Consumption of diagnostic procedures and other cardiology care in chest pain patients after presentation at the emergency department

Objective

The HEART score serves risk stratification of chest pain patients at the emergency department (ED). Quicker and more solid decisions may be taken in these patients with application of this score. An analysis of medical consumption of 122 acute chest pain patients admitted before the introduction of this score may be indicative of possible savings.

Methods

Numbers of cardiology investigations and clinical admission days were counted. Charged cost of medicine was divided into three categories: ED, in-hospital, and outpatient clinic.

Results

The total cost of care was € 469,631, with an average of € 3849 per patient. Seventy-five percent of this cost was due to hospitalisation under the initial working diagnosis of acute coronary syndrome (ACS). This diagnosis was confirmed in only 29/122 (24 %) of the patients. The low-risk group (41 patients with HEART scores 0–3) included one patient with a previously scheduled CABG. In the remaining 40 patients, hospitalisation occurred in 12/40 (30 %) patients and 30/40 (75 %) patients visited the outpatient clinic. The total cost of medical care after presentation of these 40 patients was € 37,641; there were no cases where a new diagnosis of coronary artery disease was made. When medical care in this subgroup is declared redundant, major savings on national medical care budgets could be made.

Conclusion

If the HEART score were to be routinely applied, diagnostic pathways could be shortened and costs reduced, in particular in low-risk patients.     

Characteristics of chest pain in COVID-19 patients in the emergency department

IntroductionPatients with coronavirus disease 2019 (COVID-19) can present with chest pain. However, the characteristics of this chest pain are unknown. We performed a single-centre observational study to review and summarise chest pain characteristics in COVID-19 patients at first presentation to the emergency department (ED).MethodsWe collected data on characteristics of ‘chest pain’ reported by COVID-19 patients who attended the ED of Bernhoven Hospital, the Netherlands from 4 through 30 March 2020.ResultsWe included 497 COVID-19 patients, of whom 83 (17%) reported chest pain upon presentation to the ED. Chest pain characteristics were: present since disease onset (88%), retrosternal location (43%), experienced as compressing/pressure pain (61%), no radiation (61%) and linked to heavy coughing (39%). Patients who reported chest pain were younger than those without chest pain (61 vs 73 years; p < 0.001). Patients with syncope were older (75 vs 72 years; p = 0.017), had a shorter duration of symptoms (5 vs 7 days; p < 0.001) and reported fewer respiratory complaints (68% vs 90%; p < 0.001) than those without syncope. Patients with new-onset atrial arrhythmias presented with a shorter duration of symptoms (5 vs 7 days; p = 0.013), experienced fewer respiratory complaints (72% vs 89%; p = 0.012) and more frequently had a history of cardiovascular disease (79% vs 50%; p = 0.003) than patients who presented without arrythmias.ConclusionChest pain and other cardiac symptoms were frequently observed in COVID-19 patients. Treating physicians should be aware that chest pain, arrhythmias and syncope can be presenting symptoms of COVID-19.Supplementary InformationThe online version of this article (10.1007/s12471-022-01730-7) contains supplementary material, which is available to authorized users.     

Use of Implantable Loop Recorders to Unravel the Cause of Unexplained Syncope

Syncope is a symptom of many underlying disease states, which range from the relatively benign to the life threatening. There are numerous investigations done for patients with recurrent unexplained syncope which may have very low yield when it comes to making a definitive diagnosis. Recently, the implantable loop recorder (ILR) for continuous monitoring of the cardiac rhythm has been launched in India. This review will briefly discuss these current availabel strategies and focus on the usefulness of an ILR in the definitive diagnosis and treatment of patients with a recurrent unexplained syncope.     

