Klinische Charakteristika und Entlassungsdiagnosen von nicht-traumatischen Patient*innen mit dem Leitsymptom Kopfschmerz in der Notaufnahme

Zusammenfassung Einleitung: Kopfschmerz ist ein häufiges Leitsymptom in der Notaufnahme. Das zeitnahe Herausfiltern der Patient*innen mit gefährlichen zugrundeliegenden Ursachen stellt oft eine Herausforderung für Notaufnahme-Ärzt*innen dar. In dieser Arbeit wurden demographische und klinische Charakteristika sowie die Deskription des intrahospitalen Verlaufes von Patient*innen mit dem Leitsymptom Kopfschmerz in der NA herausgearbeitet. Methodik: In einer großen Zwei-Center-Studie an zwei Notaufnahmen der Charité wurden über den Studienzeitraum von einem Jahr (Februar 2009 bis Februar 2010) Daten aller 34.333 nicht-traumatischen Patient*innen erfasst. Anschließend wurden speziell für diese Arbeit ausschließlich alle Patient*innen betrachtet, die sich davon mit dem Leitsymptom Kopfschmerz vorgestellt hatten. Die Daten wurden aus dem elektronischen Krankenhausinformationssystem extrahiert und mithilfe des Statistikprogramms SPSS® 27 ausgewertet. Neben dem Vergleich der ambulanten mit der stationären Patient*innengruppe wurden die drei Subgruppen „Patient*innen mit intrakranieller Blutung“, Patient*innen mit signifikanter Pathologie“ und „Patient*innen mit schwerem Verlauf“ (Tod und/oder ITS) näher betrachtet. Ergebnisse: Innerhalb des Einschlusszeitraumes stellten sich in beiden Notaufnahmen 1.365 Patient*innen mit dem Leitsymptom Kopfschmerz vor. Dies entsprach 4,0% aller nicht-traumatischer NA-Patient*innen. Der Altersmedian lag bei 42 Jahren, 23,3% (n = 318) aller Kopfschmerzpatient*innen wurden stationär aufgenommen. Der Anteil der Patient*innen mit intrakranieller Blutung lag bei 3,6% (n=48). Eine signifikante Pathologie fand sich bei 17,7% (n=237) aller Kopfschmerzpatient*innen, darunter war die häufigste Diagnose eine „Hypertensive Krise“ (30,8%, n=73). Ein schwerer Verlauf ergab sich für 4,0% (n=54) aller Kopfschmerzpatient*innen, darunter war die „Subarachnoidalblutung“ die häufigste Diagnose (42,6%, n=23). Frauen waren insgesamt (62,7%), unter den stationären Patient*innen (61,0%) und in den drei betrachteten Subgruppen (Patient*innen mit intrakranieller Blutung/Patient*innen mit signifikanter Pathologie/Patient*innen mit schwerem Verlauf) häufiger betroffen (64,6%/57,0%/55,6%). Der tageszeitliche Hauptvorstellungszeitraum in der Notaufnahme lag zwischen 12 und 18 Uhr und die häufigste Symptomdauer wurde mit „über 24 Stunden und unter einer Woche“ angegeben. Ambulante Patient*innen wurden am häufigsten mit der symptombasierten Diagnose „Kopfschmerz“ entlassen (30,5%), bei den stationären Patient*innen war „Meningitis/Encephalitis“ die häufigste Diagnose (9,4%). Schlussfolgerung: Unter den ambulanten Kopfschmerzpatient*innen gibt es einen hohen Anteil symptombasierter Entlassungsdiagnosen. Die hier untersuchten unterschiedlichen Subgruppen der Notaufnahme-Patient*innen mit dem Leitsymptom Kopfschmerz unterschieden sich in den betrachteten Charakteristika hinsichtlich Anamnese und klinischer Symptomatik weniger als erwartet. Die Analyse insbesondere der gut validierten stationären Entlassungsdiagnosen von Patient*innengruppen bestimmter Leitsymptome in der Notaufnahme kann klinische Entscheidungsprozesse in der Notfallmedizin unterstützen.Abstract Background: Headache is a frequent chief complaint in the Emergency Department. A fast assessment of those patients with dangerous underlying diagnoses represents a common challenge to emergency physicians. Objectives: This study analyzes demographic and clinical characteristics as well as inpatient course of headache patients presenting to the Emergency Department. Methods: In a big two-center-study in two Emergency Departments of the Charité Berlin a total of 34.333 non-traumatic patients were included over a one-year period (february 2009 – february 2010). Afterwards only the patients who presented with the chief complaint of headache were further analyzed for this study. Data was extracted from the electronic hospital information system and analyzed using the statistics software SPSS® 27. In addition to the comparison of the outpatient and inpatient groups the three subgroups “patients with intracranial hemorrhage”, “patients with significant pathologies” and “patients with a serious outcome” (death and/or ICU-admission) were further analyzed. Results: A total of 1.365 patients with the chief complaint of headache presented to the Emergency Department within the one-year study period, representing 4.0% of all non-traumatic Emergency Department patients. Median age was 42 years, 23.3% (n=318) of all headache patients were admitted. The percentage of patients with intracranial hemorrhage was 3.6% (n=48). A significant pathology was found in 17.7% (n=237) of all headache patients, of which “hypertensive crisis” (30.8%, n=73) was the most frequent diagnosis. Patients with a serious outcome represented 4.0% (n=54) of all headache patients, “subarachnoid hemorrhage” was the most common diagnosis in this subgroup (42.6%, n=23). Female patients dominated overall (62.7%), in the inpatient group (61.0%) as well as in all three subgroups (patients with intracranial hemorrhage/patients with significant pathology/patients with serious outcome: 64.6%/57.0%/55.6%). The majority of headache patients arrived between 12 p.m. and 6 p.m., the most common onset of symptoms was reported as “longer than 24 hours and less than one week” ago. Outpatients most commonly received “headache” as a symptom-based diagnosis (30.5%), the most frequent diagnosis of inpatients was “meningitis/encephalitis” (9.4%). Conclusion: A high percentage of headache patients is discharged from the Emergency Department with a symptom-based diagnosis. Analyzed subgroups in this study varied less than expected in past medical history and clinical symptoms. The analysis of good validated hospital discharge diagnoses of patients with certain chief complaints in the Emergency Department can support clinical decision-making processes in Emergency Medicine

