSThe study was carried out during the period from 2006 to 2012. It was carried out at EDs attending to all types of interconsultations except pediatrics and obstetrics–gynecology. There were no changes in physical structure, number of personnel, or organization during the study period. The main measurements taken were as followsmonthly ED census, number of interconsultations and specialties consulted, main reason for presentation at the ED during the first (2006) and last year (2012), and, for specialties demonstrating substantial quantitative changes, main reasons for the interconsultation from the ED at the beginning (2006) and the end (2012) of the study. Linear regression analysis was carried out for the relationship between time and number of interconsultations.
RESULTSA total of 628 256 care interventions were carried out, with 128 008 interconsultations (20.4%). Orthopedic surgery and traumatology, psychiatry, and general and digestive surgery were the departments most frequently consulted (54.5% of the interconsultations). Consultations significantly reduced over time (R=0.29; P<0.001) but the percentage of interconsultations (related to ED census) remained unchanged (R=0.01; P=0.49). The behavior related to specialties was heterogeneousconsultations to general and digestive surgery, hematology and hemostasis, and urology specialists decreased, whereas to thoracic surgery, angiology and vascular surgery, neurology, nephrology, neurosurgery, psychiatry, orthopedic surgery and traumatology, and critical care medicine specialists increased. Some of the reasons for specialist consultation also significantly changed over time.
CONCLUSIONThe study of interconsultations allows us to identify areas of lesser autonomy of emergency physicians. Changes in the pattern of these interconsultations over time may reflect both learning processes and changes in the healthcare circuits in the ED.
OBJECTIVEIdeally, discharges from the emergency department (ED) should be as safe as discharges after hospitalization. We have ascertained this hypothesis in patients with acute heart failure (AHF) ...directly discharged from EDs, analyzing their short-term outcome.
PATIENTS AND METHODSA prospective, cohort, multicentric, noninterventional study of consecutive patients with AHF who visited in 20 Spanish EDs was conducted. Patients were grouped according to whether discharge had been from the ED (maximum 24-h ED stay) or after hospitalization. We collected baseline and current AHF episode data. Short-term outcome (30-day mortality and revisit rates) of both groups was compared by univariate crude analysis and stratified by predicted risk of 30-day mortality as well as by logistic regression adjustment for the differences found between ED and hospital groups.
RESULTSA total of 1669 patients were analysed546 (32.7%) discharged from ED and 1123 (67.3%) after hospitalisation; 75 (4.5%) died and 420 (25.2%) revisited the ED. Crude 30-day mortality rates of ED and hospital discharges were 2.9 and 5.3%, respectively (odds ratio for ED discharge0.56; 95% confidence interval0.33–0.96), whereas 30-day revisit rates were 23.8 and 26.4% (odds ratio0.96; 95% confidence interval0.77–1.19). Stratified analysis according to predicted risk of mortality and multivariate analysis adjusted for the discrepancy in baseline and current AHF episode characteristics in ED and hospital discharges confirmed the lack of short-term outcome differences between the two groups.
CONCLUSIONDirect ED discharge of patients with AHF after treatment and a short observation period is as safe as discharge after a longer time of inpatient hospitalization in general wards.
Abstract Introduction HIV-1–infected patients have higher incidence of community-acquired pneumonia (CAP) and risk of complications. Bacteremia has been associated with a higher risk of complications ...in such patients. We investigated factors associated with bacteremia in HIV-1–infected patients with CAP presenting at the emergency department. Methods We included HIV-1–infected patients with CAP for 3 years (March 2005-February 2008). Only patients in whom blood cultures were performed were finally included. Clinical data (age; sex; CD4+ count; serum HIV viral load; previous or current intravenous drug use and antiretroviral treatment; systolic blood pressure; and cardiac and respiratory rates), analytical data (leukocyte count, arterial oxygen content, C-reactive protein value, and urgent Streptococcus pneumoniae and Legionella spp antigen urine detection), and APACHE-II (Acute Physiology and Chronic Health Evaluation) score were compiled. The need for intensive care unit admission, mechanical ventilation, mortality, and for patients finally discharged, duration of admission were retrospectively obtained from the clinical history. A multivariate analysis using logistic regression was performed to find independent predictors of bacteremia. Results We diagnosed 129 HIV-1–infected patients with CAP. Blood cultures were performed in 118 cases (91%). Bacteremia was present in 28 (24%). Independent predictors of bacteremia were the detection of S pneumoniae antigen in urine (odds ratio, 9.0; 95% confidence interval, 1.9-42.0) and the absence of current antiretroviral treatment (odds ratio, 7.1; 95% confidence interval, 1.4-33.3). In-hospital mortality was higher in patients with bacteremia (15% vs 0%). Conclusion HIV-1–infected patients with CAP who are not on current antiretroviral therapy and have positive S pneumoniae antigenuria are at increased risk of having bacteremia. Bacteremic patients have a poor outcome.
The aim of the study was to provide an overview on the current evidence on the method of cardioversion in patients presenting with recent-onset atrial fibrillation at the emergency department. ISI ...Web of Science and MEDLINE were explored for articles published between January 2000 and December 2011 in English or Spanish for the keywords ‘acute’, ‘recent-onset’ or ‘paroxysmal’ AND ‘atrial fibrillation’ AND ‘treatment’ AND ‘emergency’. Original published articles were included if they enrolled patients with atrial fibrillation episodes of short duration (<48 h) and if they specifically addressed time to conversion, length of stay in the emergency department, safety, and/or relapses. Data extracted included the number of patients included, agent(s) studied, type and level of evidence of the article, rate of sinus rhythm conversion, time to conversion, discharge rate, length of stay, adverse events, embolic complications, and relapses. Fourteen papers were included in the review, eight of them prospective and randomized. Cardioversion in the emergency department had an overall high rate of conversion and few side-effects and/or embolic complications. Direct current cardioversion was the most effective therapeutic strategy in terms of sinus rhythm restoration, rate of discharge, length of stay, and safety. Class I drugs were also effective in a selected population. Amiodarone had a longer conversion time, with a similar rate of acute adverse events. Cardioversion in the emergency department is feasible and safe. Direct current cardioversion is the most effective therapeutic strategy.
Registries are useful to address questions that are difficult to answer in clinical trials. The objective of this study was to describe and compare two heart failure (HF) cohorts from two Spanish HF ...registries.
We compared the RICA and EAHFE registries, both of which are prospective multicentre cohort studies including patients with decompensated HF consecutively admitted to internal medicine wards (RICA) or attending the emergency department (EAHFE). From the latter registry we only included patients who were admitted to internal medicine wards.
A total of 5137 patients admitted to internal medicine wards were analysed (RICA: 3287 patients; EAHFE: 1850 patients). Both registries included elderly patients (RICA: mean (SD) age 79 (9) years; EAHFE: mean (SD) age 81 (9) years), with a slight predominance of female gender (52% and 58%, respectively, in the RICA and EAHFE registries) and with a high proportion of patients with preserved ejection fraction (58% and 62%, respectively). Some differences in comorbidities were noted, with diabetes mellitus, dyslipidaemia, chronic renal failure and atrial fibrillation being more frequent in the RICA registry while cognitive and functional impairment predominated in the EAHFE registry. The 30-day mortality after discharge was 3.4% in the RICA registry and 4.8% in the EAHFE registry (p<0.05) and the 30-day readmission rate was 7.5% in the RICA registry (readmission to hospital) and 24.0% in the EAHFE registry (readmission to emergency department) (p<0.001).
We found differences in the clinical characteristics of patients admitted to Spanish internal medicine wards for decompensated HF depending on inclusion in either the RICA or EAHFE registry.
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