Violence in the emergency department: a survey of health care workers

BACKGROUND: Violence in the workplace is an ill-defined and underreported concern for health care workers. The objectives of this study were to examine perceived levels of violence in the emergency department, to obtain health care workers'' definitions of violence, to determine the effect of violence on health care workers and to determine coping mechanisms and potential preventive strategies. METHODS: A retrospective written survey of all 163 emergency department employees working in 1996 at an urban inner-city tertiary care centre in Vancouver. The survey elicited demographic information, personal definition of violence, severity of violence, degree of stress as a result of violence and estimate of the number of encounters with violence in the workplace in 1996. The authors examined the effects of violence on job performance and job satisfaction, and reviewed coping and potential preventive strategies. RESULTS: Of the 163 staff, 106 (65%) completed the survey. A total of 68% (70/103) reported an increased frequency of violence over time, and 60% (64/106) reported an increased severity. Most of the respondents felt that violence included witnessing verbal abuse (76%) and witnessing physical threats or assaults (86%). Sixty respondents (57%) were physically assaulted in 1996. Overall, 51 respondents (48%) reported impaired job performance for the rest of the shift or the rest of the week after an incident of violence. Seventy-seven respondents (73%) were afraid of patients as a result of violence, almost half (49%) hid their identities from patients, and 78 (74%) had reduced job satisfaction. Over one-fourth of the respondents (27/101) took days off because of violence. Of the 18 respondents no longer working in the emergency department, 12 (67%) reported that they had left the job at least partly owing to violence. Twenty-four-hour security and a workshop on violence prevention strategies were felt to be the most useful potential interventions. Physical exercise, sleep and the company of family and friends were the most frequent coping strategies. INTERPRETATION: Violence in the emergency department is frequent and has a substantial effect on staff well-being and job satisfaction.     

Wireless vitals—Proof of concept for wireless patient monitoring in an emergency department setting

Vital sign assessment is a common task in emergency medicine, but resources for continuous monitoring are restricted, data is often recorded manually, and entangled wires cause frustration. Therefore, we designed a small, wireless photoplethysmographic device capable of continuously assessing pulse, respiratory frequency and oxygen saturation on the sternum and tested the performance and feasibility in an emergency department setting. Fifty (56.3 ± 20.2 years), consenting emergency patients (29 male) were recruited. Heart rate, respiratory rate and oxygen saturation were recorded simultaneously using the device and standard monitoring equipment. Data was compared using Bland‐Altman plotting (heart rate, respiratory rate) and mean difference (oxygen saturation). The bias for heart‐ and respiratory rate was 0.4 (limits of agreements ?11.3, 12.2 and ?6.1, 7.0). Mean difference for oxygen saturation was ?0.21 ± 2.35%. This may be the first wireless device to use photoplethysmography on the sternum for vital sign assessment. We noted good agreement with standard monitors, but lack of standardization in data processing between monitoring systems may limit the generalizability of these findings. Although further improvements are needed, the feasibility of this approach provides proof of concept for a new paradigm of large scale, wireless patient monitoring.      

急诊重症监护病房耐甲氧西林金黄色葡萄球菌定植与感染调查分析

目的 调查急诊重症监护病房( EICU)耐甲氧西林金黄色葡萄球菌(MRSA)定植与感染状况,为实时控制医院感染暴发流行提供参考依据.方法 对临床资料进行分析,环境卫生学监测采样方法参照卫生部《消毒技术规范》,制定干预措施.结果 6例MRSA定植和感染病例平均年龄62.5岁,原发性基础疾病重;41份环境标本和16份来自接触阳性患者的医务人员手部标本中均分离到病原菌,阳性率分别为24.39％和18.75％.结论MRSA定植是造成医院感染的源头,将仅出现定植的病例并入感染病例进行统计分析,可实时监控院内医院感染的暴发.     

Insulin-induced hypoglycaemia in an accident and emergency department: the tip of an iceberg?

In one year a prospective survey in a large accident and emergency department identified 204 admissions of adults with severe hypoglycaemia, 200 in insulin-treated patients. Ninety-six had one admission while 34 others were admitted on 104 occasions. Of the 130 patients, 111 attended diabetic clinics in Nottingham, forming 9% of a known clinic population of 1229 on insulin treatment. Since many other episodes of hypoglycaemia were presumably treated outside hospital, 9% a year is a minimum estimate of the incidence of severe hypoglycaemia in our area. The mean insulin dose was 1.2 units/kilogram/day for those admitted twice or more and 0.9 U/kg/day for those admitted once; these doses were significantly higher than those of an age-matched clinic population. A year after the latest admission with hypoglycaemia, the mean insulin dose in the group with two or more admissions had fallen to 0.8 U/kg/day, suggesting that over-treatment had been an important causal factor. A similarly high incidence has been reported in other studies, and we believe that it is due mainly to the inadequacy of conventional subcutaneous insulin treatment.     

Acute asthma: emergency department management and prospective evaluation of outcome.