Emergency department consultations for respiratory symptoms revisited: exploratory investigation of longitudinal trends in patients' perspective on care, health care utilization, and general and mental health, from a multicenter study in Berlin, Germany

Background: Only few studies of emergency department (ED) consulters include a longitudinal investigation. The EMACROSS study had surveyed 472 respiratory patients in eight inner-city EDs in Berlin in 2017/2018 for demographic, medical and consultation-related characteristics. This paper presents the results of a follow-up survey at a median of 95days post-discharge. We aimed to explore the post hoc assessment of ED care and identify potential longitudinal trends. Methods: The follow-up survey included items on satisfaction with care received, beneft from the ED visit, potential alternative care, health care utilization, mental and general health, and general life satisfaction. Univariable between subject and within-subject statistical comparisons were conducted. Logistic regression was performed for multivariable investigations of determinants of dropout and of retrospectively rating the ED visit as benefcial. Results: Follow-up data was available for 329 patients. Participants of lower education status, migrants, and tourists were more likely to drop out. Having a general practitioner (GP), multimorbidity, and higher general life satisfaction were determinants of response. Retrospective satisfaction ratings were high with no marked longitudinal changes and waiting times as the most frequent reason for dissatisfaction. Retrospective assessment of the visit as benefcial was positively associated with male sex, diagnoses of pneumonia and respiratory failure, and self-referral. Concerning primary care as a viable alternative, judgment at the time of the ED visit and at follow-up did not difer signifcantly. Health care utilization post-discharge increased for GPs and pulmonologists. Self-reported general health and PHQ-4 anxiety scores were signifcantly improved at follow-up, while general life satisfaction for the overall sample was unchanged. Conclusions: Most patients retrospectively assess the ED visit as satisfactory and benefcial. Possible sex diferences in perception of care and its outcomes should be further investigated. Conceivable eforts at diversion of ED utilizers to primary care should consider patients’ views regarding acceptable alternatives, which appear relatively independent of situational factors. Representativeness of results is restricted by the study focus on respiratory symptoms, the limited sample size, and the attrition rate

