Emergency Department (ED, emergency room, ER)

Epidemiology

• return visits
  • 3-day revisit rate ~8%
  • 30 day revisit rate ~20%
  • ~1/3 of revisits were to different hospitals
  • most common index diagnoses resulting in revisit
    • skin infections & soft tissue infections (23%)
    • abdominal pain (10%)
    • headache (9%)
• elderly choose the emergency department (ED) for convenient, comprehensive, high-quality care
• ~1/3 of elderly are referred to the ED by a provider
• ~1/3 arrive by ambulance
• common reasons for presentation of elderly to the ED
  • fall-related injuries
  • other acute injuries
  • pain

Complications

• 0.12% of Medicare patients discharged from the ED die within 7 days
  • 7 day mortality 0.27% among hospitals in the lowest 1/5 of inpatient admissions from the emergency department
• ED crowding & boarding harms critically-ill patients
  • combined outcome of in-hospital mortality, persistent organ dysfunction (vasopressors, mechanical ventilation, dialysis) or death at 28 days increases from ~25% at hour 0 to 40% at hour 12 for critically-ill patients boarded in the ED
  • 47% of ICU admission requests from the ED are declined
• 10-day mortality 50% higher when EDs most crowded
• incorrect diagnosis ~5.7%, adverse event in ~2.0% due to incorrect diagnosis, ~0.3% of adverse events serious, translating to ~1 in 18 patients receiving an incorrect diagnosis, 1 in 50 suffering an adverse event, & 1 in 350 suffering permanent disability or death
  • 5 conditions (stroke, myocardial infarction, aortic aneurysm or dissection, spinal cord compression or injury, venous thromboembolism) account for ~40% of serious misdiagnosis-related harms
  • American College of Emergency Physicians & 8 other emergency medicine organizations issued a letter expressing concern about the report

Management

Choosing Wisely recommendations:

• avoid head CT in patients with minor head injury who are at low risk based on validated decision rules
• avoid head CT in asymptomatic adult patients with syncope, insignificant trauma & a normal neurological evaluation
• avoid placing indwelling urinary catheters for either urine output monitoring in stable patients who can void, or for patient or staff convenience
• do not delay engaging available palliative & hospice care services for patients likely to benefit
• avoid antibiotics & wound cultures in patients with uncomplicated skin & soft tissue abscesses after successful incision & drainage & with adequate medical follow-up
• avoid IV fluids before a trial of oral rehydration in uncomplicated cases of mild to moderate dehydration in children
• avoid CT pulmonary angiography in patients with a low- pretest probability of pulmonary embolism & a negative plasma D-dimer
• avoid lumbar spine imaging for adults with non-traumatic back pain unless the patient has severe or progressive neurologic deficits or is suspected of having a serious underlying condition (such as vertebral infection, cauda equine syndrome, or cancer with bony metastasis
• avoid prescribing antibiotics for uncomplicated sinusitis
• avoid ordering CT of the abdomen & pelvis in young otherwise healthy patients (age <50) with known histories of kidney stones, or ureterolithiasis, presenting with symptoms consistent with uncomplicated renal colic

other

• 5 elements of a nursing home to emergency department transfer form
  • emergency contact/health care proxy
  • current medication list
  • reason for emergency department transfer
  • baseline neurological state
  • relevant diagnoses/medical history
• emergency department crowding negatively impacts care
• triage seems to identify patients who need hospitalization but not those that need ICU or surgery vs outpatient care
• telephone calls after emergency department visits of seniors does not reduce return visits, hospitalization, or death
• evaluation of elderly in the emergency department by a transitional care nurse for functional status resulted in a 10% reduction in hospital admission, a decreased 30-day risk for hospital readmission, but ~1.5% increase in rate of 72-hour ED revisits at 2 of 3 sites
• cross-checking diagnostic & treatment plans with a colleague resulted in a 40% reduction in a preventable adverse event or near miss* (mostly near misses)

* a near miss = a medical error that has the potential to cause an adverse event, but did not, either by chance or after an intervention

More general terms

• health care setting