To determine the current management of acute asthma in the emergency department and to evaluate outcome we reviewed the charts of 99 patients aged 15 to 55 years who presented to the emergency department of a tertiary referral, university-affiliated hospital and were subsequently discharged with a diagnosis of acute asthma. Outcome was evaluated prospectively, with a structured questionnaire, by telephone. During the visit pulsus paradoxus was documented in four patients. Spirometry was done in 63 patients; postbronchodilator values ranged from 0.9 to 4.1 L. A total of 92 patients received inhaled bronchodilator therapy, most by wet nebulization. Sixteen patients received anticholinergic agents and three received theophylline. Ingested corticosteroids were given to 27 patients. Of the 71 patients contacted, a mean of 12 days after the visit, 26 (37%) had sought further medical attention, 19 at the emergency department; 9 had required admission. Forty-six patients reported that their condition had improved, but over 60% continued to have cough, sputum production, nocturnal waking and early-morning chest tightness. The results indicate that asthma continues to be undertreated in the emergency department and highlight the importance of routine spirometry in all patients and the need for systemic corticosteroid therapy.     

NBPF1 independently determine the risk stratification and prognosis of patients with neuroblastoma

Neuroblastoma is the most frequent extracranial malignant solid tumor in children, and the 5 year OS of high risk neuroblastoma patients was less than 15%. This study aimed to identify biomarkers for risk stratification and prognosis prediction in neuroblastoma.149 low risk samples, 108 intermediate risk samples and 619 high risk samples were included in our study, and NBPF1 gene was found to be significantly correlated with risk levels and OS. Significant negative correlations between NBPF1 and the expression of MYCN and AKT1S1, and positive correlations between NBPF1 and KIF1B expression were found, but only NBPF1 was an independent biomarker based on the construct of PPI for MYCN, NBPF1, KIF1B and AKT1S1 by STRING enrichment.     

急诊内科医生和外科医生对急性颅脑损伤患者院前急救效果探讨

目的探讨急诊内科医生和外科医生对颅脑损伤患者的院前救治效果。方法将我院120例急性颅脑损伤患者随机分为内科救治组和外科救治组各60例,比较两组的救治效果。结果两组患者的院前急救时间、急诊科救治时间、救治成功率比较,差异无统计学意义(P0.05)。结论经过专业培训的急诊内科医师能胜任急性颅脑损伤患者的院前急救和急诊救治工作。     

Triage: a working solution to overcrowding in the emergency department

Recently, emergency departments across the continent have become crowded with patients requiring non-urgent care. To alleviate this situation at The Hospital for Sick Children in Toronto, receptionists in the emergency department direct patients requiring urgent care to the emergency room and those requiring non-urgent care to a screening clinic (triage). During a two-month period, 13,551 patients visited the emergency department. The triage receptionist sent 8368 patients to the emergency room and 5183 to the screening clinic. About 45% of patients visiting the emergency room had suffered accidents and injuries, and 19% had respiratory illness; 15% of patient visits resulted in admission to hospital. In contrast to this, 49% of patients sent to the screening clinic had respiratory illness and 18% had infective disease; less than 1% of patients needed hospitalization.     

Which patients are likely to die in an accident and emergency department?

Four hundred and eighty-eight deaths occurring in an accident and emergency department over five years were analysed. Their causes were categorised as medical, surgical, or traumatic. Medical causes accounted for 87% of the deaths, of which 60% were from cardiac conditions. Blood loss was an important factor in over half the deaths from surgical and traumatic causes. Lives might have been saved by considering infectious disease in patients with medical conditions and by undertaking more rapid blood transfusion, earlier chest drainage, and lateral cervical spine x rays in appropriate surgical or traumatic cases. The admission to casualty departments of people with terminal neoplasms should be discouraged. The management of medical emergencies should be emphasised when training accident and emergency department staff.     

三级医院急诊科护士灾害护理能力现状及影响因素分析

目的 调查国内三级医院急诊科护士灾害护理能力现状及其影响因素.方法 采用一般情况资料表、临床护士灾害护理能力评估量表对12个省市、18家三级医院的418名急诊科护士进行问卷调查,并对回收问卷数据进行统计分析.结果 急诊护士灾害护理能力总体评分为(114.55±7.70)分,最高分和最低分别为159、93分.得分较高的灾...