The growing evidence on high-intensity hospital care

Despite wide variation in the amount we spend on care, patients’ outcomes are often the same. So clearly, we should just do less. Indeed, given the growing problems of overdiagnosis and overtreatment, less is more | Emergency Medicine Journal

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As emergency physicians, we deliver a fair amount of high-intensity care. Yes, good care can sometimes be as simple as an astute diagnosis or a kind word. But it can also involve cross-sectional imaging, invasive procedures and hospital admission. At the right time and for the right patient, we believe, this care can be the difference between life and death.

And yet this care is coming under increasing scrutiny from payers and policy makers.

While emergency care accounts for a small fraction of direct health system costs, the decision to admit a patient to the hospital is an expensive one indeed. There are many good reasons to send patients home—reducing crowding, avoiding hospital-acquired infections and more. But the driving force behind efforts to reduce admissions today is simple: to reduce costs. As a result, physicians everywhere face increasing pressure to discharge patients to home.

This poses a particular dilemma for emergency physicians. On one hand, the rest of the world seems very certain we should be sending more patients home. On the other, our experience suggests that failures of risk stratification and mistriage to home can have terrible consequences.

Full reference: Obermeyer, Z. (2017) Is less more, or is it less? The growing evidence on high-intensity hospital care. Emergency Medicine Journal. Published Online First: 18 August 2017. 

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Risk factors for admission at three urban emergency departments in England

An investigation into factors associated with unscheduled admission following presentation to emergency departments (EDs) at three hospitals in England | BMJ Open

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Design and setting: Cross-sectional analysis of attendance data for patients from three urban EDs in England: a large teaching hospital and major trauma centre (site 1) and two district general hospitals (sites 2 and 3). Variables included patient age, gender, ethnicity, deprivation score, arrival date and time, arrival by ambulance or otherwise, a variety of ED workload measures, inpatient bed occupancy rates and admission outcome. Coding inconsistencies in routine ED data used for this study meant that diagnosis could not be included.

Results: Outcome data were available for 19 721 attendances (>99%), of whom 6263 (32%) were admitted to hospital. Site 1 was set as the baseline site for analysis of admission risk. Risk of admission was significantly greater at sites 2 and 3 (adjusted OR (AOR) relative to site 1 for site 2 was 1.89, 95% CI 1.74 to 2.05, p<0.001) and for patients of black or black British ethnicity (AOR 1.29, 1.16 to 1.44, p<0.001). Deprivation was strongly associated with admission. Analysis of departmental and hospital-wide workload pressures gave conflicting results, but proximity to the “4-hour target” (a rule that limits patient stays in EDs to 4 hours in the National Health Service in England) emerged as a strong driver for admission in this analysis (AOR 3.61, 95% CI 3.30 to 3.95, p<0.001).

Conclusion: This study found statistically significant variations in odds of admission between hospital sites when adjusting for various patient demographic and presentation factors, suggesting important variations in ED-level and clinician-level behaviour relating to admission decisions. The 4-hour target is a strong driver for emergency admission.

Full reference: Ismail, S.A. et al. (2017) Risk factors for admission at three urban emergency departments in England: a cross-sectional analysis of attendances over 1 month. BMJ Open. 7:e011547

The role of nurses’ clinical impression in the first assessment of children at the emergency department

This study explores the diagnostic value and determinants of nurses’ clinical impression for the recognition of children with a serious illness on presentation to the emergency department (ED) | Archives of Disease in Childhood

Main outcome measures: Diagnostic accuracy of nurses’ clinical impression for the prediction of serious illness, defined by intensive care unit (ICU) and hospital admission. Determinants of nurses’ impression that a child appeared ill.

Results: Nurses considered a total of 1279 (20.0%) children appearing ill. Sensitivity of nurses’ clinical impression for the recognition of patients requiring ICU admission was 0.70 (95% CI 0.62 to 0.76) and specificity was 0.81 (95% CI 0.80 to 0.82). Sensitivity for hospital admission was 0.48 (95% CI 0.45 to 0.51) and specificity was 0.88 (95% CI 0.87 to 0.88). When adjusted for age, gender, triage urgency and abnormal vital signs, nurses’ impression remained significantly associated with ICU (OR 4.54; 95% CI 3.09 to 6.66) and hospital admission (OR 4.00; 95% CI 3.40 to 4.69). Ill appearance was positively associated with triage urgency, fever and abnormal vital signs and negatively with self-referral and presentation outside of office hours.

Conclusion: The overall clinical impression of experienced nurses at the ED is on its own, not an accurate predictor of serious illness in children, but provides additional information above some well-established and objective predictors of illness severity.

Full reference: Zachariasse, J.M. et al. (2017)  The role of nurses’ clinical impression in the first assessment of children at the emergency department. Archives of Disease in Childhood. Published Online First: 10 June 2017

Environmental factors and emergency hospital admissions due to Alzheimer’s disease

Culqui, D.R. et al. (2017) Science of The Total Environment. 592(15) pp. 451–457

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Highlights:

  • Alzheimer’s disease (AD) is the most common cause of dementia among older adults
  • Air pollutants may be risk factors regarding the decompensation of AD
  • PM2.5 concentrations are associated with the development and the exacerbation of AD
  • Heat waves can exacerbate Alzheimer’s hospital admissions
  • More epidemiologic studies will be needed to confirm the relation between AD and environmental factors

Read the full abstract here

An ED paradox: patients who arrive by ambulance and then leave without consulting an ED provider

Doupe, M.B. et al. (2017) Emergency Medicine Journal. 34:151-156.

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Background: Scientists have called for strategies to identify ED patients with unmet needs. We identify the unique profile of ED patients who arrive by ambulance and subsequently leave without consulting a provider (ie, a paradoxical visit, PV).

Conclusions: PV patients have needs that do not align with the acute model of ED care. These patients may benefit from a more integrated care approach likely involving allied health professionals.

Read the full article here

What is the relationship between age and deprivation in influencing emergency hospital admissions?

Pereira Gray, D. et al. (2017) BMJ Open. 7:e014045

Objectives: To clarify the relationship between social deprivation and age as two factors associated with emergency admissions to hospital.

Conclusions: Risk curves for all social groups have similar shapes, implying a common biological pattern for ageing in any social group. Over age 65, the biological effects of ageing outweigh the social effects of deprivation. Our model enables CCGs to anticipate and plan for emergency admissions to hospital. These findings provide a new logic for allocating resources to different populations.

Read the full article here