Concussion assessment in the Emergency Department: A preliminary study for a quality improvement project

Background In sport, concussion is assessed using the Sports Concussion Assessment Tool (SCAT) 5 and managed with return to play guidelines. Similar, user-friendly tools are rarely, if ever, used in the emergency department (ED). Objectives To evaluate a modified concussion assessment tool designed for the ED (ED-CAT) in patients presenting with a head injury and to identify variables that predict 30-day reattendance. Methods A preliminary, prospective, evaluation in a quality improvement project was conducted in one hospital in South Wales. Patients were recruited if they were over 13 years, and either did not have an ED-CT head scan or had a scan with no acute changes. The primary outcome was 30-day reattendance. Results 40 patients were recruited, 18 of whom had a CT scan. 37 were discharged on the same day with advice, two discharged the next day and one was admitted. Three (7.5%) patients reattended the department. Predictors of reattendance were headache score (median 3.0 vs 5.0; p<0.05), pressure in head score (2.0 vs 5.0; p<0.05), nausea/vomiting score (1.0 vs 3.0; p<0.05), dizziness score (1.0 vs 4.0; p<0.05), blurred vision score (0 vs 4.0; p<0.01), balance problems score (0 vs 4.0; p<0.05), sensitivity to light and confusion score (0 vs 4.0; p<0.01), orientation score (1. 0 vs 0; p<0.05) and immediate memory score (5.0 vs 4.0; p<0.05). Conclusions Key symptoms and signs predicted 30-day reattendance. The ED-CAT requires validation and refinement in a larger population to produce a short, practical, user-friendly, relevant tool for ED head injury assessment

A comparison of emergency department utilization by elderly and younger adult patients presenting to three hospitals in Hong Kong

Background The elderly population is increasing in absolute and relative terms in most developed countries, and this is protected to have a major impact on the delivery of health care, particularly acute and emergency services. The aim of this study is to describe the pattern of utilization of emergency department (ED) services in Hong Kong by the elderly and to compare it to the utilization by younger adults. Methods Data on ED visits to three acute hospitals in the eastern New Territories were retrieved from a central computerized database of ED attendances. Data on all adult patients (aged ≥15 years) who attended the three EDs in 2006 were analyzed retrospectively. Patients aged 15 to 64 years were defined as younger adults; patients aged ≥65 years were defined as elderly. The attendance rate, ED consultation process, hospital admission rate and disease pattern of the two age groups were compared. Results Elderly patients required significantly more emergency care resources than younger adults. Elderly ED patients were brought to hospital more frequently by ambulance (42.8% vs. 14.8%, p < 0.0001) and required hospital admission more often (45.0% vs. 15.5%, p < 0.0001) than younger adults. A significantly higher proportion of elderly patients were triaged as being in the critical, emergency or urgent categories compared to younger adults (44.4% vs. 18.2%, p < 0.0001). Laboratory tests, radiography and CT scanning were performed on elderly patients more frequently than on younger adults (p < 0.0001), and their lengths of stay in EDs and emergency wards were significantly longer (p < 0.0001). Neurological symptoms and chest pain were the most common presenting symptoms in elderly ED patients. Conclusion With the foreseeable rapid growth of the elderly population, ED utilization by the elderly will increase. Health service delivery, including that in the ED, needs to take account of the specific features and requirements of the elderly population in each locale

The normal ranges of cardiovascular parameters measured using the ultrasonic cardiac output monitor

The ultrasonic cardiac output monitor (USCOM) is a noninvasive transcutaneous continuous wave Doppler method for assessing hemodynamics. There are no published reference ranges for normal values in adults (aged 18– 60 years) for this device. This study aimed to (1) measure cardiovascular indices using USCOM in healthy adults aged 18–60 years; (2) combine these data with those for healthy children (aged 0–12), adolescents (aged 12–18), and the elderly (aged over 60) from our previously published studies in order to present normal ranges for all ages, and (3) establish normal ranges of USCOM-derived variables according to both weight and age. This was a population- based cross-sectional observational study of healthy Chinese subjects aged 0.5–89 years in Hong Kong. USCOM scans were performed on all subjects, to produce measurements including stroke volume, cardiac output, and systemic vascular resistance. Data from previously published studies (children, adolescents, and the elderly) were included. Normal ranges were defined as lying between the 2.5th and 97.5th percentiles. A total of 2218 subjects were studied (mean age = 16.4, range = 0.5–89; 52% male). From previous studies, 1197 children (aged 0–12, 55% male), 590 adolescents (aged 12–18, 49% male), and 77 elderly (aged 60–89, 55% male) were included. New data were collected from 354 adults aged 18–60 (47% male). Normal ranges are presented according to age and weight. We present comprehensive normal ranges for hemodynamic parameters obtained with USCOM in healthy subjects of all ages from infancy to the elderly