Diverting less urgent utilizers of emergency medical services to primary care: is it feasible? Patient and morbidity characteristics from a cross-sectional multicenter study of self-referring respiratory emergency department consulters

Objective: Diversion of less urgent emergency medical services (EMS) callers to alternative primary care (PC) is much debated. Using data from the EMACROSS survey of respiratory ED patients, we aimed to characterize self-referred EMS patients, compare these with non-EMS patients, and assess scope and acceptability of a potential redirection to alternative PC. Results: Of n = 292 self-referred patients, n = 99 were transported by EMS. Compared to non-EMS patients, these were older, triaged more urgently and arrived out-of-hours more frequently. The share of chronically and severely ill patients was greater. Out-of-hours ED visit, presence of a chronic pulmonary condition as well as a hospital diagnosis of respiratory failure were identified as determinants of EMS utilization in a logistic model, while consultation for access and quality motives as well as migrant status decreased the probability. EMS-transported lower urgency outpatients visiting during regular physicians' hours were defined as potential PC cases and evaluated descriptively (n = 9). As a third was medically complex and potentially less suitable for PC, redirection potential could be estimated at only 6% of EMS cases. This would be reduced to 2% if considering patients' judgment concerning the appropriate setting. Overall, the scope for PC diversion of respiratory EMS patients seems limited

Emergency department consultations for respiratory symptoms revisited: exploratory investigation of longitudinal trends in patients’ perspective on care, health care utilization, and general and mental health, from a multicenter study in Berlin, Germany

Background: Only few studies of emergency department (ED) consulters include a longitudinal investigation. The EMACROSS study had surveyed 472 respiratory patients in eight inner-city EDs in Berlin in 2017/2018 for demographic, medical and consultation-related characteristics. This paper presents the results of a follow-up survey at a median of 95 days post-discharge. We aimed to explore the post hoc assessment of ED care and identify potential longitudinal trends. Methods: The follow-up survey included items on satisfaction with care received, benefit from the ED visit, potential alternative care, health care utilization, mental and general health, and general life satisfaction. Univariable between-subject and within-subject statistical comparisons were conducted. Logistic regression was performed for multivariable investigations of determinants of dropout and of retrospectively rating the ED visit as beneficial. Results: Follow-up data was available for 329 patients. Participants of lower education status, migrants, and tourists were more likely to drop out. Having a general practitioner (GP), multimorbidity, and higher general life satisfaction were determinants of response. Retrospective satisfaction ratings were high with no marked longitudinal changes and waiting times as the most frequent reason for dissatisfaction. Retrospective assessment of the visit as beneficial was positively associated with male sex, diagnoses of pneumonia and respiratory failure, and self-referral. Concerning primary care as a viable alternative, judgment at the time of the ED visit and at follow-up did not differ significantly. Health care utilization post-discharge increased for GPs and pulmonologists. Self-reported general health and PHQ-4 anxiety scores were significantly improved at follow-up, while general life satisfaction for the overall sample was unchanged. Conclusions: Most patients retrospectively assess the ED visit as satisfactory and beneficial. Possible sex differences in perception of care and its outcomes should be further investigated. Conceivable efforts at diversion of ED utilizers to primary care should consider patients'views regarding acceptable alternatives, which appear relatively independent of situational factors. Representativeness of results is restricted by the study focus on respiratory symptoms, the limited sample size, and the attrition rate

