Intervention to reduce C-reactive protein determination requests for acute infections at an emergency department

Introduction C-reactive protein (CRP) levels rise during inflammatory processes and have been ordered for rheumatic disease follow-up since the 1950s. The number of tests ordered in the emergency setting has increased, but without evident improvement in medical care quality. Objective To determine the pattern of CRP determinations in the emergency department (ED) of a university hospital in Sao Paulo, Brazil, and to evaluate the effect of an intervention with staff and students about the best use of the test in the ED. Methods Data regarding CRP testing requests, related diagnoses and the number of monthly consultations in the hospital ED were analysed before and after the intervention. Because of an increase in CRP measurement requests from 2007 to 2009, the author started discussing the role of CRP determinations in the medical decision-making process in early 2010. Staff and faculty members openly discussed the pattern of requests in the hospital and related current medical literature. During 2010, the medical staff worked as multipliers to change the behaviour of new students and residents. The results of the first 4 months after the intervention were presented at another general meeting in July 2010. Results From 2007 to 2009, there were 11 786 CRP measurement requests with a clear exponential trend. After the intervention, during the calendar year 2010, there was a 48% reduction in adjusted annual CRP requests. Pneumonia, fever and urinary tract infections were the most common reasons for CRP requests. Discussion Inexpensive, well-directed, interactive educational interventions may affect professional behaviour and curb rates of laboratory tests.

Alternative management of diabetic ketoacidosis in a Brazilian pediatric emergency department

DKA is a severe metabolic derangement characterized by dehydration, loss of electrolytes, hyperglycemia, hyperketonemia, acidosis and progressive loss of consciousness that results from severe insulin deficiency combined with the effects of increased levels of counterregulatory hormones (catecholamines, glucagon, cortisol, growth hormone). The biochemical criteria for diagnosis are: blood glucose > 200 mg/dl, venous pH <7.3 or bicarbonate <15 mEq/L, ketonemia >3 mmol/L and presence of ketonuria. A patient with DKA must be managed in an emergency ward by an experienced staff or in an intensive care unit (ICU), in order to provide an intensive monitoring of the vital and neurological signs, and of the patient's clinical and biochemical response to treatment. DKA treatment guidelines include: restoration of circulating volume and electrolyte replacement; correction of insulin deficiency aiming at the resolution of metabolic acidosis and ketosis; reduction of risk of cerebral edema; avoidance of other complications of therapy (hypoglycemia, hypokalemia, hyperkalemia, hyperchloremic acidosis); identification and treatment of precipitating events. In Brazil, there are few pediatric ICU beds in public hospitals, so an alternative protocol was designed to abbreviate the time on intravenous infusion lines in order to facilitate DKA management in general emergency wards. The main differences between this protocol and the international guidelines are: intravenous fluid will be stopped when oral fluids are well tolerated and total deficit will be replaced orally; if potassium analysis still indicate need for replacement, it will be given orally; subcutaneous rapid-acting insulin analog is administered at 0.15 U/kg dose every 2-3 hours until resolution of metabolic acidosis; approximately 12 hours after treatment initiation, intermediate-acting (NPH) insulin is initiated at the dose of 0.6-1 U/kg/day, and it will be lowered to 0.4-0.7 U/kg/day at discharge from hospital.

Referral practice among Swiss and non-Swiss walk-in patients in an urban surgical emergency department

To assess the relationship between nationality, gender and age and use of health services among patients visiting an urban university hospital emergency department (ED).

Risk assessment in the first fifteen minutes: a prospective cohort study of a simple physiological scoring system in the emergency department

Introduction The survival of patients admitted to an emergency department is determined by the severity of acute illness and the quality of care provided. The high number and the wide spectrum of severity of illness of admitted patients make an immediate assessment of all patients unrealistic. The aim of this study is to evaluate a scoring system based on readily available physiological parameters immediately after admission to an emergency department (ED) for the purpose of identification of at-risk patients. Methods This prospective observational cohort study includes 4,388 consecutive adult patients admitted via the ED of a 960-bed tertiary referral hospital over a period of six months. Occurrence of each of seven potential vital sign abnormalities (threat to airway, abnormal respiratory rate, oxygen saturation, systolic blood pressure, heart rate, low Glasgow Coma Scale and seizures) was collected and added up to generate the vital sign score (VSS). VSSinitial was defined as the VSS in the first 15 minutes after admission, VSSmax as the maximum VSS throughout the stay in ED. Occurrence of single vital sign abnormalities in the first 15 minutes and VSSinitial and VSSmax were evaluated as potential predictors of hospital mortality. Results Logistic regression analysis identified all evaluated single vital sign abnormalities except seizures and abnormal respiratory rate to be independent predictors of hospital mortality. Increasing VSSinitial and VSSmax were significantly correlated to hospital mortality (odds ratio (OR) 2.80, 95% confidence interval (CI) 2.50 to 3.14, P < 0.0001 for VSSinitial; OR 2.36, 95% CI 2.15 to 2.60, P < 0.0001 for VSSmax). The predictive power of VSS was highest if collected in the first 15 minutes after ED admission (log rank Chi-square 468.1, P < 0.0001 for VSSinitial;,log rank Chi square 361.5, P < 0.0001 for VSSmax). Conclusions Vital sign abnormalities and VSS collected in the first minutes after ED admission can identify patients at risk of an unfavourable outcome.