Circulating human leucine-rich a-2-glycoprotein 1 mRNA and protein levels to detect acute appendicitis in patients with acute abdominal pain

Background Elevated levels of circulating plasma and urine leucine-rich-2-glycoprotein-1 (LRG1) protein has been found in patients with acute appendicitis (AA) and may be useful for diagnosis. This study aimed to investigate whether combined tests including circulating LRG1 mRNA levels improve the early diagnosis of AA. Methods Between December 2011 and October 2012, a prospective study was conducted on patients aged 18 years or older presenting to the ED with acute abdominal pain (< 7 days of symptom onset). Levels of whole blood LRG1 mRNA and plasma LRG1 protein taken from these patients within 24 h of arrival (mean 12.4 h) were analyzed. The primary outcome was AA. Results Eighty-four patients (40 (47.6%) with AA and 44 (52.4%) without AA; mean age 35 years; 41.6% males) were recruited. Median whole blood LRG1 mRNA and plasma LRG1 levels were higher in AA patients than in non-AA. Of 40 AA patients, 13 (32.5%) were diagnosed as complicated AA. In ROC analysis of LRG1 mRNA (normalized to GAPDH), LRG1 protein and Alvarado score for discriminating AA and non-AA, the areas under the curve (AUC) were 0.723, 0.742 and 0.805 respectively. The AUC of combination of normalized LRG1 mRNA, LRG1 protein and Alvarado score was 0.845. Conclusion A combination of modified whole blood LRG1 mRNA levels, plasma LRG1 protein and Alvarado score at the ED may be useful to diagnose simple and complicated AA from other causes of abdominal pain

STEMI outcomes in Guangzhou and Hong Kong: two-centre retrospective interregional study

BACKGROUND AND OBJECTIVES:Healthcare systems are organized very differently in Hong Kong (HK) and Guangzhou (GZ). This study compared managements of the emergency departments (ED) and one-year mortalities of ST-segment elevation myocardial infarction (STEMI) patients in two teaching hospitals in Guangzhou and Hong Kong. METHODS:Retrospective observational study of STEMI mortalities and treatments in the Prince of Wales Hospital (PWH) and the Second Affiliated Hospital of Guangzhou Medical University (AHGZMU), was conducted between January and December 2010. The primary outcome was one-year all cause mortality. RESULTS:Univariate analysis of 76 cases from PWH and 111 cases from AHGZMU showed similar clinical characteristics, except for lower proportions of males (74% vs 92%, P = 0.002), hyperlipidemia (5% vs 25%, P67 years) and hyperglycemia (>10 mmol/L). Aged over 65 years, presence of anterior wall infarct, body weight ≤65 kg, SBP 10 mmol/L were the independent predictors of in-hospital MACE. CONCLUSION:There was no statistically significant difference between the standardized one-year all-cause mortalities of STEMI patients in the setting mainly using thrombolysis with shorter door-to-treatment time and the setting mainly using PCI with longer door-to-treatment time. Aged over 67 years and glucose level over 10 mmol/L were the independent predictors of one-year mortality. Older age, presence of anterior wall infarct, lower body weight, lower SBP at ED and hyperglycemia were the independent predictors of in-hospital MACE

Comparison of outcomes in emergency department patients with suspected cardiac chest pain: two-centre prospective observational study in Southern China