Redirecting emergency medical services patients with unmet primary care needs: the perspective of paramedics on feasibility and acceptance of an alternative care path in a qualitative investigation from Berlin, Germany

Background: Against the backdrop of emergency department (ED) overcrowding, patients' potential redirection to outpatient care structures is a subject of current political debate in Germany. It was suggested in this context that suitable lower-urgency cases could be transported directly to primary care practices by emergency medical services (EMS), thus bypassing the ED. However, practicality is discussed controversially. This qualitative study aimed to capture the perspective of EMS personnel on potential patient redirection concepts. Methods: We conducted qualitative, semi-structured phone interviews with 24 paramedics. Interviews were concluded after attainment of thematic saturation. Interviews were transcribed verbatim, and qualitative content analysis was performed. Results: Technical and organizational feasibility of patients' redirection was predominantly seen as limited (theme: "feasible, but only under certain conditions") or even impossible (theme: "actually not feasible"), based on a wide spectrum of potential barriers. Prominently voiced reasons were restrictions in personnel resources in both EMS and ambulatory care, as well as concerns for patient safety ascribed to a restricted diagnostic scope. Concerning logistics, alternative transport options were assessed as preferable. Regarding acceptance by stakeholders, the potential for releasing ED caseload was described as a factor potentially promoting adoption, while doubt was raised regarding acceptance by EMS personnel, as their workload was expected to conversely increase. Paramedics predominantly did not consider transporting lower-urgency cases as their responsibility, or even as necessary. Participants were markedly concerned of EMS being misused for taxi services in this context and worried about negative impact for critically ill patients, as to vehicles and personnel being potentially tied up in unnecessary transports. As to acceptance on the patients' side, interview participants surmised a potential openness to redirection if this would be associated with benefits like shorter wait times and accompanied by proper explanation. Conclusions: Interviews with EMS staff highlighted considerable doubts about the general possibility of a direct redirection to primary care as to considerable logistic challenges in a situation of strained EMS resources, as well as patient safety concerns. Plans for redirection schemes should consider paramedics' perspective and ensure a provision of EMS with the resources required to function in a changing care environment

Exploring the views of low-acuity emergency department consulters on an educational intervention and general practitioner appointment service: a qualitative study in Berlin, Germany

Objectives Low-acuity patients presenting to emergency departments (EDs) frequently have unmet ambulatory care needs. This qualitative study explores the patients’ views of an intervention aimed at education about care options and promoting primary care (PC) attachment.Design Qualitative telephone interviews were conducted with a subsample of participants of an interventional pilot study, based on a semi-structured interview guide. The data were analysed through qualitative content analysis.Setting The study was carried out in three EDs in the city centre of Berlin, Germany.Participants Thirty-two low-acuity ED consulters with no connection to a general practitioner (GP) who had participated in the pilot study were interviewed; (f/m: 15/17; mean age: 32.9 years).Intervention In the pilot intervention, ED patients with low-acuity complaints were provided with an information leaflet on appropriate ED usage and alternative care paths and they were offered an optional GP appointment scheduling service. Qualitative interviews explored the views of a subsample of the participants on the intervention.Results Interviewees perceived both parts of the intervention as valuable. Receiving a leaflet about appropriate ED use and alternatives to the ED was viewed as helpful, with participants expressing the desire for additional online information and a wider distribution of the content. The GP appointment service was positively assessed by the participants who had made use of this offer and seen as potentially helpful in establishing a long-term connection to GP care. The majority of patients declining a scheduled GP appointment expected no personal need for further medical care in the near future or preferred to choose a GP independently.Conclusions Low-acuity ED patients seem receptive to information on alternative acute care options and prevailingly appreciate measures to encourage and facilitate attachment to a GP. Promoting PC integration could contribute to a change in future usage behaviour.Trial registration number DRKS00023480