Optimising care in a Swiss University Emergency Department by implementing a multicentre trauma register (TARN): report on evaluation, costs and benefits of trauma registries

Diagnostic and therapeutic approaches to trauma patients are, depending on experience, equipment and different therapeutic doctrines, subject to wide variations. The ability to compare trauma centres using a standardised trauma register helps to reveal unresolved systemic issues and simplifies the quality management in an Emergency Department (ED).

Ignoring non-specific abdominal pain in emergency department patients may be related to decreased quality of life. A follow up of an underestimated problem

Patients suffering from chronic pain have a high prevalence of depression, resulting in a significant impact on overall quality of life. Our aim was to investigate how long term acute non-specific abdominal pain (NSAP) affected overall physical and mental well-being in patients admitted to our emergency department (ED).

Temporal factors in violence related injuries--An 11 year trend analysis of violence-related injuries from a Swiss Emergency Department

Injury from interpersonal violence is a major social and medical problem in the industrialized world. Little is known about the trends in prevalence and injury pattern or about the demographic characteristics of the patients involved.

Sexual activity-related emergency department admissions: eleven years of experience at a Swiss university hospital

PRINCIPALS: Most people enjoy sexual intercourse without complications, but a significant, if small, number need to seek emergency medical help for related health problems. The true incidence of these problems is not known. We therefore assessed all admissions to our emergency department (ED) in direct relation to sexual intercourse. METHODS: All data were collected prospectively and entered into the ED's centralised electronic patient record database (Qualicare, Switzerland) and retrospectively analysed. The database was scanned for the standardised key words: 'sexual intercourse' (German 'Geschlechtsverkehr') or 'coitus' (German 'Koitus'). RESULTS: A total of 445 patients were available for further evaluation; 308 (69.0%) were male, 137 (31.0%) were female. The median age was 32 years (range 16-71) for male subjects and 30 years (range 16-70) for female subjects. Two men had cardiovascular emergencies. 46 (10.3%) of our patients suffered from trauma. Neurological emergencies occurred in 55 (12.4%) patients: the most frequent were headaches in 27 (49.0%), followed by subarachnoid haemorrhage (12, 22.0%) and transient global amnesia (11, 20.0%). 154 (97.0%) of the patients presenting with presumed infection actually had infections of the urogenital tract. The most common infection was urethritis (64, 41.0%), followed by cystitis (21, 13.0%) and epididymitis (19, 12.0%). A sexually transmitted disease (STD) was diagnosed in 43 (16.0%) of all patients presenting with a presumed infection. 118 (43.0%) of the patients with a possible infection requested testing for an STD because of unsafe sexual activity without underlying symptoms. CONCLUSIONS: Sexual activity is mechanically dangerous, potentially infectious and stressful for the cardiovascular system. Because information on ED presentation related to sexual intercourse is scarce, more efforts should be undertaken to document all such complications to improve treatment and preventative strategies.

Geriatric urolithiasis in the emergency department: risk factors for hospitalisation and emergency management patterns of acute urolithiasis

Urolithiasis is one of the most common conditions seen in emergency departments (ED) worldwide, with an increasing frequency in geriatric patients (>65 years). Given the high costs of emergency medical urolithiasis treatment, the need to optimise management is obvious. We aimed to determine risk factors for hospitalisation and evaluate diagnostic and emergency treatment patterns by ED physicians in geriatric urolithiasis patients to assist in optimising treatment.

Do we need new personalized emergency telehealth solutions? A survey of 100 emergency department patients and a first report of the swiss limmex emergency wristwatch: an original study

Development of new personal mobile and wireless devices for healthcare has become essential due to our aging population characterized by constant rise in chronic diseases that consequently require a complex treatment and close monitoring. Personal telehealth devices allow patients to adequately receive their appropriate treatment, followup with their doctors, and report any emergency without the need of the presence of any caregivers with them thus increasing their quality of life in a cost-effective fashion. This paper includes a brief overview of personal telehealth systems, a survey of 100 consecutive ED patients aged >65 years, and introduces "Limmex" a new GSM based technology packaged in a wristwatch. Limmex can by a push of a button initiate multiple emergency call and establish mobile communication between the patient and a preselected person, institution, or a search and rescue service. To the best of our knowledge, Limmex is the first of its kind worldwide.

Acute health problems in African refugees: ten years' experience in a Swiss emergency department

Over the last two decades, the total number of applications from Africans for asylum in the countries of the European Union has increased from 578,000 to more than 2.9 million. About 20 % (7,196/36,100) of the asylum seekers in Switzerland originate from Africa. The disease profile of African asylum seekers is remarkably different from that of the native population in the country of application. We have therefore conducted an analysis of African asylum seekers presenting themselves to our emergency department.

Why do walk-in patients prefer a busy urban emergency department during office hours? A pilot survey of 200 consecutive patients from Switzerland

In Switzerland, more and more patients go directly to the emergency department, bypassing general practitioners. However, a mixture of non-urgent walk-in patients and acute emergencies in the same emergency department can inevitably make it more difficult to provide genuine emergencies with rapid treatment, leading to deterioration in the quality of emergency services, and tending to increase on-floor mortality and morbidity, together with higher overall costs.

Emergency department admissions to a prison hospital: a retrospective cohort study from Switzerland

There are more than 10 million prison inmates throughout the world and this number is increasing continuously. Prisoners are a particularly vulnerable minority group that has special healthcare needs and demands on healthcare services and providers. The aim of this study was to give an overview of prisoners' healthcare problems leading to emergency department admission, in order to make recommendations to help to optimise treatment of this target group.