Background Hong Kong (HK) and Guangzhou (GZ) are cities in China with different healthcare systems. This study aimed to compare 30-day and 6-month mortality and characteristics of patients with suspected cardiac chest pain admitted to two emergency departments (ED) in HK and GZ. Methods A prospective observational study enrolled patients with suspected cardiac chest pain presenting to EDs in the Prince of Wales Hospital (PWH), HK and the Second Affiliated Hospital of Guangzhou Medical University (AHGZMU),GZ. The primary outcome was 30-day and 6-month mortality. Results In total, 996 patients were recruited, 407 cases from GZ and 589 cases from HK.The 30-day and 6-month mortality of chest patients were 3.7% and 4.7% in GZand 0.3% and 1.9% in HK, respectively. Serum creatinine level (Cr) was an independent factor for 30-day mortality whilst Cr and systolic blood pressure (SBP) were independent factors for 6-month mortality. In Cox regression analysis, unadjusted and adjusted hazard ratios for 30-day and 6-month mortality in GZ were significantly increased. Conclusion The 30-day and 6-month mortality of patients with suspected cardiac chest pain in Guangzhou were higher than in Hong Kong due to due to different baseline clinical characteristics of patients and different distributions of diagnoses, which were associated with different healthcare systems. Serum creatinine and SBP were independent factors for 30-day and 6-month mortality

Epidemiology of emergency department acute kidney injury

Aim The epidemiology of Acute Kidney Injury (AKI) diagnosed in the Emergency Department (ED) is poorly described. This study describes the incidence, demographics and outcomes of patients diagnosed with AKI in the ED (ED‐AKI). Methods A prospective cohort study was completed in a University Teaching Hospital, (UK) between April and August 2016. In total 20,421 adult patients attended the ED and had a serum creatinine measurement. The incident ED‐AKI patient episodes were compared to a randomly selected cohort of non‐AKI ED patients. Results 572 patients had confirmed eAlert ED‐AKI (548 incident cases), incidence 2.8% (of all ED attendances). ED‐AKI was associated with a 24.4% in‐patient mortality (non‐AKI 3.2%, p<0.001) of which 22.3% of deaths occurred within 24‐hours and 58% within 7‐days. Progression of the admission AKI stage to a higher AKI stage was associated with a 38.8% mortality compared to a 21.4% mortality in those who did not progress (p<0.001). In multivariate analysis ED‐AKI was an independent risk for mortality (HR, 6.293; 95% CI, 1.887 to 20.790, p=0.003). For those discharged from hospital 20.4% of ED‐AKI patients re‐attend for acute assessment within 30‐days post discharge (non‐AKI 7.6%, p<0.001). At 90‐days post discharge 10.0% of ED‐AKI patients died (non‐AKI 1.4%, p<0.001). 12‐months post discharge 17.8% of ED‐AKI patients developed CKD progression or de‐novo CKD (non‐AKI 6.0%). Conclusion ED‐AKI is an independent predictor of death. Mortality is predominantly in the early stages of hospital admission, but for those who survive to discharge have significant long‐term morbidity and mortality

Derivation of a prediction rule for unfavorable outcome after ischemic stroke in the Chinese population

Background Efficient assessment of patients after ischemic stroke has important reference value for doctors to choose appropriate treatment for patients. Our study aimed to develop a new prognostic model for predicting outcomes 3 months after ischemic stroke among Chinese Population. Methods A prospective observational cohort study among ischemic stroke patients presenting to Emergency Department in the Second Affiliated Hospital of Guangzhou Medical University was conducted from May 2012 to June 2013. Demographic data of ischemic stroke patients, assessment of NIHSS and laboratory results were collected. Based on 3-month modified Rankin Scale (mRS) ischemic stroke patients were divided into either favorable outcome (mRS: 0-2) or unfavorable outcome groups (mRS: 3-6). The variables closely associated with prognosis of ischemic stroke were selected to develop the new prognostic model (NAAP) consisted of 4 parameters: NIHSS, age, atrial fibrillation, and prealbumin. The prognostic value of the modified prognostic model was then compared with NIHSS alone. Results A total of 454 patients with suspected stroke were recruited. One hundred eighty-six patients with ischemic stroke were included in the final analysis. A new prognostic model, NAAP was developed. The area under curve (AUC) of NAAP was .861 (95%confidence interval: .803-.907), whilst the AUC of NIHSS was .783 (95%CI: .717-.840), (P = .0048). Decision curve analysis showed that NAAP had a higher net benefit for threshold probabilities of 65% for predictive risk of poor outcomes. Conclusions The modified prognostic model, NAAP may be a better prognostic tool for predicting 3-month unfavorable outcomes for ischemic stroke than NIHSS alone